Pine Rivers Private Hospital is fully accredited against the National Safety and Quality Health Service Standards (NSQHSS), a mandatory set of standards established by the Australian Government for all public and private hospitals.

Accreditation involves a visit to the hospital from an independent team of expert health professionals who review the quality and safety of services provided. This occurs every three years, in accordance with the Australian Commission on Safety and Quality in Health Care. The hospital is measured against eight overarching standards with many different criteria, including patient-centred care, medication management, clinical handover, infection prevention and staff education. Each item receives a rating, and recommendations for improvements may be made.

At the most recent survey in October 2025, Pine Rivers Private Hospital achieved full accreditation. The hospital's accreditation report can be viewed here.

Your Best Life - Our Best Care

 

 

Patient Experience at Pine Rivers Private Hospital – Driving Trust

At Pine Rivers Private Hospital, we understand the value of a positive patient experience is as important as achieving a positive clinical outcome. More than 70% of our patients are offered the opportunity to complete a patient experience survey at discharge or shortly after to evaluate the care that they received and their overall patient experience. Completion of our survey is voluntary and anonymous, with most surveys completed electronically. Patient experience surveying is continuous which provides feedback that is statistically more meaningful than short cycle surveying.  Annually, we receive more than 350 responses from patients who have completed a patient experience survey in our acute medical and surgical hospitals.

Our senior hospital staff have access to Pine Rivers Private Hospital's survey results via an electronic Patient Experience Portal. This allows for immediate review of feedback and to identify any opportunities for improvement. Maintaining anonymity, both positive and negative patient comments are shared with relevant team members who will work together to implement any required actions to improve overall patient experience.

Pine Rivers Private Hospital's patient experience surveys are monitored and reported at every level of corporate governance. Consumer Consultants are on the membership of clinical governance committees where patient feedback is reported.

The Story behind the Numbers - Our Patients, their Voice

We know that the numbers are only part of the story. In 2025, more than 50% of patients who returned a patient experience survey took the time to provide us with a comment. 
The key to being able to make meaningful change in patient experience is by analysing the patient comments, listening to the patient voice telling us their story. 

Continuous Patient Comment Analytics 

 

Patient and family trust in their healthcare providers and the system in which we deliver care is the biggest influence in creating a positive experience for our patients and their loved ones.  During Patient Experience Week in April 2025, Pine Rivers Private Hospital launched our “Driving Trust” Patient Experience Program. 

Continuously listening to the patient voice assists us in creating positive patient experiences and delivering care with caring to deliver excellence in both care and experience.
 
The Pine Rivers Private Hospital Patient Experience Monthly Driving Trust Report is month over month continuous reporting of key themes which are moments in the patient journey which our patients tell us are the main emotional drivers of patient experience. By listening to the patient voice, we are providing clear, actionable data which empowers our teams to make informed decisions that facilitate true co-design of care with our patients to deliver positive patient experiences and health outcomes. 
 

Relationship Centred Caring 

•    Relationship Centred Caring is the foundation of how Pine Rivers Private Hospital delivers healthcare, by connecting and caring for everyone 
•    All relationships are important – not just the clinical-patient/carer relationship
•    Value and respect the relationship as much as the outcome Relationship Centred Caring 
•    Belief that everyone contributes to the overall patient experience and the delivery of safe, quality care. 
•    Moments matter – make every moment count and take every opportunity to create a positive moment that matters
•    Deliver care with caring - Relationship-Centred Caring transfers focus from performing tasks, to building meaningful relationships to deliver care with caring.
•    Co-design of care - actively involving patients, caregivers, and healthcare professionals in the design and development and delivery of healthcare services.

 

At Pine Rivers Private Hospital, we measure the mental health of patients on admission and again on discharge, to see how they are improving. We use the internationally recognised HoNOS (Health of the Nation Outcome Scales), a tool which allows clinicians to assess various aspects of a patient's mental health, such as depression, anxiety or problematic behaviour.

The graph below shows the decrease in mental health problems in patients after treatment. The dark coloured bars represent mental health problems on admission to Pine Rivers Private Hospital. The pale coloured bars represent mental health problems on discharge. This is compared to the outcomes at other Australian private mental health facilities, shown in the grey bars.

HoNOS Scores

 

This graph shows that patients' mental health problems have decreased after treatment. On average, patients at Pine Rivers Private Hospital have achieved similar improvement to patients at other Australian private mental health facilities. In 2025, the scores on both admission and discharge were higher than in the comparison group, suggesting that problems were more severe, however the improvement from admission to discharge was significantly greater. 

 

Mental Health Questionnaires

It is also important to ask patients whether they think their mental has improved during their hospital admission. This is part of collecting patient-reported outcome measures (PROMs) and an important method of obtaining feedback on our services. We use the MHQ-14 (Mental Health Questionnaire), a PROMs tool, which asks questions about symptoms of fatigue, anxiety and depression and the impact of those in daily life.

The graph below shows the improvement in patients' self-assessed mental health ratings. The dark coloured bars represent the rating on admission to Pine Rivers Private Hospital. The pale coloured bars represent the ratings on discharge. This is compared to the outcomes at other Australian private mental health facilities, shown in the grey bars.

 

This graph shows that patients feel that their mental health has improved after treatment. On average, patients at Pine Rivers Private Hospital have achieved similar levels of improvement to patients at other Australian private mental health facilities. They generally rate their mental health at time of discharge more highly than the comparison group. 

What are we doing to improve mental health outcomes?

Pine Rivers Private Hospital employs a variety of strategies to improve our patients' mental health outcomes. These include:

• a multidisciplinary approach, including expert nursing and allied health professionals
• group therapy, counselling and other kinds of therapy
• regular review of patient medication to ensure it is optimal
• involving family and carers in treatment, with the patient's consent

If you are worried about your mental health, or that of someone close to you, there are people who can help you right now:

• Lifeline Australia - 13 11 14
• Kids Helpline - 1800 55 1800
• Mens' Line Australia - 1300 78 99 78
• Suicide Call Back Service - 1300 659 467
• Beyond Blue - 1300 224 636
• Veterans and Veterans' Families Counselling Service - 1800 011 046

Pine Rivers Private Hospital follows strict infection control procedures, and staff take every precaution to prevent infections. Specialised infection control staff collect and analyse data on infections in order to identify and implement best practices to reduce infection rates.

Patients with weakened immune systems, wounds or invasive devices such as drips are at greater risk of infection than the general public.

One of the infections that we closely monitor at Pine Rivers Private Hospital is Staphylococcus Aureus Bacteraemia, also known as SAB or 'Golden Staph.' SAB can cause skin infections, blood poisoning, pneumonia and other infections.

The graph below shows the number of Staphylococcus Aureus infections. The coloured bars represent Pine Rivers Private Hospital's rate. This is compared to the Australian government target shown in the grey bar. The national benchmark for SAB is no more than 1 case per 10,000 days of patient care.

 

 

This graph shows that there have been no cases of SAB infections at Pine Rivers Private Hospital in recent years.

To find out how we generated this data, see: Infection Rate Formulas

Methicillin is an antibiotic commonly used to treat Staph infections. Most cases of SAB respond to methicillin. These are known as MSSA, or methicillin-sensitive Staphylococcus Aureus. However, some cases of SAB are resistant and therefore more difficult to treat. These are called MRSA, or methicillin-resistant Staphylococcus Aureus.

We started reporting MSSA and MRSA rates separately in 2018. The graph below shows the number of MSSA and MRSA infections. The coloured bars represent the rate at Pine Rivers Private Hospital. This is compared to the rate in Australian public hospitals, as shown in the grey bars.

 

 

This graph shows that during the reporting period, there have been no cases of MSSA and MRSA infections at Pine Rivers Private Hospital.

What are we doing to prevent infection?

Pine Rivers Private Hospital employs a variety of strategies to prevent infections. These include:

• auditing how often and how well staff wash their hands using soap and water or hand sanitiser
• using gloves and specialised sterile equipment
• assigning a dedicated Infection Control Nurse responsible for educating staff and implementing infection control strategies
• using specialised disinfectants when cleaning facilities
• following national guidelines for high level disinfection and sterilisation processes
• placing hand sanitiser dispensers in public areas throughout our hospital so that they are readily accessible to staff, patients and visitors

What can you do to help?

At Pine Rivers Private Hospital, patients and visitors are part of the health care team. There are a number of things you can do to reduce the risk of infection for yourself and others:

• Wash your hands carefully with soap and water or use hand sanitiser upon entering and leaving the hospital. This is the most important way in which you can prevent the spread of infection.
• Cover your mouth and nose with a tissue when you cough or sneeze. Clean your hands afterwards - every time!
• If you do not have a tissue available, cough or sneeze into your elbow, not into your hand.
• As a patient, report any infection you have had, especially if you are still on antibiotics.
• Make sure you take the full course of antibiotics you have been given, even if you are feeling better
• If you have a dressing for a wound, keep the skin around the dressing clean and dry. Let the healthcare worker looking after you know promptly if it becomes loose or wet.
• Tell your healthcare worker if the area around any drips, tubes or drains inserted into your body becomes red, swollen or painful.
• Let the healthcare worker looking after you know if your room or equipment has not been cleaned properly
• Stop smoking before any surgery or procedure, as smoking increases the risk of infection.

Visitors

• Please do not visit if you have an illness such as a cough, cold or gastroenteritis ('gastro') or are feeling generally unwell.
• Wash your hands carefully with soap and water or use hand sanitiser when entering and leaving a patient's room.

For more information on how you can help, please read this Hand Hygiene Information Fact Sheet.

 

Hand Hygiene is another name for hand washing or cleaning. Good hand hygiene is an important part of infection control. Germs can survive on unwashed hands for over an hour, and we can unknowingly transmit bacteria and viruses to others.

All Healthscope staff are required to frequently wash their hands with soap and water or with waterless hand sanitiser. Both are equally effective. We follow the World Health Organization's guidelines for hand hygiene, which specify the following times when health care staff must wash their hands:

• before touching a patient
• after touching a patient
• before a procedure
• after a procedure
• after touching a patient's belongings or surroundings

At Pine Rivers Private Hospital, we use auditors who are accredited by Hand Hygiene Australia to record whether or not hand hygiene has been performed correctly.

The graph below shows the levels of hand hygiene compliance. The coloured bars represent Pine Rivers Private Hospital's rate. This is compared to the Australian national benchmark of 80%, shown in the grey bar.

This graph shows that there was a dip in hand hygiene compliance at Pine Rivers Private Hospital in 2022/23. Due to concerted efforts to improve this, the rates in 2024/25 were again well above the national benchmark.

When audits are performed, each professional group is checked - including doctors, nurses, cleaners and other hospital staff.

The first graph below on the left shows which groups were audited. The graph on the right shows the hand hygiene compliance rate for different staff within the hospital. It shows that the compliance rate for nurses and other staff has been higher than for doctors.

These graphs show excellent compliance rates across all three groups audited. 

What are we doing to improve hand hygiene compliance?

Pine Rivers Private Hospital employs a variety of strategies to improve hand hygiene compliance. These include:

• ongoing education programs for staff about infections and hand hygiene
• a designated Infection Control Nurse responsible for educating staff and implementing infection control strategies
• placement of hand sanitiser dispensers in convenient areas throughout the hospital, including hallways and patient rooms
• use of specially designed washbasins where water can be turned on and off without touching the tap

What can you do to help?

At Pine Rivers Private Hospital, patients and visitors are part of the health care team. Good hand hygiene is the most important way in which patients and visitors can prevent the spread of infection in hospital. There are a number of things you can do:

• Wash your hands carefully with soap and water or use hand sanitiser upon entering and leaving the hospital.
• Wash your hands carefully with soap and water or use hand sanitiser when entering and leaving a patient's room.
• Observe hospital signage about hand hygiene.
• If you are unable to find a hand sanitiser station, please ask staff for assistance.

For more information on how you can help, please read this Hand Hygiene Information Fact Sheet.

 

 

Falls are a leading cause of hospital-acquired injury and frequently prolong or complicate hospital stays. Patients may experience a fall because they are weakened by a medical condition or after an accident or injury.

The graph below shows the percentage of patients who have had a fall. The coloured bars represent Pine Rivers Private Hospital's rate. This is compared to the rate of falls at other Australian hospitals, shown in the grey bar.

This graph shows that in recent years, the rate of falls at Pine Rivers Private Hospital has been variable when compared to patients in other Australian private hospitals. While it was higher in 2023/24, it was on a par in 2025.

For a discussion on the data, see: Limitations of data

What are we doing to prevent patient falls?

Pine Rivers Private Hospital employs a variety of strategies to minimise the risk of patients falling. These include:

• provision of falls prevention information in the patient handbook and via brochures and notice boards
• risk assessments to identify patients at risk of falling
• review of patients falls risk when planning therapeutic outings and exercise activities
• ongoing staff education on falls prevention
• patient education on prevention of falls in hospital and at home
• use of safety equipment such as lifting hoists, walking aids and chair or bed sensors that alert staff when a patient at risk of falling gets up unassisted
• review of each fall to assess if there were any preventable factors

What can you do to help?

At Pine Rivers Private Hospital, patients and visitors are part of the health care team. You may like to print a brochure containing handy hints about preventing falls. You can also watch a helpful video.

Brochure: Don't Fall For It

Video: Speak Up reduce Your Risk of Falling

 

 

Safe medication management is important to us at Pine Rivers Private Hospital. There are many systems in use throughout the hospital to support and promote safety for supplying and administering medications, as well as monitoring their effects.

Staff at Pine Rivers Private Hospital follow strict guidelines to ensure that all medications are administered safely and correctly. We adhere to the 7 Rights of Medication Administration:

• The Right Person
• The Right Documentation and clinical context
• The Right Drug
• The Right Dose
• The Right Date/Time
• The Right Route
• The Right to Uninterrupted Medication Administration

Errors in medication administration are captured in the hospital’s incident reporting system and investigated.

The graph below shows the rate of medication errors which required intervention. The coloured bars represent the rate at Pine Rivers Private Hospital. This is compared against the rate in other Australian hospitals, shown in the grey bar.
 

 

This graph shows that in recent years, the rate of medication errors requiring intervention at Pine Rivers Private Hospital has been above the Industry Rate. A new staff education module has been rolled out to address this. 

What are we doing to reduce the risk of medication errors?

Pine Rivers Private Hospital employs a variety of strategies to reduce the risk of medication errors. These include:

• annual medication competency training for staff involved in medication management
• regular audits covering all aspects of safe medication management
• ongoing staff training by Pharmacists and other relevant professions
• implementation of Healthscope-wide policies and procedures which ensure safe medication management
• use of the Pharmaceutical Benefits Scheme Hospital Medication Chart (PBS HMC) for prescribing medications, in accordance with the Australian Commission on Safety and Quality in Health Care
• labelling of medications as per the National Standard for User-Applied Labelling of Injectable Medicines, Fluids and Lines
• use of Australia’s National ‘Tall Man Lettering’ List in medication store rooms to better distinguish between medications that have similar names
• access to resources that assist with safe medication management, e.g. MIMS Online, Therapeutic Goods Administration, Clinical Excellence Commission and Australian Commission on Safety and Quality in Health Care
• recording of all medication incidents and near misses in the hospital’s incident reporting system
• staff completing a self-reflection tool after any medication incident
• formal review of each medication error to identify contributing factors and prevent it from recurring

What can you as a patient do to help?

We encourage you to bring an up-to-date list of your current medications to hospital with you. This should include the name of the medication, the dose and when, how and why you are taking it. Please give this list to your nurse or doctor when you are admitted. If you bring your own medications into hospital with you, these have to be checked and documented by staff. It is important that you talk to your nurse or doctor if you are uncertain or concerned about any of your medications.