Quality Care

Accreditation is a formal process through which a health service is assessed to ensure it continues to provide safe and high quality care to its consumers. It is an opportunity to have an independent assessment of the services and care provided and the systems that are in place.

Maryvale Private is accredited against the National Safety and Quality Health Service Standards

The NSQHS Standards are a mandatory set of standards established by the Australian Government for all public and private hospitals. They provide a nationally consistent statement of the level of care consumers should be able to expect from health services.

For a full explanation of each of these standards and what they entail, please click on the following; https://www.safetyandquality.gov.au/consumers

National Safety and Quality Health Service Standards

Maryvale Private Hospital complies with the 10 National Safety and Quality Health Service Standards.

The National Safety and Quality Health Service (NSQHS) Standards were developed by the Commission to drive the implementation of safety and quality systems and improve the quality of health care in Australia.

The 10 NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect from health service organisations

For a full explanation of each of these standards and what they entail, click on a standard below or visit the National Safety and Quality Health Service Standards site.

Governance and quality improvement system

Governance and QualityMaryvale Private Hospital works within strong Clinical Governance and Quality and Safety Frameworks that support the delivery of quality and safe care.

Governance systems are an important element to safeguard and improve safety and quality of care.

Effective governance involves setting direction, making policy and strategy decisions, overseeing and monitoring organisational performance and ensuring overall accountability for the hospital.

Credentialing and registration processes for medical officers and clinical staff

Maryvale Private Hospital follows the Australian Commission on Safety and Quality in Health Care “Credentialing health practitioners and defining their scope of clinical practice: a guide for managers” and the Department of Human Services Policy; “Credentialing and defining the scope of clinical practice for medical practitioners in Victorian health services – a policy hand book.”

An annual national registration process is in place for all nursing staff.
Confirmation of registration is conducted annually through the Australian Health Practitioner Registration Agency (AHPRA) to confirm that the qualifications and registrations of all relevant staff practicing at Maryvale are up to date.

Accreditation processes

Maryvale regularly participates in Accreditation processes which incorporate an evaluation of performance against a range of standards and which provide a quality assurance framework and mechanism to review systems and processes in operation across the organisation.

Maryvale Private is Accredited through an accreditation review against the 10 National Safety and Quality Health Service Standards and ISO 9001;2008.

Partnering with consumers

Partnering with ConsumersMaryvale Private recognises and values the importance of partnering with consumers, carers and the community to improve its safety and quality of care.

Consumer engagement is encouraged and facilitated through the, consultation and feedback processes and consumer representation on the Maryvale Private Hospital Community Advisory Committee.

Feedback is received from consumers in a variety of ways, including direct consultation, surveys and the Maryvale Private Hospital compliments and complaints system.

Person Centred Care

Maryvale Private Hospital promotes the provision of person centred care to improve consumer outcomes. At Maryvale Private, the consumer is involved in the planning for their care, open communication and shared decision making and discussions about their discharge, including any services they may need to assist them in their recovery process when they go home.

Community Advisory Committee

The Maryvale Private Community Advisory Committee provides opportunities for consumers to be involved in the development of strategies to increase consumer engagement across the organisation, to review reports on safety and quality including incidents and feedback reports, and to review organisational documents, such as information brochures.

Preventing and Controlling Healthcare Associated Infections

Preventing and Controlling Effective Infection Prevention and Control programs are vital in preventing healthcare associated infections which may result in inconvenience or injury to patients and which are an undesirable, often unnecessary healthcare expense.

Each year, infections associated with health care occur in a large number of patients, making healthcare associated infections the most common complication affecting patients in hospitals. Some of these infections require stronger and more expensive medicines (with the added risk of complications).

Maryvale Private Hospital Infection Prevention and Control Program strongly endorses a culture of prevention and focuses firmly on promoting good routine standard precautions throughout the organisation.

Antimicrobial Stewardship (AMS)

Maryvale Private Hospital ensures appropriate prescribing of antimicrobial (Antibiotics), to prevent and manage health care associated infections and improve patient safety and quality of care Effective hospital AMS programs have been shown to reduce inappropriate antimicrobial use (in the order of 22–36%), improve patient outcomes and reduce adverse consequences of antimicrobial use (including antimicrobial resistance, toxicity and unnecessary costs).

National hand hygiene initiative

Clean hands are the best protection against infection. With an increase in drug resistant bacteria present in all hospital settings, it has become increasingly important for health care employees to follow hand hygiene guidelines.
Maryvale Private Hospital participates in the ASQHC national initiative to develop hand hygiene cultural change. The aim is to standardise hand hygiene practice and make available alcohol based hand rub in all clinical areas of our hospital. Our current performance demonstrates that Maryvale Private is performing better than the national benchmark of 70% compliance.

Surveillance and Reporting

Maryvale Private participates in the Victorian Healthcare Infection Surveillance System (VICNISS). This program collects data, adjusts risks and reports results to all Victorian Public Hospitals. The programs aim is to reduce the incidence of healthcare associated infections from multi drug resistant organisms (MDRO or Superbugs) such as Methicillin Resistant Staphylococcus Aureus (MRSA) and Vancomycin resistant Enterococcus (VRE), through notification of results compared to similar healthcare facilities.

Medication Safety

Medication Safety Maryvale Private utilises strategies and systems known to reduce the risk of common causes of medication errors which can lead to patient harm.

National Inpatient Medication Charts (NIMC)

This chart is used across the organisation to ensure consistent recording of information and alert sheets are used to identify and document allergies and other relevant information.

Partnering with Consumers

To assist with greater understanding about medication use, patients and carers are included in discussions with health professionals in planning for their care and at discharge from hospital.


Audits are regularly undertaken and medication incidents are monitored and reported on through the hospital committee structure.

Risk Assessments

Nursing staff conduct a simple risk assessment to highlight those patients who are more likely to suffer from a medication error once home.

Patient Identification and Procedure Matching

Patient IdentificationThis describes the systems and strategies to identify patients and correctly match their identity with the correct treatment.

Maryvale Private Hospital has established systems to ensure the correct identification of patients and correct matching of patients with their intended treatment.

Patient identification and the matching of a patient to an intended treatment is an activity that is performed routinely across all areas of Maryvale Private Hospital.

Maryvale Private has implemented a standard patient identification band to improve the patient identification process.

Maryvale Private has adopted the principles of the World Health Organisation (WHO) Surgical Safety Checklist and the STOP before you BLOCK campaign supported by Australian & New Zealand College of Anaesthetists (ANZCA)

Clinical Handover

Clinical HandoverThis describes the systems and strategies for effective clinical communication whenever accountability and responsibility for a patient’s care is transferred.

Clinical leaders and senior managers of a health service organisation implement documented systems for effective and structured clinical handover.

Clinicians and other members of the workforce use the clinical handover systems.

Bedside Clinical Handover Information

Blood and Blood Products

Blood and Blood ProductsThis describes the systems and strategies for the safe, effective and appropriate management of blood and blood products so the patients receiving blood are safe.

Clinical leaders and senior managers of a health service organisation implement systems to ensure the safe, appropriate, efficient and effective use of blood and blood products.

Clinicians and other members of the workforce use the blood and blood product safety systems.
Treatment with blood and blood products can be lifesaving however, as biological materials they are not without risk. Screening and testing of donors and donated blood and ensuring that decisions to transfuse follow consideration of all treatment options, their risks and benefits all contribute to minimising the inherent risks.

Preventing and Managing Pressure Injuries

Preventing and Managing Pressure InjuriesThis describes the systems and strategies to prevent patients developing pressure injuries and best practice management when pressure injuries occur.

Clinical leaders and senior managers of the health service organisation implement evidence-based systems to prevent pressure injuries and manage them when they do occur.

Clinicians and other members of the workforce use the pressure injury prevention and management systems.

Pressure injuries not only occur in geriatric patients, but in all patients with any or all of the associated risk factors. These factors are not restricted to increased immobility, but include factors such as nutritional status, skin integrity, age and the level of oxygenation of the blood supply to pressure point injuries.

A pressure injury can commence in any setting, including acute areas such as theatre and intensive care.

Recognising and Responding to Clinical Deterioration in the Healthcare Setting

Recogn ising and Responding to Clinical DeteriorationThis describes the systems and processes to be implemented by health service organisations to respond effectively to patients when their clinical condition deteriorates.

Health service organisations establish and maintain systems for recognising and responding to clinical deterioration. Clinicians and other members of the workforce use the recognition and response systems.

Serious adverse events such as unexpected death and cardiac arrest are often preceded by observable physiological and clinical abnormalities.

Early identification of deterioration may improve outcomes and lessen the intervention required to stabilise patients whose condition deteriorates in hospital.

Preventing falls and harm from falls

Preventing Falls and Harm from FallsThis describes the systems and strategies to reduce the incidence of patient falls in health service organisations and best practice management when falls do occur.

Clinical leaders and senior managers of a health service organisation implement systems to prevent patient falls and minimise harm from falls. Clinicians and other members of the workforce use the falls prevention and harm minimisation systems.

Falls remains a significant issue in the safety of patients.

Falls occur in all age groups; however the risk of falls and harm from falls varies between individuals due to factors such as eyesight, balance, muscle strength, bone density and medication use.

Besides the cost implications, the impact of falls on individuals is far reaching. The social impact of reduced independence through fear, the potential for loss of independence and the increased burden on families can be significant.

Maryvale Private Hospital has an assessment program to identify patients who are at risk of falling to minimise potential falls and harm caused if a fall does happen

Compliments & Complaints

The Maryvale Private Hospital staff is committed to high quality health care. Should any issue arise that does exceed/or does not meet your expectations, bring it to the attention of the nurse looking after you who will then refer it to the Unit Manager. The Unit Manager will either address the issue or refer it to the Complaints Officer as we wish to continually improve our service.

A sealed box is situated at reception desk for comments/complaint forms.

A complaints brochure is given to all patients and details of the hospital Complaints Officer are detailed on the board in the hospital foyer.

Contact Info

Maryvale Private Hospital
Excellence in Health Care.

286 Maryvale Road, Morwell, VIC 3840

  • Phone: (03) 5132 1200
  • Fax: (03) 5133-9505
  • Email: enquiry@maryvaleph.com.au