BEST CARE DASHBOARD FEBRUARY 2020 Executive Summary 100

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BEST CARE DASHBOARD FEBRUARY 2020 – Executive Summary 100 WH 60 100 Dec-18 Mar-19

BEST CARE DASHBOARD FEBRUARY 2020 – Executive Summary 100 WH 60 100 Dec-18 Mar-19 Jun-19 Actual 0, 9 0, 5 Medication 0, 6 0, 0 4 0, 8 Sep Nov 72, 7 70, 2 72, 2 2, 0 1, 0 Jan 69 71 73 сен-18 дек-18 мар-19 июн-19 сен-19 28 Day Readmission Rate (HRT) (previous 12 mths for each date) Feb FH 8, 4 8, 1 3, 0 2, 2 0, 5 0, 9 Peer Hosp июн-18 сен-18 OP first appointment within recommended time Cat 1 -5 ED patients seen within recommended timeframe 2017/18 2018/19 2019/20 YTD WH 60 50 0 Target Months YTD births > capacity = 6/8 5, 7 5, 6 мар-19 июн-19 FH дек-18 YTD Patients Admitted off the ESWL Western Health 9, 075 70 0, 7 7, 5 5, 8 80 0, 9 7, 7 6, 8 5, 5 SH Peer 2 1 98 96 CLABSI Number YTD = 0 Babies in poor condition after birth (Apgar) 1, 5 Vic 65 8, 3 3, 0 1, 0 WH Sentinel events YTD = 5 98 SH 4, 0 0, 0 Jul 101 HRT 65 5, 0 Target 0, 9 Sep-19 Dec-19 Major hospital acquired complication rate (HRT) 2018 Oct – 2019 Sep 1, 0 Birthing 3 Dec-18 Mar-19 Jun-19 Dec-19 1, 5 Surgery ICU Fall 2 70, 6 71, 8 90, 5 60 Infection Prevention - SAB Rate YTD 2019/20 ISR 1 Incidents YTD = 6 1 Sep-19 FH 70 50 ISR 1 Incidents 0 88, 2 70 SH Peer Hospitals 80 89, 9 80 The Best Care Report provides an overview of the 6 adverse patient events YTD with an incident severity rating (ISR) of 1. In relation to elective surgery, Western Health has provided good access with patients admitted off the elective surgery waiting list aligning with the Statement of Priorities (SOP) target. Peer Hospitals 90 Western Health Staphyloccus Auerus Bacteraemia (SAB) rates have reflected a pattern of increase since November 2019. The target for health-associated SAB infections per 10, 000 bed days is equal to or less than 1. 0. The Western Health SAB rate is currently 1. 0. 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. WH 88, 1 The February 2020 Best Care Dashboard (Executive Summary) highlights continued high birthing activity at Western Health. While birthing activity has exceeded target for the majority of months YTD, the high number of births is pleasingly accompanied with Apgar scores reflecting a low rate of full-term babies considered in poor condition. 91, 3 Commentary Standardised Mortality Ratio (HRT) (previous 12 mths from each date) Inpatient Satisfaction with Discharge Planning (VHES) Inpatient Satisfaction with Overall Care (VHES) 89, 9 48, 2 63, 8 47, 9 2017/18 2018/19 2019/20 YTD 62 46, 7 57 40 SH FH DHHS Target 87, 8 60 56, 4 2017/18 2018/19 Urgent Target 82, 4 87, 4 2019/20 YTD Routine Target 9, 096 DHHS Target (>) 5 6 7 8 9 10 Thousands

PERSON-CENTRED CARE DASHBOARD FEBRUARY 2020 Feedback in the form of compliments continues to be

PERSON-CENTRED CARE DASHBOARD FEBRUARY 2020 Feedback in the form of compliments continues to be received in higher numbers when compared with the same period in 2018/19. Complaint numbers are relatively similar for February 2020 and 2019. Achieving the target of 95% of complaints closed within 35 days of receipt remains a challenge. Quality of care, access to services and communication remain the most common complaint themes. Rate of falls at Western Health remains consistently well above target (ACHS aggregate falls rate per 100 bed days). However, comparisons between 2018/19 and 2019/20 reveal the rate of falls at Western Health has been consistently lower during 2019/20. Complaints and Compliments 2019/20 Jun-19 Sep-19 Dec-19 Complaints by Theme (as a %) YTD 200 50 Aug Sep Oct Nov Dec Jan Complaints - prev yr Compliments - curr yr Compliments - prev yr 0, 90 8 0, 70 0, 30 6 0, 61 0, 67 0, 63 0, 62 4 10, 0% Falls resulting in serious injury per 10, 000 episode (HRT) Actual Previous Yr Serious Falls YTD = 15 Target 0 70% 60% 4, 08 2, 84 20, 0% 30, 0% 2, 74 2018 Oct-2019 Sep Footscray Latest Qtr Peer 70, 9% Jul 50, 0% 68, 4% 69, 3% 66, 8% 71, 7% 73, 1% 70, 0% Aug Sep Oct Nov Dec Jan Actual Target Pressure Injuries per 10, 000 episodes (HRT) 10 7, 06 5, 21 0, 11 5 0, 08 0, 05 Sunshine 40, 0% 0, 14 2 Jul Aug Sept Oct Nov Dec Jan Feb 80% Hosp-acquired Pressure Injuries per 100 bed days YTD 2019 -20 6, 44 6, 88 5, 34 Dec-19 Timing/Access Safety 0, 0% Sep-19 Communication Quality Complaints - curr yr Falls per 100 bed days YTD 2019 -20 0, 50 Feb Jun-19 90% Caring Jul Mar-19 100% Patient Rights 100 Dec-18 Complaints closed within 35 days YTD 2019 -20 Institutional Issues 150 0 50 89, 6 Mar-19 84, 6 Dec-18 85, 3 Dec-19 83, 55 Sep-19 65 85, 5 Jun-19 Peer Hospitals 80 62 Mar-19 WH 95 60, 4 Dec-18 Peer Hospitals 58, 1 90, 5 60 88, 2 70 89, 9 90 80 WH 75 60 45 30 15 0 60, 93 Peer Hospitals 60, 1 WH 100 Inpatient satisfaction with being treated with respect and dignity (VHES) Inpatient satisfaction with involvement in care decisions (VHES) 88, 1 VHES reporting for Qtr 2, 2019/20 provides opportunity for longitudinal Western Health data comparison and comparison with peer hospitals. Inpatient satisfaction in the areas of overall care, involvement in care decisions and being treated with respect and dignity have improved by 2. 3%, 1. 6% and 5% respectively. Treating patients with respect and dignity is a core component the Person-Centred Care domain of our Best Care Framework. We launched our Live Best Care approach and website in October 2019 which is likely to have contributed to the improvement in inpatient satisfaction in the areas of overall care, feeling respected and involvement in care decisions. Inpatient Satisfaction with Overall Care (VHES) 91, 3 Commentary Jul Aug Sep Oct Nov Dec Jan Feb Actual Previous Yr Serious PIs YTD = 3 Target 0 2, 17 1, 78 2, 42 Sunshine 2018 Oct-2019 Sep 3, 65 Footscray Latest Qtr Peer

CO-ORDINATED CARE DASHBOARD FEBRUARY 2020 Considering the increasing number of patients presenting with mental

CO-ORDINATED CARE DASHBOARD FEBRUARY 2020 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. Patients stays >24 hours at our EDs totalled 31 for the 2018/19 financial year. Reviewing 2019/20 YTD, Western Health has experienced a total of 192 patients stays >24 hrs, 96% of these being at Sunshine ED. All patient stays >24 hrs were related to patients presenting with mental health conditions. Sep-19 Dec-19 70 60 Jul Aug Sep Oct Nov Dec Jan Feb Actual Previous Yr YTD Patient stays >24 hrs ED Presentations with a LOS <4 hrs (%) YTD 200 80 70 60 50 40 56, 8 62, 1 51, 5 2017/18 2018/19 2019/20 YTD SH FH DHHS Target YTD Cat 1 -5 ED patients seen within recommended timeframe 50 60 [VAL UE] 17 0 Sunshine 22 50 40 Footscray 48, 2 63, 8 47, 9 2017/18 2018/19 SH patient stays >24 hrs YTD = 192 YTD Patients Admitted off the ESWL Elective Surgery Wait List Number Western Health 3657 Western Health 2 9, 075 DHHS Target (>) DHHS Target (<) 1 4037 9, 096 3000 4000 5000 9 10 Thousands 62 FH 46, 7 Sep-19 Dec-19 YTD Ambulance Transfers within 40 minutes 2019 -20 68, 8 57 60, 2 69, 1 96% 94% 92, 8% 93, 5% DHHS Target Sunshine Footscray OP first appointment within recommended time YTD 94, 0% 94, 1% 94, 2% 89, 9 91, 7% 91, 8% 60 Aug Sep Oct Nov Dec Jan Feb Actual 76, 7 2019/20 YTD ESWL Cat 1 -3 pts admitted within recommended timeframe 90% 2000 Jun-19 70 [VAL UE] 100 43, 5 Dec-18 Mar-19 Target 80 150 55, 9 55, 1 50 Peer Hospitals 72, 3 Dec-18 Mar-19 Jun-19 65% WH 80 69, 9 50 70, 2 60 78% 77% 75% 76% 75% 75% 69, 9 70% 72, 7 70 72, 2 75% Emergency Patient Satisfaction with Discharge Planning (VHES) 71, 4 80% Peer Hospitals 80 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 percentage of category 1 -3 patients admitted from the Elective Surgery Waiting List within the recommended timeframe shows a pattern of improvement since August 2019 and currently sits above the 94% target. Discharge Summaries completed within 48 hours of discharge YTD 77, 1 WH 70, 6 Inpatient and Emergency patient satisfaction with discharge planning, as measured by the VHES, reflects an increase for Qtr 2 in 2019/20 of 2. 5% and 2. 4% respectively. The level of Emergency patient satisfaction with discharge planning at Western Health is above that of peer organisations and is a considerable achievement given the access challenges our EDs face. Inpatient Satisfaction with Discharge Planning (VHES) 71, 8 Commentary Target 87, 8 82, 4 87, 4 56, 4 2017/18 2018/19 Urgent Target 2019/20 YTD Routine Target

RIGHT CARE DASHBOARD FEBRUARY 2020 95 Improving the rate of patients aged over 75

RIGHT CARE DASHBOARD FEBRUARY 2020 95 Improving the rate of patients aged over 75 having an Advanced Care Directive at admission continues to be a challenge. A pattern of decline for this rate has occurred at Western Health since November 2019. Neonatal Life Support - Online Epidural Analgesia 81, 1 78, 2 82, 7 50 Mar-19 Jun-19 Sep-19 Dec-19 8, 4 8, 3 Peer 8, 1 7, 5 5, 7 5, 6 6, 8 5, 5 июн-18 сен-18 дек-18 мар-19 Babies in poor condition after birth (Apgar) 2 60, 0% 70, 0% 1, 5 7, 7 80, 0% 1, 024 0, 5 Apgar Oct 2018 – Sep 2019 (Target: <=1. 4) 100, 0% 6% 4, 7% 3, 4% 3, 2% 3, 4% 0, 645 70, 0% 4, 2% 3, 7% 0% Jul Aug Sep Oct Nov Dec Jan Feb 0, 9 2017/18 2018/19 2019/20 YTD WH 0, 8 Sunshine Mercy RWH Monash 80 70 16, 8 15 Target Months YTD births > capacity = 6/8, YTD = 3, 980 births Sunshine Mercy Maternity Patient Rating of overall Care (VHES) Oct - Dec 2019 90 332, 6 31, 3 12, 7 RWH Monash FH Peer Hosp 100 500 1, 5 1, 4 1, 6 SH WH Perineal laceration during delivery per 10, 000 vaginal delivery episodes (HRT) 3, 0 2, 2 0, 0 Target (>) Fetal Growth Restriction Oct 2018 – Sep 2019 (Target: <=28. 6) 100, 0% 3, 0 589, 3 608, 3 0, 7 90, 0% 4, 0 1000 0, 9 80, 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 июн-19 Basic Life Support – Face to Face Aseptic Non Touch Technique Average gain in Functional Independence Measure for Rehab patients Q 1 2019 -20 28 Day Readmission Rate (HRT) (previous 12 mths from each date) FH Back 4 Life – Patient Handling Blood Transfusion Practice (JMS) 50, 0% SH Neonatal Life Support – Face to Face Blood Transfusion Practice (NMW) Dec-18 65 Western Health continues to performs above the state-wide target and peer health services for average again in Functional Independence Measure (FIM). Life Support Training Compliance (as at end of Feb 2020) Fetal Surveillance Peer Hospitals 80 Inpatient satisfaction of Western Health staff working together, as measured by the VHES, has improved by 4. 5% for Qrt 2, 2019/20. Similarly, maternity patient satisfaction with overall care, as measured by the VHES, improved in Qrt 2, 2019/20. Western Health also 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 75, 37 Compliance with mandatory training has improved in all areas. Mandatory training compliance in the areas of Epidural Analgesia, Blood Transfusion Practice (nursing and midwifery), Neonatal Life Support (Face to Face) and Back 4 Life (Patient Handling) all exceeded the 90% target at the end of February 2020. Mandatory Training Compliance (as at end of Feb 2020) Inpatient Rating re Doctors & Nurses working together (VHES) 81, 7 Commentary 0 Last Qtr 92, 5 60 Sunshine 2018 Oct-2019 Sep 89, 8 Peer 50 Sunshine Peer Group

SAFE CARE DASHBOARD FEBRUARY 2020 Commentary Western Health Staphyloccus Auerus Bacteraemia (SAB) rates have

SAFE CARE DASHBOARD FEBRUARY 2020 Commentary Western Health Staphyloccus Auerus Bacteraemia (SAB) rates have reflected a pattern of increase since November 2019. The target for health-associated SAB infections per 10, 000 bed days is equal to or less than 1. 0. The Western Health SAB rate is currently 1. 0. Pleasingly, high risk medication errors at Western Health for the 2019/20 November-February period are considerably less that the same period in 2018/19. Safer Care Victoria updated the Sentinel Event categories in 2019 with these changes coming into effect on 1 st July 2019. In addition to the 10 national categories, Victoria now has an 11 th category: ‘All other adverse patient safety events resulting in serious harm or death’. Despite the additional category, Western Health has recorded 5 Sentinel Events YTD compared with 6 YTD at the same time point for 2018/19. YTD for 2019/20, falls is the incident category that accounts for the largest number of ISR 1 and ISR 2 incidents and is a focus area for improvement projects at Western Health. 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 = 6 2019 People Matter Survey – Patient Safety Culture ISR 2 Incidents YTD = 50 SH FH 101 100 HRT 98 Surgery ICU Fall Vic 96 98 65 65 69 71 73 сен-18 дек-18 мар-19 июн-19 сен-19 Major hospital acquired complication rate (HRT) 2018 Oct – 2019 Sep 5, 0 4, 0 3, 0 2, 0 1, 0 0, 0 Birthing (baby) Birthing Medication 0 1 2 Medicati on Error Sentinel events YTD = 5 Medication Complications per 10, 000 episodes (HRT) 0 5 Other Birthing (mother ) Falls Infectio n Delayed Care 10 Hospital acquired Infection per 10, 000 episodes (HRT) 150 40 121, 2 100 20 3, 0 2, 2 SH Sunshine Infection Prevention - SAB Rate YTD 2019/20 1, 5 Actual Target 0, 0 Latest Qtr Actual 0, 9 0, 6 Jul Sep 0, 8 Nov 0, 9 Jan 1, 0 Feb CLABSI Number YTD = 0 40 62 67 75 Peer Aug Sep 122, 9 Deteriorating Patient Incidents YTD Prev Yr 1 SAE for unrecognised clinical deterioration 0 Failure to respond to UCR 59 50 52 45 52 Jan Feb 0 0 Jul 121, 7 Sunshine Footscray 2018 Oct-2019 Sep Latest Qtr Peer Footscray High Risk Medication Errors 120 93, 3 87, 1 112 80 1, 0 0, 5 50 28, 2 29, 4 0 2018 Oct-2019 Sep Peer Hosp 35, 2 12, 4 10, 7 0 FH WH 28, 8 15 Oct Nov Dec ISR 1&2 Medication Incidents YTD = 20 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