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.

August 2021 

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

  • Hospital Diagnosis Standardised Mortality Ratio (HDxSMR) reflects a pattern of decline at both Sunshine and Footscray Hospitals –with Footscray well below the HRT and Victorian ratios
  • Birthing activity continues to be high and the percentage of full term babies considered in poor condition after birth continues to be low
  • Restrictions to patients admitted off the elective surgery have been applied as part of the COVID-19 response

August 2021

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

  • Complaint numbers remain high and the rate of complaints closed within 35 days of receipt remains well below target
  • Factors contributing to the rate of malnutrition and delirium at Footscray Hospital being higher than the peer rate are for inclusion in the current and December Best Care variation reporting
  • A summary of factors contributing to the rate of persistent incontinence at Sunshine Hospital being higher than the peer rate are for inclusion in the December Best Care variation reporting
  • The rate of falls per 100 bed days reflects a pattern of reduction at all sites throughout 2021.  In particular, a considerable reduction in falls/100 bed days from June 2021 is evident at Williamtown Hospital  
  • Rate of hospital associated pressure injuries per 10,000 episodes at Footscray Hospital increased by 1.1 in Q4 2020/21, and decreased by 1.3 at Sunshine Hospital.  Rate of pressure injuries at Footscray Hospital remains above target and peer rates

August 2021

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

  • Western Health continues to face considerable access challenges
  • Restrictions to patients admitted off the elective surgery have been applied as part of the COVID-19 response
  • The proportion of routine patients receiving an initial outpatient appointment within the recommended time continues to improve, and is approaching target

August 2021

The August 2021 Right Care Dashboard highlights the following:

  • Compliance with mandatory training continues to improve for all areas
  • There was a reduction the percentage of patients undergoing surgery for their fractured neck of femur with 48 hours throughout Q4 2020/21
  • 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 rate of postpartum haemorrhage >1,500ml associated with emergency caesarean reflects a pattern of reduction, as does the overall rate (all birth types) and compares favourably against the 2.5% target

August 2021

The August 2021 Safe Care Dashboard highlights the following:

  • 17 incidents with an ISR 2 YTD compared with 31 ISR 2 incidents within the comparable time period in 2020/21
  • Incident data for 2021/22 indicates deteriorating patient, birthing (baby), delayed care, infection, and medication complications are the categories that account for the largest number of ISR 1 & 2 incidents and continue to be a focus for improvement projects at Western Health
  • Rate of hospital associated infections per 10,000 episodes at Sunshine Hospital reduced by 9.9 in Q4 and remains well below the peer rate. The 13.3 increase for this rate at Footscray Hospital in Q4 has raised the hospital associated infection rate at Footscray Hospital above the peer rate
  • The rate of medication complications per 10,000 episodes at Footscray Hospital in Q4 increased by 7.8 and is now above the peer rate

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