Standard 1


Standard 1: Governance for Safety and Quality in Health Service Organisations



Ensuring the organisation has the frameworks required to implement safe systems.

Hospital Standards

Epworth is accredited under the National Safety and Quality Health Service Standards. These national standards apply to all health services organisations and state the minimum level of care – the national benchmark – that consumers can expect. Hospitals must report their performance against the standards on a regular basis and are also subject to periodic reviews and assessments.

For further information, refer to the National Safety and Quality Health Service Standards Guide (PDF).


Epworth Standards

At Epworth we want to provide excellent patient care. For this reason, we set our own, stricter benchmarks against each of the standards, and we measure our performance against these. The table below provides details of the national benchmark, the Epworth internal benchmark and our average result against each of the items.

​Standard 1: Governance for Safety and Quality in Health Service Organisation ​National Benchmark ​Epworth HealthCare Internal Benchmark ​Epworth HealthCare Average 2014 ​Epworth HealthCare Average 2015 Averag​e FY
2015-16 †​
​Total incidents ​n/a* ​n/a ​916 ​902 877​
​Clinical (Patient) Incidents ​n/a ​n/a ​620 ​680 595​
​Clinical Incident rate ​24 ​18 ​18 ​18 19​​
​Near miss patient incidents rate ​n/a ​12% ​13% 12% 12%​​
​ISR 1 patient incidents rate** ​0.10 ​0.00 ​0.01 ​0.02 0.02​​
​ISR 2 patient incidents rate** ​0.37 ​0.20 ​0.16 ​0.16 0.18​
​Case reviews complete within 45 days ​n/a ​100% ​83% ​81% ~ ​ 81% ~​
​Unexpected Readmissions within 28 days rate ​1.20% ​0.30% ​0.30% ​0.20% 0.20%​
​Unexpected Readmission with infection rate ​n/a ​0.15% ​0.10% ​0.10% 0.10%​​
​Unexpected Returns to theatre rate 0.35% ​0.27% ​0.10% ​0.10% 0.10%​​
​Unexpected overnight admissions of day surgery patients rate ​1.20% ​0.95% Nil​ ​1.30% 0.8%​
​Unexpected Discharges from rehabilitation to an acute facility rate ​2.40% ​2.40% ​3.10% ​1.50% 1.50%​​

Rate=per 1,000 bed days.

 * n/a denotes that no national benchmark has been defined, so Epworth has set its own. 

 ** ISR 1 and 2 patient incidents are serious harm events that are directly related to a hospital admission, such as wrong treatment or delayed hospital stay.​

~ Higher number is better.

 For all other indicators a lower number is better.

 † Figures for year ending 30/6/2016.



  • At Epworth we believe that the only acceptable serious patient incident rate (ISR1 and ISR2) is 0 (zero) and have made this our goal. Our performance of 0.02% in financial year 2015/16 is five times better than the accepted standard. Our performance against ISR2 is about 50% better than the national benchmark.
  • Our rate of unexpected readmissions within 28 days is 0.3%, which is 40 times better than the national benchmark.

We are working on

  •  It is important to review every case where outcomes are not as expected. This needs to be consultative and thorough, and we are working on ways to improve our rate of case reviews complete within 45 days.
  • We continue to monitor and look for ways to reduce our already​ low rates of patient incidents.
  • We are working on ways to improve our rate of unexpected discharges from rehabilitation to an acute facility.


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