Ulladulla Endoscopy and Medical Centre 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 and the Australian Commission of Safety and Quality in Healthcare [ACSQHC] National Safety and Quality Health Service Standards.

At the Ulladulla Endoscopy and Medical Centre we are proud of the quality and safety of the services we offer. We have an enviable record but that does not prevent us from continuing to strive to improve.

To keep you informed about the quality and safety of our services we publish a number of performance indicators for you to review and evaluate. The table below is a summary of some of the key measures:

Ulladulla Endoscopy and Medical Centre Key Performance Indicators January-December 2021
Infection Rate 0%
Hand Hygiene Audit 90.3%
Patient Falls 0%
Number of Unplanned Transfers 0.06%
Number of Patients Returning to the Operating Theatre 0.12%
Patients Developing Pressure Injury 0%
Medication Safety Errors 0%


Accreditation is an important driver for safety and quality improvement.

Through accreditation our hospital has been able to assess our level of performance in relation to established national and international standards and implement ways to continuously improve.

The Ulladulla Endoscopy and Medical Centre is licensed by NSW Health as a Private Day Hospital and is fully accredited under the Australian Commission on Safety and Quality in Healthcare in the National Safety and Quality Health Service Standards.  This is done through an external organisation.


We arecommitted to partnering with consumers to ensure that the services we provide are patient centered and meet the needs of our patients, carers and other consumers.

There are 4 key attributes of patient-centered care:
  • “Whole-person” care

  • Coordination and communication

  • Patient support

  • Ready access 

We encourage patients to be involved in decisions about their care.  Understanding your condition and asking questions of your doctors, nurses and other health professionals will help you make important decisions about your care. There is evidence that the patient centered approach to care leads to a reduction in anxiety, better health outcomes and quicker recovery, which is why we encourage you to work with us.

Here’s how you can assist:
  • Be actively involved in your own health care

  • Know who your care providers are. If staff don’t introduce themselves, ask for their name and position

  • Make sure we confirm your identity when doing a procedure or giving medications

  • Ask what new medications are for

  • Write down any questions you may have as you think of them

  • Be sure you read and understand any information given to you

  • Make sure you understand what to do when you get home

Handover & Patient Identification


The Day Hospital has implemented infection control procedures, and staff take every precaution to avoid infections. However, some patients have a higher risk of acquiring an infection in hospital. Patients with wounds, invasive devices (such as drips) and weakened immune systems are at greater risk of infection than the general public. We need to avoid infections because they may lead to a longer recovery time.

What are Healthcare Associated Infections?

Healthcare associated infections are infections that occur as a result of healthcare interventions and are caused by micro-organisms such as bacteria and viruses. They can happen when you are being treated in hospital, at home, in a GP Clinic, a nursing home or any other healthcare facility.

Some infections occur after an invasive procedure such as surgery and can be treated with antibiotics. However there are some infections that are more difficult to treat because they are resistant to certain antibiotics.

The risk of getting these infections depends on how healthy you are, how long you have been in hospital and certain medications that you take (including antibiotics).

These specific infections require the use of special antibiotics and, at times, admission to hospital.

What are we doing to prevent infections & to further reduce infections?

We collect data on hospital acquired infections and analyse the data to identify patterns and trends. Infection rates are shared and discussed with clinicians in an effort to identify and implement the best practices to reduce the risks for infection.

Improvement strategies can include Watching, auditing and measuring how often staff wash their hands using soap and water or hand sanitiser. Routine use of gloves and sterilised equipment.

A Director of Nursing to investigate issues, educate staff and carry out strategies to reduce infections.

Use of specialised approved disinfectants for cleaning and disinfecting rooms, bathrooms, equipment and shared areas. High level disinfection and sterilisation are used according to national guidelines.

Placement of hand sanitiser dispensers.

How can you help?

Patients and visitors play an important role in health care. Hand washing is the most important way that patients and visitors can prevent the spread of infection in hospital. Waterless hand sanitiser is just as effective as washing with soap and water.

There are a number of things you can do to reduce the risk of infection:

  • Wash your hands carefully with soap and water or use hand sanitiser upon entering the hospital

  • Cover your mouth and nose with a tissue when you cough or sneeze (or into your elbow if you don’t have one). Clean your hands afterwards – every time!

  • Report any infection you have had, especially if you are still on antibiotics

  • Make sure you take the full course of antibiotics you have been given, even if you are feeling better

  • If you have a dressing or a wound, keep the skin around the dressing clean and dry. Let the healthcare worker looking after you know promptly if it becomes loose or wet

  • Stop smoking before any surgery, as smoking increases the risk of infection



Hand hygiene is the single most important factor in reducing hospital acquired infections. Our hands may look clean but germs are invisible to our eyes. We can unknowingly transmit germs on our hands to others and our environment.  The accepted way of measuring hand hygiene is for an auditor to watch healthcare workers as they go about their day, treating patients in hospital.

There are five moments for hand hygiene that have been identified by the World Health Organisation as the critical times when hand hygiene should be performed in hospital, and they are:

  • Before touching a patient

  • Before a procedure

  • After a procedure

  • After touching a patient; and

  • After touching a patient’s belongings or surroundings

The recent results from the hand hygiene audits are displayed in the tables below.
It’s very important that each time you visit someone our day Hospital you clean your hands, even if your hands look clean. It is important to perform hand hygiene as you enter and leave the hospital and also:

  • After going to the toilet

  • After blowing your nose

  • After smoking

  • After handling/patting animals

  • Before, during & after preparing food; and

  • When your hands are visibly dirty


The risk of falling increases with age in particular for people over the age of 65 years.  Falls related injuries can include minor skin abrasions, joint dislocation, fractures and head injuries.  These injuries may result in hospitalisation or an increase in length of hospital stay.  The risk of falling can greatly increase when admitted to hospital due to a range of factors including illness and unsteadiness, adapting to a new environment, the introduction of new medication s and walking in unsafe footwear or slippers.

The Ulladulla Endoscopy and Medical Centre has a falls prevention program that provides guidelines for everyone involved in the care of patients who are identified as being at risk.  The hospital uses specific criteria and tools to risk assess patients and put in place a number of strategies to minimise falls whilst in hospital.

What are we doing to reduce falls?
  • Assessment of all patients at risk from falls

  • Implementation of precautions to reduced the risk of falling – for example use of lifting equipment and walking aids

  • Education and training of staff in falls prevention, reduction and management

  • Reporting, investigating and monitoring  falls incidents

  • Quality improvement activities to prevent falls and minimise harm

  • Spot inspections of the hospital environment to reduce the risk of falls


Pressure injuries are areas of damage to the skin and underlying tissue caused by constant pressure or friction. This type of skin damage can develop quickly in anyone with reduced mobility, such as older people or those confined to a bed or chair.

Pressure injuries are recognised worldwide as a common cause of harm to patients and could cause significant pain and discomfort which may result in a slower recovery for the patient.

What are we doing to reduce pressure injuries?
  • A risk assessment is performed on admission using an evidenced based tool to identify patients that are vulnerable to pressure injuries

  • Pressure relieving devices are used.  These include specialesed mattresses, cushion, wedges, sheepskins, water filled supports, heel elevators and gel filled supports

  • Preventing exposure to excessive moisture or dryness

  • Positioning: regularly changing the position of the patient and encouraging walking or movement if possible

  • Education for nursing staff in pressure injury identification, prevention and management

  • Patient education provided on pressure injury  prevention at pre admission and during the hospital stay


After a hospital stay, the most important task for patients and families and staff is preparing for a successful discharge home.  It is disappointing for everyone if a patient requires and unexpected readmission into hospital.

Tracking the number of patients who experience unplanned readmission to hospital after a previous hospital stay is one way that we can judge the quality of hospital care. It is important to note that unplanned readmissions may or may not be related to the previous visit, and some unplanned readmissions are not preventable.  Good discharge plans can help reduce the rate of unplanned readmission. By giving patients the care instructions they need after a hospital stay and by helping patients recognise symptoms that may require immediate medical attention.

What are we doing to reduce unplanned readmission to hospital?
  • Reviews each case of an unplanned readmission to hospital with in 28 days of discharge to check if there were any preventable factors

  • Check each patient’s risk for readmission

  • Use a consistent process for discharging patients that includes making sure patients understand their medication and other instructions

  • Arranging prompt follow up care and ongoing appointments e.g. with physiotherapist and GP

  • Monitor the data to make sure the rate of unplanned readmission is not increasing


The Ulladulla Endoscopy and Medical centre carries out many sessions of surgery every year.  One of the ways of monitoring the success of surgery is to check whether any patients require an unexpected second operation – we call this “return to theatre”.  There are many reason why a patient may need a further operation. We aim to minimize incidences of this type.

What are we doing to reduce unplanned return to the theatre?
  • Careful monitoring of patients in recovery

  • Ensuring patient’s level of pain is carefully assessed

  • Reviewing every case when a patient requires a return and to work out the reasons why and how to prevent it in the future

  • Conducting thorough pre-operative evaluation

  • Pre-admission assessment of high risk patients to make sure all required  test and precautions are taken


Medicines are commonly used to treat a variety of conditions in the healthcare setting and therefore it is important to measure the risk of errors.

The Ulladulla Endoscopy and medical Centre has introduced a number of safety initiatives for medication administration, which include:

  • Use of the National Inpatient Medication Chart which standardises the documentation on how medicines are prescribed and ordered

  • Implementation of the User-Applied Labeling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered

In addition, we have medication policies and processes in place which have been developed over many years and using best practice principles.

We take all medication errors very seriously.  Staff are encouraged to report all error no matter how minor they may seem.  All medication incidents are investigated thoroughly and reported.