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Excellence in Care

Excellence in care is fundamental to St John of God Health Care’s Mission. It is a guiding principle of our Vision and embraced in our number one strategic priority ‘To be a recognised leader in the Australian health sector for the provision of high quality care.’

Commitment to excellence in healthcare is an aspiration that requires safe, effective, appropriate and responsive care from engaged and competent caregivers and accredited health practitioners.



Accreditation of our hospitals provides important validation of how we compare against health industry standards of care. During 2016-17, seven of our hospitals underwent organisation-wide accreditation to National Safety and Quality Health Service (NSQHS) Standards (Standards 1-10) - St John of God Bendigo, Berwick, Bunbury, Geraldton, Mt Lawley, Midland and Subiaco Hospitals. In addition, St John of God Midland Public Hospital was accredited against Mental Health Standards, and St John of God Health Choices achieved full accreditation to Australian Council on Healthcare Standards EQuIP6.

Many of our hospitals achieved multiple ‘met with merit’ criteria. St John of God Subiaco Hospital achieved 27 such criteria.

New Zealand

St John of God Hauora Trust is an accredited provider of services with a diverse range of government agencies including the Ministry of Social Development, Ministry of Health, Ministry of Education, and Oranga Tamariki (Ministry for Vulnerable Children) as well as the Department of Corrections and Accident Compensation Corporation.

Patient satisfaction and Experience

We use the Press Ganey Annual Patient Satisfaction Survey to assess and evaluate how patients feel about their care experience with us. This year, many of our hospitals showed outstanding achievements across inpatient, day surgery and emergency department areas in relation to patient satisfaction:

  • Overall, St John of God Health Care was positioned in the 75th percentile against private peers.
  • Seven of our 12 acute private hospitals achieved better than the 75th percentile rank against their private peers: St John of God Bendigo, Subiaco, Ballarat, Warrnambool, Bunbury, Berwick Hospitals and lastly St John of God Geelong Hospital, which scored “best in class”.

In relation to patient experience, four hospitals achieved a top quartile ranking against all Australian hospitals surveyed: St John of God Bunbury, Geraldton, Bendigo and Geelong Hospitals. St John of God Midland Public Hospital achieved “best in class” and was ranked at the 99th percentile compared to all public hospital peers.St

John of God Bunbury, Geraldton and Bendigo Hospitals achieved top quartile ranking against Magnet hospitals internationally. Magnet Recognition is a US-based organisational credential awarded to exceptional healthcare organisations that meet American Nurses Credentialing Center (ANCC) standards for quality patient care, nursing excellence, and innovations in professional nursing practice.

St John of God Health Care was positioned at the 80th percentile of the all-private health systems benchmark for day patient satisfaction, an improvement from the 67th percentile in 2015. Four hospitals achieved top quartile rankings against their peer group: St John of God Geelong, Ballarat, Bunbury and Warrnambool Hospitals.

St John of God Health Care has five emergency departments and was ranked at the 88th and 80th percentile compared to all health system and private emergency facility benchmarks respectively. St John of God Geelong, Ballarat and Murdoch Hospitals achieved top quartile benchmarks against their private peer emergency facilities.

Net promoter score, a quick and easy satisfaction measure that asks participants to rate on a scale of 1 to 10 how likely it is that they would recommend something to their friends and family, was rolled out to patients for the first time at St John of God Health Care, commencing at St John of God Murdoch Hospital. This method allows patients to provide feedback on their experience in our facilities in close-to-real time, allowing us to understand what is working well as well as providing opportunity for more immediate continuous improvement. Net promoter score measures will be rolled out to all St John of God Health Care services by the end of 2017-18.

Doctor satisfaction surveys

Doctor engagement and satisfaction analysis is conducted annually across St John of God Health Care.

In 2016, the organisation achieved a ranking of 58th percentile against externally benchmarked private peers, an improvement from 49th percentile in 2015.

Seven hospitals recorded results within the top 75th percentile ranking: St John of God Bendigo, Geelong, Subiaco, Warrnambool, Bunbury, Frankston Rehabilitation Hospital and Ballarat Hospitals, with St John of God Subiaco and Geelong Hospitals both rated “best in class” at the top percentile.

In 2016, 45.6% of doctors considered themselves “dedicated partners”, a very good result when compared with the private not-for-profit benchmark (34.8%) and the national benchmark (35.1%).

Clinical Risk Management

Over the past 12 months, St John of God Health Care has progressed implementation of an electronic clinical incident management system, which will assist our hospitals in identifying key risks and help us to develop strategies to further improve patient safety and experience.

St John of God Health Care has an open disclosure policy. This means we have an open discussion with patients if an incident occurs while they are being cared for by us that results in harm. To strengthen our effectiveness in communicating with patients, the Cognitive Institute Open Disclosure Expert Training program was rolled out across the organisation. The training program provided Australian Open Disclosure Framework guidance, advanced communication skills training and included simulated scenarios.

Improving clinical risk support to hospitals, through analysis, reports and resources to better manage clinical risk, is a key growth area identified for 2017-18.

Infection Control

In 2016-17 our group compliance rate for hospitals exceeded 83.3%, which is higher than the Australian Commission on Safety and Quality in Health Care’s National benchmark of 80%.

We benchmark rates of hospital-acquired staphylococcus aureus bacteraemia (SAB) – the most common bacteria causing serious bloodstream infection – against other acute hospitals on the MyHospitals website. Our hospitals recorded a rate of 0.54 SAB cases per 10,000 patient-care days, which is significantly better than the national benchmark of no more than two cases per 10,000 patient-care days.

Clinical Practice

Post-fall management guidelines

St John of God Health Care reviewed and revised the approach to monitoring and managing patients who have had a fall resulting in admission to hospital or a fall while in our care.
A cross-hospital working group undertook a literature and document review to identify existing practice on post-fall management in Australia and internationally, resulting in more robust post-fall management guidelines focused on risk reduction.

Pressure injury project

Work continued on initiatives to reduce the risk of pressure injury for patients in our care.

Collaboration among clinicians across several disciplines, hospitals and departments facilitated the development of a pressure injury clinical guideline, revised patient education and information, and a St John of God Health Care caregiver online education module. All these initiatives reflect current best practice.

Blood and blood product clinical guidelines

The Blood and Blood Product Reference Group is currently developing and standardising blood policy and documentation requirements across our hospitals together with new clinical guidelines for blood administration.

In 2016, hospitals in Victoria and Western Australia introduced the national system - BloodSTAR - to manage authorisation of and access to immunoglobulin products for patient treatments. It has been an important change to clinical practice that provides efficiencies and stewardship of this blood product, enhancing outcomes for both patients and communities.

Patient Safety Strategy

Obstetric, mental health and surgical safety initiatives were implemented as part of the patient safety strategy for 2016-17.


As part of the Obstetric and Midwifery Strategy, key achievements supporting patient safety this year, included:

  • Establishment of an organisation-wide Obstetric and Midwifery Steering Committee. The committee brings together obstetricians, neonatologists, paediatricians and midwives from across three States where we provide obstetric and midwifery care. The committee plays a key role in identifying opportunities for improvement and clinical engagement in implementing quality improvement initiatives.
  • Completion of an organisation-wide deployment of K2 Guardian™ to all birth suite rooms. This provides continuous electronic fetal monitoring with remote viewing capability. The system allows obstetricians to remotely monitor fetal well-being in real time, which enables collaborative decision making with midwifery caregivers providing clinical care at the bedside. As a large-scale change management project involving technology and vendors, capital and people, the project was delivered on budget, on time and with positive feedback from all involved.
  • Introduction and coordination of the RANZCOG Fetal Surveillance Education Program (FSEP) in liaison with hospital midwifery managers and educators. In 2016-17 411 midwives participated in the FSEP.

Mental health

A Mental Health Community of Practice was established with group-wide representation from across the three States in which St John of God Health Care provides mental health care. The key focus to date has included policy and practice review in client triage and admission processes, review of client outcome measurement systems, and various client safety initiatives, including environmental safety.

Surgical safety

Work was undertaken to improve surgical safety, including surgical instrument count, specimen transfer, checklist compliance and instrument tracking.


In 2017, a new program called Bigger, Better, Brighter was introduced to showcase excellence in nursing and midwifery practice at St John of God Health Care. Nominations are received from across the organisation, focusing on projects and activities that have increased our reach, improved the safety, quality, efficiency and effectiveness of our care, and enriched patient, client, family, doctor, caregiver or other health professional experiences.

Pastoral Services

Pastoral services are a distinguishing and defining feature of our Catholic Ministry and a means of expressing our holistic care approach.

Our pastoral practitioners have formal training to enable them to relate compassionately and skillfully to patients, family members and carers faced with significant events, such as illness, disability and death.

Pastoral services are available to all, regardless of culture, religion or spiritual orientation, including those with no belief systems.

During the year, our focus was to establish a contemporary pastoral services model at Hawkesbury District Health Service, St John of God Midland Hospitals and St John of God Accord to meet the specific needs of these services and their communities.

The St John of God Midland Public Hospital Pastoral Services team successfully integrated their practice within the traditional models of patient care, with key initiatives including having pastoral practitioners in multidisciplinary team meetings, education sessions presented by the Pastoral Services Manager to various caregiver cohorts and presentations during orientation programs for all new caregivers.

At Hawkesbury District Health Service, a new pastoral coordinator was appointed and education sessions on the role of pastoral services were conducted for caregivers.

Pastoral services have been embedded within St John of God Accord and provide support to clients referred from 22 of St John of God Accord’s 25 shared support accommodation sites, as well as assisting with the transition of new clients into our day support services.

By 2019, Pastoral Services aims to be recognised as a leader in the development of best practice and contemporary pastoral care, which responds to the needs of individuals and the communities we serve. We will continue to focus on professional development, best practice and research and service development.

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St John of God Health Care has developed and installed new ‘clinical command’ technology in its Murdoch Hospital operating theatres that has resulted in less waiting time in patient holding areas and freed up the theatre team to spend more time on patient care.