John Fawkner Private Hospital is fully accredited against The National Safety and Quality Health Service Standards, a mandatory set of standards established by the Australian Government for all public and private hospitals.

Accreditation involves a visit to the hospital from an independent team of expert health professionals who review the quality and safety of services provided. Our achievements are measured against industry standards by this review team. Hospitals are measured against ten overarching standards and many different criteria including patient care, medication management, clinical handover, infection control, complaints management and preventing falls.

Hospitals receive a rating for each one of these criteria – either satisfactorily met or not met. If a criterion is not met, the hospital is given an action that it must follow-up within 3 months to ensure the criterion is satisfactorily met.

For hospitals achieving a higher level of quality, a higher rating is awarded “MM” or “met with merit


John Fawkner Private Hospital is fully accredited by the Australian Council on Healthcare Standards (ACHS).

The following ratings were successfully met and achieved using the rating scale below

  • Met with Merit – in addition to achieving the actions required, measures of good quality and a higher level of achievement are evident. This would mean a culture of safety, evaluation and improvement is evident throughout the hospital in relation to the action or standard under review.
  • Satisfactorily Met – the actions required have been achieved
  • Not Met – the actions required have not been achieved
    Accreditation involves a visit to the hospital from an independent team of expert health professionals who review safety and quality in health care. Every two years we undertake a periodical review and every 4 years a full accreditation survey.  Our achievements and compliance to best practice is measured against the 10 National Safety and Quality Health Services Standards (NSQHS) criteria.

Standard 1 Governance for Safety and Quality in Health Service Organisations
Standard 2 Partnering with Consumers
Standard 3 Preventing and Controlling Healthcare Infections
Standard 4 Medication Safety
Standard 5 Patient Identification and Procedure Matching
Standard 6 Clinical Handover
Standard 7 Blood and Blood Products
Standard 8 Preventing and Managing Pressure Injuries
Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care
Standard 10 Preventing Falls and Harm from Falls

Our recent accreditation survey in 2013 was a periodical review,  based on compliance with National Standard 1 (containing 53 core criteria), National Standard 2 (containing 14 criteria) and National standard 3 (containing 43 criteria.)

John Fawkner Private Hospital received an award at this year’s 2013 Healthscope Leadership Conference for achieving the most Met with Merit ratings under the new National Standards guidelines.
In 2015 John Fawkner Private Hospital will undergo a full accreditation survey against all 10 National Standards.  Listed are the following achievements and ongoing quality improvement activities we have implemented and practice to support and achieve all 10 National Standard Guidelines.

Falls Prevention Program (National Standard 10)
An active program with ongoing review to assist with falls prevention strategies for our patients.

In 2010 JFPH won the Healthscope Service Excellence Awards for the Falls Working Party.
The Falls Working Party implemented an improved risk assessment tool and changes to environmental factors, achieving a reduced number of falls.  The risk assessment tool developed by the working party is now used in all Healthscope hospitals

Patient Centred Care Project (National Standard 2)
This is a project that was implemented over 2 years ago to improve care and communication with our consumers.  It includes bedside handover (National Standard 6) and hourly rounding to engage and educate patients and carers in reducing risk of falls, malnutrition,  venous thromboembolism and pressure injuries, (including access to a wound care specialist nurse who provides resources to patients and staff on the prevention of pressure injuries in hospital (National Standard 8).

To ensure our patients and carers are well informed, Consumer Iinformation brochures have been developed and are available pre-admission or upon admission, and many are available in multilingual format.  Some of these Include
• Keeping a Step Ahead of Falls
• Move, Move, Move - Preventing Pressure Injuries
• Stop the Clot, Reducing Your Risk of Blood Clots
• Blood Transfusions, Frequently Asked Questions.

We also have a Blood Transfusion Nurse on site who has developed education packages for both patients and staff about blood transfusions and informed consent. 
(National Standard 7)

Patient Care Boards 
Display of these care boards in patient areas has enabled patients and their carers to be more informed about their stay, care and access to information required

Appointment of Three Volunteer Consumer Consultants 
Quarterly Patient Forums are ran by our Volunteer Consumer Consultants to provide beneficial feedback to assist with patient satisfaction and Quality care initiatives

In 2014 John Fawkner Private Hospital received an award from the Department of Veteran Affairs for achieving high patient satisfaction. All DVA patients that were admitted for an overnight and/or multiday stay to John Fawkner Private Hospital during the period Dec 2012-June 2013 were asked to provide feedback on our quality of services. This included how they perceived our admission process, the care and communication from Nurses and Doctors, the hospital environment including infection control practices, safe medication management, patient education and discharge planning.

The DVA satisfaction survey results are benchmarked against other hospitals and the national average. John Fawkner Private Hospital has a DVA Liaison Nurse that visits and supports every DVA patient and their families/carer's admitted to our hospital. This is to ensure they are well informed and educated on their health condition and services available to them during admission and on discharge. Our DVA Liaison nurse works closely with our DVA Volunteer Consumer Consultant to ensure a high quality of service is provided.

Rapid Response Systems (National Standard 9)
Implementation of these guidelines for clinical staff enables carers and relatives to also initiate a rapid response when they have concerns about their relative’s or friend’s health condition in hospital. This information is also available in brochure form

Other Awards

In addition to accreditation, John Fawkner Private Hospital is proud of the recognitions of excellence bestowed on its hospitals and staff. Examples of recent awards are:

2013 Healthscope Achievement Award - Best Accreditation Performance
John Fawkner Private Hospital

2013 Healthscope Service Excellence Awards - Quality Improvement
2nd Floor Surgical Unit/ICU
John Fawkner Private Hospital (VIC)
Won the award for Quality Improvement for their world-first study, comparing the sensitivity of two renonwned Early Warning Track and Trigger systems. An abstract from the findindgs of the reseach has been submitted for consideration for the 8th International Rapid Response Conference - Royal College of Physicians, London.

2010 Healthscope Service Excellence Awards
The Falls Working Party
John Fawkner Private Hospital (VIC)
The Falls Working Party implemented improved risk assessment tool and changes to environmental factors, achieving a reduced number of falls. The risk assessment tool developed by the working party is now used in all Healthscope hospitals.


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