Quality of care

While modern facilities and equipment are vital, healthcare is largely about people – patients, residents, staff, doctors, volunteers, families and our community. At The Bays, we take pride in our attention to detail. In addition to our patients’ medical needs, this may include physical comfort and emotional needs. A holistic approach to care requires a coordinated effort in all areas and by all our people. The Bays Healthcare Group has a culture of excellence and continuous improvement.

Strategic planning

Our Strategic Plan 2016–2020 sets a road map for our future over the next few years and informs our decision-making processes. Our annual operational plans also set clear targets, priorities and actions for the year ahead. These are valuable tools for us to get the whole organisation working in a concerted effort towards delivering our outcomes.

Key to achieving our strategic priorities are our quality improvement initiatives, monitoring outcomes, review processes, and benchmarking to world-class standards. While we continually measure our performance, we are also assessed through independent clinical and non-clinical audits and national accreditation bodies.

Risk management

The Bays Healthcare Group carefully considers and manages all clinical, operational, financial, external and strategic risks. We have a culture of transparency and accountability. Risk is mitigated by identification, reporting, evaluation and management strategies. These activities are supported by extensive and ongoing staff education programs.


Our Board of management sets the governance framework for the safety and quality of patient care. The Executive team implement and maintain the systems, materials, education and training to deliver our high quality care.

The Bays staff and volunteers all undertake training to ensure they understand our safety and quality procedures and expectations. All staff participate in regular performance review procedures.

Infection control

We continually monitor our environments and implement the best practices to reduce the risks of infection, including:

  • maintaining a clean environment
  • using appropriate disinfection and sterilized equipment
  • isolating people who have infectious illnesses
  • washing hands with soap or using alcohol-based hand sanitizer
  • wearing protective equipment such as gloves, gowns, masks and goggles.

You can help us reduce the risk of infection by:

  • washing your own hands with soap or using alcohol-based hand sanitizer
  • covering your mouth and nose with a tissue when you cough or sneeze
  • reporting any infections you have had recently, especially if you are still on antibiotics
  • taking the full course of antibiotics you have been given, even if you are feeling better
  • keeping the skin around wounds and dressing clean and dry
  • telling a nurse if the area around drips, lines, tubes or drains becomes red, swollen or painful
  • following instructions you are given on looking after wounds or medical devices you have
  • reporting if your room or equipment hasn’t been cleaned properly
  • stopping smoking before and after surgery
  • taking your doctor’s advice about the timing of your discharge
  • discussing any concerns with your doctor or nurse.

As a visitor you can help us reduce the risk of infection by:

  • reconsidering your visit if you have a cold, cough or have been vomiting or had diarrhoea
  • cleaning your hands with the alcohol-based hand sanitizer
  • not bringing too many visitors into the hospital at a time
  • being careful not to touch dressings, drips or other equipment around the bed.

Fall prevention

Falls are a major cause of injury in hospitals and they can result in serious injury or disability.

Please help us by taking the following precautions:

  • make sure you can reach your call bell – or ask your nurse to move it within your reach
  • if you need help, do not hesitate to call 
  • advise our staff if you forget things or are confused
  • turn on the light if you need to find something in the dark
  • wear supportive, flat, non-slip shoes
  • bring your walking stick or walking frame to hospital
  • bring your glasses and/or hearing aid to hospital
  • ask us to adjust your bed height if necessary
  • ask where the nearest toilet is
  • do not overstretch to reach something – ask for our help
  • lie in the middle of your bed to avoid falling out
  • call for our help if you are frightened that you may fall.


Please tell us about any medications you are taking (either prescribed by your doctor, or vitamin and herbal supplements). Let us know about any allergies you have, or any reactions you have had to medications in the past. We encourage our patients to be involved in the management of medications. If you have any concerns or questions please ask your nurse or your doctor.

Your rights and responsibilities

To ensure you receive the best quality care it is important that you understand your rights and responsibilities.

Please find a summary of our responsibilities, your rights and your responsibilities here.

For more information you can view the Australian Government Department of Health and Ageing Private Patients Hospital Charter

Your rights 

The Bays Healthcare Group respects your right to participate in health care choices that affect you. As such you have a right to:

  • Access, and receive, the best health care available.
  • Be treated respectfully and with regard to personal dignity at all times.
  • Be treated without discrimination in any form.
  • Have your cultural and religious beliefs respected.
  • Feel safe, clean and comfortable within the hospital environment.
  • Be informed, prior to and during admission, about your treatment, investigations or operation and the alternatives available in terms you can understand.
  • Be accurately and adequately informed about the hospital services available and the cost of your care and stay in hospital.
  • Ask questions about your treatment and obtain a second opinion should you wish to do so.
  • Give your informed consent for medical treatment; you also have the right to refuse treatment. You may also appoint someone to make medical decisions for you in the event you lose the capacity to do so.
  • Participate in decisions made about your ongoing needs upon discharge and receive information about available services.
  • Discharge yourself against your doctor’s advice, however, you will be asked to sign a form accepting responsibility for your decision.
  • Be informed about the information that is collected about you and who has access to it.
  • Have your personal privacy and the confidentiality of personal information, conversations and medical records maintained.
  • Request access to your medical record, this will require completion of a form and a small fee will be charged. Requests should be made via the unit manager, hospital supervisor or health information manager. Access may be denied, but you have the right to contact the Health Services Commissioner for further advice.
  • Know the identity, professional status and qualifications, and how to contact the staff involved in caring for you.
  • Receive visitors and contact people outside the hospital during your stay.
  • Access an accredited interpreter for essential information such as admission, and discussions about your medical history and treatment. Please inform your nurse or doctor as soon as possible if this service is required.

Your responsibilities

To assist hospital staff in providing you with the best possible health care, it is important that you take responsibility for:

  • Understanding and keeping a record of your treatment and medications.
  • Providing hospital staff with accurate and relevant information about your health, present treatment and circumstances that may influence your treatment, recovery or stay in hospital.
  • Following your prescribed treatment.
  • Informing the appropriate person if you are not able to keep an appointment.
  • Telling hospital staff if you notice changes in your condition.
  • Being considerate and respectful of staff and other patients and asking your visitors to be likewise.
  • Accepting responsibility for your own health care and for the decisions you make about your own care and treatment.


We welcome your feedback.

If you have a comment or complaint, please bring the matter to the attention of a staff member on duty at the time, or to the manager of the ward or department. Our staff want to resolve issues quickly, but they need to be told about them first. It is our policy to follow up any issues brought to our attention and to pursue a satisfactory resolution.

If you or a family member can see ways that our services can be improved, please share them with us, and let our staff know.

If you would like to make a formal statement about the care or the services you have received at The Bays, please give us your feedback here or write to:

Executive Office
The Bays Healthcare Group
PO Box 483
Mornington VIC 3931

Satisfaction surveys are available from the reception desks at our Aged Care, Hospital or on our wards. A copy is also available in the patient information folder available in our hospital rooms.

If you are not satisfied with the way your complaint is dealt with, you can contact an independent complaints resolution body such as the Office of Health Services Commissioner (OHSC). The OHSC provides a free and confidential service for anyone with a complaint about a health service provider in Victoria.

Office of the Health Services Commissioner
call: 1300 582 113

email: hsc@health.vic.gov.au