Kathryn Holly, quality manager with the Mater Private Hospital, believes hospitals have been behind when it comes to ensuring standards
I have responsibility for overseeing quality and risk management at the 168-bed Mater Private Hospital. Basically, this means making things better and safer for our patients and our 700 hospital staff.
A major part of my day-to-day work is auditing. In the Mater Private we have an instant reporting system.
Hospitals are very complex places and by their nature can be dangerous - we are dealing with surgery and drugs.
It is very important to try to keep improving and there can be a real danger associated with people being afraid of reporting incidents.
Things nearly go wrong a lot of the time. We encourage staff to report if something happens or if something nearly happens. We have a no-blame policy. The idea is to investigate each incident, however small, and watch out for trends. In any year we work on 20 or 30 quality improvement programmes in the hospital.
The Mater Private has an accreditation award from the Joint Commission International, which is a branch of the biggest accreditation agency for hospitals in the world. This agency comes and surveys the hospital every three years.
We are judged under 1,033 different standards which relate to things like patient care, infection control, equipment care and how we involve patients in their own care.
My job is to ensure we comply with all these standards. Our last survey was in September and we were successful.
Unfortunately, because we are a private hospital we were not involved in the Government's recent national hospital hygiene audit. We are hoping to invite the audit group to come to audit us too.
Measuring what we do in the hospital is also a big part of what I do. Measuring is a very big thing in healthcare at the moment.
Healthcare is way behind other industries in terms of quality control. Hospitals have always been focused on doing things better and delivering good quality services but they have been behind in checking everything they do and they are only learning about quality management now.
We measure whether we are doing things well and if not try to improve them. We measure a whole range of areas - how much infection and MRSA we have, how many bed sores we have, how we clean the hospital and how well we give blood.
We take a very active approach to the management of MRSA. The reality is that not everybody picks it up in hospitals, it has been around for a very long time. We screen high-risk patients coming into the hospital for MRSA. These would be patients being transferred from another hospital or nursing home or someone who has been in hospital recently.
Writing policy documents is also part of my role, but policies are absolutely pointless unless they can be implemented and are implemented. So I spend a lot of time out on the wards auditing, measuring and consulting with staff.
I usually work office hours but when it's busy can put in 14 or 15-hour days.
(In conversation with Fiona Tyrrell)