BEST CARE DASHBOARD DECEMBER 2019 Executive Summary WH

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BEST CARE DASHBOARD DECEMBER 2019 – Executive Summary WH 100 60 Sep-18 Dec-18 Mar-19

BEST CARE DASHBOARD DECEMBER 2019 – Executive Summary WH 100 60 Sep-18 Dec-18 Mar-19 Surgery ICU Fall Birthing Medication 1 2 3 Actual 1. 0 0. 9 Target 0. 8 0. 6 100 0. 7 0. 0 4 Nov Dec 2. 2 70. 2 71 73 Sep-18 Dec-18 Mar-19 Jun-19 Sep-19 28 Day Readmission Rate (HRT) (previous 12 mths for each date) 8. 4 FH Peer 8. 1 7. 7 7. 5 5. 7 5. 6 Mar-19 Jun-19 6. 8 5. 5 SH 98 96 69 3. 0 FH WH Sentinel events YTD = 5 98 Vic 65 8. 3 3. 0 101 HRT SH 4. 0 0. 0 FH 65 5. 0 0. 5 Sep-19 Major hospital acquired complication rate (HRT) 2018 Oct – 2019 Sep 2. 0 Jul 72. 2 Sep-18 Dec-18 Mar-19 Jun-19 Sep-19 1. 5 70. 6 71. 75 74. 83 88. 2 Jun-19 Infection Prevention - SAB Rate YTD 2019/20 ISR 1 Incidents YTD = 5 0 60 50 ISR 1 Incidents The Best Care Report provides an overview of the 5 adverse patient events YTD with an incident severity rating (ISR) of 1. 70 89. 9 70 88. 1 80 SH Peer Hospitals 80 Footscray Hospital’s Standardised Mortality Ratio (SMR) continues to be well below the Victorian and HRT medians. A pattern of reduction is evident for Sunshine Hospital over the 2018/19 financial year, however, this remains above the HRT median. The percentage of patients readmitted within 28 days of discharge has reduced at both Sunshine and Footscray Hospitals and remains well below the HRT median at Sunshine Hospital. WH 90 Staphyloccus Auerus Bacteraemia (SAB) rates at Western Health continue to be below target and Western Health has not recorded any CLABSIs this financial year. Western Health faces ongoing challenges with providing timely access to care at both Sunshine and Footscray Emergency Departments. Enhancing access is a focus of a number of improvement initiatives across the organisation. Peer Hospitals 91. 3 The December 2019 Best Care Dashboard (Executive Summary) highlights continued high birthing activity at Western Health that exceeds predicted. The high number of births is pleasingly accompanied with Apgar scores reflecting the percentage of full-term babies considered in poor condition remains below target and peer hospitals. 89. 9 Commentary Standardised Mortality Ratio (HRT) (previous 12 mths from each date) Inpatient Satisfaction with Discharge Planning (VHES) Inpatient Satisfaction with Overall Care (VHES) Peer Hosp Jun-18 Sep-18 Dec-18 CLABSI Number YTD = 0 Babies in poor condition after birth (Apgar) Cat 1 -5 ED patients seen within recommended timeframe OP first appointment within recommended time YTD Patients Admitted off the ESWL 2 80 1. 5 1 0. 5 Western Health 3, 409 70 0. 9 0. 8 0. 9 60 50 0 2017/18 2018/19 2019/20 YTD WH Target Months YTD births > capacity = 5/6 48. 2 67 49. 2 62. 5 2017/18 2018/19 2019/20 YTD 45. 6 58. 6 40 SH FH DHHS Target 88. 6 87. 2 60. 5 56. 2 2017/18 2018/19 Urgent Target 82. 5 87. 2 2019/20 YTD Routine Target DHHS Target (>) 4, 337 2, 000 3, 000 4, 000 5, 000

PERSON-CENTRED CARE DASHBOARD DECEMBER 2019 Rate of falls at Western Health remains consistently well

PERSON-CENTRED CARE DASHBOARD DECEMBER 2019 Rate of falls at Western Health remains consistently well above target (ACHS aggregate falls rate per 100 bed days). The rate of falls resulting in serious injury at both Footscray and Sunshine Hospitals remains above the HRT median, however, a focus of improvement initiatives at Footscray Hospital and the positive impact of these is reflected in a reduction in the rate of falls resulting in serious injury over the past Qtr and 12 months. Hospital-acquired pressure injuries per 100 bed days remain above the ACHS aggregate rate. Removal of Stage 1 pressure injuries from submitted data, aligning with data practices at other organisations, has been approved and will facilitate more equitable comparisons in future. Complaints and Compliments 2019/20 Dec-18 Mar-19 Jun-19 Sep-19 Communication Oct Nov Complaints - prev yr Compliments - curr yr Compliments - prev yr 0. 90 8 0. 70 0. 50 0. 30 6 0. 67 0. 63 0. 62 0. 63 0. 61 4 0. 0% 10. 0% Falls resulting in serious injury per 10, 000 episode (HRT) 4. 08 2. 84 Actual Aug Sept Oct Nov Dec Previous Yr Serious Falls YTD = 11 Target 0 2. 74 2018 Oct-2019 Sep Footscray Latest Qtr Peer 70. 9% Jul 50. 0% 68. 4% 69. 3% 66. 8% Aug Sep Oct Actual 71. 7% 73. 1% Nov Target 10 7. 06 5. 21 5 0. 08 Jul Aug Sep Oct Nov Dec Actual Previous Yr Serious PIs YTD = 1 Dec Pressure Injuries per 10, 000 episodes (HRT) 0. 11 0. 05 Sunshine 40. 0% 0. 14 2 Jul 30. 0% Hosp-acquired Pressure Injuries per 100 bed days YTD 2019 -20 6. 44 6. 88 5. 34 20. 0% 70% 60% Quality Complaints - curr yr Falls per 100 bed days YTD 2019 -20 Safety Dec Sep-19 80% Timing/Access Sep Jun-19 90% 50 Aug Mar-19 100% Caring Jul Dec-18 Complaints closed within 35 days YTD 2019 -20 Patient Rights 100 0 50 Institutional Issues 150 Sep-18 65 Complaints by Theme (as a %) YTD 200 84. 6 Sep-18 85. 3 Sep-19 83. 55 Jun-19 80 85. 5 Mar-19 Peer Hospitals 85. 98 Dec-18 WH 95 60. 4 Sep-18 Peer Hospitals 58. 1 60 88. 2 70 89. 9 80 88. 1 90 WH 60. 93 75 60 45 30 15 0 60. 1 Peer Hospitals 61. 71 WH 100 Inpatient satisfaction with being treated with respect and dignity (VHES) Inpatient satisfaction with involvement in care decisions (VHES) 91. 3 All feedback is an opportunity to improve clinical practice and our ability to provide Best Care for our patients, families and carers. The number of compliments received for December 2019 has more than doubled when compared with December 2018. This is hypothesised to reflect more open avenues of communication between Western Health, our patients and their families/carers and improvements in person-centred care provision. Achieving the target of 95% for complaints closure within 35 days remains a challenge, however, improvements in the closure rate are noted over the past 3 months. Inpatient Satisfaction with Overall Care (VHES) 89. 88 Commentary Target 0 2. 17 1. 78 2. 42 Sunshine 2018 Oct-2019 Sep 3. 65 Footscray Latest Qtr Peer

CO-ORDINATED CARE DASHBOARD DECEMBER 2019 Western Health faces ongoing challenges with providing timely access

CO-ORDINATED CARE DASHBOARD DECEMBER 2019 Western Health faces ongoing challenges with providing timely access to care. Patients stays >24 hours at our EDs totalled 31 for the 2018/19 financial year. Reviewing the first half months of the 2019/20 financial year reveals a total of 115 patients stays >24 hrs, 97% 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. On a positive note, the proportion of urgent patients receiving an initial outpatient appointment within 30 days has improved by 26% when compared with June 2019 and reflects a pattern of improving patient access to outpatient appointments. Discharge Summaries completed within 48 hours of discharge YTD Emergency Patient Satisfaction with Discharge Planning (VHES) 80 80% 78% 75% 80 70 70% 50 70. 2 70. 6 60 Peer Hospitals 72. 2 WH 71. 75 The percentage of category 1 -3 patients admitted from the Elective Surgery Waiting List within the recommended timeframe, while remaining consistently above target over the previous year, suffered a reduction to be below the 94% target in August 2019. Pleasingly this rate reflects a pattern of improvement since this time and reached target in December 2019. Inpatient Satisfaction with Discharge Planning (VHES) 74. 83 Commentary Sep-18 Dec-18 Mar-19 Jun-19 75% Jul Aug Actual Sep Oct 56. 9 100 56. 2 58. 2 2017/18 SH 55. 8 54. 1 FH 40 60 18 50 [VAL UE] 13 20 0 DHHS Target Sunshine 40 Footscray 48. 2 67 2017/18 SH YTD Patients Admitted off the ESWL Western Health 3291 Western Health 2 DHHS Target (>) 1 4337 4, 337 2000 3000 4000 5000 1 Jun-19 Sep-19 YTD Ambulance Transfers within 40 minutes 2019 -20 2 3 4 Thousands 5 6 45. 6 58. 6 2018/19 94% 92% FH 92. 8% 91. 7% 61. 2 93. 5% DHHS Target Sunshine 94. 0% 88. 6 91. 8% Sep Actual Oct Nov Target Footscray OP first appointment within recommended time 60. 5 Aug 75. 1 2019/20 YTD ESWL Cat 1 -3 pts admitted within recommended timeframe 90% 0 Dec-18 Mar-19 69. 5 49. 2 62. 5 96% 3, 409 DHHS Target (<) Sep-18 68. 7 patient stays >24 hrs YTD = 115 Elective Surgery Wait List Number 50 70 [VAL UE] 60 2018/19 2019/20 YTD Dec 80 80 49 Peer Hospitals 70 75% YTD Cat 1 -5 ED patients seen within recommended timeframe 120 80 70 60 50 40 Nov Previous Yr YTD Patient stays >24 hrs ED Presentations with a LOS <4 hrs (%) YTD 76% 75% WH 60 65% Sep-19 77% Dec 87. 2 82. 5 87. 2 56. 2 2017/18 2018/19 Urgent Target 2019/20 YTD Routine Target

RIGHT CARE DASHBOARD DECEMBER 2019 95 Rate of perineal lacerations for 10, 000 vaginal

RIGHT CARE DASHBOARD DECEMBER 2019 95 Rate of perineal lacerations for 10, 000 vaginal delivery episodes remains above the HRT median with this area being a focus of a number of improvement initiatives. 81. 1 78. 2 Sep-18 Dec-18 Mar-19 Jun-19 Sep-19 8. 4 8. 3 Peer 8. 1 7. 5 5. 7 5. 6 6. 8 5. 5 Jun-18 Sep-18 Dec-18 Mar-19 Babies in poor condition after birth (Apgar) 2 50. 0% 60. 0% 70. 0% 1. 5 7. 7 80. 0% 1. 024 0. 5 Apgar Oct 2018 – Sep 2019 (Target: <=1. 4) 40. 0% 6% 4. 7% 3. 4% 3. 2% 3. 4% 0. 645 4. 2% 0% Jul Aug Sep Oct Nov Dec Perineal laceration during delivery per 10, 000 vaginal delivery episodes (HRT) 2017/18 2018/19 2019/20 YTD WH 0. 8 Sunshine Mercy RWH Monash 80 70 16. 8 15 Target Months YTD births > capacity = 5/6 Sunshine Mercy Maternity Patient Rating of overall Care (VHES) Jul - Sep 2019 90 332. 6 31. 3 12. 7 RWH Monash FH Peer Hosp 100 500 1. 5 1. 4 1. 6 SH WH 0. 9 3. 0 2. 2 0. 0 Target (>) Fetal Growth Restriction Oct 2018 – Sep 2019 (Target: <=28. 6) 90. 0% 3. 0 589. 3 608. 3 0. 8 80. 0% 4. 0 1000 0. 9 70. 0% Major hospital acquired complication rate (HRT) 2018 Oct – 2019 Sep 1. 0 1 0 60. 0% 2. 0 1. 5 0. 5 50. 0% 2% 0 WH 90. 0% Patients over 75 with an Advance Care Directive 2019 -20 YTD 4% 1 Jun-19 Basic Life Support – Face to Face Aseptic Non Touch Technique Average gain in Functional Independence Measure for Rehab patients Q 4 2018 -19 28 Day Readmission Rate (HRT) (previous 12 mths from each date) FH Back 4 Life – Patient Handling Blood Transfusion Practice (JMS) 40. 0% SH Neonatal Life Support – Face to Face Blood Transfusion Practice (NMW) 75. 37 50 Western Health continues to performs above the state-wide target and peer health services for average again in Functional Independence Measure (FIM). Neonatal Life Support - Online Epidural Analgesia 65 As the indicator of demand, the monthly birth rate has continued to be higher than predicted for five of the six months in 2019/20. Life Support Training Compliance (as at end of Dec 2019) Fetal Surveillance Peer Hospitals 80 The percentage of patients readmitted within 28 days of discharge has reduced at both Sunshine and Footscray Hospitals and remains well below the HRT median at Sunshine Hospital. Western Health continues to have positive performance when compared with peer hospitals for two key maternity indicators, condition of babies after birth (Apgar) and Fetal Growth Restriction (FGR). Western Health consistently performs better than the state-wide target for both metrics. WH 81. 7 Generally compliance with mandatory training and life support training are improving. Blood Transfusion Practice (nursing and midwifery) and Back 4 Life (Patient Handling) exceeded the 90% target in December 2019 and a number of areas are approaching target. Mandatory Training Compliance (as at end of Dec 2019) Inpatient Rating re Doctors & Nurses working together (VHES) 80. 86 Commentary 0 Last Qtr 92. 1 60 Sunshine 2018 Oct-2019 Sep 88. 2 Peer 50 Sunshine Peer Group

SAFE CARE DASHBOARD DECEMBER 2019 Commentary Standardised Mortality Ratio (SMR) at Footscray Hospital continues

SAFE CARE DASHBOARD DECEMBER 2019 Commentary Standardised Mortality Ratio (SMR) at Footscray Hospital continues to be well below the Victorian and HRT medians. Sunshine Hospital’s SMR continues to be higher than the HRT median, however, pleasingly reflects a pattern of reduction. Medication complications per 10, 000 episodes at Footscray and Sunshine Hospitals decreased over the past quarter. Reduction in medication complications at Footscray for Qtr 1 2019/20 meant this rate has pleasingly reduced below the HRT median. Sunshine Hospital compares favourably to the HRT median for medication complications per 10, 000 episodes. Major hospital acquired complication rate at Sunshine Hospital continues to remain below that of peer hospitals. The rate of hospital acquired infection at both Sunshine and Footscray Hospitals compares favourably against the HRT median. Staphyloccus Auerus Bacteraemia (SAB) rates at Western Health continue to be below target and Western Health has not recorded any CLABSIs this financial year. An overview of the adverse patient events with an incident severity rating (ISR) of 1 or 2, and the 5 Sentinel Events reported YTD are provided within the following pages. Standardised Mortality Ratio (HRT) (previous 12 mths from each date) Adverse Patient Events ISR 2 ISR 1 Incidents YTD = 5 2019 People Matter Survey – Patient Safety Culture ISR 2 Incidents YTD = 38 SH FH 101 100 HRT 98 Surgery ICU Fall Birthing Medication Vic 96 98 65 65 69 71 73 Sep-18 Dec-18 Mar-19 Jun-19 Sep-19 Major hospital acquired complication rate (HRT) 2018 Oct – 2019 Sep 5. 0 4. 0 3. 0 2. 0 1. 0 0 1 2 3 Other Birthing (mother) Birthing (baby) Falls Infection 4 Medication Error Delayed Care Sentinel events YTD = 5 Medication Complications per 10, 000 episodes (HRT) 40 0 2 4 6 8 Hospital acquired Infection per 10, 000 episodes (HRT) 150 121. 2 100 20 3. 0 2. 2 SH Sunshine Infection Prevention - SAB Rate YTD 2019/20 1. 5 1. 0 Actual 0. 9 Target 0. 8 0. 6 0. 7 0 Dec CLABSI Number YTD = 0 Peer Deteriorating Patient Incidents YTD Prev Yr 0 80 0. 0 Nov Latest Qtr 62 Jul 67 Aug 75 Sep 122. 9 121. 7 Sunshine Footscray 2018 Oct-2019 Sep Latest Qtr Peer Footscray Actual 120 40 Sep 93. 3 87. 1 112 High Risk Medication Errors 0. 5 Jul 50 28. 2 29. 4 0 2018 Oct-2019 Sep Peer Hosp 35. 2 12. 4 10. 7 0 FH WH 28. 8 10 SAE for unrecognised clinical deterioration 0 Failure to respond to UCR 59 Oct 50 52 Nov Dec ISR 1&2 Medication Incidents YTD = 15 0 0 Failure to escalate (TBC) 1 2 3 4 Question Actual Target I am encouraged by my colleagues to report any patient safety concerns 95% 80% Patient care errors are handled appropriately 94% 80% My suggestions about patient safety would be acted upon 90% 80% The culture in my work area makes it easy to learn from errors 89% 80% Management is driving us to be a safety centred organisation 91% 80% This health service does a good job of training new and existing staff 85% 80% Trainees in my discipline are adequately supervised 85% 80% I would recommend a friend or relative to be treated as a patient here 89% 80% Safety culture among healthcare workers 90% 80%

Clinical Governance: Std 1 Partnering with Consumers: Std 2 Infection Prevention: Std 3 Medication

Clinical Governance: Std 1 Partnering with Consumers: Std 2 Infection Prevention: Std 3 Medication Safety: Std 4 Comprehensive Care: Std 5 Communicating for Safety: Std 6 Blood M’ment: Std 7 Acute Deterioration: Std 8