Patient Safety & Quality

St Luke’s Private Hospital is committed to ongoing improvement of patient care and experience in all areas. While we are proud of our excellent record in delivering quality, person-centred patient care and in managing risks, we continue to focus on improvements to ensure that our services are as safe as possible and that we are minimising risks at all times.

St Luke’s Private Hospital has a strong commitment to safety and quality and this is reflected in our ongoing approach to:

  • Continuously reviewing and improving the performance of our patient safety and quality systems
  • Assisting our healthcare professionals and Accredited Medical Practitioners to monitor the safety and quality of care they deliver
  • Creating safe environments and systems of work for our staff
  • Ensuring accountability for the safety and quality of care at all levels of our organisation reporting through to the St Luke’s Care Board

St Luke’s Private Hospital operates under the St Luke’s Care’s Quality and Risk Management Framework based on an integrated approach to clinical and corporate risk management and continuous quality improvement.

This framework incorporates three main principles:

  • Risk Management as a process to ensure quality
    • All risks are identified and assessed
    • A plan of action aims to manage all identified corporate and clinical risks including identification of risk, proposing risk limits, establishing and treating controls, evaluating controls and communicating risk
  • Corporate Governance
    • Meeting the obligations under the Corporations Act (2001) and all other federal and state legislations and regulations applicable to health
    • Meeting statutory and industry standards for financial, asset and business management
    • Human resources management will foster an environment of teamwork, open communication and support of professional development while meeting all statutory requirements including work, health and safety standards
  • Clinical Governance
    • Accreditation and credentialing of all Accredited Medical Practitioners and Allied Health Practitioners
    • Clinical Incidence reporting, review and corrective action when required
    • Quality and Safety Indicators are used to measure and monitor performance
    • Quality and Safety Indicators are benchmarked and reported to the St Luke’s Care Board
    • Effective management and monitoring of complaints
    • All St Luke’s Care Corporate and Clinical policies are developed, reviewed and monitored in accordance with evidence based best practice
    • Development and monitoring of the St Luke’s Private Hospital Quality, Safety and Operational Plan
    • St Luke’s Private Hospital meets all 10 NSQHS standards for accreditation with the Australian Council on Healthcare Standards (ACHS)

Performance across these areas by St Luke’s Private Hospital is closely monitored by the St Luke’s Care Medical Advisory Committee, the St Luke’s Care Quality Risk and Review Committee and reported to the Board of St Luke’s Care.

Our Safety & Quality Performance


The Australian Commission on Safety and Quality in Healthcare (ACSQHC) developed the National Safety and Quality Health Service (NSQHS) Standards to improve the quality of health service provision in Australia. The NSQHS Standards provide a nationally consistent statement of the level of care consumers can expect from a health service. There are 10 NSQHS Standards focusing on areas that are essential to drive the implementation and use of safety and quality systems. 

St Luke’s Private Hospital received full accreditation under the 10 NSQHS Standards by the Australian Council on Healthcare Standards (ACHS) in 2017. The accreditation period is for 3 years and remains valid until December 2020.

Performance Indicator Data 

ACHS Clinical Indictor Program 

St Luke’s Private Hospital participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program. Data is submitted twice per year and is analysed, allowing benchmarking by the participating healthcare organisations at a peer and national level. 

St Luke’s Private Hospital submits data for the following data sets;

  • Anaesthesia and Perioperative Care
  • Day Patient
  • Hospital Wide
    • Unplanned readmissions
    • Unplanned returns to operating room
    • Pressure Injuries
    • Falls
    • Adverse Blood Transfusion Events 
  • Infection Control
  • Medication Safety
  • Rehabilitation Medicine

St Luke’s Private Hospital is proud to have been consistently equal to or better than benchmark for these Clinical Indicators. 

The National Hand Hygiene Initiative

Health care associated infections (HCAI) are a major and growing issue in the quality and safety of health care, in both hospital and community settings.  Health care associated infections require urgent national consideration and action. 

Health care associated infections have been nominated as a priority area by the Australian Commission on Safety and Quality in Health Care (ACSQHC). Improved healthcare worker hand hygiene (HH) is the highest priority area to reduce the risk of healthcare-associated infections. Reliable indicators of HH compliance are essential, and mechanisms for the wider implementation and monitoring are required.

The purpose of the National Hand Hygiene Initiative (NHHI) is to develop a national approach to improving HH and monitor its effectiveness. This initiative is based on the World Health Organisation (WHO) - World Alliance for Patient Safety campaign – “Clean Care is Safer Care” launched in 2005.

Ref: Hand Hygiene Australia (2017)

The graph below demonstrates the St Luke’s Private Hospital hand hygiene compliance rate against the average of other hospitals nationally, who audit the 5 moments of hand hygiene.

Hand Hygiene 2017

Patient Satisfaction Surveys

St Luke’s Private Hospital actively seeks feedback and suggestions from patients and their families or carers regarding their experience with clinical care, housekeeping and catering.  Quarterly and Annual reports are prepared and reviewed by the Quality Review and Risk Management Committee and the St Luke’s Care Board.

Overall patient satisfaction rates have remained very high, with the majority of patients scoring their patient experience as between 8 and 10 out of 10. 

Patient Rating 2017

Infection Prevention and Control

St Luke’s Private Hospital is reviewed and audited biannually by Healthcare Infection Control Management Resources (HICMR) which is the largest provider of Infection Prevention and Control services in Australia.

The most recent audit was conducted in November 2016 and the Hospital scored an overall compliance rate of 95%.

If you have any questions regarding Infection Prevention and Control, please contact the Infection Control Nurse Manager on (02) 9356 0345.