Quality, Safety & Accreditation
Providing the best possible care hinges on maintaining impeccable standards, particularly when it comes to safety and quality. That’s exactly what we take care to do at the San – with nursing and medical staff supported by a dedicated Clinical Governance Management team. We have outlined our various procedures and standards below.
Maintaining quality
Our comprehensive quality management program is in place across all Adventist HealthCare sites. Designed to monitor, assess, evaluate and improve the quality of patient care, the program is constantly evolving – with our Adventist HealthCare Quality Awards program providing motivation to always do better.
To ensure compliance with evidence-based standards, both clinical and non-clinical practices are regularly audited, and we encourage customer feedback.
Infection prevention & control
Preventing the spread of infection is now more important than ever before. At the San, we have a stringent Infection Prevention and Control program that uses evidence-based research to guide clinical practice.
The program encompasses the education for staff, patients and their families, as well as the auditing of staff practices and participation in the National Hand Hygiene program.
Key Quality Indicators - Hand Hygiene (March 2025)
Sydney Adventist Hospital
91.4%
San Day Surgery Hornsby
98.5%
National Benchmark KPI
80%
Managing risk
Across all Adventist HealthCare operations, we take an integrated proactive approach to managing the risk involved with providing our services. This encompasses risk identification, analysis, evaluation, treatment, monitoring and review. Our keen focus is risk prevention, and creating the safest possible environment for patients, staff and visitors.
Clinical review
Adventist HealthCare takes part in a number of benchmarking programs – monitoring clinical indicators through ACHS (Australian Council on Healthcare standards) and Key Performance Indicators through HBN (Hospital Benchmark Network). We ensure compliance with best practice standards through our peer review program.
Speaking up for safety
As part of our commitment to maintaining a safe environment for everyone who visits the San, we have teamed with the Cognitive Institute – which develops specialised training for the healthcare sector. Through this partnership, we’re promoting the Speaking up for Safety program, which encourages safety to be everyone’s responsibility. Our goal is to constantly build an ‘Always Checking’ culture, where everyone feels confident to speak up about safety issues.
Consumer Advisory Council
Members of the community are welcome to join our Consumer Advisory Council as a volunteer member. This is a great way to act as a voice for the consumer, and make sure your needs are heard and understood.
REACH
Another way we’re taking care of our patients’ interests is by implementing the Clinical Excellence Commission’s REACH program at Sydney Adventist Hospital. This is a protocol that empowers patients (and their loved ones) to speak up if they have an urgent clinical concern that hasn’t yet been acted on.
Australian Commission on Safety and Quality in Health Care Standards (2nd Edition) Accreditation
Sydney Adventist Hospital
San Day Surgery Hornsby
ISO Certification
Pathology Department (ISO 15189)
Quality Care Pharmacy Program (QCPP)
Pharmacy Department
NATA Accreditation
Pathology Department (Facility 1924)
Radiology Department
San Ultrasound for Women
Australian General Practice Accreditation Limited (AGPAL)
Fox Valley Medical & Dental Centre
HACCP certification
Food Services Department