Safety & Quality at Repromed
At Repromed we are committed to providing patients with the highest level of care and providing an effective and safe environment for treatment.
Repromed DSU maintains annual accreditation with the National Safety and Quality Health Service (NSQHS) Standards . In July 2016 Repromed Day Surgery Unit attained accreditation on 109 Core Action Items with 3 items granted ‘Met with Merit’ Status.
Repromed maintains full accreditation to:
a) RTAC Code of Practice (Reproductive Technology Accreditation Committee – August 2015). Repromed is audited annually to this Code of Practice to ensure continuous improvement in the quality of care offered to people accessing fertility treatment.
b) Repromed is also accredited to the Department of Health Diagnostic Imaging Accreditation Scheme (DIAS) established 2007. In 2015 these Standards were revised ensuring that Medicare funding is directed to Diagnostic Imaging services that are safe, effective and responsive to the needs of Repromed’s clients. The DIAS Standards are divided into 4 parts:
1 – Organisational
Including Safety and Quality; Registration and Licensing; Equipment Inventory and Servicing; and Heath Care Associated Infection.
2 – Preprocedure Standard
Including Provision of Service; Client Consent; Patient Identification and Medication Management.
3 – Procedure Standard
Including Diagnostic Imaging Protocol
4 – Post Procedure Standard
Including communication results and reports, client and stakeholder feedback and complaints management.
All business and clinical aspects of Repromed DSU are managed through the Monash IVF Board of Directors and the Repromed Medical Advisory Committee. These 2 committees are the highest levels of governance within the Monash IVF Group and Repromed and regularly review:
- Quality Management System
- Key Clinical and Performance Indicators
- Internal audit results
- Incident reports and Adverse Events
- Consumer feedback
Repromed DSU values feedback and input from our consumers (patients and carers). Consumers are able to participate in the improvement of quality and care provided at Repromed in the following ways:
- Annual patient satisfaction survey
- Feedback forms
- Consumer Advisory Group
- Consumer review of quality documents
- Individual feedback
Infection Prevention and Control
At Repromed we are continually seeking to improve our practice.
Repromed DSU has robust infection prevention and control systems in place and undertakes frequent audits to ensure that we comply with the following standards and guidelines:
- Australian Standards for Reprocessing of Reusable Medical Devices in Health Service Organisations (AS/NZS 4187:2014)
- NHMRC (2010): Australian Guidelines for the Prevention and Control of Infection in Healthcare.
- ACORN Standards for Perioperative Nursing (2014-15)
- Hand Hygiene Australia Guidelines. Audited 3 times per year. National Benchmark for compliance is 70%. Repromed continues to excel with the following results. Aug 15 = 91.5%, Dec 15 = 91.2% & Apr 16 = 91.7%
Internally at Repromed DSU we audit our practice and performance regularly in the following areas:
- Environmental cleanliness
- Hand Hygiene of Nursing, Medical, Administration and Laboratory staff
- Standard Precautions, Additional Precautions and Aseptic Non-Touch Technique
- Aseptic Technique
- Meditrax Tracking (Tracking of sterilized instruments)
- Ultrasound Probe Reprocessing and Tracking
- Waste management
- Personal Protective Equipment
- Antimicrobial Stewardship (The appropriate prescribing and use of antibiotics)
To provide our consumers with a well-trained and skilled workforce, BDS staff are required to undertake mandatory training in all of the following areas:
- Basic Life Support (CPR)
- Advanced Life Support (ALS)
- Aseptic Technique
- Hand Hygiene
- Aseptic Non Touch Technique
- Management of Invasive Devices
- Medication Management
- Patient Centred Care
- Open Disclosure
- Falls Prevention and Pressure care
- Manual Handling and WH&S
- NSQHS Standards
Safety and Data collection
Repromed Day Surgery is committed to providing patients with the highest level of care and providing an effective and safe environment for treatment.
Part of this process, is about collecting and evaluating information regarding:
- Patient Falls
- Patient Skin Tears
- Post-Operative Infections
The following list of Clinical Indicators is reported on:
- Patient complaints
- Patients who experience an adverse event during care delivery
- Unplanned return to operating room on same day as initial procedure
- Unplanned transfer or overnight admission related to procedure
- Unplanned transfer or admission related to ongoing management
- Delayed discharge for clinical reasons exceeded 1 hour
- Unplanned delayed discharge for non-clinical reasons more than 1 hour
Repromed has regularly revised governance systems that maintain and improve the reliability and quality of patient care as well as improve patient outcomes.
Repromed supports active participation by consumers in the improvement of patient experiences and patient health outcomes, for continuous quality improvement. If you are interested in participating please contact our Day Surgery Manager firstname.lastname@example.org
Repromed has very effective governance systems for the control of health care associated infections. Our facilities and associated environments are subjected to the highest standard of cleaning, disinfection and sterilization through robust infection prevention and control strategies. Repromed’s post operative infection rate is zero.
Hand Hygiene Australia benchmark hand hygiene compliance at 70%. Repromed is currently 91% compliant and auditing is conducted quarterly. All Repromed staff including clinicians and administration are included in hand hygiene statistics.
Repromed has governance systems in place to reduce or eradicate the occurrence of medication incidents and improve the safety and quality of medicine use.
Repromed has governance systems in place to ensure the correct identification of patients and correct matching of patients with their intended treatment.
Repromed implements systems for effective and structured clinical handover ensuring safe, continual and confidential patient care.
Repromed has an exemption to this standard as no blood or blood products are administered in the Day Surgery Unit.
Repromed implemented evidence based systems to prevent pressure injuries. Repromed Day Surgery Unit has never had an incidence of pressure injury.
Repromed has governance and clinical systems in use to recognize and respond to clinical deterioration promptly to ensure appropriate action is taken.
Repromed implemented systems to prevent falls minimizing harm from falls. Repromed has had no incidences of falls or harm from falls.
Repromed Day Surgery staff pride themselves on providing the highest possible standards of patient care. If you would like to discuss patient safety and quality please do not hesitate to contact the Day Surgery Manager on 08 8333 8111.
Tours of the Repromed Day Surgery Unit can be arranged at a time that suits you.