Knowing How We’re Doing

Every two months, a Western Health Best Care Report is generated to bring together data and commentary on how we are performing against Best Care.

The Reports contain individual dashboards for Person-Centred, Co-ordinated, Right and Safe Care, with a summary Best Care dashboard drawing key indicators from each.

Current and past Best Care Reports are available on this site.

Looking forward, we aim to develop this section to expand on Best Care reporting.

October 2020

The October 2020 Best Care Dashboard (Executive Summary) highlights continued high birthing activity with 547 the average monthly number of births for Q1 2020/21.  Percentage of full term babies considered in poor condition after birth continues to be low at Western Health – well below target and rates of peers.  The rate has decreased by 0.3% when compared with August Report.

The proportion of urgent patients receiving an initial outpatient appointment within 30 days continues to reflect a pattern of improvement, approaching the 100% target.

Western Health faces ongoing challenges with providing timely access to care at both Sunshine and Footscray Emergency Departments. The percentage of Cat 1-5 patients seen within the recommended timeframe is higher for the Footscray and Williamstown Emergency Departments when compared with 2019/20.

Western Health Staphylococcus Aureus Bacteraemia (SAB) rates were unusually high for August 2020.  The SAB rate is currently sitting at the target per 10,000 bed days of equal to or less than 1.0. SAB cases are being investigated and strategies implemented to further reduce this rate.

A significant reduction in patients admitted off the elective surgery waiting list has occurred and the COVID-19 response has directly impacted this metric.

October 2020

Complaints closed within 35 days of receipt reflects a pattern of considerable improvement for Q1 2020/21, increasing by 15.4%. Communication, quality of care, and access to services have been the most common complaint themes for 2019/20.  Complaints relating to institutional issues have increased during Q1 2020/21, with visitor restrictions during our COVID response being a large subgroup of these.

Rate of falls at Western Health remains consistently above target (falls rate per 100 bed days) for Footscray, Sunshine and Williamstown Hospitals.  While a pattern of decline for 2020/21 is evident for Sunshine and Williamstown Hospitals, this has not been reflected at Footscray Hospital.  Of particular concern is an uptick in falls resulting in serious injury per 10,000 episodes at Footscray Hospital during Q1 2020/21.  Comparisons with Q4 2019/20 reflect a rate increase of  7 for Footscray Hospital for Q1 2020/21, 9.7 above the peer rate.

Rate of pressure injuries at Footscray Hospital remain consistently well above target (pressure injury rate per 100 bed days). The rate of  pressure injuries per 10,000 episodes at Sunshine Hospital continues to remain below the peer rate.  Of concern is the uptick in rate of  pressure injuries per 10,000 episodes at Footscray Hospital, increasing by 9.8 during Q1 2020/21 when compared with Q4 2019/20.  

October 2020

The proportion of discharge summaries completed within 48 hours of discharge has improved during 2020/21 and is approaching the target of 80%.

Considering the increasing number of patients presenting with mental health conditions, the ongoing challenge for the Western Health EDs is to provide timely access to care. Reviewing 2020/21, Western Health has experienced a total of 147 patients stays >24 hrs, 88% of these being at Sunshine ED. All patient stays >24 hrs were related to patients presenting with mental health conditions.

Further reflecting the access challenges at Sunshine ED, the percentage of patients transferred to ED from the ambulance within 40 minutes remains lower at Sunshine Hospital when compared with Footscray Hospital. The rate of ambulance transfers within 40mins has decreased at Sunshine and Footscray by 1.5% and 1.6% respectively when compared with the August 2020 report.

Metrics reflecting access to elective surgery have been impacted by restrictions implemented as part of the response to the COVID-19 pandemic.

October 2020

Birthing activity continues to be high at Western Health and is pleasingly accompanied with positive performance when compared with peer hospitals for two key maternity indicators, Apgar and Fetal Growth Restriction (FGR).

Unfortunately compliance with mandatory training has reduced in all areas, with the exception of Neonatal Life Support (face to face) and Basic Life Support (face to face).  Blood Transfusion Practice (NMW) and Neonatal Life Support (face to face) are the only two areas that exceeded the 90% target at the end of October 2020.

The percentage of patients readmitted within 28 days of discharge reflects a pattern of increase at Footscray Hospital and remains above the peer rate.  The 28 day readmission rate at Sunshine Hospital continues to remain well below the HRT median.  

Western Health continues to perform above the state-wide target and peer health services for average again in Functional Independence Measure (FIM). The average gain in FIM improved at Western Health during Q4 2019/20 when compared with Q3 2019/20.

October 2020

Western Health has recorded 2 Sentinel Events YTD for 2020/21 and 1 ISR 1 incident.  The number of Sentinel Events and ISR 1 incidents are lower than comparisons with October 2019 where 4 Sentinel Events and 4 ISR 1 incidents had been recorded and investigated. 

Incident data reveals YTD for 2020/21, birthing, delayed care, falls and medication error are the incident categories that account for the largest number of ISR2 incidents and continue to be a focus area for improvement projects at Western Health.

Western Health Staphylococcus Aureus Bacteraemia (SAB) rates were unusually high for August 2020.  The SAB rate is currently sitting at the target per 10,000 bed days of equal to or less than 1.0. SAB cases are being investigated and strategies implemented to further reduce this rate.

A similar number of monthly Adult Code Blue calls/1,000 admissions have been recorded YTD during 2020/21.  A pattern of reduction in the number of monthly Adult MET calls/1,000 admissions is evident during 2020/21 YTD.


Results of the inaugural ABC

Inaugural Audit of Best Care Day was on Thursday 13 February 2020 

  • >240 audits were completed across the organisation
  • Auditing was made easier with audit tools customised to align with Live Best Care at WH and requirements of the NSQHS Standards
  • The previous audit comprised 158 questions in total.  ABC has been condensed to 30 questions that reflect our ability to provide Best Care for our patients
  • The ABC provides more timely access to data with staff using WoWs to complete the audit with results able to be filtered by Division and Ward on Sharepoint 
  • Staff were offered some delicious treats to help them during their audits –  Apples, Biscuits, and Chocolates.  More apples were selected at Footscray than any other site!
  • We are great at goal setting with 84% of patients/family/carers being involved with setting goals and developing a care plan
     Our bedside areas are looking good with 96% being clean and free from clutter
  • 97% of our patients were wearing a correct and legible identification band

In-house auditing presents advantages for Western Health staff, including greater flexibility with audit content and more timely access to data.  Staff using WoWs to complete the ABC means results are immediately available on SharePoint.  A summary of the results for each ABC question can be accessed through the link below, with results able to be filtered to Divisional and Ward Level.