Accreditation is recognized as an important driver for safety and quality improvement. Colin Street Day Hospital is certified by DNV GL (Healthcare Certification and Accreditation Services) according to ISO 9001:2015 International Quality Management System Requirements in Health Care and accredited against all mandatory criterion as outlined by the Australian National Safety and Quality Health Service Standards (NSQHS).

Accreditation requires the hospital to meet 8 Standards and all mandatory associated criterion that sit under these Standards. The hospital is visited annually by a team of independent health expert auditors who review the hospitals quality and safety systems according to the services we provide. Our achievements are then measured against best practice and to the level we meet these Standards.

The National Standards include:

Standard 1. Clinical Governance
Standard 2. Partnering with Consumers
Standard 3. Preventing and Controlling Healthcare – Associated Infections
Standard 4. Medication Safety
Standard 5. Comprehensive Care
Standard 6. Communicating for Safety
Standard 7. Blood Management
Standard 8. Recognising and Responding to Acute Deterioration

Colin Street Day Hospital is also required to be licensed annually by the Western Australian Health Licensing Standards and Review Unit (LSRU) according to the “Licensing Standards to the Arrangements for Management, Staffing and Equipment. Day Hospitals Class A.”

Each year auditors from LSRU visit the hospital and audit the facility against the Standards set out under Management, Building and Design, Equipment and Staffing.



Patient Safety and Quality
Colin Street Day Hospital is committed to the continual improvement of patient care. In 27 years of providing hospital services to Western Australians, CSDS continues to have an exemplary record in delivering quality care to our patients.

Our Clinical and Corporate Governance framework is integrated so that it promotes patient safety and quality. Four key areas we focus on are;

  • + Clinical Risk Management
  • + Financial Risk Management
  • + Safe Workplace
  • + Human Resources – skilled workforce

Our consumer-centered approach involves:

  • + Consumer and patient representation on the Colin Street Day Hospital Board and Executive Committee
  • + Treating all our consumers with respect and dignity
  • + Communicating and sharing information that is relevant to you
  • + Encouraging you and your carer to participate in your care
  • + Encouraging you to provide feedback – are we doing well or can we improve our service delivery to you
  • + Encouraging you to participate in decision making that involves how we care for you

For further information on consumer participation and patient centered care go to:

Colin Street Day Hospital has implemented many infection control procedures which involve all members of the health care team, including our patients and carers. These policies and procedures assist us in effectively managing any potential healthcare associated infections by using evidence based strategies.

What is a Healthcare Associated Infection?
These are infections that occur as a result of healthcare interventions and are caused by micro-organisms such as bacteria and viruses. They can happen when you are being treated in a hospital, GP clinic, at home, at school or anywhere. Most infections are easily treated by antibiotics but there are a few infections that are resistant to treatment.

What is Colin Street Day Hospital doing to prevent infections?
Colin Street Day Hospital has employed a Specialist Infection Control Consultant to assist our Infection Control Nurse and Staff in implementing and monitoring policies and procedures we have in place in order to ensure our patients, carers, visitors, clinicians and employees are protected from acquiring a hospital based infection.

Procedures in place but are not limited to include:

  • + Annual clinician and staff education and competency programmes
  • + Tri-annual Hand Hygiene Audits – data submitted to Hand Hygiene Australia https://www.hha.org.au/
  • + Routine internal and external auditing of our Infection Control Programme, systems, policies and procedures against the National Standards on preventing and controlling healthcare associated infections
  • + Waste management
  • + Surgical site surveillance of infection rates with participation from our visiting surgeons.
  • + Staff must wear gowns, gloves, masks and goggles when required.
  • + Routine audits of cleaning, sterilizing and storing of sterile equipment and facility
  • + Tri-annual audits of prescribing of antibiotics according to Australian Therapeutic Guidelines

What can you do to help?
All patients and visitors are considered part of the health care team when it comes to preventing infections. Colin Street Day Hospital has a patient notice board that displays information on how well the hospital is performing against our peers. We also display information on a number of things you as a patient or visitor can do to help us to reduce the risk of acquiring HAI’s (Hospital Acquired Infections).

This includes:

  • + Wash your hands carefully. There are a number of waterless hand sanitisers available in the waiting room and in the patient toilets.
  • + If you are to be admitted to the facility for a procedure, report to us any infection, diarrohea or vomiting you have recently had, especially if you are still on antibiotics.
  • + If you are on antibiotics, ensure you complete the full course
  • + All patients should shower using soap prior admission
  • + Cover your mouth and nose with a tissue when coughing or sneezing. Wash your hands immediately afterwards
  • + Inform the nurse if you have any open wounds
  • + Stop smoking. Smoking increases the risk of infection

If you are a visitor or service provider and you have or have recently had an illness, please reconsider your visit to the facility.

For further information on Healthcare Acquired Infections go to:


What is a pressure injury or a skin tear?

Pressure injuries are wounds which form as a result of prolonged pressure to an area of skin

Skin tear is a type of wound caused by trauma that leads to a tearing of the skin that can be shallow or deep, leaving a loose flap of skin and surrounding bruising.

This type of injury is recognized worldwide as a common cause of harm in patients and is known to slow the recovery process.

Who is at risk of a pressure injury or skin tear?

  • + Persons with fragile skin
  • + Persons who are vision impaired or are immobile
  • + Persons taking steroid or blood thinning medications
  • + Persons suffering from poor nutrition or dehydration

What do we do to prevent these types of injures occurring while you are in our care?
Due to the type of services Colin Street Day Hospital offers to its patient population, you are very unlikely to acquire this type of injury while in our care.

Colin Street Day Hospital assists staff in preventing these injuries by:

  • + Assessing our patients risks factors prior to admission, this includes reviewing your health questionnaire, types of medications you are taking, your age and what type of procedure you are having with us.
  • + Nurses follow care plans, polices and procedures which are targeted at minimizing your risk of a skin tear or pressure injury while in our care
  • + Ensuring appropriate equipment and pressure injury alerts are available to staff in assisting injury prevention

What can you do to prevent a skin tear or pressure injury while in our care?

  • + Inform our nurses if you have a history of or currently have a pressure injury or skin tear prior to your admission
  • + Use a moisturizer regularly
  • + Drink plenty of fluids (but not too much caffeine or alcohol)
  • + Specialised limb protectors are available from medical suppliers for persons at risk of skin tears.

For more information go to:

Falls related injury is one of the leading causes of morbidity and mortality in older Australians with more than 80% of injury-related hospital admissions in people aged 65 years and over due to falls and falls-related injuries.

Due to the type of services Colin Street Day Hospital offers its patient population, you are very unlikely to experience a falls-related injury while in our care. In over 27 years of caring for Western Australians, we have not had one patient suffer from a fall related injury.

What does CSDS do to reduce the incidence or risk of you falling or harm from falling while in our care?

  • + We assess your risks factors for a fall related injury prior to admission by reviewing your health history, your age and type of surgery you will be having at this facility
  • + Nurses follow care plans, policies and procedures which are targeted at minimizing your risk of a fall related injury pre and post procedure
  • + Ensuring appropriate equipment and falls alert notices are available to staff
  • + Staff education
  • + Quarterly falls monitoring – data submitted to a national day hospital benchmarking network.

What can you do to prevent a falls-related injury while in our care?

  • + Inform our nurses if you have a history of falling, suffer from balance problems or have poor vision
  • + If you require a walking stick or frame to mobilize, please bring it with you on admission
  • + Do not mobilize without assistance unless in the company of a nurse or carer post procedure especially if you feel dizzy or unsteady on your feet
  • + Restrict alcohol for 24 to 48hours post anaesthesia
  • + Once discharged, be mindful that some pain medicines prescribed to you can cause fatigue and confusion that could lead to you falling

For further information on falls-related injuries and falls prevention in healthcare organizations or at home go to;