Our Mission Statement
Chelsea Heights Day Surgery (CHDS) is committed to providing the community and surrounding areas with excellent health services and patient care in an environment where the principles of patient safety and surgical and medical care are of paramount importance.
CHDS proudly serves the local community with well-trained, motivated, friendly, and respectful doctors, nurses and supporting staff, offering THE BEST HEALTH SERVICES that are of low cost, with a flexible schedule, in a pleasing environment.
- CHDS goal is to provide safety and quality day surgery service for the local and wider community.
- We are committed to providing a safe environment and quality service to the community.
- We are committed to providing opportunities for the education of staff in all aspects of day surgeries.
We believe that:
- CHDS is an integral part of the local community health service and as such we hope to correlate our activities with the other health services to provide optimum care for the patient and his family.
- The patient has the right to expect our best care and attention and the aim of our service is to be patient centred.
- Each patient should be treated as an individual who has rights, and is a member of a family unit, and also of the community.
- CHDS is an essential service, and that through the training and continuance of learning, we can provide a service based on sound knowledge and experience.
- We have a duty to provide for the physical, psychological and social needs of each patient.
- We should preserve and promote human dignity.
- We should return the patient to his/her family and the community, restored to his/her maximum level of health and independence.
All our staff are individuals combining to provide optimum care for all our patients, and, as such, hope to attain personal satisfaction.
Our Core Values & Guiding Principles
- We will pursue excellence in the delivery of health care.
- CHDS is committed to proving the community with excellent health services and patient care in a first class facility with highly qualified employees. Employees will be provided opportunities to excel through a commitment to continuing education.
- We will always maintain customer focus.
- Our goal is to better understand and address our customer needs in a courteous and compassionate manner. We will strive to meet or exceed customer expectations.
- We will always strive to enhance productivity
- We will face the challenges of a rapidly changing health care environment with a continuing focus on enhancing practice while not sacrificing care standards.
- We embrace change & flexibility
- Change creates great opportunity
- We will maintain an open mind towards change and use it as an opportunity to find new and more effective ways to meet the challenges confronted.
Honesty & Trust
- Honesty and open communication will help to create a safe and efficient workplace.
- We will create and maintain a supportive environment which encourages open communication with patients and employees. This will create an environment which breeds strong trust and maximum efficiency.
CHDS by-laws provides a framework for our governance, operations and management. See link.
CHDS has met and achieved accreditation for all the National Safety and Quality in Health Service (NSQHS) Standards in 2015 and NSQHSS 2nd ed in 2019.
What are the National Standards for Australian Hospitals?
The NSQHS Standardswas endorsed by Australian Health Ministers in 2011 which provide a clear statement about the level of care consumers can expect from health service organisations. This is the essential accreditation arrangement under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.
Accreditation improves the safety and quality at CHDS. It is also a way of verifying the following:
- Quality actions are being taken
- System data is being used to inform activity
- Improvements are made in safety and quality continuously
To be eligible for an on-going accreditation award, a health service organisation may undergo:
- Periods of self-assessment
- Comprehensive assessment against the NSQHS 2nd ed Standards
- Interim or mid cycle assessment against some NSQHS 2nd ed Standards.
Working in partnership with patients and carers
When you are ready for discharge the nurse in the recovery room will give you a patient survey form. We would like you or your carer to complete the survey form and either leave it with the recovery room nurse or send the completed form back via the post. Your feedback is treated with the utmost confidentiality and may be provided anonymously. We value your feedback good or bad. All feedback is tabled at our Management Committee meetings. With your assistance we can continually improve our services.
From time to time, we will require opinions and input from our community. If you would like to volunteer your time please complete the required section on the patient survey form. The volunteers will be treated without fear or favour. Our consumer feedback form is also available for use. Please ask any of our staff.
A periodic Quality of Care Report is available for your perusal. It has all the information about our activities at CHDS to improve the safety and quality of care. These include:
- Information on our available services
- Our quality objectives and commitment
- Facts about our service
- Facts about our diverse needs
- Your participation in care
- Regular reviews & feedbacks from you
- Risk management
- Incident monitoring – falls, pressure injury, medication safety
- Infection control
- Internal audit reports
- Training & education of our staff, etc.
Clinical indicators are also collected to screen and identify areas where we can improve our practice. These include:
- Failure to arrive
- Unplanned overnight admission
- Unplanned delay in discharge
- Cancellation after arrival due to health reasons
- Unplanned return to theatre
- Medication error/Adverse drug reaction
- Hospital acquired infection
- Patient fall, etc
CHDS is committed to the Hand Hygiene Australia program and conducts regular hand hygiene audits to ensure compliance with requirements.
Infection Prevention and Control:
It is very important that you inform our staff during booking if
- you are currently suffering from a viral illness or infectious disease requiring special needs.
- If anyone you have been in contact with, in the past month was suffering from an infectious disease.
- If the patient is a child inform us if your child has been exposed to an infectious disease such as chicken pox or measles.
CHDS has an effective infection control program to provide a safe working environment that minimizes the risk of sharps injury or exposure to body fluids and prevents the transmission of infections from person to person.
Our facility and staff are regularly audited for compliance with the national infection prevention and control guidelines. CHDS Infection Control Management Plan is in place and reviewed annually.
Please inform staff at booking if you have a current Treatment Limiting Order. You will be booked for a pre-anaesthetic consult with the anaesthetist.
What is open disclosure?
Open disclosure is the process of open communication with a patient, and or their family/support person, following an adverse or unexpected event that may or may not result in harm to the patient.
The open disclosure process
The Open Disclosure Process will commence after the detection of a clinical incident by:
Following the detection of a clinical incident, members of the clinical team must ensure that steps are taken to immediately prevent or reduce the occurrence of further suffering and harm to the patient. After any such steps have been initiated, the following measures should be implemented:
Investigation of a clinical incident
A clinical incident may signal a serious breakdown in health care systems and require thorough investigation and response. Any clinical incidents identified by CHDS must be appropriately investigated to determine what happened and, where possible, to reduce the risk of a similar clinical incident happening again.
Members of the clinical team are required to participate in any investigation that may arise from a clinical incident.
Undertaking the investigation process under legal privilege
If an investigation into a clinical incident is carried out at the request of CHDS’s legal advisers, the communications generated during the investigation, including the investigation report, may be subject to legal professional privilege. If a document or record is subject to legal professional privilege, that document or record is protected from disclosure unless legal professional privilege is waived.
For further information on Open Disclosure, see the Australian Commission on Safety & Quality in Healthcare website:
At any time if you have any questions or concerns in relation to our Safety and Quality you may also contact the Director of Nursing. We are here to assist you so please do not hesitate to ask for assistance at any time.
Victorian Duty of Candour
This is a recent introduction of Guidelines made by the Minister for Health as permitted by section 128ZF of the Health Services Act 1988 to set out the steps a health service entity must take to discharge the Statutory Duty of Candour (SDC).
Amendments to the Health Services Act 1988 (Vic) introduces new legal obligations that will require relevant Victorian health service entities to apologise to patients and their families or carers when the patient has suffered a serious adverse patient safety event. The reforms also introduce new protections for serious adverse patient safety reviews.
Statutory duty of candour means that from 30 November 2022, relevant health services will be required to:
- Apologise to any person seriously harmed while receiving care
- Explain what went wrong
- Describe what action will be taken and improvements put in place.
Building on the Australian Open Disclosure Framework, the amendments also introduce legal protections around health service apologies under the duty of candour and protections for serious adverse patient safety event reviews. This means that an apology will not constitute an admission of fault or liability or be relevant in a civil proceeding. And any documents created as part of a protected review will also not be admissible in a legal proceeding.
These reforms will help foster an open and honest culture where errors and harm are effectively identified, discussed and reviewed, and where consumers are kept informed.
For further information go to https://www.safercare.vic.gov.au/support-training/adverse-event-review-and-response/duty-of-candour
Quality Policy, our commitment to Quality
The following statement represents our Quality Policy.
|Chelsea Heights Day Surgery members of staff and Management are committed to: |
Providing the best available care to our patients,
Providing the best available service to our doctors,
Provide a competitive, affordable and safe health care service to our community.
We are committed to continuously complying with our Management System which is based on ISO 9001:2014, the International Standard for Quality Management and the National Safety & Quality Health Services Standards (2nd ed). We are also committed to continuously improving, through reviewing our practice in response to established world’s best practice, internal systems review and education. We have processes for planning: these are transparent, and affect all team members. The outcome of the planning process is a set of objectives which will be reviewed and updated at least yearly.
Finally it is important that all team members:
Are aware of the requirements of our management systems,
Identify, report, record all problems, incidents, complaints, or areas of improvements,
Comply with the intent and the content of our management system.
By doing so, we will achieve our targets and the outcomes identified above.
Please contact me or my office if you have any questions or comments on this policy or its implementation.
Signed by: CEO with support from the Board of Management
Patient Rights and Responsibilities
- To receive quality health care from appropriately qualified and experienced staff and to receive continuity of care when attending Chelsea Heights Day Surgery.
- To receive health care that does not discriminate, particularly on the basis of race, religion, gender, health insurance status, mental status, socioeconomic background or age.
- To expect consideration of any special dietary needs
- To obtain complete and current information on your care and treatment in a language that you understand.
- To receive information about choices and options for your care and treatment including advantages, disadvantages, risks, benefits and alternatives to these treatments.
- To be given adequate opportunity to have any information clarified or any questions answered
- To be treated with courtesy and respect and have your privacy and cultural background respected by staff as well as having access to an interpreter if required.
- To expect that a safe and secure environment is maintained whilst receiving the services, including physical and emotional support.
- To be secure in the knowledge that information concerning your condition and care is treated as confidential and only used by staff who are involved in your care, unless you direct us otherwise.
- To have your health care discussed where others could not overhear it.
- To be given the opportunity to participate in decisions affecting your health care, where relevant.
- To know the identity and professional status of all attending Chelsea Heights Day Surgery and to refuse the presence of other people during the delivery of the treatment.
- To expect staff to routinely introduce themselves to you.
- To seek a second opinion on your condition or treatment / care plan.
- Where applicable, to know in advance the charges for the services provided to you.
- To give your informed consent before the services are provided; to refuse the care or treatment options provided to you by the staff, after being fully informed of the consequences of that decision.
- To discuss any concerns, questions, provide feedback or make complaints about issues related to the services provided to you, the processes involved with the service provision and any treatment undergone at Chelsea Heights Day Surgery.
- To continue to receive appropriate alternative care if any decision to refuse treatment is made.
- To expect that expert/professional decisions to be made on your behalf and in your best interest after discussion with next of kin, partner, carer, guardian or medical agent, should you be unable to speak.
- To participate and cooperate with an agreed treatment and care program or inform staff of your intention not to comply.
- To be considerate of staff and other patients, treating them with courtesy and respect.
- To provide the relevant information about your health, to assist the staff involved in your care, including the possibility of infectious diseases.
- To inform staff if you are covered by any special benefits/ schemes.
- To contribute to a safe and comfortable environment in relation to noise, alcohol, smoking and illicit drugs.
- Consider your ability to meet your financial obligations to pay any accounts and fees for which you are responsible.
- To advise Chelsea Heights Day Surgery if you are unable to keep an appointment within at least 24 hours notice.
(Australian Charter of Healthcare Rights in Victoria in 25 community languages: http://www.health.vic.gov.au/patientcharter/charter.htm)
What happens to patient information?
A medical record is made which includes your name, address, contact details, health information and the treatment you will be given when you become a patient of CHDS. New information is added to the medical record with each subsequent contact or visit with us. We are required to keep medical records for 7 years after last attendance for adults, and for children until they reach the age of 25 years. The record is then destroyed using secure means.
We collect and keep this information to ensure that each health care professional involved in your care has all the facts. Your previous health information and care can help us to quickly identify which treatments are likely to be safe and effective for you. This information may also be used for the planning and evaluation of our care and services. In this situation, your personal details are removed so that you cannot be identified.
Your Information is stored securely within the hospital. Computer stored information allows all health care professionals involved with your care to access information more easily and quickly when needed. If you used other services within the hospital, some information held on our computer systems will be available to health care professionals in that service. This is to ensure that you receive high quality care and avoid the inconvenience of duplication. CHDS maintains strict policies with respect to access to your personal information. All staff employed by CHDS is bound by a strict code of confidentiality.
Who else has access to patient information?
There are a number of services outside CHDS that might be involved in your care once you leave here. These services may include:
• Your general practitioner (GP)
• Community nursing services
• Hostels, nursing homes, rehabilitation services, etc
Information about you needs to be given to community agencies so that services can be organized. Information including diagnosis, treatment and medication may be sent to your referring doctor or GP to facilitate ongoing care. Sometimes your referring doctor or GP will write to or telephone CHDS for additional information about your treatment. In this situation, we routinely release information to the doctor whom you have specified or who is/will be caring for you. In an emergency situation we will release information about you to other hospitals or doctors to facilitate your care.
In some circumstances CHDS is obliged by law to release personal information about you. Examples of this include:
Other examples include Private Health Fund Claim, Administrative requirements for billing and debt collection, and other matters as required by law.
Information Collected by Chelsea Heights Day Surgery
Chelsea Heights Day Surgery holds the following information with respect to its patients.
- Personal address.
- Postal address.
- Next of Kin
- Telephone numbers.
- Fax number
- Date of birth.
- E-mail address.
- Medical History
The purpose of the above information is to assist the Staff – both Medical and Administrative to conduct the operation of the day surgery which is dedicated to the medical care and general welfare of patients referred to the centre for treatment. The purpose of the above information is to enable the centre to effectively treat patients
How does Chelsea Heights Day Surgery use information?
Manner of collection
Information is collected from patients through the provision of that information on their behalf by their treating practitioner or directly from the patient.
Storage and data protection
Personal information about patients is contained in hard copy documents stored and protected within the office on the day of admission. Information concerning patients is then stored electronically on our computer system which is maintained in a secure environment.
Hard copy and electronic records are only accessible to personnel of the centre who require access to such personal information for the purpose of carrying out their duties. All personnel have signed Privacy and Confidentiality Agreements binding them to comply with the Australian Privacy Principles.
Access to records
Patients of the centre may request access to personal information by writing to the Office Manager. Persons entitled to access do not have to provide a reason for requesting access. The patient will be notified when their record will be available for personal viewing at the centre.
Applications should be made in writing. Verification will be made prior to response.
Applications should be forwarded to:-
Chelsea Heights Day Surgery
93 Wells Road
Ph: 9771 7177
Fax: 8759 4593
If a person believes that information held by the centre is incorrect, incomplete or inaccurate they may request amendment of that personal information. The centre will consider if the information requires amendment. If the centre does not agree that there is any ground for amendment it will, if the person seeking the amendment requires, place with that person’s personal information, a statement from that person as to why the information is not accurate or up to date.
If patients wish to obtain access to or wish to notify any changes to their details kept at the centre, they should contact the Office Manager for a copy of the protocol and the forms for carrying out these functions.
The staff at Chelsea Heights Day Surgery recognises the customer’s right to make a complaint.
We welcome the opportunity to improve standards by actively identifying areas of concern in current performance. By analyzing complaints, we can actively improve the quality of care and service provided to customers. We have a process in place, where Management will respond constructively to legitimate concerns of patients and their families. Anyone can make a complaint, patient, family or friend. A person making a complaint will not adversely affect the treatment of the patient because a complaint has been made.
A complaint can be lodged in writing, by telephone or in person. Complaint form (F-QM00-02) can be requested from the Admin staff. You can also make an anonymous complaint, although CHDS is not able to respond to the complaint immediately.
Patients and their families who wish to make a complaint are advised to:
- Speak to the staff.
- If by phone, the staff are required to record every complaint including:
– Complete a IIIR form
– Nature of the complaint
– Date of concern
– Name, Address and Phone Number
– Action taken in respect of the complaint
- If the problem can be resolved at the staff level we will endeavor to rectify it as quickly as possible.
- If the complaint cannot be rectified then and there, the matter will be referred to the Complaints Officer for investigation and the appropriate follow up action (complaints procedure) will be taken.
- Chelsea Heights Day Surgery will provide written feedback within 2 weeks.
- If the customer remains dissatisfied, they are advised to utilize external services such as the Health Services Commissioner.
A complaint can be made about a health service provider who has
- Failed to provide satisfactory care
- Failed to provide enough information or denied the patient’s right to choose
- Denied patient’s respect, dignity or privacy
- Been negligent or unprofessional
- Or any other issues about the health service provider
Health service providers at CHDS are:
- Doctors, anaesthetists, specialists
- Reception and administration staff
- Anyone else who provides a health service
Note* A provider named in a complaint may be any person or organisation
Who can make a complaint:
- A patient or user of a health service
If the patient or user is unable to complain then:
- A relative friend or guardian
- A health service provider
- Anyone with sufficient interest
The Complaints Officer:
Director of Nursing
93 Wells Road
Ph: 9771 7177
Fax: 8759 4593