Quality and Safety Report

Quality and Safety Report 2020-2021


Peninsula Sleep Clinic (PSC) provides high quality patient care while ensuring that the highest standard of polysomnography (Sleep Study) recording is achieved and maintained.

The Clinic is licensed by the NSW Ministry of Health licence number: PH00300003 and is recognised by the Australian Department of Health and Aging as a private hospital, provider number: 0017230A

The Clinic performs diagnostic and therapeutic polysomnography and has a well-established CPAP clinic that is committed to providing immediate and long-term care, support and clinical advice for patients getting established on or are established on CPAP / NIV treatment

Accreditation / Certification Quality and Safety:

Peninsula Sleep Clinic (PSC) is accredited by the Australasian Sleep Association (ASA) / NATA current until July 2021. Re-accreditation was conducted in July 2017. The Clinic has been continually accredited since 2004. This process involved clinical peer review by an expert panel of Sleep Physicians and technical personnel nominated by the ASA / NATA independent of PSC. The panel reviewed all systems, documentation, tests (except bi-level ventilation, home and ApneaLink studies), servicing, quality and technical records, staff recruitment and development, equipment, provision for emergencies and the quality assurance programs. As a result of this audit our electrical supply was updated in the patients bedrooms / bathrooms in accordance with AS / NZ 3003:2011 at a body protected level.

PSC is accredited to National Safety and Quality in Health Service Standards (NSQHS) developed by the Australian Commission on Safety and Quality in Health Care (www.satetyandquality.gov.au). An independent assessor reviews the quality and safety of the services provided and measures the Clinic’s achievements against the industry standard. PSC successfully complied with the version 2 of the Standards in July 2019. The next review is due in July 2022. Auditors’ comments: “We believe that the health service organisation has the capacity to systematically meet the requirements of the NSQHSS against the activities identified within the scope of certification”.

PSC was first assessed by Global Mark in 2013 against the National Safety and Quality Services Standards version 1.

The second edition of the NSQHS Standards was released in November 2017.This edition addresses gaps identified in the first edition, including mental health and cognitive impairment, health literacy, end-of-life care, and Aboriginal and Torres Strait Islander health. Assessment to the second edition will commence from 1 January 2019.

Version 2 Standards include:

  • Clinical Governance
  • Partnering with Consumers
  • Preventing and Controlling Healthcare Associated Infections
  • Medication Safety
  • Comprehensive Care
  • Communicating for Safety
  • Blood management – not applicable to PSC
  • Recognising and Responding to Acute Deterioration

PSC also continually reviews and strives to improve the quality of the service we provide. At our last review in November 2018 the Global-Mark independent auditors in summary reported that ‘Peninsula Sleep Clinic continues to demonstrate strong leadership in Quality and Safety processes’.

In 2014 PSC was recognised by the Sleep Health Foundation as a supplier of CPAP Sleep Therapies. Current recognition is valid until 13/9/2021. This is to ensures a high standard is maintained as PSC must comply with a ‘Code of Practice’ set out by the Foundation (www.sleephealthfoundation.org.au)

Monitoring of Clinical Key Indicators

PSC routinely monitors and records key elements of our performance to facilitate continuous improvement to ensure we provide a quality service to our patients, consumers, carers and to our referring doctors.

Elements monitored:

  1. The quality of the polysomnography recording
  2. The quality of the doctors reporting
  3. Patient Satisfaction
  4. Referring doctors survey
  5. CPAP Clinic outcomes
  6. CPAP Clinic survey

In addition the Clinic occasionally hosts an educational evening for our referring doctors at which their opinion and suggestions are an integral part of the evening.

All results are analysed and presented at the Management Review Committee (MRC) and the Medical Advisory Committee (MAC) meetings.
Partnering with Consumers: 
Effective communication is an essential element to providing excellent patient care. Patients and carers have the right to be involved in their care and therefore engagement and comments are actively sort.
In 2012 PSC independently sought opinions on our information provided to prospective patients, our CPAP information packs, and our CPAP charges. Since then, PSC has continued to seek further feedback from consumers who have utilised our CPAP clinic services. Feedback is regularly reviewed by management and at routine meetings.

The feedback for 2018 remained at 98% satisfaction. The next survey was due in 2020, however due to COVID and other factors this will now be completed later in 2021 (currently developing new software).

PSC continues to seek comments from consumers regarding our ‘Quality and Safety’ report including any recommendation for improvement. Recommendations and suggestions are discussed at the regular management meeting and where appropriate change is instigated.

Staff In-service training includes regular education by “CPAP and other users”.

In February 2021, the staff were trained by a consumer who had recently been established on CPAP.

Polysomnography Recording:

A monthly random audit is undertaken to determine the quality of the recordings and to determine whether there are any systematic equipment issues or other issues. The results and feedback from these surveys are presented to management and discussed with staff at their regular technical meetings.

In 2020 our overall quality of all the recordings was 97.4%

Polysomnography Reporting:

The Medical Director who is a recognised Respiratory / Sleep Physician regularly monitors the quality of the reports of the other Sleep Physicians. This ensures consistency in reporting and that the key elements of the report are conveyed to the referring doctors. The results are discussed by management and the reporting Sleep Physicians.

In 2020 the overall quality of reporting was 92.5%

CPAP Clinic Outcomes – Quality Assurance:

Adherence to CPAP treatment is the largest factor impacting on the effectiveness of CPAP treatment. PSC routinely collects data to be able to demonstrate this effectiveness. Data is collected during the home trial period, at 6- and 12-month intervals and any time there is an issue. The data is analysed and presented at management meetings and CPAP Clinic meetings. In 2020 the months completed showed home trial compliance at 93.75% (not all data was available due COVID restrictions and updating of software which is still in progress)

Patient Feedback:

PSC continually monitors patients’ satisfaction regarding the care and services provided, and seeks opinions on how we can improve our services. PSC considers consumers’ opinions to be very important and encourages all patients to take the time to complete the questionnaire prior to discharge.

PSC seeks feedback on:

  1. Whether there was sufficient pre-procedure information
  2. Whether you were happy with the care you received
  3. Whether you were happy with the attitude and behaviour of the staff
  4. Whether you felt your privacy and confidentiality were maintained
  5. Would you return to the facility
  6. Whether you were happy with the cleanliness of the facility
  7. Whether you had any suggestion for improvement
  8. And on a scale 1-10 how would they rate the facility
    At the end of 2015 we added two further points:
  9. Whether you have any suggestions for improving our paperwork
  10. Whether you have read the Quality & Safety report and whether you have any recommendation or suggestions for improvement
    In 2019 added a further point:
  11. Whether staff washed their hand or used alcohol rub

In 2020: 85.2% of patients completed a survey with 99.95% satisfaction. In 2014, 2015, 2016, 2017 and again in 2018: Global-Mark independent auditors reported that “the actions taken to maximise patient quality care was met with merit”
Referring Doctors’ survey:
Every two years our referring doctors are surveyed to determine their level of satisfaction with the services provided by PSC to their patients. The data collected is analysed and reviewed by management who may make recommendations as a result of the outcomes / suggestions. The last survey was completed in 2019 a survey was conducted with an overall satisfaction rate of 87.5%. 100% of the doctors’ surveyed would recommend PSC to other referrers. The next survey is due in 2021 (this may be delayed as again depending on the software update).

CPAP Clinic Survey and CPAP Consumers Feedback:

PSC is trying hard to improve the service provided to our CPAP users and as a result have actively sought feedback from patients who have both recently used the services or have previously used the services of the Clinic. In 2020: the consumer initial feedback remains 99.9% satisfaction. A ‘blind’ CPAP Clinic survey has not been completed since 2018. The next blind survey was due later in 2020 – currently on hold until later in 2021.
Healthcare Associated Infections:
The risk of getting an infection in hospital depends on how healthy you are, how long you have been in hospital, certain medications and whether you have had an invasive procedure such as surgery. At PSC patients stay overnight only, there are no invasive procedures performed and no medication is prescribed or altered, and all accommodation is in single rooms. PSC does not accept admission from other hospitals. Anyone with a respiratory infection (including COVID 19), colds, flu, vomiting, diarrhea, or other communicable disease including shingles, other hospital acquired infections such as MRSA are re-scheduled or in the case of COVID 19 must have a negative swab. PSC does not have the resources to do wound dressings and therefore will not accept patients who require this intervention. Prospective patients are given information regarding minimising the risks. It is considered that the risk of contracting an infection at PSC is extremely low.

At the Global-Mark audit conducted in November 2017 as part of the NSQHS requirements PSC were required to implement a 5 year ‘Action Plan’ to ensure compliance with the infection control standard AS / NZ 4187:2014. In 2018 a printer was purchased for the current thermal disinfector to ensure a record of thermal disinfection is maintained. Procedure and protocols were updated, and staff were given additional training. Later in 2021 PSC plans to purchase a thermal disinfector with drying capacity to achieve the last of the 5 year ‘Action Plan’.

Staff In-service training includes regular education on infection control.

Hand Hygiene

The single most effective strategy in preventing and or minimizing the spread of infection is hand hygiene. There are hand basins throughout the facility, there is hand rub (which is just as effective as soap & water) in every room and there is hand rub on each set-up trolley. Staff are educated in hand hygiene and participate in on-line hand hygiene modules set-up by Hand Hygiene Australia. Hand hygiene is regularly monitored, and the outcomes are reported to management.

Consumers are asked whether staff washed their hands or used alcohol rub during set-up.

How can you help to limit the spread of infection?

  1. Do not come to the Clinic if you have been in or transited through a declared COVID hotspot in the last 14 days.
  2. Do not come to the Clinic if you have been diagnosed with or have been in contact with a known or suspected case of COVID 19 or told to quarantine by a health professional.
  3. Do not come to the Clinic if you are waiting for the results of a COVID swab.
  4. Call the Clinic prior to admission if you have an infection, particularly if you have a cough or the flu, an open wound, or a contagious disease – your appointment will be re-scheduled.
  5. Wash your hands with soap and water or the hand rub on admission.
  6. Cover your mouth and nose when you cough or sneeze and wash your hands afterwards.
  7. Wash your hands after using the toilet.
  8. Do not bring visitors into the Clinic if they have an infection.
  9. Follow NSW Ministry of Health guidelines with regards to ‘out-breaks’.
  10. Use QR codes and respiratory masks as advised

Identification and Clinical Handover:

While PSC only performs Polysomnography it is important that patients are identified correctly. On admission and again prior to consenting to a Sleep Study the patient’s identity will be confirmed. Details such as date of birth, name, address, or Medicare card number will be used. There is usually only one clinical handover during a patient’s stay in the Clinic and this occurs at 11.00pm. At this time, the staff stop what they are doing and confirm the patient’s identity, the type of Sleep Study, whether there are any allergies / alerts / Advanced Care directive / Enduring Guardian Directive and any other relevant clinical history.

Staff Training:

Polysomnography is a comprehensive recording of the bio-physiological changes that occur during sleep and is a very specialised medical field. Therefore, staff require intensive training to ensure they have the necessary skills to perform their duties to the highest standard. PSC has a well-documented orientation program; new staff are provided with one-on-one training with an experienced staff member and there is regular in-service education which is compulsory and where relevant staff are provided external education. In addition, staff are given the opportunity to attend the Sydney University Sleep Course. Staff performance is reviewed and documented annually and if necessary further training is provided.

In 2014, 2015, 2016, 2017 and 2018: Global Mark independent auditors reported that “agreed and documented guidelines and pathways are available to clinical workforce and the use of agreed clinical guidelines by the clinical workforce in monitored: both were met with merit” However in 2018 PSC was required to provide evidence that staff were trained in ‘Patient Centred Care” – this was provided in December 2018.

Visit our Resources page to view various news items and research studies conducted by Peninsula Sleep Clinic.

Why do a sleep study with Peninsula Sleep Clinic?

Peninsula Sleep Clinic aims to be the best Sleep Clinic in NSW. With friendly knowledgeable staff, accredited procedures and a variety of testing available, we offer a full service approach.

Home trials of CPAP equipment are available to all patients who have undergone a sleep study through Peninsula Sleep Clinic.

Our CPAP Education Clinics have a unique structure where we can provide CPAP Therapist consultations to patients on a one-to-one basis,  giving patients the best opportunity for success.

If you are a patient of Peninsula Sleep Clinic and are experiencing any CPAP related issues, just call our friendly staff within office hours to help you resolve your problem.

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 Accredited to the National Safety & Quality Health Services Standards.

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“Peninsula Sleep Clinic helped me to get established onto CPAP therapy to treat my sleep apnoea. My experience in the clinic during my trial was not as daunting as I though beforehand.”

Ted – Northern Beaches


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