BEST CARE DASHBOARD OCTOBER 2020 Executive Summary 100

BEST CARE DASHBOARD OCTOBER 2020 – Executive Summary 100 WH 60 Sep-19 Dec-19 ISR 1 Incidents YTD = 1 Invasive procedure 1 2 3 Infection Prevention - SAB Rate YTD 2020/21 Major hospital acquired complication rate (HRT) 2019 Jul – 2020 Jun 1, 5 Actual 2019/20 Target 98 73 75 сен-19 дек-19 HRT 2, 0 0, 0 1, 0 0, 0 Aug Sep Oct Nov Dec 74 69 69 мар-20 июн-20 сен-20 SH FH WH Peer Hosp FH Peer 7, 9 7, 6 7, 8 8 5, 4 5, 5 июн-19 сен-19 дек-19 мар-20 июн-20 7, 1 3, 0 2, 2 CLABSI Number YTD = 1 Cat 1 -5 ED patients seen within recommended timeframe YTD Patients Admitted off the ESWL OP first appointment within recommended time Western Health 90 80 1, 0 70 0, 8 0, 0 0, 4 2018/19 2019/20 2020/21 WH Target Months YTD births > capacity = 4/4 105 100 97 SH 3, 0 Babies in poor condition after birth (Apgar) 1, 5 Vic 28 Day Readmission Rate (HRT) (previous 12 mths for each date) 5, 0 0, 5 Jul FH 98 4, 0 Sentinel events YTD = 2 0, 5 70, 9 Sep-19 Dec-19 Mar-20 Jun-20 4 2, 0 70 Jun-19 Mar-20 1, 0 0 72, 7 70, 2 60 50 Jun-19 SH 70 72, 2 90, 7 91, 7 70 Peer Hospitals 80 90, 5 80 Western Health faces ongoing challenges with providing timely access to care at both Sunshine and Footscray Emergency Departments. The percentage of Cat 1 -5 patients seen within the recommended timeframe is higher for the Footscray and Williamstown Emergency Departments when compared with 2019/20. A significant reduction in patients admitted off the elective surgery waiting list has occurred and the COVID-19 response has directly impacted this metric. Peer Hospitals 90 The proportion of urgent patients receiving an initial outpatient appointment within 30 days continues to reflect a pattern of improvement, approaching the 100% target. Western Health Staphylococcus Aureus Bacteraemia (SAB) rates were unusually high for August 2020. The SAB rate is currently sitting at the target per 10, 000 bed days of equal to or less than 1. 0. SAB cases are being investigated and strategies implemented to further reduce this rate. WH 88, 2 The October 2020 Best Care Dashboard (Executive Summary) highlights continued high birthing activity with 547 the average monthly number of births for Q 1 2020/21. Percentage of full term babies considered in poor condition after birth continues to be low at Western Health – well below target and rates of peers. The rate has decreased by 0. 3% when compared with August Report. Standardised Mortality Ratio (HRT) (previous 12 mths from each date) Inpatient Satisfaction with Discharge Planning (VHES) Inpatient Satisfaction with Overall Care (VHES) 89, 9 Commentary 60 50 4, 453 54, 9 55, 9 40 2018/19 55, 5 86, 9 83, 6 87, 8 95, 2 2018/19 2019/20 2020/21 55, 4 50, 9 44 2019/20 2020/21 SH FH WTN DHHS Target 56, 5 Urgent Target DHHS Target (>) 75, 7 Routine Target 0 1 2 3 4 5 Thousands

PERSON-CENTRED CARE DASHBOARD OCTOBER 2020 Patient Rights Jul FH Aug SH Sept WTN Oct Target Serious Falls YTD = 5 10, 0% 14 12 10 8 6 4 2 0 4, 7 5, 8 2, 5 Sunshine 2019 Oct - 2020 Sep 2, 2 Footscray Latest Qtr 30, 0% 86, 5 40, 0% Peer 0, 28 0, 24 0, 20 0, 16 0, 12 0, 08 0, 04 0, 00 WTN Target Serious (Stage 3 or 4) PIs YTD = 2 87, 9% 85, 7% 78, 7% 72, 5% 81, 4% 20 16, 3 2, 6 SH Target Pressure Injuries per 10, 000 episodes (HRT) 10 FH 72, 9% 70, 1% 69, 1% 73, 1% Actual Hosp-acquired Pressure Injuries per 100 bed days YTD 2020 -21 11, 9 3, 4 20, 0% 65, 6% 0, 0% Falls resulting in serious injury per 10, 000 episode (HRT) Falls per 100 bed days YTD 2020 -21 1, 50 1, 30 1, 10 0, 90 0, 70 0, 50 0, 30 Quality Oct Compliments - prev yr 70% Safety Sep Compliments - curr yr Jun-20 80% Timing/Access Complaints - prev yr Mar-20 90% Communication 50 Complaints - curr yr Dec-19 100% Caring Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Sep-19 71, 7% 100 Jun-19 Complaints closed within 35 days YTD 2019 -20 Institutional Issues 150 0 50 Complaints by Theme (as a %) YTD 200 89, 3 Jun-20 89, 6 Mar-20 84, 6 Dec-19 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep-19 65 66, 8% Complaints and Compliments 2019/20 Jun-19 85, 3 Jun-20 64, 6 Mar-20 59, 2 Dec-19 Victoria 80 62 Sep-19 WH 95 60, 4 Jun-19 Victoria 58, 1 90, 7 60 91, 7 70 90, 5 90 80 WH 75 60 45 30 15 0 Aug Rate of pressure injuries at Footscray Hospital remain consistently well above target (pressure injury rate per 100 bed days). The rate of pressure injuries per 10, 000 episodes at Sunshine Hospital continues to remain below the peer rate. Of concern is the uptick in rate of pressure injuries per 10, 000 episodes at Footscray Hospital, increasing by 9. 8 during Q 1 2020/21 when compared with Q 4 2019/20. Victoria Jul Rate of falls at Western Health remains consistently above target (falls rate per 100 bed days) for Footscray, Sunshine and Williamstown Hospitals. While a pattern of decline for 2020/21 is evident for Sunshine and Williamstown Hospitals, this has not been reflected at Footscray Hospital. Of particular concern is an uptick in falls resulting in serious injury per 10, 000 episodes at Footscray Hospital during Q 1 2020/21. Comparisons with Q 4 2019/20 reflect a rate increase of 7 for Footscray Hospital for Q 1 2020/21, 9. 7 above the peer rate. WH 100 Inpatient satisfaction with being treated with respect and dignity (VHES) Inpatient satisfaction with involvement in care decisions (VHES) 88, 2 Complaints closed within 35 days of receipt reflects a pattern of considerable improvement for Q 1 2020/21, increasing by 15. 4%. Communication, quality of care, and access to services have been the most common complaint themes for 2019/20. Complaints relating to institutional issues have increased during Q 1 2020/21, with visitor restrictions during our COVID response being a large subgroup of these. Inpatient Satisfaction with Overall Care (VHES) 89, 9 Commentary 0 2 4, 6 Sunshine 2019 Oct - 2020 Sep 7, 5 4, 8 Footscray Latest Qtr Peer

CO-ORDINATED CARE DASHBOARD OCTOBER 2020 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. The rate of ambulance transfers within 40 mins has decreased at Sunshine and Footscray by 1. 5% and 1. 6% respectively when compared with the August 2020 report. Discharge Summaries completed within 48 hours of discharge YTD 50 90 80 70 60 50 40 Jun-19 55, 5 54, 9 55, 4 55, 9 44 2018/19 2019/20 SH WTN Jan Mar Actual 50, 9 2020/21 FH DHHS Target 140 120 100 80 60 40 20 0 May Jul Previous Yr Sunshine [VAL UE] 3 Footscray YTD Patients Admitted off the ESWL Western Health Metrics reflecting access to elective surgery have been impacted by restrictions implemented as part of the response to the COVID-19 pandemic. 4, 448 2 4, 453 Target 44, 8 58, 7 65, 8 2018/19 2019/20 2020/21 3 000 4 000 5 000 94, 0%94, 2%94, 3% 6 Jun-20 62, 3 Sunshine 76, 5 68, 8 Footscray OP first appointment within recommended time YTD 92, 5% 85, 5% 83, 6% Oct Dec Feb Apr Jun Aug Oct Actual Dec-19 Mar-20 YTD Ambulance Transfers (%) within 40 minutes 2020 -21 FH DHHS Target YTD ESWL Cat 1 -3 pts admitted within recommended timeframe 80% 2 4 Thousands Peer Hospitals 72, 6 59, 6 85% 0 Sep-19 58, 4 49 90% 1 2 000 50 SH WTN 95% 92, 8% Western Health Oct YTD Cat 1 -5 ED patients seen within recommended timeframe 90 80 70 60 50 40 [VAL UE] 43 Sept Patient stays >24 hrs YTD = 147 Elective Surgery Wait List Number Jun-19 60 YTD Patient stays >24 hrs ED Presentations with a LOS <4 hrs (%) YTD WH 80 70 65% Sep-19 Dec-19 Mar-20 Jun-20 78% 72, 7 70 60 79% 70 70% 79% 75% 72, 3 70 75% 69, 9 75% 70, 9 80 75% Emergency Patient Satisfaction with Discharge Planning (VHES) 69, 9 80% Peer Hospitals 72, 7 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 147 patients stays >24 hrs, 88% of these being at Sunshine ED. All patient stays >24 hrs were related to patients presenting with mental health conditions. WH 70, 2 The proportion of discharge summaries completed within 48 hours of discharge has improved during 2020/21 and is approaching the target of 80%. Inpatient Satisfaction with Discharge Planning (VHES) 72, 2 Commentary Target 86, 9 83, 6 87, 8 2018/19 2019/20 56, 5 Urgent Target 95, 2 75, 7 2020/21 Routine Target

RIGHT CARE DASHBOARD OCTOBER 2020 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 Q 4 2019/20 when compared with Q 3 2019/20. Neonatal Life Support - Online Epidural Analgesia 80 82, 6 80 Sep-19 Dec-19 Mar-20 Jun-20 FH 7, 9 7, 1 Peer 7, 6 7, 8 8 1 5, 4 5, 5 июн-19 сен-19 дек-19 мар-20 июн-20 2, 0 70, 0% 1, 5 5, 4 Babies in poor condition after birth (Apgar) 60, 0% Average gain in Functional Independence Measure for Rehab patients Q 4 2019 -20 28 Day Readmission Rate (HRT) (previous 12 mths from each date) Basic Life Support – Face to Face Aseptic Non Touch Technique 50, 0% SH Back 4 Life – Patient Handling Blood Transfusion Practice (JMS) 1, 12 0, 5 0, 645 0 WH Apgar Jul 2019 – Jun 2020 (Target: <=1. 4) 80, 0% 90, 0% 100% 80% 60% 40% 20% 0% 70, 0% Target (>) 2, 0 1, 0 Fetal Growth Restriction Jul 2019 – Jun 2020 (Target: <=28. 6) 2018/19 2019/20 2020/21 WH 0, 9 1, 3 1, 6 1, 9 30, 6 15, 2 23, 4 Target Months YTD births > capacity = 4/4 YTD = 2, 211 births Sunshine Mercy RWH Monash Sunshine Mercy SH WH RWH Monash FH Peer Hosp Maternity Patient Rating of overall Care (VHES) Apr 2020 - Jun 2020 100 455 90 338, 2 80 70 16, 5 3, 0 2, 2 0, 0 Perineal laceration during delivery per 10, 000 vaginal delivery episodes (HRT) 500 0, 4 100, 0% 4, 0 580, 2 0, 8 90, 0% Major hospital acquired complication rate (HRT) 2019 Jul – 2020 Jun 1000 0, 8 80, 0% 3, 0 1, 0 0, 0 60, 0% Patients > 75 years asked about Advance Care Directive 2020 -21 YTD 1, 5 0, 5 50, 0% 67% 63% 64% 66% 50 Blood Transfusion Practice (NMW) Jun-19 65 Neonatal Life Support – Face to Face Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun The percentage of patients readmitted within 28 days of discharge reflects a pattern of increase at Footscray Hospital and remains above the peer rate. The 28 day readmission rate at Sunshine Hospital continues to remain well below the HRT median. 95 Life Support Training Compliance (as at end of Aug 2020) Fetal Surveillance Peer Hospitals 82, 7 Unfortunately compliance with mandatory training has reduced in all areas, with the exception of Neonatal Life Support (face to face) and Basic Life Support (face to face). Blood Transfusion Practice (NMW) and Neonatal Life Support (face to face) are the only two areas that exceeded the 90% target at the end of October 2020. WH 78, 2 Birthing activity continues to be high at Western Health and is pleasingly accompanied with positive performance when compared with peer hospitals for two key maternity indicators, Apgar and Fetal Growth Restriction (FGR). Mandatory Training Compliance (as at end of Aug 2020) Inpatient Rating re Doctors & Nurses working together (VHES) 81, 1 Commentary 0 Last Qtr 90, 8 60 Sunshine 2019 Jul-2020 Jun 90, 9 Peer 50 Sunshine Peer Group

SAFE CARE DASHBOARD OCTOBER 2020 Commentary Western Health has recorded 2 Sentinel Events YTD for 2020/21 and 1 ISR 1 incident. The number of Sentinel Events and ISR 1 incidents are lower than comparisons with October 2019 where 4 Sentinel Events and 4 ISR 1 incidents had been recorded and investigated. Incident data reveals YTD for 2020/21, birthing, delayed care, falls and medication error are the incident categories that account for the largest number of ISR 2 incidents and continue to be a focus area for improvement projects at Western Health Staphylococcus Aureus Bacteraemia (SAB) rates were unusually high for August 2020. The SAB rate is currently sitting at the target per 10, 000 bed days of equal to or less than 1. 0. SAB cases are being investigated and strategies implemented to further reduce this rate. A similar number of monthly Adult Code Blue calls/1, 000 admissions have been recorded YTD during 2020/21. A pattern of reduction in the number of monthly Adult MET calls/1, 000 admissions is evident during 2020/21 YTD. An overview of the adverse patient events with an ISR of 1 or 2, and reporting requirements for Sentinel Events, are provided within the following pages. Standardised Mortality Ratio (HRT) (previous 12 mths from each date) SH FH HRT Adverse Patient Events ISR 2 ISR 1 Incidents YTD = 1 2019 People Matter Survey – Patient Safety Culture ISR 2 Incidents YTD = 48 Birthing Baby Vic Birthing. . . Invasive procedure Delayed Care 98 98 73 75 сен-19 дек-19 97 Falls 105 100 Infection 74 69 69 мар-20 июн-20 сен-20 Major hospital acquired complication rate (HRT) 2019 Jul – 2020 Jun 0 1 2 3 4 Medication Other Sentinel events YTD = 2 0 Medication Complications per 10, 000 episodes (HRT) 10 3, 0 2, 2 SH 0 FH WH 14, 7 21, 1 Sunshine Infection Prevention - SAB Rate YTD 2020/21 1, 5 Actual 1, 0 2019/20 1, 2 Target 1, 2 48, 7 50 28, 3 0 Footscray 2019 Jul - 2020 Jun Peer Hosp 33 29, 5 Latest Qtr Peer Actual 49 1, 0 40 49 33 Jul 0, 0 Aug Sep Oct CLABSI Number YTD = 1 Sunshine Footscray 2019 Jul - 2020 Jun Latest Qtr Peer 80 40 0, 5 0, 0 0 0 Jul Aug Sep 116 Adult Code Blue & MET calls/1, 000 Admissions Prev Yr 53 109, 7 126, 6 86, 5 101, 3 Deteriorating Patient High Risk Medication Errors 80 20 136, 3 100 20 15 150 50 30 10 Hospital acquired Infection per 10, 000 episodes (HRT) 40 5, 0 4, 0 3, 0 2, 0 1, 0 0, 0 5 Oct ISR 1&2 Medication Incidents YTD = 7 47 7, 7 Jul 59 49 40 5, 8 5, 2 6, 4 Aug Sep Oct Adult MET calls Adult Code Blue 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 Safety: Std 4 Comprehensive Care: Std 5 Communicating for Safety: Std 6 Blood M’ment: Std 7 Acute Deterioration: Std 8