Quality & Safety Highlights Eastern Health 2024-25

Eastern Health seeks to hear the voice of the patient, families and carers in a number of different ways.  Patients, families or carers can: 

• speak with any staff member 
• call, email or write to the Centre for Patient Experience 
• use paper feedback forms  
• use the online feedback form on the Eastern Health website 
• complete the Eastern Health Patient Experience Survey  
• Complete the Victorian Healthcare Experience Survey (VHES) 

There were 23,189 items of feedback received by Eastern Health in 2024/2025. This is 4,480 more items of feedback than the year before. The different ways feedback was received in the past year are shown in the graph below.

In 2024, Eastern Health started sending text messages to invite consumers to complete the patient experience survey.  This has led to double the number of people completing the survey.  More survey responses mean our services have valuable information to help guide improvement work. 

The Victorian Healthcare Experience Survey (VHES) is another way patients can provide feedback about their experience with Eastern Health. The VHES collects information from recent users of Victoria’s public health system.  The survey is conducted by an independent contractor on behalf of the Department of Health.  The table below relates to the survey question “Overall, how would you rate the care you received?”.  It shows the percentage of Eastern Health Adult Inpatients who answered “very good” or “good” to this question.  Eastern Health performed above or equal to the state average for three out of the last four quarters. 

Each year, Eastern Health recognises Patient Experience Week. Patient Experience Week is a worldwide event to thank healthcare workers for providing a positive patient experience. In 2025, Eastern Health held the first ‘CareXperience Tanks’. The CareXperience Tanks gave staff the chance to pitch their ideas to make the patient experience even better. 24 staff presented their ideas. The Eastern Health Foundation gave $30,749 to make these ideas happen.  The goal is to improve care, comfort, dignity, wellbeing and experience for patients. 

Eastern Health uses patient feedback to identify ways to improve services and patient experience. Below are some examples of taking action based on patient feedback. 

Eastern Health wants to be a health service where everyone in our diverse community feels included and respected. We believe that patients, families, and community members should be listened to, supported, and treated as partners in their care. 

In 2025, we launched our Community Participation Plan  for 2025 and 2026.  The plan explains how our staff, patients, and the community will work together to make sure the voices of patients and families are part of everything we do. The plan was created with our community and shows our strong commitment to ‘Partnering in Care’. 

Eastern Health is committed to ensuring a safe and welcoming place for all. 

The LGBTQIA+ Equity Action plan was the key project for the Rainbow eQuality working group this year. The actions that were developed include: 

• Collecting better data to understand LGBTQIA+ needs 
• Training staff to ask respectfully about gender, pronouns, and names 
• Encouraging staff to share their own background to help with inclusive planning 
• Creating education programs for staff and leaders 
• Testing Rainbow Tick Accreditation in one service area 
• Participating in national benchmarking to track progress 
• LGBTQIA+ Health Team working with Aboriginal Health Team to improve inclusive care 
• Building stronger partnerships with LGBTQIA+ community groups 
• Putting up inclusive signs at all sites 
• Making sure all-gender toilets are included in new buildings and upgrades.  

In the past year, The Disability Working Group focused on developing a new Disability Action Plan. This plan is about making our health services fairer and removing barriers for people with disabilities. 

Over the next two years, we’ll work on actions like: 

• Providing feedback forms in formats like Easy Read, Braille, AUSLAN, and audio 
• Adding disability identification options in staff and patient systems 
• Launching a Health Passport to help share important health needs 
• Creating training programs to help staff understand disability inclusion 
• Joining the Hidden Disabilities Sunflower program 
• Making tools to support people with Autism in Emergency Departments 
• Helping staff request changes to their work environment 
• Disability Health Team working with the Aboriginal Health Team to improve inclusive care 
• Promoting the Disability Liaison Service 
• Starting a Disability Employee Network to support staff 
• Making disability information easier to find on our website 
• Creating low-sensory spaces or offering sensory tools in waiting rooms 
• Installing augmented listening systems to help people hear better 
• Improving accessible parking 
• Reducing the loss of personal aids like glasses, hearing aids, and dentures during hospital stays 

The Closing the Health Gap Committee continues to oversee the implementation and monitoring of safety and quality priorities for First Nations Health. Regular feedback is also sought from Community representatives from the Aboriginal Health Advisory Committee.  

One key focus is to reduce the number of Aboriginal patients who leave the Emergency Department before seeing a doctor. A working group has been formed with the guidance of Aunty Lucia Baulch and Aunty Janet Turpie Johnstone to look at ways to improve how Aboriginal patients are identified and supported in emergency care. 

The Women and Children Program is also focused on helping First Nations families. They are working to lower the number of babies born too early and are giving Aboriginal families priority access to a program where the same midwife supports them through pregnancy. 

More Aboriginal patients are coming to Eastern Health’s Emergency Departments, and more are being discharged from hospital care each year. Ensuring all patients are asked the question “Do you identify as of Aboriginal and/or Torres Strait Islander origin?” to support Aboriginal patient identification is an ongoing priority. Eastern Health has maintained a rate of over 80% of our patients having been asked the question in bed-based services.  

Eastern Health has completed its first Innovate Reconciliation Action Plan. A significant number of actions have now been embedded as regular business practices, including continuing to expand on our First Nations suppliers and partner with First Nations staff and Elders in the recognition of significant events on the Aboriginal and Torres Strait Islander calendar. In early 2025, leaders visited Coranderrk for a cultural learning experience to further deepen understanding of self-determination in the region. After consultation with Reconciliation Australia, Eastern Health is now working on a second Reconciliation Action Plan for 2025–2027. 

We have also created two new roles to support First Nations health: a Director of First Nations Health and a Manager of Cultural Safety and Workforce Development. These roles will help design better services with the Aboriginal Community and support the Aboriginal Workforce Plan. 

Eastern Health values the role that consumer voice and lived experience plays in shaping decisions about healthcare.  Consumer representatives come from all walks of life and by sharing their experiences, help to keep the needs of health service users at the front and centre of decision making.  

Consumer representatives’ partner with Eastern Health by participating in a range of committees, working groups, consultations, research, improvement projects, recruitment and staff training. Examples of how consumer representatives have been involved at Eastern Health in 2024/2025 include: 

• reviewing health information and education resources 
• supporting staff on projects to improve care, such as the palliative care outpatient cancer clinics and Timely Emergency Care. 
• joining governance committees focusing on quality and safety 
• being part of steering committees and working groups for topics such as strategic planning and staff education 
• helping choose new staff by joining interview panels 

When something goes wrong in a patient’s care, it’s called an incident. All staff are encouraged to report all incidents that occur as part of our commitment to a culture of safety 

Each incident is rated based on how serious it is and whether it changed the care or treatment the patient needed. 

There are four levels. 

• Level 1 is the most serious, where someone was badly harmed. 
• Level 4 means no one was hurt, but it was a close call (a “near miss”). 

These ratings help Eastern Health decide how to follow up on the incident and fix any bigger problems in the system. 

All reported incidents are initially reviewed by the manager of the location where the incident occurred. There is an immediate assessment of safety and care of those involved and any identified concerns are addressed. Information is gathered from staff, patients and visitors at the time of the event to get a thorough picture of what has occurred. 

All incident reviews apply the following key principles: 

1. Determine the timeline of events leading up to an including the incident 
2. Identify if there are any issues/ variations from expected practice.
3. Identify what may have contributed to the issues.
4. Consult and communicate with the patient/family to ensure a collaborative and informed process.  

 The most serious incidents are reviewed by a panel of clinicians, service providers and consumers.   

Sentinel events are unexpected events that result in death or serious harm to a patient while in the care of a health service. Eastern Health notified Safer Care Victoria (SCV) of 15 sentinel events during 2024-2025. 

Graphic demonstrating incidents numbers with and without harm 

Incident numbers by month 

• An average of 2133 patient incidents are reported each month. 
• Of these incidents, 700 incidents on average, resulted in a level of harm that ranged from minor to more serious.   
• The majority of reported patient incidents do not result in harm. 

 The three main types of patient incidents reported in 2024-2025 were: 

• Falls (4088) 
• Behaviours of concern* (8405); and *Behaviours of Concern are behaviours that people engage in, that may be a problem for themselves or others. Behaviours of concern may include someone harming themselves, other people, or things.  
• Medication related incidents (3295)  

Improvements 

The goal of incident review is to learn from it and find ways to stop it from happening again. Sometimes, when several similar incidents are looked at together, a common problem or pattern is found. This helps Eastern Health improve its processes and make care safer. 

If a patient is seriously harmed while receiving care (called a Serious Adverse Patient Safety Event, or SAPSE) the Victorian Statutory Duty of Candour (SDC) applies.  Eastern Health has a legal and ethical responsibility to maintain open, honest and empathic communication with patients, families and carers. This includes when an adverse event or unexpected outcome has occurred.  

Eastern Health is legally required to provide the patient, and/or their next-of-kin (NOK)/carer, with: 

• a written explanation of what happened  
• an apology for the harm caused 
• an explanation of what Eastern health did in response to the event 
• information on what changes have been made to stop it from happening again. 

Statutory Duty of Candour builds on the Australian Open Disclosure Framework, which already encourages honest communication when mistakes or near misses happen. Talking openly helps patients and families understand what went wrong and builds trust between them, their healthcare team, and Eastern Health. 

From 1 July 2024 until 30 June 2025, Eastern Health reviewed 71 SAPSEs.  49 consumers accepted the SDC process and 22 declined. Compared to the previous year, less patients are declining the process of SDC.  This shows that patients and families want to be involved in the SDC process.  Following completion of the SDC process, consumers are invited to complete an evaluation survey. The feedback received is mostly positive and consumers are grateful to be included in the review of their clinical incidents.  

Eastern Health demonstrates its commitment to excellence through external accreditations against a wide range of industry standards, including: 

• National Safety and Quality in Healthcare Services (NSQHS) Standards  
• Aged Care Quality and Safety Standards  
• General Practice (GP) Accreditation Standards 
• Diagnostic Imaging Standards  
• Pathology Standards.  

The aim of these accreditations, undertaken by independent accrediting agencies, is to protect the public from harm and to improve the safety and quality of health care provision. They require Eastern Health to develop ways of working that reduce harm and improve care. 

Eastern Health was fully re-accredited by the Australian Council on Healthcare Standards (ACHS) against the NSQHS Standards in a short notice assessment in November 2024. The final report from this assessment found that Eastern Health demonstrates a strong culture of continuous quality improvement, with staff across all disciplines expressing a clear commitment to aligning quality and safety initiatives with current best practices. Assessors noted that the voices of consumers, carers, the lived experience workforce, and community members from diverse backgrounds are meaningfully reflected in Eastern Health’s planning, operations, and service delivery. The potential for impactful partnerships through the respectful inclusion of these voices was clearly evident. Eastern Health continues to be accreditation ready every day with a commitment to ongoing improvement through our clinical governance processes. 

Eastern Health is preparing for accreditation of all our aged care services as a single provider under the strengthened Aged Care Quality Standards. These services include: 

• Two residential aged care homes – Monda Lodge and murrenda Residential Aged Care Home  
• Community Home Support Programs  
• Transition Care Program. 

Eastern Health is working on a project with the Department of Health and the Institute for Healthcare Improvement.  It aims to make emergency care faster and better through a program called TEC2 (Timely Emergency Care Collaborative). 

The main goal of TEC2 is to help patients—especially older people—spend less time in hospital. This way they get home sooner with the right care. 

What’s been done so far: 

• Short Stay Unit at Angliss Hospital: Patients who only need a short stay (6–24 hours) can be treated here and go home quickly. 
• Specialist Support for Older Patients: Geriatricians (doctors who specialize in older people’s health) are now working in Emergency Departments at Box Hill and Maroondah Hospitals. They help plan care so patients can go home with support or move to a different care unit if needed. 
• Red to Green Process – a way for our staff to know what problems need to be fixed to help make sure patients are ready for discharge. Red = problems to be solved, Green = ready to go. This system has helped reduce hospital stays in sub-acute wards by nearly 6 days. 
• Transit Lounge: More use of this space helps patients leave hospital faster. 
• Better Discharge Planning: General medicine teams are improving how they plan for patients to leave hospital. 
• Hospital in the Home: More patients at Box Hill can now continue their recovery at home after leaving hospital. 

What has improved: 

• Less time spent in emergency departments 
• Fewer older patients needing full hospital admission 
• Shorter hospital stays overall 
• These changes mean people in our community get care faster and can return home sooner. 

Eastern Health is continuing to learn and work with other hospitals to keep improving Emergency Care.