Fullarton Private Hospital
Part of Ramsay Health Care

Patient Safety & Quality

Fullarton 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.

Fullarton 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

Fullarton 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 Fullarton Private Hospital.


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

All Ramsay Health Care hospitals are fully accredited with either the Australian Council on Healthcare Standards (ACHS) or certified by a recognised body as being compliant with the International Organization for Standardization (ISO) 9001 standard.

To assess the improvement in a patient’s mental health issues, our facility uses the HoNOS (Health of the Nation Outcome Scales) - an internationally recognised scale. On admission and again prior to discharge, the patient's mental health problems are assessed. A decrease in the score on discharge indicates that there has been improvement in the patient's mental health problems since their admission.

HoNOS Score

Lower score on discharge is better

Hospital Colour Admission
Industry Standard Colour Discharge
* Latest Other Private Hospital data

To assess the improvement in a patient’s mental health condition, our facility uses the MHQ-14 (Mental Health Questionnaire) - an internationally recognised scale. On admission and again prior to discharge, the patient assesses their mental health status. An increase in the score on discharge indicates that the patient has noted an improvement in their mental health conditions since their admission.

The graph below shows the improvement in patient's self-assessed mental health ratings.


Higher score on discharge is better

Hospital Colour Admission
Industry Standard Colour Discharge
* Latest Other Private Hospital data

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.

All Patient Falls

Lower score is better

Hospital Colour Fullarton Private Hospital
Industry Standard Colour Average Industry Rate


Patient Falls resulting in fracture or head injury

Lower score is better

Hospital Colour Fullarton 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 Fullarton 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.  Fullarton 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 Fullarton 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 Fullarton 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, Fullarton Private Hospital has medication administration policies and processes in place which have been developed using best practice principles.

Fullarton 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 Fullarton 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.

Fullarton 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 Fullarton Private Hospital
Industry Standard Colour Average Industry Rate

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

Fullarton 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 Private Patients Hospital Charter and this suggests a number of ways for you to express your concerns.

Patient Satisfaction

Higher score is better

Hospital Colour Fullarton Private Hospital
Industry Standard Colour Average Industry Rate

Awards & Recognition

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