Safety and Quality 



Bendigo Day Surgery is committed to providing patients with the highest level of care by providing a safe and effective environment for treatment.


Bendigo Day Surgery maintains accreditation with AS/NZS ISO 9001:2008 Quality Management System and the National Safety and Quality Health Service (NSQHS) standards 1, 2 & 3. The complete suite of 10 NSQHS standards will be accredited to in August 2015 when BDS undergoes a 3 yearly re-certification of its accreditation status.

Corporate Governance

All business and clinical matters of BDS are managed through the Board of Directors and the Medical Advisory Committee. These 2 committees are the highest levels of governance at BDS and regularly review:

  • Quality Management System
  • Clinical Indicators
  • Internal audits
  • Incident reports
  • Consumer feedback

Consumer Participation

BDS values feedback and input from our consumers (patients and carers). Consumers are able to participate in the improvement of quality and care provided at BDS in the following ways:

  • Annual patient satisfaction survey
  • Feedback forms
  • Post-operative phone calls
  • Annual Consumer Focus Group
  • Consumer review of quality documents
  • Interaction with BDS website

Infection Prevention and Control (IPC)

Bendigo Day Surgery uses the expertise of an external IPC consultant to provide and oversee this comprehensive program. We undertake an annual external Infection Prevention and Control Audit to ensure that we comply with the following standard and guidelines:

  • Australian Standards for reprocessing of reusable medical devices in health service organisations (AS 4187:2014)
  • NHMRC (2010): Australian Guidelines for the Prevention and Control of Infection in Healthcare.
  • GENCA (2010) :Infection Control in Endoscopy
  • ACORN Standards for Perioperative Nursing (2014-15)

Internally at BDS we audit our practice and performance regularly in the following areas:

  • Environmental cleanliness
  • Hand Hygiene of Nursing and Medical staff
  • Standard Precautions and Aseptic Non-Touch Technique
  • Waste management
  • Antimicrobial Stewardship (The appropriate prescribing and use of antibiotics)

Staff Training

To provide our consumers with a well-trained and skilled workforce, BDS staff are required to undertake mandatory training in all of the following areas:

  • Basic Life Support (CPR etc)
  • Hand Hygiene
  • Aseptic Non Touch Technique
  • Management of Invasive Devices
  • Safe Medication Management
  • Patient Centred Care
  • Open Disclosure
  • Falls Prevention and Pressure care
  • Manual Handling and OH&S
  • NSQHS standards

Safety and Data collection

Bendigo Day Surgery is committed to providing patients with the highest level of care and providing an effective and safe environment for treatment.

Part of this process, is about collecting and evaluating information regarding:

  • Patient Falls
  • Patient Skin Tears
  • Post-Operative Infections

The following list of Clinical Indicators are reported on:

  • Patient complaint
  • Booked patients who fail to arrive
  • Cancellation after arrival – pre-existing medical condition
  • Cancellation after arrival – acute medical condition
  • Cancellation after arrival – administrative/organisational reasons
  • Patients who experience an adverse event during care delivery
  • Unplanned return to operating room on same day as initial procedure
  • Unplanned transfer or overnight admission related to procedure
  • Unplanned transfer or admission related to ongoing management
  • Unplanned return to facility (BDS or otherwise, within 24 hours of discharge)
  • Delayed discharge for clinical reasons exceeded 1 hour
  • Unplanned delayed discharge for non-clinical reasons more than 1 hour
  • Departure without an escort

Results from this data are benchmarked against national industry results.

How do you access results of this safety and quality information?


If you wish to access this information, please feel free to either

Email      This email address is being protected from spambots. You need JavaScript enabled to view it.

Or write to

Quality Management Department

Bendigo Day Surgery

PO Box 2735

Delivery Centre Bendigo
Victoria 3554

Open Access Gastroscopy and Colonoscopy at BDS