ACHS Peer Group Comparison Chatswood Private Hospital Second Half 2018 Organisation Code: 160523
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ACHS Peer Group Comparison
Chatswood Private Hospital
Second Half 2018
Organisation Code: 160523
Anaesthesia and Perioperative Care Version 6
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where All organisations are stratified into public / private categories and surgical complexity as defined by number of ICU beds during the 6 month data collection period.: Free Standing Day Only Facility
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 32
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
3.1 Relief of respiratory distress in the recovery period (L) 1 3676 0.027% (0.000-0.097) 0 21 0.013%
3.4Severe pain not responding to pain protocol in the recovery period (L)
3 3676 0.082% (0.000-0.203) 4 18 0.119%
4.1Unplanned ICU admission equal to or less than 24 hours after procedure (L)
1 3676 0.027% (0.000-0.097) 0 15 0.004%
Page 2
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(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Day Patient Version 5
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Type of service: Free-standing - stands alone and purpose built
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 73
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
1.1 Booked patients assessed before admission (H) 3702 3702 100.00
0% (99.904-100.000) 3633 36 98.140%
2.1 Booked patients who fail to arrive (L) 0 3702 0.000% (0.000-0.096) 15 59 0.401%
3.1Cancellation of the procedure after arrival due to pre-existing medical condition (L)
2 3702 0.054% (0.000-0.152) 3 61 0.079%
Page 3
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(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Day Patient Version 5
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Type of service: Free-standing - stands alone and purpose built
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 73
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
3.2Cancellation of the procedure after arrival due to an acute medical condition (L)
17 3702 0.459% (0.174-0.745) 8 62 0.207%
3.3
Cancellation of procedure after arrival due to administrative/ organisational reasons (L)
7 3702 0.189% (0.006-0.373) 4 60 0.121%
4.1Patients who experience an adverse event during care delivery (L)
10 3702 0.270% (0.051-0.489) 5 49 0.134%
Page 4
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Day Patient Version 5
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Type of service: Free-standing - stands alone and purpose built
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 73
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
5.1Unplanned return to operating room on same day as initial procedure (L)
2 3676 0.054% (0.000-0.153) 1 66 0.026%
6.1Unplanned transfer or overnight admission related to procedure (L)
6 3676 0.163% (0.000-0.334) 6 64 0.155%
6.2Unplanned transfer or admission related to ongoing management (L)
1 3676 0.027% (0.000-0.097) 2 42 0.055%
Page 5
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Day Patient Version 5
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Type of service: Free-standing - stands alone and purpose built
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 73
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
7.1
Unplanned delayed discharge for clinical reasons >1 hour beyondexpected (L)
1 3676 0.027% (0.000-0.097) 4 53 0.111%
9.2Follow-up phone call received by patient or carer within 7 days (H)
3676 3676 100.000% (99.903-100.000) 3440 26 93.574%
Page 6
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Infection Control Version 5
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Number of beds: 1 - 199 beds
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 152
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
6.1Reported parenteral exposures sustained by staff (L)
2 3676 0.054% (0.000-0.153) 1 131 0.021%
6.2Reported non-parenteral exposures sustained by staff (L)
0 3676 0.000% (0.000-0.097) 0 127 0.006%
Page 7
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Medication Safety Version 4
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : No Peer Groups defined for this set, comparing your results for all organisations submitting data in this category
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 187
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
6.3Medication errors - adverse event requiring intervention (L)
0 3676 0.000% (0.000-0.097) 0 184 0.003%
Page 8
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Ophthalmology Version 6
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Number of ophthalmology separations in 6 month data collection period: 300 or more separations
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 21
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
1.1Cataract surgery - unplanned readmissions within 28 days (L)
2 1871 0.107% (0.000-0.301) 2 19 0.132%
1.2Cataract surgery - treatment within 28 days due to endophthalmitis (L)
1 1871 0.053% (0.000-0.191) 0 20 0.011%
1.3 Cataract surgery - unplanned overnight admission (L) 0 1871 0.000% (0.000-0.191) 0 16 0.014%
Page 9
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Ophthalmology Version 6
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Number of ophthalmology separations in 6 month data collection period: 300 or more separations
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 21
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
1.4 Cataract surgery - anterior vitrectomy (L) 6 1871 0.321% (0.000-0.657) 4 16 0.232%
1.5 Cataract surgery - antibiotic prophylaxis (H) 1871 1871 100.00
0% (99.809-100.000) 1810 11 96.741%
1.6Cataract surgery - toxic anterior segment syndrome (TASS) (L)
1 1871 0.053% (0.000-0.191) 0 10 0.019%
Page 10
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Ophthalmology Version 6
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Number of ophthalmology separations in 6 month data collection period: 300 or more separations
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 21
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
2.1Intraocular glaucoma surgery - unplanned readmissions within 28 days (L)
0 141 0.000% (0.000-2.514) 0 9 0.199%
2.2Intraocular glaucoma surgery - micro-invasive glaucoma surgery (MIGS) (H)
88 141 62.411% (51.928-72.894) 101 9 71.713%
2.3Intraocular glaucoma surgery - treatment within 28 days due to endophthalmitis (L)
0 141 0.000% (0.000-2.514) 0 9 0.199%
Page 11
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Ophthalmology Version 6
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Number of ophthalmology separations in 6 month data collection period: 300 or more separations
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 21
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
3.2Retinal detachment surgery - treatment within 28 days due to endophthalmitis (L)
1 19 5.263% (0.000-18.429) 0 8 0.110%
3.4Retinal detachment surgery - unplanned reoperation within 28 days (L)
0 19 0.000% (0.000-17.850) 1 7 3.871%
4.1Intraocular lens implantation with planning record present at time of surgery (H)
1871 1871 100.000% (99.809-100.000) 1871 9 99.990%
Page 12
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
Ophthalmology Version 6
ACHS Organisation Code: 160523 Second Half 2018 Australasia Private Facility
Peer Group : Comparison of your results with public/private organisations in selected category submitting data where Number of ophthalmology separations in 6 month data collection period: 300 or more separations
Total number of organisations for the selected category submitting data for this set for Second Half 2018: 21
CI NO Indicator Number/Description
Your Numerator
Your Denominator
Your Rate
99% Confidence Interval for Your
Rate
Your Expected Number of
Events
Number of Orgs
Submitting Data
2H2018
Aggregate Rate for These Organisations
2H2018
Outlier Graph
4.2
Toric intraocular lens implantation with planning record present at time of surgery (H)
993 993 100.000% (99.641-100.000) 993 9 100.000%
Page 13
8-Apr-19 09:37
(L) - a low rate is desirable, (H) - a high rate is desirable, (N) - desirable rate is unspecified
% - per 100, * - per 1,000, ^ - per 10,000, X ̅ - mean, M - median
# - Please note: data for this indicator were NOT collected in accordance with the CI User Manual
Lines in bold highlight results where the aggregate rate is outside the 99% confidence interval
Flag indicates where an organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is undesirably lower or higher than the expected rate.Star indicates the organisation is statistically significantly 'different' to all other organisations submitting data for that particular indicator and where the result is desirably lower or higher than the expected rate.
The information in this report is to provide assistance to organisations in continuous quality improvement. Responsibility for the accuracy of submitted data lies with the contributing organisation. The ACHS makes every effort to validate the information it receives prior to analysing and publishing results.
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