Safety and Quality at MDPC

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Mission Statement

Manningham Day Procedure Centre is committed to providing the highest standard of patient care by creating an environment in which excellence and service flourish.


MDPC is a Nexus Hospital, providing robust and effective Board of Director Governance. This is achieved through various committees from the Nexus Board of Directors, subsidiary hospital Boards and respective Medical Advisory and Operational and Quality Committees.

Quality Objectives

  • To meet all relevant health authority requirements
  • Provide a high level of professional care to all patients & families
  • Provide a high standard health care facility which encompasses current and future technological advancements in order to achieve optimum safety and comfort for all patients and staff
  • Develop and achieve a high level of staff involvement and ensure a client focused team approach to all patient and doctor services
  • Optimise the use of the operating suite to achieve high levels of efficiency, productivity and occupancy
  • Maintain the best clinical standards through strategic staff recruitment, staff training, peer review and update, quality assurance programs and critical evaluation of services.

Safety and Quality

Medical Advisory Committee

MDPC has a formal Medical Advisory Committee, with representatives from Ophthalmology, Oral Surgery, Gastroenterology, Anaesthetics and Nursing. The committee has the ability to co-opt other specialist members and consumers as required. This committee addresses clinical compliance and excellence.

Safety and Quality

MDPC is certified to ISO 9001:2016, is accredited to the National Safety and Quality Health Service Standards (NSQHSS).and is licensed by the Department of Health. MDPC is committed to the employment and ongoing training of licensed and qualified staff appropriate to the needs of our patients as specified by the Australian Commission of Safety and Quality in Healthcare (ACSQHC).

Quality Policy

The senior management team and staff at Manningham Day Procedure Centre are committed to ensuring that a robust Quality System is in place as directed by the Quality System Manual to:
Planned outcomes
– To provide a timely, safe, healthcare service, which encompasses measurable ongoing continual improvement to our customers, as a basis of all practices
– To provide healthcare of a high standard using a risk focused, process approach, based on Best Practice and regulatory requirements
– Provide a competitive, affordable and safe health care service to our customers
– Engage regularly with our customers, both internal and external, to ensure we are meeting their needs effectively
– Regularly review and assess the effectiveness of our Quality Management System and implement improvements, which is based on AS/NZ 9001:2016
– Ensure Manningham Day Procedure Centre’s Quality Policy is available to all interested parties
We have processes in place for the ongoing transparent planning, review and improvement to our Quality Management System. The outcome of the planning process is a set of objectives which will be reviewed and updated at least annually.
It is important that Manningham Day Procedure Centre stakeholders:
– Are aware of the requirements of our Quality Management Systems,
– Identify, Record, Report all problems, incidents, complaints, compliments or areas for improvement
– Comply with the intent and the content of our Quality Management system

Please contact Manningham Day Procedure Centre Director of Nursing/Regional General Manager if you require further information on our Quality Policy

Infection Prevention and Control

Manningham Day Procedure Centre complies with a comprehensive Infection Prevention and Control program. Our facility and staff are regularly audited for compliance with national infection prevention and control guidelines, Australian Standards for reprocessing of reusable instruments (AS/NZ 4187:2014) and the Australian Commission of Safety and Quality in Healthcare [ACSQHC] National Safety and Quality Health Service Standards (NSQHSS).

Hand Hygiene Australia program

Manningham Day Procedure Centre is committed to the Hand Hygiene Australia program and conducts regular audits to ensure compliance. The results of hand hygiene audits conducted on our Medical, Nursing and support staff are well above benchmark industry standards.

Clinical Indicators and Audits

Clinical indicators assist Manningham Day Procedure Center in measuring clinical care which may, when assessed over time, provide a method of assessing the quality and safety of care. Manningham Day Procedure Centre collect a number of clinical indicators that can be benchmarked against published data.
Manningham Day Procedure Centre Clinical indicator results are compared against published data. Our results are not only in line with, but in the majority of cases, are lower than the industry benchmark. The results from the analysis of these indicators reveal a very high level of clinical effectiveness and safety.

Risk Management

Manningham Day Procedure Centre is committed to the highest quality care and robust risk management. Manningham Day Procedure Centre has an active reporting culture and in addition to the collection of clinical indicators, all adverse events are monitored and reported for review to the Medical Advisory and Operational and Quality Committee and Board of Directors on a regular basis.

Day Surgery Quality – Benchmarked

Manningham Day Procedure Centre is a member of a Day Surgery Benchmarking group. Our Centre contributes to a formal process of review, comparing the results of a range of clinical and operational activities with similar facilities throughout Australia. The aim of the benchmarking group is to compare selected outcome data, monitor trends and identify opportunities for improvements to develop policies and procedures based on evidence and best practice.
Across all areas of data collection including Clinical Indicators, operational audits, clinical process reviews, documentation and consumer involvement the results for current year are above benchmark standards.
These results are reported for review to the Medical Advisory Committee and Board of Directors on a regular basis.

Staff Mandatory Training

Manningham Day Procedure Centre is committed to ensuring our workforce is competent and appropriately credentialed and trained. Our training is supported by Referenced Learning Packages, Policies and Work Instructions that are updated on a regular basis reflecting a best practice approach to patient care. Additionally a robust process for checking credentials and scope of practice for all clinical staff and accredited medical practitioners is practiced and audited.
This is ensured through the provision and maintenance of well-developed orientation and annual mandatory training and competency program.
If you require information about staff training or results regarding safety and quality activities and outcomes at Manningham Day Procedure Centre, please contact Denise Penn Director of Nursing ( .

Discharge Information

Manningham Day Procedure Centre prepare for your safe discharge from our hospital at the pre admission stage. We provide comprehensive information both before your admission and after your surgery, during the discharge process with both you and your carer. This information will assist you and your carer with the necessary preparation of your discharge and follow up care.

Patient Feedback and Consumer Engagement- How can you help us manage Safety and Quality

As a result of patient feedback there have been a number of positive changes made to the patient information and care we provide. Your opinion is important to us. All patients are given the opportunity to provide feedback, both formally and informally. This feedback is treated with the utmost confidentiality and may be provided anonymously. All feedback is de-identified and reviewed at our Medical Advisory Committee, Operational and Quality Committee and Board of Directors meetings.
Please feel welcome to complete a patient feedback form, available under the Patient Feedback tab and also available in hard copy at our reception. Alternatively you may email our Director of Nursing on

Would you like further information?

If you require information or results regarding safety and quality, please contact the Director of Nursing Denise Penn at or the Regional General Manager Wes Radulski at
Alternatively you can call on 03 88 500 590.