• Patient Safety
    and Quality

Patient Safety & Quality Performance

Ramsay Health Care 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.

Ramsay Health Care 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

Clinical Governance Framework

Ramsay Health Care has developed a 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:

  • 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'
  • 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.
  • 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.
  • 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.

Detailed Patient Safety & Quality Performance Results

All Australian facilities are accredited using the National Safety and Quality Health Service Standards which were 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 (SAB)

RHC Rate: 0.287/10,000 patient days
National Benchmark: 2.0/10,000 patient days

Infection Rate (Staph Aureus Bacteraemia)

Lower score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Industry Benchmark Rate



There are currently no Private Peer group benchmarking rates for this period

We aim to minimise the risk of infection to patients, staff and visitors that come to our facilities across Australia. Our infection rates have been consistently below the industry benchmark and the organisation has a number of programs in place to detect and prevent infections that are common within health care facilities. Ramsay hospitals continue to achieve outstanding results in scheduled infection control compliance audits conducted by an external provider.

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


Clostridium Difficile (C. Difficile)

RHC Rate: 1.59/10,000 patient days
Government Target: 2.0 - 3.0 / 10,000 bed days

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 suppress 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 Ramsay Health Care
Industry Standard Colour Industry Benchmark Rate

RHC Rate: 87.1%
National Benchmark: 70.0%

Hand Hygiene

Higher score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Industry Benchmark Rate



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.

Ramsay hospitals participate in the national hand hygiene strategy through Hand Hygiene Australia.

Hand hygiene audits are conducted three times per year.

A steady improvement in these compliance audits can be seen over last 2 audits. Over 43 Gold Standard Auditors within Ramsay have received specific training to report audit data to Hand Hygiene Australia.

Visitors to Ramsay facilities are encouraged through appropriate signage to use antiseptic hand rub located throughout Ramsay Health Care facilities.

Serious Patient Falls
RHC Rate:
Average Industry Rate: 0.008%

Patient falls resulting in fracture or head injury

Lower score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate



All Patient Falls
RHC Rate:
Average Industry Rate: 0.328%

All Patient Falls

Lower score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate



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 fall-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 of patients falling whilst in our hospitals.

RHC Rate: 0.505%
Average Industry Rate: 1.222%

Unplanned Readmissions within 28 Days

Lower score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate



Ramsay has a low percentage of 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.

RHC Rate: 0.235%
Average Industry Rate: 0.244%

Unplanned Return to Theatre

Lower score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate



Ramsay Health Care doctors undertake surgery in many speciality areas which range from minor procedures to more complex surgery requiring specialised care. We monitor our patient outcomes by comparing any unplanned returns to theatre to other Australian hospitals nationally. The aim is to reduce returns to theatre where possible; however there are many factors which influence these returns and sometimes these returns may save a life.

Unplanned returns to the operating theatre are frequently due to complications, for example to treat bleeding or other problems occurring early after the operation. Some complications following complex surgery are to be expected due to patients’ pre-existing diseases or conditions and the nature of the disease or condition being treated. Our hospitals monitor all returns to theatre and implement any quality measures which may be required so that our patients have the best possible outcomes following surgery.

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. Ramsay Health Care has a very low rate of medication errors due to its implementation of a range of medication safety strategies.
RHC Rate: 0.002%
Average Industry Rate: 0.015%

Medication Safety Errors

Lower score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate



The above data relates to patients who require medical intervention as a result of a medication safety incident. The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and Ramsay Health Care 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 Ramsay Health Care 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 Ramsay Health Care has medication administration policies and processes in place which have been developed using best practice principles.

Ramsay Health Care 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 and any serious medication incidents are investigated thoroughly and monitored by the Company’s Clinical Governance Unit.

RHC Rate: 0.026%
Average Industry Rate: 0.068%

Patients Developing Pressure Injuries Whilst in Hospital

Lower score is better

Hospital Colour Ramsay Health Care
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.

Ramsay Health Care facilities are 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 minimise 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.

With these initiatives the incidence of pressure injuries at Ramsay facilities is well below the Industry Benchmark for all hospitals for both reporting periods.

RHC Score: 0.032%
Average Industry Rate: 0.113%

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 reasons 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 is only prescribed after a doctor has deemed it necessary. Sometimes an adverse reaction to blood transfusion can occur and is treated immediately. Ramsay has a low rate of adverse transfusion reactions in comparison to the average industry rate. Blood transfusion administration and management are governed by the Australian Commission on Safety and Quality in Health Care Standard for Blood and Blood products.

Blood Transfusions with Adverse Outcomes

Lower score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate

RHC Rate: 1.107%
Average Industry Rate: 1.316%

Apgar Scores < 7

Lower score is better

Hospital Colour Ramsay Health Care
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.

RHC Rate: 97.239%
Average Industry Rate: 93.778%

Rehabilitation - Functional Independence Measure

Higher score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate



Rehabilitation programs aim to enable the highest level of independence (physically, psychologically and socially) to people with loss of function or ability due to injury or disease. At the time of admission into the rehabilitation program the patient has a Functional Independence Measure (FIM) rating conducted by a qualified member of the rehabilitation team. The FIM is redone during and at the end of the program to determine the patient’s functional improvement and therefore the level of independence gained in activities of daily living. Progress in the areas of social interaction and psychological wellbeing is also measured. The FIM (functional independence measure) is the industry standardised functional assessment tool that is used by all Ramsay Rehab facilities to measure this information. A higher score indicates that the patient has achieved a higher level of improvement in all the areas being measured. Ramsay rehabilitation facilities have achieved higher than industry average scores for functional improvement.

RHC Score: 86.3
Average Industry Rate: 83.9

Patient Satisfaction

Higher score is better

Hospital Colour Ramsay Health Care
Industry Standard Colour Average Industry Rate



Ramsay Health Care receives feedback from our consumers in a number of ways. Formally, an independent company carries out an organisation-wide patient satisfaction survey every two years which provides us with a snapshot satisfaction report.

In 2014 this independent organisation surveyed over 35,000 Ramsay Health Care patients. The results of this extensive survey showed that there were statistically significant improvements in the areas of:

  • Admission
  • Room
  • Meals
  • Nursing Care
  • Test and Therapy
  • Visitors and Family
  • Discharge
  • Personal Issues and
  • Overall Assessment

Specialty areas with the highest customer satisfaction rating were:

  • Coronary Care
  • Orthopaedics
  • Haematology/Oncology

Keeping our patients informed on how to voice a complaint and inclusion in decision-making were identified as areas for improvement. Since that time, the organisation has ensured that every hospital website contains a link to the Australian Charter of Healthcare Rights and suggested ways for voicing a complaint.

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