We currently have precautionary measures in place to protect our patients and staff. Read more

Quality and safety at Cabrini

Quality and safety are paramount at Cabrini. A culture of quality improvement requires strong governance.

Cabrini’s clinical governance structure includes our Patient Experience and Clinical Governance Board Committee. A range of committees monitor patient risks and work to prevent risks and improve the quality of patient care. Our planned approach to continuous quality improvement involves reviewing and improving each stage of the patient journey and includes audit, feedback, service redesign activities and innovation. Our quality improvement approach ensures ongoing development of strategies and measures to enhance safety for patients and minimise risk and optimise service quality.

Cabrini’s promise to our patients, families and each other includes the following key principles:

  • We put patient safety first
  • We ask questions to understand the problem
  • We admit when we make a mistake and seek a solution
  • We look for opportunities to improve our care and services

The care we provide at Cabrini is based on the National Safety and Quality Health Service (NHQHS) Standards, click here to learn more.

Find out more about the importance of clinical governance and the role it plays in quality, safety and patient experience at Cabrini.

Child safety - statement of commitment

All children and young people who come to Cabrini have a right to feel and be safe. Cabrini policies and practices aim to keep children safe from harm and proactively address any child safety risks.

Cabrini is committed to providing a safe environment for children and young people and child safety is an identified priority. This includes the identification of, and response to, child safety risks and incidents, and compliance with legislation.

Cabrini has a zero tolerance of child abuse. All allegations and safety concerns are treated seriously and consistently with structures in place to report child safety issues at the highest level of governance.

Organisational policies and procedures are in place to –

  • minimise risk and eliminate the potential for harm to children and young people;
  • empower and support children and young people and ensure their voices are heard;
  • implement robust human resources practices for all staff, contractors and volunteers, recognising that every person at Cabrini has a role to play in creating a safe environment for children and young people; and
  • meet the Child Safe Standards (Vic) and other legislative requirements including duty of care and reporting obligations.

Cabrini strives to embed a culture of child safety across the organisation. Ongoing monitoring and review will ensure the system is responsive to the needs of children. Additional consideration is given to the needs of vulnerable children – specifically children with a disability, Aboriginal and Torres Strait Islander children, and children from culturally and linguistically diverse backgrounds.

We put the safety of our patients first and look for opportunities to improve our care and services.

Our performance against key clinical indicators

Including results on staff hand hygiene compliance, staph aureus bacteraemia rates, pressure injuries and skin tears, falls, patient satisfaction and benchmarking with peer hospitals

Cabrini’s hospitals, facilities and services all hold the necessary accreditation with the relevant authorities. Accreditation is one way we assure the community that Cabrini meets the high standards set for service providers and the level of care and service that consumers can expect from our services.

Safety and Quality Accreditation – National Safety and Quality Health Service Standards

All Australian health services are required to be assessed under a national safety and quality accreditation program overseen by the Australian Commission on Safety and Quality in Health Care.

In May 2022, Cabrini was successfully accredited to the National Safety and Quality Health Service Standards (NSQHS Standards). The eight  NSQHS Standards provide a national statement about the level of care consumers can expect from health service organisations. The primary aim of the standards is to protect the public from harm and improve the quality of health care provided.

The accreditation process involves a three yearly review of our performance by an independent team of healthcare professionals. The team rates the performance of the organisation against set criteria and actions in areas of governance and clinical risk. Our clinical sites at Malvern, Brighton, Elsternwick – Glenhuntly Rd (Rehabilitation) and the Lisa Thurin Women’s Health Centre (Elsternwick – Hopetoun St) are assessed against the NSQHS Standards.

Cabrini is assessed by the Australian Council of Health Care Standards (ACHS) To find out more about these standards please visit:

For more information about the NSQHS Standards or quality and risk management in health services please visit Australian Commission for Safety and Quality in Health Care:

Clinical Care Standards

In addition to the safety and quality standards, the Commission have developed a range of clinical care standards related to specific high risk conditions, procedures and potential adverse outcomes. Cabrini integrates these Clinical Care Standards into our policies and procedures.

Unwarranted variation is variation that is not explained by a patient’s choice or clinical circumstances. The Clinical Care Standards program is a priority of the Australian Commission on Safety and Quality in Health Care. The program identifies and defines the care people should expect to be offered or receive.

How do patients help Cabrini to improve its care and service?

In line with our mission to provide excellence in all our services, we are committed to achieving 100 per cent patient satisfaction and 100 per cent safe care. For these reasons, we are monitoring our services through a series of audits (or checks) designed to help us identify risks to our patients and thereby ensure the safest possible care. Our patients are an invaluable source of information about our services. We plan to encourage feedback by inviting individual patients to participate in brief meetings with Cabrini auditors to answer specific questions about their hospital experience. This sheet outlines our audit process and what we hope to achieve with the help of our patients.

What kinds of audits will be conducted?

We will seek feedback on an individual basis about various health service activities such as:

  • Your understanding of the consent process
  • Your involvement in planning your care at Cabrini
  • Your understanding of specific risks e.g. falls, infection control and medications
  • Your nutritional needs while in hospital

Who are the auditors?

The auditors are Cabrini staff who have completed specific training. They may be qualified nursing staff or they may be staff from our pharmacy, health information services, infection control or medical imaging (x-ray) departments.

What does the audit process involve?

  • An invitation to participate will be distributed to some patients or a group of patients e.g. patients receiving a particular type of care or located in a particular ward
  • If you agree to participate, we will tell you when the audit will take place and the focus of the audit, then the auditor(s) will visit you in your room at a convenient time to conduct the audit
  • If you participate, relevant information may be sought from your medical records to support the audit e.g. evidence that staff have assessed your risk for falls, nutrition, skin health, medication, infection and discharge; evidence that you have provided consent for relevant procedures; and/or evidence that staff have implemented strategies to reduce risk to you while in hospital
  • The information you provide will remain confidential: your name will not be included in the audit reports and your feedback will not be linked to you in any way
  • Participation is completely voluntary and it is up to you whether to participate
  • You are free to change your mind at any time and this will have no impact on your relationship with Cabrini or the care you receive


At Cabrini, we manage and monitor risks across many areas such as operational, financial, reputation and clinical risks. Effective risk management is a vital component of Cabrini’s mission. We prioritise keeping our patients and staff safe and free from harm – this will allow Cabrini to grow and keep our health service strong to meet the needs of our community.

A planned approach to continuous quality improvement involves reviewing and improving each stage of the patient journey and includes audit, feedback, service redesign activities and innovation. We aim to improve safety for patients and staff by minimising key risks and optimising the quality of the services we provide.

At Cabrini, we are targeting known clinical risks which include falls, medication errors and pressure injuries, in order to:

(a) Reduce the occurrence of these clinical incidents

(b) Reduce the severity of harm associated with these incidents

We encourage all our staff to report all incidents using our incident reporting system so that we can monitor and track the effectiveness of our risk controls and prevent incidents occurring. The incident management system is actively monitored daily so that when incidents occur, the appropriate manager is notified and they can follow up and manage it in a timely way. The system can also track patients who may have had frequent falls. Additional attention and resources can then be planned to prevent further falls/injury.

Cabrini’s mission is clear – we are committed to providing excellence in all our services. We put patient’s safety first and look for opportunities to improve our care and services. 

Even with efforts to minimise risk, unfortunately incidents can occur. We need to respond promptly if a patient or staff member does suffer an accident or event that results in them being hurt or harmed in any way. These incidents are also called adverse events.

Cabrini supports open disclosure – this is the process of open communication with patients and their families following an adverse event that has resulted in unintended harm. The process also involves discussion of the incident, investigation and makes recommendations for system improvement. Staff also need to be supported through such incidents and Cabrini is committed to providing the right environment, resources and culture to guide staff.

How does Cabrini improve its care and service?

A feature of the National Safety Quality Healthcare Standards (NSQHS) second edition is to strengthen the roles of patients, carers and families as partners in their own care. It is recognised that patient involvement leads to a more positive experience and also enables high-quality health care and improved safety.

Feedback from patients and their families gives us a valuable insight into the experience they have had with our services, staff and facilities, and the care received.

Feedback is captured in a variety of ways at Cabrini, including questionnaires, follow up phone calls, focus groups, formal complaints and via the Cabrini Compliments Suggestions Complaints form. Feedback is also received from committees and members of the Patient and Family Register.

Cabrini services are monitored through a series of audits (or checks) designed to help identify risks to our patients. An annual audit program that supports the National Standards is managed by Cabrini Clinical Governance Unit. The range of audits have been developed to assess how well processes and services are delivered. By identifying and then taking steps to reduce or remove risks and making improvements, we can ensure the safest possible care. Specific services within Cabrini Health also conduct regular audits to ensure services are delivered as required.

Initiatives being worked on in partnership with our consumers are:


  • Cabrini Patient Portal
  • Refresh of the website
  • Patient Experience Strategy
  • Cabrini Gandel Wing


  • Consumer health resources and various Cabrini services


  • Discharge planning
  • Discharge information provision
  • Consumer involvement in bedside clinical handover
  • An escalation process whereby patients and families can escalate clinical concerns in collaboration with Safer Care Victoria

What can you do?

Your feedback is important to us. If you would like to send your compliments, offer suggestions to help us improve our service, or to make a complaint, please click here.