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.

April 2021 

The April 2021 Best Care Dashboard (Executive Summary) highlights that patient experience with overall care during the COVID-19 pandemic, as measured through VHES since September 2020, is generally slightly higher at Western Health than peer organisations.  

Birthing activity has continued to be high with an average of 549 monthly births for the period July 2020 – April 2021.  Percentage of full term babies considered in poor condition after birth continues to be low at Western Health – well below target and rates of peer hospitals.

The proportion of urgent patients receiving an initial outpatient appointment within 30 days is approaching the 100% target. The percentage of routine patients receiving appointments within the recommended time continues to reflect a pattern of improvement, having increased by  1.5 % since the February Best Care Report.

Providing timely access to care at both Sunshine and Footscray Emergency Departments (EDs) continues to be a challenge.  Reflecting on the current and previous two financial years, the percentage of Cat 1-5 patients seen within the recommended timeframe has remained at around 50% for Sunshine ED, and has become an increasing challenge at Footscray ED with the percentage decreasing by 10%.

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

April 2021

The number of complaints received reflects a pattern of increase since November 2020.  The highest number of complaints for the 2020/21 FY were received in March and April 2021. In consideration of this, the rate of complaints closed within 35 days of receipt has decreased considerably since December 2020. Communication, organisational issues, quality of care, and timing/access to care have been the most common complaint themes for 2020/21.  Complaints relating to organisational issues have increased during 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 per 100 bed days) for Footscray, Sunshine and Williamstown Hospitals. Of particular concern is Williamstown Hospital where the rate of falls per 100 bed days persistently remains well above target. 

Rate of hospital associated pressure injuries at Western Health remains consistently above target (pressure injuries per 100 bed days) for Footscray and Sunshine Hospitals.  A concerning increase in pressure injuries at Williamstown Hospital is evident throughout this FY with the rate per 100 bed days currently above target. 

Both falls and pressure injuries continue to be a focus for improvement initiatives at Western Health.

April 2021

Western Health continues to face considerable access challenges.  This is reflected through the rate of ED presentations with a length of stay (LOS) less than 4 hours at Sunshine and Footscray EDs. A significant pattern of decline is event at Footscray ED where the percentage of patients with a LOS less than 4 hours has reduced by 18.4% when compared with the same time last year.

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 334 patients stays >24 hrs, 93% of these being at Sunshine ED. All patient stays >24 hrs were related to patients presenting with mental health conditions.

Achieving the 80% target for discharge summaries completed within 48 hours of discharge remains a challenge.

Reflecting the increasing access challenges at Footscray ED, the rate for ambulance transfers within 40 mins has reduced by 6.5% when compared with the same time last year.

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

April 2021

Compliance with mandatory training has increased in the all areas since February 2021, with the exception of Basic Life Support.  However, as of the end of April 2021, all areas of mandatory training were well below the 90% target.

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

The YTD percentage of babies in poor condition after birth (as indicated by the Apgar scores taken within 10 minutes of birth) is lower in the current FY, than both 2018/19 and 2019/20.

Major hospital acquired complication (HAC) rate at Footscray Hospital consistently remains above the rate of peer hospitals with high rates of pressure injuries per 10,000 episodes and falls resulting in serious injury per 10,000 being two of the main contributors.

The percentage of patients older than 75 years asked about their Advanced Care Directive (ACR) while at Western Health for care has shown no significant improvement throughout 2020/21 and has oscillated around an a mean of 64%.

April 2021

Western Health has classified 7 incidents as Sentinel Events YTD for 2020/21, the same number as the comparable time period in 2019/20.

The number of incidents with an ISR 2 YTD total 117, considerably higher than the 91 ISR 2 incidents recorded in the comparable period for 2019/20.

Incident data reveals YTD for 2020/21, birthing (mother) and delayed care are the 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) rate has continued to be high since August 2020.  The SAB rate is currently 1.2 and above the target per 10,000 bed days of equal to or less than 1.0. SAB cases are being investigated and organisational strategies implemented to further reduce this rate.

The number of high risk medication errors reflect an increase by 18 in both March and April 2021 when compared with March and April 2020.

A considerable increase in the rate of Code Blue calls/1,000 admissions is evident since January 2021.

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