North Shore Private Hospital

Patient Safety & Quality

North Shore Private Hospital is committed to ongoing improvement of patient care in all areas. While we have an excellent record in delivering quality patient care and managing risks, our hospitals continue to focus on improvements to ensure that our services are as safe as possible and that we are minimising risks at all times.

North Shore Private Hospital has a strong commitment to safety and quality and this is reflected in our approach to:

  • Creating safe environments and systems of work for our staff;
  • Reviewing and improving on a continuous basis the performance of our patient safety and quality systems;
  • Assisting our healthcare professionals and Visiting Medical Practitioners to monitor the safety and quality of care they provide;
  • Ensuring accountability for the safety and quality of care at all levels of our organisation reporting through to the Board of Ramsay Health Care

North Shore Private Hospital operates under Ramsay Health Care’s comprehensive Clinical Governance Framework based on an integrated approach to clinical risk management and continuous quality improvement. This Framework measures four major areas of organisational performance including:

1. Clinical Risk Management (making sure our services are safe and minimising risk of error)

  • The Ramsay culture promotes and encourages staff to report incidents, risks and near misses;
  • Incident Management policy outlines the process for assessing and investigating incidents;
  • Ramsay clinical policies are developed in accordance with evidence based best practice;
  • Clinical, risk and safety policies are reviewed on a regular basis and updated as required; and
  • Ramsay has a strategy and policy for ‘whistle blowers’.

2. Clinical Effectiveness (making sure that the clinical services we provide are effective)

  • Quality and Safety Indicators are used to measure and monitor performance;
  • Quality plans are initiated when significant issues are flagged;
  • Quality and Safety Indicators are benchmarked nationally;
  • Serious clinical incidents are reported and investigated;
  • Clinicians are represented on the Governance Committee and expert clinical advisory panels;
  • High risk areas are audited on a regular basis;
  • Quality performance and safety issues are reported to the Ramsay Board; and
  • All facilities meet the standards for accreditation.

3. Effective Workforce (making sure our staff are competent and up-to-date)

  • Facility Rules are available to all existing and new medical and allied health personnel;
  • Ramsay Health Care has a strict process for checking credentials, registration and scope of practice for all clinical disciplines;
  • Ramsay Health Care has targeted education and competency requirements in all clinical areas with a particular focus on high risk areas; and
  • Staff are orientated and updated on quality and risk systems.

4. Consumer Participation (involving our patients and carers in their care)

  • Consumers participate in our risk management and quality improvement activities;
  • Consumer complaints and feedback processes are managed in a timely way;
  • Consumer feedback from Ramsay Patient Satisfaction
  • Surveys informs strategic and business planning;
  • Consumers participate and partner in improving patient experiences and health outcomes;
  • Health and safety performance is publicly available on hospital website; and
  • Open disclosure between clinicians and consumers is actively promoted when things don’t go to plan.

Performance across these areas by all Ramsay hospitals is closely monitored by Ramsay’s Clinical Governance Unit and reported through to the Company’s Risk Management Committee and the Board of Ramsay Health Care.

Our Safety & Quality Performance

The following table provides the most recent performance for North Shore Private Hospital.


All Australian facilities are accredited using the National Safety and Quality Health Service Standards which was introduced in 2013.

Accreditation is an important driver for safety and quality improvement. Through accreditation Ramsay Health Care has been able to assess our level of performance in relation to established national and international standards and to implement ways to continuously improve our service delivery.

Staph Aureus Bacteraemia

At North Shore Private Hospital we aim to minimise the risk of infection to patients, staff and visitors who come to our facility. This hospital has a number of programs in place to detect and prevent infections that are common within health care facilities.

One of the most effective means to prevent infection spreading amongst patients is for all health professionals to wash their hands.

Infection Rate (Staph Aureus Bacteraemia)

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Industry Benchmark Rate


C. Difficile

Clostridium difficile – is an infection of the bowel that causes diarrhoea and does not cause problems in healthy people. Ramsay Health takes every precaution to prevent these infections from occurring in patients during hospitalization through a well-established infection prevention program.

However, if an individual is unwell, taking antibiotics, taking some cancer medications or medications to supress gastric acid, they may be more likely to contract Clostridium difficile. These infections can be acquired in the community (community acquired) or during your admission (hospital acquired).

The chart shows a breakdown of these infections and where the infection was contracted, as knowing where the infection started can help us prevent the spread to other patients.

Clostridium difficile

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Industry Benchmark Rate

Hospital Colour C diff - hospital acquired
 C diff - present on admission

Hand hygiene is conducted in accordance with the ‘five moments’ that is; before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient’s environment.
North Shore Private Hospital participates in the national hand hygiene strategy through Hand Hygiene Australia. Hand hygiene audits are conducted three times per year.

Visitors to this hospital are encouraged through appropriate signage to use antiseptic hand rub located throughout the hospital.

Hand Hygiene

Higher score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Industry Benchmark Rate



The Hand Hygiene brochure has more information on hand hygiene.

The risk of falling increases according to age with data suggesting that one third of people over the age of 65 years have one or more falls a year.

Whilst falls can occur at all ages, the frequency and severity of falls- related injuries increases significantly with age. These injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. These injuries may result in hospitalisation or an increased length of stay in hospital.

The risk of falling can greatly increase when admitted to hospital due to a range of factors including illness and unsteadiness, adapting to a new environment, the introduction of new medications and walking in unsafe footwear or slippers.

In 2015 Ramsay increased the focus on falls prevention in hospitals by appointing a National Falls Prevention Advisory Group.  This group has standardized the approach to falls prevention across all Ramsay hospitals by targeting a structured risk assessment, policy and guidelines, equipment for falls prevention and clinical staff education.  Our hospitals use a number of strategies to prevent falls and these include: targeted hourly rounding of patients identified as high risk of falling; ensuring that call bells and personal items are within patient reach; call bells are answered promptly and patients are assisted to the toilet at regular intervals. In addition, Ramsay has purchased low beds, falls mats, and patient alarms to minimise the risk patients falling whilst in our hospitals.

In 2015 the ACHS changed the definition for the falls indicator to include only serious falls. This is reflected in the National Average rate of falls dropping from .062% in 2014 to 0.011% in 2015. Ramsay rate has decreased in accordance with this change.

Patient Falls Requiring Intervention

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate


All Patient Falls

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate



Our Falls Prevention brochure entitled 'Keeping on your Feet' has more information on preventing falls.

Our hospital reviews patients who have an unplanned readmission to hospital following discharge. Monitoring of this information is very important as it provides an indication of the effectiveness of our discharge planning processes

Unplanned Readmissions within 28 Days

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate

North Shore Private Hospital performs a higher percentage of complex surgery than most hospitals. Sometimes patients need to return to theatre unexpectedly to treat bleeding or other problems occurring early after the operation - we call this ‘return to theatre’. There are many reasons why patients may be required to return to theatre and this can be associated with complex procedures in areas of cardiac, neurosurgery and general surgery. Our data shows that in the last period some patients undergoing complex surgery in these areas have required a return to theatre. Although some of these returns may not be preventable, we examine each case where this has occurred to minimise these returns and to get the best possible outcomes for our patients.

Unplanned Return to Theatre

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate

Medicines are commonly used to treat a variety of conditions in the healthcare setting and therefore it is important to measure the risk of errors.  North Shore Private Hospital is continually reviewing and implementing a range of medication safety strategies to further improve performance in this area.

The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and North Shore Private Hospital has adopted many of these strategies. This includes the National Inpatient Medication Chart which standardises the documentation on how medicines are prescribed and ordered.  Adoption by North Shore Private Hospital of the User-Applied Labelling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered.

In addition, North Shore Private Hospital has medication administration policies and processes in place which have been developed using best practice principles.

North Shore Private Hospital takes all medication errors very seriously. We encourage staff to report all errors no matter how minor they may seem. All medication incidents are investigated and actioned. Any serious medication incidents are investigated thoroughly and monitored by the national Clinical Governance Unit.

Medication Safety Errors

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate

Pressure injuries are wounds which form as a result of prolonged pressure to an area of skin. Pressure injuries are recognised worldwide as a common cause of harm to patients and could cause significant pain and discomfort which may result in a slower recovery for the patient.

North Shore Private Hospital is well equipped with the latest equipment to assist staff to prevent these injuries from occurring. Patients are risk-assessed on admission using an evidenced-based tool.  Staff follow a care plan which is targeted to minimising a patient’s risk of developing a pressure injury for those patients assessed as high risk. This includes inspecting the patient’s skin frequently, managing moisture, keeping the skin dry, optimising nutrition and hydration and moving the patient frequently or using special pressure relieving mattresses when needed.

Patients Developing Pressure Injuries Whilst in Hospital

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate

Our Pressure Injury Prevention brochure has more information on preventing pressure injuries.

As part of your hospital admission, you may require a blood transfusion, which is a procedure where you receive blood through an intravenous cannula in your vein.  Blood transfusions may be necessary for a number of reason for example: if your have a surgical procedure, you are anaemic and if your body is not producing sufficient blood cells.  Blood transfusions can be a lifesaving measure, but is not without some risk and therefore are only prescribed after a doctor has deemed it necessary.  Sometimes an adverse reaction to blood transfusion can occur and is treated immediately. Blood transfusion administration and management are governed by the Australian Commission on Safety and Quality in Health Care Standard for Blood and Blood products.

The graph shows the percentage of transfusion with adverse outcomes. 

Blood Transfusions with Adverse Outcomes

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate

For all babies delivered at our Ramsay maternity facilities an Apgar score is completed for each infant at one minute and again at five minutes after birth. The Apgar score is a simple assessment of how a baby is at birth, which helps determine whether the newborn is ready to meet the world without the need for additional medical assistance. It is determined by five characteristics of the baby – heart rate, breathing effort, muscle tone, reflex irritability and skin colour. Each characteristic is rated from zero to two and the sum of these five characteristic is the total Apgar score of the baby. The rating scale is from 1 –10 with 7 and above being considered normal and the baby is in good health. If the Apgar score is < 7 then it is indicating that the baby requires further attention and support from the health professionals present. Ramsay Maternity Hospitals have less babies requiring additional support in comparison to other maternity hospitals, this means we have health babies at birth.

Apgar Scores < 7

Lower score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate


North Shore Private Hospital focuses on listening and responding to the needs of our patients. Your feedback allows us to continually evaluate and improve on all aspects of our performance.

We encourage feedback from our patients via our website; or via our patient satisfaction surveys.  It is advisable that you express your concerns before you leave the hospital so we can fix any problems for you. The nurse in charge of your ward is a good start but if you remain concerned please ask to speak to a Director or Assistant Director of Nursing/Clinical Services.

Alternatively, there are a number of other ways that you can voice a concern. Our website contains a link to the Australian Charter of Healthcare Rights and this suggests a number of ways for you to express your concerns.

Patient Satisfaction

Higher score is better

Hospital Colour North Shore Private Hospital
Industry Standard Colour Average Industry Rate

Awards & Recognition

For more information on Safety and Quality Performance of Ramsay hospitals.