We strive to provide exceptional care for every person, every time……
At Jessie McPherson Private Hospital, we take quality and safety seriously. To ensure we continue to keep our patients, staff and visitors safe and free from harm, we review a number of clinical indicators. Some of these have been published below for your information.
Apgar is a quick test that is performed on a baby at 1 and 5 minutes after birth. The 1 minute score determines how well the baby tolerated the birthing process. The 5 minute score tells the doctor how well the baby is doing outside the mother’s womb. The highest Apgar score is 10.
Apgar scores are measured for every baby born at Jessie McPherson Private Hospital. A healthy Apgar score is defined as a score of seven or above.
The graph below shows the percentage of babies born at Jessie McPherson Private Hospital with a healthy Apgar score.
This data is submitted to the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program which compares our data to other hospitals. A higher rate is better.
The percentage of babies born at Jessie McPherson Private Hospital with a healthy Apgar score is higher than the benchmark rate which is an excellent result considering the high number of complicated obstetric cases referred to the hospital.

Birth weight is a key indicator of infant health and wellbeing of the mother in pregnancy and a principal determinant of a baby’s chance of prospective survival, good health, development and wellbeing.
It is also an indicator of the quality of antenatal care provided to monitor fetal growth. Babies born at or after 40 completed weeks of gestational age (280 or more days after the first day of the last menstrual period) with a birth weight less than 2,750 grams are likely to have intrauterine growth restriction (IUGR). Poor fetal growth is associated with increased risks of fetal death and compromise in labour.
This data is submitted to the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program which compares our data to other hospitals. A lower rate is better.
The percentage of babies born in Jessie McPherson Private Hospital with birth weight less than 2,750 grams at 40 weeks gestation is lower than the benchmark which is an excellent result.

For women who have previously had a caesarean section, it is important to determine whether it is medically safe to attempt a vaginal birth. Caesarean sections can be potentially life-saving procedures, however they are associated with greater health risks for both the woman and her baby.
This indicator looks at the rate of women who plan a vaginal birth after a caesarean section and actually give birth vaginally.
This data is submitted to Safer Care Victoria as a Perinatal Service Performance Indicator which compares our data to other hospitals. A higher rate is better.
At Jessie McPherson Private Hospital, the rate of women who achieved a planned vaginal birth following a primary caesarean section is higher than the benchmark which is an excellent result and currently one of the best in the state.

One of the most effective ways to prevent infection spreading amongst patients is to ensure that all health professionals and anyone entering our facilities is engaged in good hand hygiene practice.
It is important to check that healthcare workers are using correct hand hygiene. Hand hygiene auditing is used at Jessie McPherson Private Hospital to monitor compliance against the critical times when hand hygiene should be performed in hospital. These are:
- Before touching a patient
- Before a procedure
- After a procedure
- After touching a patient
- After touching a patient’s belongings or surroundings
The graph below shows hand hygiene compliance for Jessie McPherson Private Hospital and compares this to the national benchmark of 80%.

Healthcare associated infections are a common and preventable risk to patient safety. Healthcare associated infections are infections that are either acquired in a healthcare facility, or occur as a result of healthcare interventions and are caused by micro-organisms such as bacteria and viruses. At Jessie McPherson Private Hospital we are committed to minimising the risk of infection to our patients, staff and visitors within our facilities.
One way we do this is by collecting data on hospital acquired infections and reviewing this data to identify any trends or patterns, so that we can identify and implement best practice to reduce the risks of infection occurring.

Influenza (flu) is a highly contagious and potentially severe disease. Influenza vaccination is the only preventative measure to protect ourselves, our patients and visitors. People who work with those that might be at risk of serious complications should be immunised to avoid spreading the flu.
Jessie McPherson Private Hospital monitors staff compliance with the influenza vaccination. The graph below shows the rate of permanent staff members who have received an influenza vaccination at Jessie McPherson Private Hospital.
This data is submitted to the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program which compares our data to other hospitals. A higher rate is better.
The benchmark rate is the national target set by the Department of Health. Jessie McPherson Private Hospital’s influenza compliance is equal or higher than the benchmark rate in all these years.

Patients are at an increased risk of falling when they are in hospital. Falls are a common cause of hospital-acquired injury and it is important to assess patients to determine if they are at risk of falling and to ensure measures are in place to prevent falls.
At Jessie McPherson Private Hospital we report and investigate every fall and ensure actions are in place to reduce the number of patient falls in hospital. The graph below shows the rate of falls at Jessie McPherson Private Hospital.
This data is submitted to the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program which compares our data to other hospitals. A lower rate is better and Jessie McPherson Private Hospital’s falls rate is lower than the benchmark rate.
Jessie McPherson Private Hospital is currently working on further reducing the number of falls through improvement projects implementing evidence based strategies.

In hospital, pressure injuries can sometimes occur when a patient is lying or sitting on a chair and unable to move easily for a long period. Pressure injuries are caused by unrelieved pressure, shearing or friction resulting in pain and damage to skin and sometimes underlying tissue.
On admission, an assessment is completed to determine if patients are at risk of developing a pressure injury. Many strategies are in place to prevent pressure injuries developing in hospital and all incidents are reported and investigated to monitor the success of prevention strategies and to ensure compliance with assessment and prevention.
The graph below shows the rate of pressure injuries reported at Jessie McPherson Private Hospital.
This data is submitted to the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program which compares our data to other hospitals.
