Quality & Safety

Quality And Safety - Wyndham Clinic

Medical Advisory Committee

Wyndham Clinic Private Hospital has a formal Medical Advisory Committee, with representatives from visiting medical officers and surgeons. This committee meets to ensure that the centre complies with all requirements of the relevant legislation. This committee makes recommendations regarding clinical practice, ethical and professional conduct. This is compliant with AS/NZS ISO 9001:2016

Board of Management

Wyndham Clinic Private Hospital has a formal Board of Management consisting of departmental management and supervisory representatives. The committee reviews the quality system to ensure its continuing suitability and effectiveness in satisfying the requirements of all relevant standards, codes of legislation and the requirements of the facility. The review will use data from audit results, risk clear management, patient satisfaction surveys, staff feedback, external documents and review of meeting minutes. This committee meets fortnightly.

How can you help us manage safety and quality

We value our patients and carers feedback. Patient are asked to complete a satisfaction survey prior to discharge. This information is collated and reported to the Board of Management to identify areas that need improvement and staff education. This feedback is treated with the utmost confidentiality and may be provided anonymously.
Please let one of our staff know if you would like to assist with reviewing any of our Safety and Quality initiatives

Patient Centred Care

Wyndham Clinic Private Hospital is committed to the education of staff in the delivery of patient centred care. Staff are given training to ensure compliance. For more information visit

Falls Prevention

Wyndham Clinic Private Hospital screens patients prior to admission to enable us to  recognise and create a safe hospital environment for patients assessed as an increased falls risk. For more information visit

Open Disclosure

Wyndham Clinic Private Hospital is committed to the education of staff about open disclosure. The provision of open and honest disclosure of information pertaining to the patients’ health care is ensured through the delivery of this training. For more information visit

Safe Medication Management

To comply with the Drugs, Poisons and Controlled Substances Act, Wyndham Clinic Private Hospital continually monitors and audits safe medication management to ensure compliance. Staff also undertake annual competency training to minimize risks to our patients. For more information on medication safety visit

Australian Charter of Healthcare Rights

To ensure you all have the necessary information about your Rights and Responsibilities prior to admission please visit

Clinical Partners

Wyndham Clinic Private Hospital considers patients and carers to be partners in the delivery of individualised health care.

Wyndham Clinic Private Hospital welcomes feedback from its patients and their carers.

Please complete our patient satisfaction survey before you leave the Day Surgery Unit and add suggestions and comments that you feel may improve our service.

Consumer Centred Care

We encourage comments including our performance in delivering patient centred care. How well did we care for you and your Carer? Can you identify any areas where we can improve if so please let us know via our satisfaction survey.

Partnership Training

Your feedback will be incorporated into training and education for our clinical workforce. What would you like us to include in our education for our clinical workforce? How can we teach our clinical workforce to work more collaboratively with you as the patient/carer? How can we be better partners?

Please contact our Director of Nursing, Felicity Connor with any feedback. The information you provide shall be treated with respect and confidentiality.

Medical By-Laws

Every registered private hospital and day procedure centre in Victoria must produce their own by-laws, which must be accessible to interested parties, according to the Health Services (Health Service Establishments) Regulations 2013 (the Regulations).

The Regulations refer to by-laws as ‘health service establishment protocols’ and some hospitals and day procedure centres call their by-laws ‘clinical governance frameworks’. By-laws are a set of rules that are made by the hospital that set out how the quality and safety of the services provided at the facility will be ensured. 

The By-laws in place at Wyndham Clinic Private Hospital contain the following:

  • the processes used to assess health professionals’ credentials, with re application every three years
  • the developed set of scope of practices for health professionals at the facility
  • how the competence and performance of each health professional is continually assessed
  • how the health services provided by each health professional at the hospital is continually assessed and reviewed
  • how the hospital continually assesses its capacity to provide safe, patient-centred and appropriate cares to its patients
  • the frequency and procedures for meetings of committees within the facility that have the responsibility of ensuring quality and safety of the health services provided
  • how appropriate the arrangements are made to evaluate, monitor and improve the quality and safety of health services provided by the facility

To view a full copy of the current Wyndham Clinic Private Hospital Medical By-Laws, please contact info@wyndhamclinic.com.au