Accreditation & Quality


The delivery of care and services at St Andrew's Toowoomba Hospital must comply with external standards, which include routine hospital accreditation by the Quality Innovation Performance Standards (QIP) and the National Safety and Quality Health Service Standards developed by the Australian Commission on Safety and Quality in Healthcare and endorsed by Federal Government for implementation nationally.



St Andrew's Toowoomba Hospital completes ongoing accreditation with QIP to provide assurance to consumers and health service regulatory bodies that our services are safe and of a high quality. Accreditation with QIP is a formal process where an external body conducts an onsite review of a facility to ensure that the organisation meets a set of agreed health care standards.


St Andrew's Toowoomba Hospital underwent an organisation wide survey with Australian Council on Healthcare Standards (ACHS) in April 2016. Full accreditation was maintained for four years with the next organisation review due in 2018. Nil recommendations were received and 11 'Met with merit' awards were given. Assessment is against a three point rating scale:

  • Not Met – the actions required have not been achieved.
  • Satisfactorily Met – the actions required have been achieved.
  • Met with Merit – in addition to achieving the actions required, measures of good quality and a higher level of achievement are evident. This would mean a culture of safety, evaluation and improvement is evident throughout the organisation in relation to the action or standard under review.


Met with Merit awards were given for the following:

Standard 1: Governance for safety and quality in health service organisations

Action 1.2.2 Core: Action is taken to improve the safety and quality of patient care.

There is an impressive and extensive list of major projects that have been developed, implemented and evaluated with consumer i8nput to improve the quality, safety and best practice treatment methods across the hospital. These include new robotic surgery services, extended cancer services, redevelopment ward areas, improved car parking and specific improvements made as a result of incidents. These improvements have been based on close analysis of demographic data and patient activity. The comprehensive planning process is also independently evaluated. The action is considered Met with Merit (MM).


Action 1.6.2 Core: Actions are taken to maximise patient quality of care

Throughout the survey, actions taken to improve the quality and safety of care were observed, reported and evaluated in many of the standards. Actions include improvements at the governance level, strategic capital investment projects, quality and safety activities at the department level and the consistent inclusion of staff, VMOs and consumers in the evolution and planning of activities. The mechanisms to improve and maximise quality of care have been sustained over the last two years. The action is considered Met with Merit (MM).


Standard 2: Partnering with consumers

Action 2.2.1 Developmental: The health service organisation establishes mechanisms for engaging consumers and/or carers in the strategic and/or operational planning of the organisation.

Through the comprehensive review of the governance undertaken by the Board and CEO, the consumer's role in governance, service planning, quality and safety monitoring and improving the experience of patients and carers has matured with a demonstrable impact over several years. The engagement process is considered genuine and sustainable. That consumers have had input into over $10m investment over the last two years demonstrates that the improvements continue to be sustained. The action is considered Met with Merit (MM).


Action 2.5.1 Developmental: Consumers and/or carers participate in the design and redesign of health services

Consumers have been engaged in reviewing and improving services through multiple mechanisms which include review of key safety indicators, provision of feedback in an ongoing process and contribution to the projects to improve service and quality of care. Consumers have also been involved in evaluating such contributions. The action is considered Met with Merit (MM).


Standard 10: Preventing falls and harm from falls

Action 10.2.4 Core: Action is taken to reduce the frequency and severity of falls in the health service organisation

The survey team was impressed by the responsibility taken by all levels of staff to prevent potential patient falls. A significant reduction in the frequency of falls is evident since the introduction of coloured non-slip socks that identify patients who are specifically at risk. Patients who must only ambulate with a staff member wear black socks. It was noted that a catering staff member assisted a patient who was assessed as not being safe to mobilise alone (as indicated by black socks) safely back to a sitting position in a chair. The improvement activity is organisation-wide and the improvement has been sustained for over 12 months. The action is considered Met with Merit (MM)


Standard 12: Provision of Care

Action 12.8.1 Mandatory: Discharge/ transfer information is discussed with the consumer/ patient and a written discharge summary and/or discharge instructions are provided.

SATH shows evidence of over 97% of discharge summaries reaching referring medical practitioners within the agreed timeframe of 48 hours. This is organisational wide and is continuing. Discharge is monitored by a Clinical Liaison Nurse. This allows all appropriate services within the community to be accessed and managed and these functions are audited on a monthly basis and encompass the whole organisation. Transfers are also monitored and found to be 100% appropriate. The action is considered Met with Merit (MM).

Action 12.8.3 Mandatory

Results of investigations follow the consumer/ patient through the referral system.

Results are provided to the ordering physician within 24 hours of receipt on the ward and, in the case of the Oncology Unit, they are sent by email within six hours of receipt. These are documented and monitored by the CNM. The timely use of discharge summaries augments this organisational wide protocol. Evidence is produced that the Clinical Nurse Managers have the responsibility to ensure timely notification of results of clinical tests to the referring practitioner and inspection revealed this is carried out throughout the clinical areas. This action is considered Met with Merit (MM.


Standard 13: Workforce planning and management

Action 13.12.1 Non-mandatory: Strategies to motivate staff, acknowledge the value of staff, support flexible work practices are evaluated with staff participation, and improved as required.

 Flexible staff practices to accommodate unexpected/ unplanned situations are in place. Staff retention, contentment and loyalty were also noted across all disciplines. The survey team was impressed by the fact that staff barbeques, hosted by the CEO and Director of Clinical Services, are held as one of several staff recognition activities. Requests and suggestions from staff are respected and acted upon in a notable and generous manner. Press Ganey analysis of staff satisfaction is conducted regularly; recent results indicate that staff feel connected to their work, are very satisfied with their workplace and are both respected and supported by their employer. The survey team was impressed by the loyalty and commitment to SATH demonstrated by staff and the evident culture of engagement. The results of the survey have been sustained for several years. The action is considered Met with Merit (MM).


Standard 15: Corporate Systems and Safety

Action 15.1.1 Non-mandatory: The strategic plan includes vision, mission and values; identifies priority areas for care, service delivery and facility development; considers the most efficient use of resources; includes analysis of community needs in the delivery of services; formally recognises relationships with relevant external organisations and is regularly reviewed by the governing body.

The Board and CEO have undertaken a comprehensive review of the governance structure. This exercise has been facilitated by an external contractor with expertise in this field. The review considered the Board's effectiveness in identifying and addressing priority areas for care and service development in accordance with the needs of the Toowoomba community. The comprehensive evaluation and subsequent changes have had an impact on the whole organisation. Through the implementation of the new constitution, the initiative is sustainable. The action is considered Met with Merit (MM).


Action 15.1.2 Non-mandatory: Leaders and managers act to promote a positive organisational culture.

The positive culture exhibited by all staff was evident through formal interviews with staff and informal interaction throughout the survey. The number of activities where staff described the ways in which they are consulted and involved in planning, redevelopment, and contributing to significant capital and service improvements was reported as extensive. Several staff recognition programs are also in place. Staff nominate peers as well as patients and carers. Awards are conferred monthly. The system has been evaluated and the staff report that they are invited to contribute to new initiatives for recognition. The action is considered Met with Merit (MM).


Action 15.3.1 Non-mandatory: The processes of governance and the performance of the governing body are evaluated to ensure that they include formal orientation and ongoing education for members of the governing body; defined terms of reference, composition and procedures for meetings of the governing body; communication of information about the governing body activities and decisions with relevant stakeholders and defined duties and responsibilities and a role for strategy and monitoring.

The Board and CEO have undertaken a comprehensive review of the governance structure. This exercise has been facilitated by an external contractor with expertise in the field. The review has considered the performance of the Board individual skill sets and gaps identified. Consultation has occurred with consumers, staff and visiting medical officers. This comprehensive activity has resulted in a new constitution being implemented. The constitution has revised the terms of reference, Board composition and strengthened the Board's role in involving consumers in governance and quality and safety. The action is considered Met with Merit (MM).

National Safety and Quality Health Service Standards

A major component of accreditation is achieving compliance with the set of National Safety and Quality Health Service (NSQHS) Standards. The standards demonstrate a nationally consistent statement of the level of healthcare consumers should be able to expect Australia-wide.


The National Safety and Quality Service Standards address the following areas:

  1. Governance for Safety and Quality in Health Service Organisations: Ensuring integrated governance systems are in place to maintain and improve the safety and quality of patient care.
  2. Partnering with Consumers: Having a health service that is responsive to consumer feedback and actively seeks consumer involvement in service planning and development.
  3. Preventing and Controlling Health Care Associated Infections: Preventing patients from acquiring preventable health care associated infections and effectively managing infections when they occur.
  4. Medication Safety: Ensuring clinicians are competent to safely prescribe, dispense and administer appropriate medicines to informed patients.
  5. Patient Identification and Procedure Matching: Correctly identifying all patients whenever care is provided and ensuring that the correct procedure occurs to the correct patient.
  6. Clinical Handover: Ensuring there is a timely, relevant clinical handover that supports appropriate ongoing clinical care.
  7. Blood and Blood Products: Ensuring that blood and blood products are given in an appropriate and safe manner.
  8. Preventing and Managing Pressure Injuries: Preventing patients from developing pressure related injuries and effectively managing pressure areas when they occur.
  9. Recognising and Responding to Clinical Deterioration: Ensuring a patients clinical deterioration is always escalated in a timely manner and appropriate action is taken.
  10. Preventing Falls and Harm from Falls: Reducing the incidence of patient falls and minimising harm from falls.