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Quality & Customer Service

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The Quality, Clinical Risk & Customer Services Department focusses on ensuring systems are in place to promote patient safety, support quality improvement & evidence-based practice. The Department works to support staff so that the expectations of patients and their families for high quality care are met and where they not met making sure that complaints and incidents are fully investigated and improvements are made to prevent the same thing happening again.

Peninsula Health is a fully accredited health service. The Quality and Customer Services Department supports all parts of the health service in meeting the:

Peninsula Health has a robust system of Clinical Governance.In this way we ensure we have the right people and right systems are in place to continue to provide the highest standards of care. Clinical Governance is implemented through a framework based on the Victorian Government Clinical Governance Policy Framework which promotes consumer participation, clinical effectiveness, an effective workforce and risk management. 

Clinical Governance is overseen by the Peninsula Health Board Quality and Clinical Governance Committee. The Committee, chaired by a Board Director and attended by Board Directors, the Chief Executive Officer, Executive Directors and members of the Quality Department, monitors the work of each service within Peninsula Health  to continuously improve quality and safety. Consumers also participate in this Committee providing invaluable input into the work we do.

Areas of service and safety monitored by the Quality and Customer Services Department include:

  • Infection Prevention and Control is responsible for monitoring the strategies that prevent infection and supporting staff to minimise risks by ensuring a safe, clean hospital environment. The Infection Prevention Team provides expert advice and consultation on a broad range of activities within the health service. They implement measures to reduce infections and the impact of those infections on patients. The Infection Prevention and Control Unit works closely with all staff to develop guidelines and policies that underpin clinical practice, educate, support and monitor staff in infection prevention practices including hand hygiene and staff immunisation.
  • The Mortality, Major Morbidity Review Committee reports on patient safety issues to the Board Quality and Clinical Governance Committee. Sentinel events, serious adverse events and deaths are reviewed by the Committee with the assistance of independent audits undertaken by an external medical expert.
  • Patient Safety is everyone’s responsibility and Quality, Clinical Risk and Customer Services monitors the care people receive in hospital. The Clinical Risk Unit investigates any adverse event or near miss.  Peninsula Health fully investigates these types of events to improve practice and help prevent similar incidents from happening again.   
  • Victorian Health Incident Management System (VHIMS) is a state-wide incident management systemthat is monitored by Quality, Clinical Risk and Customer Services.  This systemwas implemented across the health service in July 2010 to report & manage all incidents that occur across the Health Service. Information provided by the system is evaluated and investigated where required.
  • The Consumer Information Steering Committee is facilitated by the Quality and Customer Services Department. Consumers participate as members of the committee that was established to ensure written information developed across the health service is clear, relevant, accessible and friendly to the consumer.
  • The Quality and Customer Services Department  utilises two avenues to monitor our consumer’s voice:
  1. The Victorian Healthcare Experience Survey (VHES) is an independent body which regularly monitors and reports on the patient experience within public hospital services throughout Victoria. This information allows Peninsula Health to compare the experience of our patient against like hospitals and the state.
  2. Peninsula Health seeks ‘on the spot’ feedback from consumers across the organisation using Feedback forms. Our volunteers are available to assist patients with the completion of the forms if required. The internal feedback is analysed by individual departments and wards and is reported to the Board of Directors.
  • Customer Relations Service is part of Quality, Clinical Risk and Customer Services and is responsible for responding to your complaints and concernsComplaints and compliments provide an opportunity to better understand ways to improve our services.  Peninsula Health welcomes feedback on the services it provides and works with consumers to resolve their concerns. We encourage our consumers to express their concerns via telephone, Peninsula Health’s website, in writing, in person to the person in charge of the relevant department/ program or email the  Customer Relations Manager by Email: Customer Relations.
  • The Redesigning Care Program at Peninsula Health aims to create, spread and sustain improvements in delivering patient care. It is aligned with the Commission for Hospital Improvement and the Department of Health and is part of Quality, Clinical Risk & Customer Services.

Some other areas the Quality and Customer Service Department manage include:

  • Implementation and maintenance of the Charter of Healthcare Rights throughout Peninsula Health.
  • Management of Blood and Blood Product Administration Safety.
  • Management, maintenance and development of Clinical and Care Planning Pathways to ensure patients are provided with evidence based best possible care.

The Quality of Care Report is developed by the Quality and Customer Services Department and provides an opportunity to report to our consumers our achievements in quality and safety, and identify the improvements made to continue to achieve higher standards of care. We invite your feedback on this report. To learn more about our quality systems and services you can view the latest Quality of Care Report.