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.

February 2021 

The February 2021 Best Care Dashboard (Executive Summary) highlights continued high birthing activity with an average of 544 monthly births for the period July 2020 – February 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. When compared with the December 2020 Best Care Report, a 2.8% increase in routine patients receiving appointments within the recommended time is evident.

Western Health faces ongoing challenges with providing timely access to care at both Sunshine and Footscray Emergency Departments (EDs). Despite this, comparison of the percentage of Cat 1-5 patients seen within the recommended timeframe for the current and previous financial years indicates an equivalent rate for Footscray ED, and higher rates for Sunshine and Williamstown EDs in 2020/21.

Western Health Staphylococcus Aureus Bacteraemia (SAB) rate has continued to be high since August 2020.  The SAB rate is currently 1.3 and above the target per 10,000 bed days of equal to or less than 1.0.

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

February 2021

Complaints received in February 2021 were the highest in number for the previous 12 months.  In consideration of this, the rate of complaints closed within 35 days of receipt decreased for the January and February period. Communication, organisational issues, and quality of 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 rate 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.  Falls resulting in serious injury (per 10,000 episode) at Footscray Hospital increased by 4.4 in Q2 2020/21 when compared with Q1, and remain well above the rate for peer hospitals.

Rate of pressure injuries at Footscray Hospital reflect a pattern of reduction since August 2020, however, concerningly this rate remains well above target (pressure injury rate per 100 bed days). Pressure injuries per 10,000 episodes at Footscray Hospital remain well above the rate for peer hospitals.

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

February 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 indicating a pattern of decline when compared with 2019/20.

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 260 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.

The rates for ambulance transfers within 40 mins at Sunshine Hospital are favourable when compared with 2019/20 rates.  However, it remains a challenge to achieve an ambulance transfer within 40 minutes for one-third of our ambulance presentations to Sunshine and Footscray Hospitals.

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

February 2021

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).

Compliance with mandatory training has considerably reduced in all areas.  As of the end of February 2021, all areas of mandatory training were well below the 90% target.

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 Q1 2020/21 when compared with Q4 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.  Comparisons between Q1 and Q2 2020/21 reveals a 0.3 increase in the HAC rate for Footscray Hospital, 0.8 above the peer rate. 

While the rate of perineal lacerations per 10,000 vaginal delivery episodes remains above the peer rate, a decline in this rate has been evident throughout 2020/21.

February 2021

Western Health has classified 4 incidents as Sentinel Events YTD for 2020/21 and has recorded 3 ISR 1 incidents.  The number of Sentinel Events and ISR 1 incidents are lower than comparisons with February 2020, where 5 Sentinel Events and 6 ISR 1 incidents had been recorded and investigated. 

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 1.3 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 rates of medication complications and hospital acquired infections have increased in the past 12 months and remain well above the rates for peer organisations.

A decreasing number of monthly Adult Code Blue calls/1,000 admissions have been recorded during 2020/21.


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.