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.

December 2021 

The December 2021 Best Care Dashboard (Executive Summary) highlights the following:

  • Following redesign of the state-wide patient satisfaction survey process, VHES results for Q1 21/22 across a range of indicators reflect a high rate of positive patient responses.
  • There were no IS1/2 events over November – December 2021, with the cumulative number of ISR2s considerably lower than for the same time last year. There is however an increase in categorised ISR1 events YTD, 4 of which have been reported as Sentinel Events.
  • Although above target at the start of 2021/22, the SAB rate is currently sitting slightly below the target per 10,000 bed days of equal to or less than 1.0
  • WH continues to face considerable access challenges, including consistently achieving timely ambulance transfers and length of stay for patients presenting for mental health care.
  • Birthing activity continues to be high and the percentage of full term babies considered in poor condition after birth continues to be lower than targeted threshold.
  • COVID-19 restrictions are having a marked impact on the number of patients admitted off the elective surgery waiting list and ESWL number.

December 2021

The December 2021 Person-Centred Care Dashboard highlights the following:

  • VHES results for Q1 21/22 reflect a high rate of positive responses from adult inpatients when asked about their overall care.
  • Complaint numbers remain high and the rate of complaints closed within 35 days of receipt remains well below target. A complaints processing blitz and rapid system redesign is currently being undertaken to address the backlog of unclosed complaints.
  • The Health Roundtable (HRT) indicator on malnutrition has been expanded to cover both malnutrition and hypoglycaemia.
  • An increase in the rate of falls at Williamstown Hospital is informed by the cessation of surgical services at this site as part of the COVID surge plan. Surgical patients rarely fall and it’s not uncommon for GEM patients to fall, hence the increase in the falls rate at Williamstown from October.

December 2021

The December 2021 Co-ordinated Care Dashboard highlights the following:

  • WH continues to face considerable emergency access challenges, including length of stay for patients presenting for mental health care.
  • It is flagged January 2022 data on patient ED stays >24hrs will include non-mental health patients. A review of these cases has been undertaken, with contributing factors including above average ED presentations, significant decrease in discharge numbers over a three day (public holiday) weekend and allocation to beds being restricted by COVID cohorting requirements.
  • Consistently achieving ambulance transfers within 40 minutes continues to be a challenge with a significantly lower rate informed by higher ambulance attendance at both FH and SH YTD in 2021/22 when compared with 2020/21.
  • COVID-19 restrictions are having a marked impact on the number of patients admitted off the elective surgery waiting list and ESWL number. The YTD ESW Cat 1-3 admitted within recommended timeframe indicator looks positive because only Cat 1 patients were admitted off the wait list in October, November and December.
  • Patient satisfaction ratings on discharge planning are comparable or better than peers for Q1 2021/22.
  • With the assistance of telehealth, good performance against the timeliness of outpatient first appointment within recommended time has been maintained.

December 2021

The December 2021 Right Care Dashboard highlights the following:

  • Mandatory training compliance is challenging in COVID times, however performance has remained stable, with the lowest rated training compromised due to face-to-face delivery mode.
  • Format for displaying emergency surgery performed <48hrs for #NOF changed to a line chart with an 80% target. Q1 VAHI (PRISM) reporting shows comparable performance compared to peers.
  • Following an unfavourable variation in Q4 2020/21, the average change in functional independence measure (FIM) per day of care for rehabilitation patients is again positioned comfortably above target. The Division of Allied Health is reviewing possible contributory factors to the unfavourable variation from Q4 2020/21 and will report their findings to the Best Care Steering Committee.
  • VHES results for Q1 2021/22 reflect a high rate of positive responses from adult inpatients regarding staff working as a team to provide care, and overall care received by maternity patients.
  • Birthing activity continues to be high at Western Health, but with positive performance against targets and peers for two key maternity indicators, Apgar and Fetal Growth Restriction (FGR).
  • W&C have reviewed the spike in reportable Elective Caes. PPHs. 2 of the 4 cases were just above the cut off for reporting and besides all 4 being complex cases, there was no identified trend/attributable cause for the spike.
  • While the HRT perineal laceration rate during delivery is higher than peer average, it has significantly reduced over the past 12 months. 

December 2021

The December 2021 Safe Care Dashboard highlights the following:

  • There were no IS1/2 events over November – December 2021, with the number of ISR2s considerably lower than for the same time last year. There is however an increase in categorised ISR1 events YTD, 4 of which have been reported as Sentinel Events.
  • Although above target at the start of 2021/22, the SAB rate is currently sitting slightly below the target per 10,000 bed days of equal to or less than 1.0
  • It is noted VicNISS has suspended surveillance monitoring due to COVID activity but Western Health will continue to collect SAB and CLABSI data in-house.
  • High MET numbers in October co-incide with a spike in ICU bed utilisation with the latest COVID surge. Numbers have remained above average in November and December. This increase in numbers is also attributable to very high acuity across COVID wards, especially at Sunshine Hospital.
  • It is noted VAHI have recalculated the People Matter Survey – Patient Safety Culture rates to match how PMS results are directly reported to Health Services. This has resulted in lower reported rates and state-wide targets.

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.  

Audit-of-Best-Care-ABC_Summary-of-Results_February2020_LBCsite