Safety & Quality

Safety & Quality

Safety & Quality

Mission Statement

Manningham Day Procedure Centre is committed to providing the highest standard of patient care by creating an environment in which excellence and service flourish.


Robust and effective governance, both corporate and clinical, is an integral and important element in ensuring organisational focus on achievement of our goals.

Oversight of governance is achieved through various committees from the Nexus Board of Directors, subsidiary hospital Boards and respective Medical Advisory Committees.

Quality Objectives
  • To meet all relevant health authority requirements in both facilities and standards
  • Provide a high level of professional care to all patients & families
    Design, develop and maintain a high standard facility which encompasses current and future technological advancements to achieve optimum safety and comfort for all patients and staff
  • Develop and achieve a high level of staff involvement and ensure a client focused team approach to all patient and doctor services
  • Optimise the use of the operating suite to achieve high levels of efficiency, productivity and occupancy
  • Maintain the best clinical standards through strategic staff recruitment, staff training, peer review and update, quality assurance programs and critical evaluation of services.

Safety and Quality

Medical Advisory Committee

MDPC has a formal Medical Advisory Committee, with representatives from Ophthalmology, Oral Surgery, Gastroenterology, Anaesthetics and Nursing. The committee has the ability to co-opt other specialist members and consumers as required. This committee addresses clinical compliance and excellence.

Safety and Quality

MDPC is certified to ISO 9001:2008, is accredited to the National Safety and Quality Health Service Standards (NSQHSS).and is licensed by the Department of Health. MDPC is committed to the employment and ongoing training of licensed and qualified staff appropriate to the needs of our patients as specified by the Australian Commission of Safety and Quality in Healthcare (ACSQHC).

Infection Prevention and Control

MDPC has a comprehensive infection prevention and control program in place. Our facility and staff are regularly audited for compliance with national infection prevention and control guidelines, Australian Standards for reprocessing of reusable instruments (AS/NZ 4187:2014) and the Australian Commission of Safety and Quality in Healthcare [ACSQHC] National Safety and Quality Health Service Standards (NSQHSS).

Hand Hygiene Australia program

MDPC is committed to the Hand Hygiene Australia program and conducts regular audits to ensure compliance. The results of hand hygiene audits conducted on our Medical, Nursing and Allied Health and support staff at 96% are well above benchmark industry standards.

Clinical Indicators and Audits

Clinical indicators are measures of elements of clinical care which may, when assessed over time, provide a method of assessing the quality and safety of care. MDPC collect a number of clinical indicators that can be benchmarked against published data. These include:

  • Failure to arrive
  • Returned to theatre
  • Patient transfer
  • Cancellation of procedure
  • Delay in discharge
  • Unaccompanied discharge
  • Ophthalmology clinical indicator
  • Endoscopy clinical indicator
  • Anaesthetic clinical indicator
  • Oral surgery clinical indicator

MDPC results of the clinical indicators (listed above), when compared against published data are not only in line, but in the majority of cases, are lower than the industry benchmark.

The results from the analysis of these indicators reveal a very high level of clinical effectiveness and safety.

Risk Management

MDPC is committed to the highest of quality care and risk management.

MDPC has an active reporting culture and in addition to the collection of clinical indicators all adverse and sentinel events are monitored and reported for review to the Medical Advisory Committee and Board of Directors on a regular basis.

Audits and surveys conducted annually:

  • Hand Hygiene Australia audit – Overall 96% compliance by Medical, Nursing, Allied Health and support staff.
  • Infection Prevention and Control audit – 98% compliance
    Aseptic Non-Touch Technique (ANTT) audit – 98% compliance of training and compliance by MDPC staff
  • Post discharge infection audit – no incidents
  • Pressure injuries/skin tear event whilst in-patient audit – minimal incidents resulting in no adverse outcomes.
  • Patient falls – no incidents
  • Medication Management and incidents audit – minimal medication errors resulting in no adverse outcomes.
  • Clinical Process review including correct patient identifiers, clinical handover and clinical deterioration- 99% compliance
  • Medical records audit – 100% compliance with legislative requirements
  • Accredited Medical Practitioner (AMP) Credentialing audit – 99% compliance with administrative requirements and 100% compliance with legislative requirements.
  • Patient satisfaction survey – 100% of patients would recommend MDPC
  • Consumer survey – showed a strong level of support by consumers to be involved in contributing to MDPC quality activities eg: publications and staff training.
  • Staff satisfaction survey – overwhelming majority of staff reported above average satisfaction with their employment and greater than 75% of staff have been employed at MDPC for longer than 4 years.

The above results, for the year 2013-2014, are very pleasing and well above acceptable industry standards.

Day Surgery Quality – Benchmarked

MDPC is involved in a Day Surgery specific national benchmarking group.

MDPC contributes to a formal process of review comparing the results of a range of clinical and operational activities with other like facilities. The aim of the benchmarking group is to compare selected outcome data, monitor trends and identify opportunities for improvements to develop policies and procedures based on evidence and best practice.

Across all areas of data collection including Clinical Indicators, operational audits, clinical process reviews, documentation and consumer involvement the results for year 2012-2014 are above benchmark standards.

These results are reported for review to the Medical Advisory Committee and Board of Directors on a regular basis.

Staff Mandatory Training

MDPC is committed to providing an effective, well trained and up to date workforce. All training is supported by policies and procedures that are updated on a regular basis reflecting a best practice approach to care delivery. Additionally a strict process for checking credentials, registration and scope of practice for all clinical staff and accredited medical practitioners is practiced and audited.

This is ensured through the provision and maintenance of well-developed orientation and annual mandatory training and competency program including:

  • Hand hygiene
  • Basic life support
  • Infection Prevention and Control- Aseptic non touch technique
  • Medication management
  • Management of invasive devices
  • Patient centred care
  • Open disclosure
  • Manual handling
  • Fire and evaculation

Greater than 95% of staff have completed mandatory training.

If you require information about staff training or results regarding safety and quality activities and outcomes at MDPC, please contact the Chief Executive Officer, Leanne Kemp, on

Discharge Information

MDPC provides comprehensive information both before and after your surgery to assist patients and carers to be fully informed, prepared and in control of your planning for discharge and post discharge follow up.

Patient Feedback and Consumer Engagement- How can you help us manage Safety and Quality

As a result of patient feedback there have been a number of positive changes made to the patient information we provide. Your opinion is important to us.

All patients are given the opportunity to provide feedback, both formally and informally. This feedback is treated with the utmost confidentiality and may be provided anonymously.

All feedback is de-identified and reviewed at our Medical Advisory Committee and Board of Directors meetings.

We value your thoughts and suggestions. Should you wish to:

  • offer a comment on your experience at MDPC
  • be involved in our safety & quality program by reviewing our safety and quality activities
  • contribute to our publications or surveys

Please feel welcome to complete a patient feedback form, available in reception and on our website, or alternatively you may email our Director of Nursing on

Would you like further information?

If you require information or results regarding safety and quality, please contact the Chief Executive Officer, Leanne Kemp at or alternatively call 03 88 500 590.

Contact us

Suite 304, Level 3
Manningham Medical Centre
200 High Street
Templestowe Lower
VIC 3107
P (03) 88 500 590

On the corner of Manningham Road and High Street.