Data sources and definitions

How we measure Clinical Quality and Safety

In July 2014, Calvary undertook a comprehensive update of our clinical incident information systems to ensure that our data complied with the most current incident definitions and standards. Here are the definitions and sources of data used to calculate our Clinical Safety and Quality indicators.

Infection rate Staphylococcus aureus Bacteremia (SAB)

Numerator

Number of healthcare acquired SAB infections identified in multi and same day patients

Denominator  

10,000 Occupied Bed Days

Benchmark

0.87/10,000 Occupied Bed Days

Reference

AIHW 2014. SAB in Australian public hospitals 2013–14: Australian hospital statistics. Health services series no. 59. Cat. no. HSE 155. Canberra: AIHW.

Hand Hygiene

Numerator

Number of observed (audited) hand hygiene moments that are associated with appropriately performed hand hygiene

Denominator  

Number of hand hygiene moments observed

Benchmark

85%

Reference

Hand Hygiene Australia http://www.hha.org.au

 Patient falls

Numerator

Number of patient/resident falls

Denominator  

1,000 Occupied Bed Days

Benchmark

 3.5/1,000 Occupied Bed Days

Reference

There is no Australian recommended rate for hospital falls. An “industry rate” 3.5/1000 Occupied Bed Days has been used, based on the references below:

  • Victorian Quality Council (2006). Evaluation of the effectiveness of the “Minimising risk of falls and fall-related injuries guidelines for acute, subacute and residential care settings”. Falls rates vary between 2 and 7 per 1000 Occupied Bed Days in acute settings.
  • National Database of Nursing Quality Indicators (NDNQI) in the USA. Falls – approx. 3.6 per 1000 bed days
  • Institute for Clinical Systems Improvement (ICSI). Prevention of falls (acute care). Health care protocol. Bloomington (MN): 2010 Apr. In 2007, Massachusetts publicly reported average rates of 3.57 falls/1,000 Occupied Bed Days in hospitals of 200-299 beds, and 4.76 falls/1,000 Occupied Bed Days in hospitals over 500 beds.

Medication  incidents

Numerator

All medication errors

Denominator  

1,000 Occupied Bed Days

Benchmark

<5 / 1,000 Occupied Bed Days

Reference

Clinical Excellence Commission NSW (2013) clinical incident management Jul-Dec 2013