Our Performance in Safety and Quality (2024 - 2025 FINANCIAL YEAR)
Other safety and quality performance measures
NSLHD upper limit
NSLHD Average
Performance Indicator
Symbol Comment
"Staphylococcus Aureus Bloodstream Infections (per 10,000 occupied bed days) • A1- C2 facilities (Royal North Shore, Hornsby Ku-ring-gai, Ryde) " • D1a – F8 facilities (Greenwich, Neringah, Mona Vale Hospital)
0.8
<1
NSLHD has met and exceeded the target
0.0
<1
Hand Hygiene Compliance (%)
88% >80%
NSLHD has met and exceeded the target
"Unplanned Hospital Readmissions (%) within 28 days of separation" "Unplanned and Emergency Re-presentations to the same ED within 48 hours (%) • All persons "
6.5% <6.52
NSLHD has met and exceeded the target
2.6% -
While no target is set, year-to-date trend value is lower to that of the previous year. High rates may be caused by low patient volumes.
• Aboriginal patients
4.3% -
While no target is set, year-to-date trend value is lower than previous years. Fluctuations in the figures reported due to lower number of aboriginal patients being admitted to NSLHD. NSLHD is leading the way in enhancing culturally safe care for Aboriginal and Torres Strait Islander patients and families. The district is standardising the referral process for Aboriginal Liaison Officers through electronic referrals via eMR, ensuring timely, appropriate, and consistent cultural support across all services. This streamlined approach strengthens continuity of care and contributes to a reduction in Discharge Against Medical Advice (DAMA) rates. In a collaborative effort between the NSLHD Aboriginal and Torres Strait Islander Health Service and the Mental Health, Drug and Alcohol team, all cultural support referrals have now been unified through eMR. Staff will be informed of this important change through targeted communications. Additionally, in partnership with the North Foundation, NSLHD is working to transform emergency care by placing Aboriginal Liaison Officers in every Emergency Department. A dedicated donations page has been launched to support the growth of this vital workforce and further improve patient outcomes.
Discharged Against Medical Advice for Aboriginal Inpatients (%)
2.6% <2.0%
Mental Health: Acute Post Discharge Community Care – follow-up within 7 days: All Persons (%) Mental Health: Acute Readmission – within 28 days: All Persons (%) Mental Health: Acute Seclusion Occurrence – Episodes (per 1,000 bed days) Mental Health: Acute Seclusion Duration – Average (Hours)
83%
≥75%
NSLHD has met and exceeded the target
13%
≤13%
NSLHD has met and exceeded the target
4.3
≤5.1
NSLHD has met and exceeded the target
5.7
<4
Between July 2024 and June 2025, NSLHD recorded 197 Acute Seclusion events. A small number of outlier events (7 exceeding 24 hours) significantly skewed this figure. Excluding these outliers, the average duration was 3.6 hours—within the target range. NSLHD continues to monitor each seclusions event individually to ensure appropriate review and follow-up.
30 Safety and Quality Account 2024-2025 Report
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