ACT Endoscopy values the positive contributions consumers and the community can make to improve our service.
Improving quality is about making our service safe, effective, patient-centred, timely and efficient.

Mechanisms in place are:

  • Consumer feedback via Patient Satisfaction surveys
  • Consumer face to face interviews on their episode of care
  • Consumer representative on the Quality, Safety and Planning Committee
  • Open disclosure policy and procedures
  • Consumer complaints and feedback management system ensuring any issues are dealt with in a timely manner

If you would like to provide feedback whether in writing, by phone or would like to be involved by being a representative on our Quality, Safety and Planning Committee please feel free to contact our Director of Nursing.


ACT Endoscopy is committed to providing a quality service with positive patient outcomes by continually assessing and monitoring all our practices.

We are accredited against the National Standards through the Australian Council on Healthcare Standards (ACHS) which is an independent organisation committed to continually improve the quality of healthcare in Australia. A feature of the accreditation process is regular on-site inspections and reviews. This ensures the very highest quality is maintained and independently audited to meet recognisable standards.

As part of our continual strives for improvement key indicators are collected and compared with like organisations. We have a detailed Quality Management Plan which incorporates regular and ongoing auditing and review of all aspects of our processes.

Examples of audits carried out regularly:

  • Six monthly Patient Satisfaction Audit
  • Sterilizing Audit
  • Environmental Audit
  • Medical Records Audit
  • Hand Hygiene Audit
  • Endoscope Reprocessing Audit
  • Patient Information Publications Audit 
  • Confidentiality Audit
  • Risk Management Audit

Our Risk Management plan is comprehensive and adopts principles and practices that eliminate, reduce and manage risk across our organisation. ACT Endoscopy promotes a culture that encourages staff to report incidents and potential risks.

Quality Indicators for Colonoscopy

The measurement that best reflects how carefully colonoscopy is performed is a Doctor's adenoma detection rate. Higher adenoma detection rates are linked to lower lifetime colorectal cancer incidence and death.

Adenoma detection dates should be at least 30% in men and 20% in women as set by the American Society for Gastrointestinal Endoscopy and American College of Gastroenterology (2015).

Adenoma Detection Rates at ACT Endoscopy are:           

Males        43 - 60%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Females    28 - 39%                                                                                                                                                                            


Correct cleaning, disinfecting and maintenance of all medical equipment is an essential component of our safety and quality services. All processes are regularly audited and all staff has in depth training and are assessed at least three times yearly to ensure continuing high standards. We follow strict guidelines from the Gastroenterological Nursing College of Australia (GENCA), Gastrointestinal Society of Australia (GESA) and AS/NZS 4187.

We are required as part of our guidelines to microbiologically test all our scopes three monthly and our reprocessing machines monthly to ensure that the cleaning and maintenance processes in place are effective and that no micro-organisms that cause infection are identified.

Hand Hygiene is an integral part of our everyday practice. All staff (Medical and Nursing) are required to complete the Hand Hygiene module online yearly.

National Hand Hygiene data

- overall compliance rate is 85.1%.


 ACT Endoscopy

- overall compliance rate is 91.5%.


National Hand Hygiene data

 overall compliance rate:

  - Nurses - 88.1%

  - Medical Practitioners - 73.3%


ACT Endoscopy

 - Nurses – 95%

- Medical Practitioners - 86.7%




(152 replies)


1.Were the instructions given to you before coming to the Endoscopy unit clear?


2.Was ACT Endoscopy easy to locate?

99.3% 0.7% 

3.Was the staff courteous and friendly when you arrived for your procedure?


4.Did the nursing staff respond well if you had a concern or complaint?


5.Was the staff readily available during your time in the unit?

6.Was the waiting time before your procedure acceptable? 98%


7.Did the staff give you a sufficient explanation of the procedure you were going to have?


8.Was your privacy maintained during your visit?

99.3% 0.7% 

9. Were you comfortable?

10.  Did you have pain following your procedure?


11. Did you have any nausea?



12. Did you find the Endoscopy unit clean and tidy?


13. Were your refreshments after the procedure adequate?

98.7%  1.3%

14. Were clear discharge instructions given to you after your procedure?

99.3% 0.7% 


Comments: There can be delays before a procedure if the previous procedures take longer than expected. We aim to minimise this by staggering admission times. We will continue to update patients waiting for their procedure when there are any delays.

If you would like to view our Quality Improvement Plan, Indicator Comparison Reports or Risk Register and Management Plan please contact the Director of Nursing (02) 6232 4790.