ANNUAL PERFORMANCE MANAGEMENT FRAMEWORK

Transcription

1 ANNUAL PERFORMANCE MANAGEMENT FRAMEWORK Activity Based Funding and Management Program improving care managing resources delivering quality

2 Department of Health, State of Western Australia (2013). Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (C wth Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Performance Activity and Quality Division, Western Australian Department of Health. The Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health when reproducing or quoting material from this source. Important Disclaimer: All information and content in this Material is provided in good faith by the WA Department of Health, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use. Owner: Contact: Department of Health, Western Australia Performance Directorate Version: 3.3 Approved by: Professor Bryant Stokes, A/Director General Date: 09 July 2013 Links to: Performance Management Framework ( ) Performance Management Framework ( ) 1

3 Contents 1 Overview Structure of the PMF Service Agreements Structure of Performance Management Framework Reporting of KPIs Policy Drivers WA Health Strategic Direction National Health Reform NHRA and governance National performance reporting NHRA and performance monitoring ACSQHC Standards, Accreditation and LARU Independent Hospital Pricing Authority Changes to the PMF Maturity Assessment Data Quality Statements Outcome Statements Performance Reporting, Monitoring and Evaluating Performance Reporting KPI Targets KPI Thresholds Identifying an indicator Performance Monitoring and Evaluating Performance Management Elements of Performance Management Intervention Levels Incentives and Premium Payment Program Service Provider Governance Accountabilities ABF- funded hospitals Next Steps Vertical Equity Gaps in Performance Reporting Facilities and Equipment Employee measures

4 Schedule A. Outcome Measures & Health Service Measures, Scope and Reporting Frequency Schedule B. Outcome Measures Targets and Thresholds Schedule C. Outcome Measures and Health Service Measures Target Source Schedule D. Maturity Assessment Schedule E. Outcome Statements for PMF KPIs Effectiveness/Access Key Performance Indicators EA1 - Proportion of emergency department patients seen within recommended times EA2 - National Emergency Access Target percentage of ED attendances with length of episode less than or equal to 4 hours EA3 - Average overdue wait time of elective surgery cases waiting beyond the clinically recommended time, by urgency category EA4 - Elective surgery patients treated within boundary times by urgency category EA5 - Percentage of selected elective cancer surgery treated within boundary times Effectiveness/Appropriateness Outcome Measures EAP1 - Rate of selected potentially preventable chronic condition hospitalisations (for specified chronic conditions) Effectiveness/Quality Key Performance Indicators EQ1 - Age-Adjusted Rate of avoidable deaths EQ3 - Staphylococcus aureus bacteraemia (SAB) infections per 10,000 patient days EQ5 - Hospital standardised mortality ratio EQ7 - Death in low-mortality Diagnostic Related Groups EQ8 In hospital mortality rates EQ10 - Rate of total hospital readmissions within 28 days to a designated mental health inpatient unit Efficiency/Inputs per output unit Key Performance Indicators EI1 - Volume of weighted activity year-to-date EI3 - Average cost per test panel for PathWest EI6 - Year-to-date distance of net cost of service to budget EI8 - Ratio of actual cost of specified public hospital services compared with the state efficient price Equity/Access Key Performance Indicators EQA1 - Standardised Mortality Ratio of deaths among Aboriginal children and non- Aboriginal children EQA4 - Proportion of eligible population receiving dental services Sustainability/Workforce Key Performance Indicators SW3 - Staff turnover Processes/Coding Key Performance Indicators

5 PC2 - Percentage of cases coded within boundary Processes/Finance Key Performance Indicators PF2 - Manually corrected payroll errors (underpayments) PF3 - Percentage of service calls resolved at first point of contact Schedule F. Performance Management Processes Schedule G. Recommendations from the Indigenous identification in hospital separations data quality report, February Recommendations Schedule H. Ability to report PMF KPIs by Aboriginality split Document control References

6 Acronyms ABF ABM ABF/ABM ACSQHC CE COAG CSF DG DOH DRG DQS ED GP HCN HIN IHPA KPI LARU LHN NEP NHPA NHRA NSQHS PAF PAQ PMF PMR SA Activity Based Funding Activity Based Management Activity Based Funding and Management Australian Commission on Safety and Quality in Health Care Chief Executive Council of Australian Governments Clinical Services Framework Director General Department of Health WA Diagnosis Related Group Data Quality Statement Emergency Department General Practitioner Health Corporate Network Health Information Network Independent Hospital Pricing Authority Key Performance Indicator Licensing and Accreditation Regulatory Unit Local Hospital Network National Efficient Price National Health Performance Authority National Health Reform Agreement National Safety and Quality Health Service Performance and Accountability Framework Performance Activity and Quality Performance Management Framework Performance Management Report Service Agreement/s 5

7 SQuIRE WA WA Health YTD Safety and Quality Investment for Reform Western Australia Western Australian Health System Year to Date 6

8 1 Overview This document presents the Performance Management Framework (PMF) and consolidates work commenced in the PMF and progressed in the PMF and PMF Activity Based Funding and Management (ABF/ABM) commenced on 1 July 2010 for the Western Australian health system (WA Health). ABF/ABM provides a more transparent and accountable way of funding health service delivery. The framework of the WA Health ABF/ABM is consistent with the Council of Australian Governments (COAG) Activity Based Funding initiative which commenced in 2008 under the National Partnership Agreement and is now part of the National Health Reform Agreement 2011 (NHRA) i. ABF is a management tool that is designed to enhance accountability to the West Australian (WA) public and improve the efficiency and effectiveness of WA Health services. The application of ABF in WA is complemented by Activity Based Management (ABM) which is made operational through the Annual PMF. The Annual PMF continues as a Service Agreement between the purchaser and the provider of services and is based on a performance management cycle, including a system of reporting performance against specified Key Performance Indicators (KPIs). It was introduced in for ABF-funded hospitals 1 in WA and consolidates performance reporting, monitoring, evaluation, management and intervention. The inaugural PMF had a preliminary focus on 10 KPIs relating to the acute sector with emphasis on inpatients and Emergency Department (ED). The PMF advanced to a more comprehensive suite of 31 KPIs including population based health outcome measures and dental health; chosen to ensure that service providers place appropriate emphasis on the ongoing standards and viability of services and not just the cost of delivering services. By , the PMF progressed towards a more refined system, aligning more closely with the NHRA and national principles. The additional focus on refinement resulted in the PMF being further prioritised to report on 23 KPIs (as outcome measures) and 33 supporting Health Service Measures as well as incorporating Statewide Support Services including Health Corporate Network (HCN) and Health Information Network (HIN) indicators. In its fourth year, the PMF has matured to focus on consolidation and strength, whilst continuing to align with state and national priorities. To progress the maturity of the use of performance measures, each KPI is accompanied by a Data Quality Statement and an Outcome Statement. Data Quality Statements are designed to sufficiently inform users of the quality of data enabling confidence in the decisions being made concerning performance management. Outcome Statements provide insight to users in determining the relevance of a KPI; enabling them to form of a more reasonable opinion of the intent of results presented. No new KPIs have been included in the PMF , one KPI has been reclassified as a Health Service Measure, one new Health Service Measure has been introduced and one Health Service Measure has been removed (Schedules A, B and C provide specific information relating to the KPIs and Health Service Measures). The progression of the PMF since its inception is illustrated in Figure 1. 1 Note: ABF-funded hospitals include the metropolitan hospitals and the WA Country Health Service regional resource centres and integrated district health centres. 7

9 Figure 1: Progression of the PMF since its inception in Preliminary Comprehensive Refined Consolidated 2 PMF PMF PMF PMF Reporting Obligations Performance Monitoring & Evaluation Governance 10 KPIs, Targets and Thresholds for Performance Rating Performance Management Intervention Process 31 KPIs, Targets and Thresholds for Performance Rating 23 KPIs, Targets and Thresholds for Performance Rating 33 Health Service Measures and Targets Alignment with national health reform (including PAF indicators) Data Quality Statements Outcome Statements 22 KPIs, Targets and Thresholds for Performance Rating 34 Health Service Measures and Targets Health Services Inpatient, ED & Ambulatory Surgery Alignment with national health reform (including PAF indicators) Dental Health & Public Health HIN & HCN Mental Health 8

10 The Annual PMF continues to be aligned to state and national strategic priorities. The Health Activity Purchasing Intentions ii provides details on the annual purchasing priorities and ABF/ABM policy drivers for the Department of Health. Accordingly, the Annual PMF should be read in conjunction with other Department of Health (DOH) documents and publications including the following: 1. ABF/ABM Annual Performance Management Framework PMF Definitions Manual 3. Performance Reporting and Data Quality within the PMF 4. Triennial Strategic Directions for Performance Management to ABF/ABM Review of Incentives and Pay for Performance in the Health Industry 6. Health Activity Purchasing Intentions and related ABF/ABM technical documents 7. WA Strategic Plan for Safety and Quality in Health Care Activity Based Funding and Management Policy on Admissions, Discharges and Transfers in WA Hospitals. All ABF/ABM documents published by the DOH will be available from the ABF/ABM intranet website at: or the ABF/ABM website 2 Structure of the PMF 2.1 Service Agreements The PMF forms the Health Services Service Agreements (SAs) between the Director General of Health as the delegated Board and the Health Services. The SAs, in turn, form the basis of the Personal Performance Agreements between the Director General of Health, Health Service Chief Executives (CEs) and Executive Directors who have a direct accountability for delivery of health services. Service Providers operate in an environment of delivering the services set out in the SA. The SA is informed by the WA Health Clinical Services Framework iii (CSF ), specifying the scope of services and target levels of activity for a facility. The SAs ensure that the Governments policy objectives on service delivery are clearly set out and provide the basis for both payment and evaluation of performance. The performance management of the SAs is undertaken as prescribed in the PMF. 2.2 Structure of Performance Management Framework The PMF is based on a performance management cycle and consolidates performance reporting, monitoring, evaluation and management (including intervention). 2 Note: this document is in the process of being reviewed and may change (as at June 2013). 9

11 The PMF involves a system of reporting performance against specified KPIs for each Service Provider. Reporting on the performance of Service Providers against the KPIs occurs on a regular basis, with the level of performance assessed against an agreed target. If the level of performance against the target is unacceptable, an intervention process will commence to bring the performance back on track. The intervention will be tailored to the specific circumstances of the non-performing area to ensure an agreed and workable solution can be implemented. Figure 2 depicts the structure of the PMF schematically. Figure 2: Structure of Performance Management Framework Service Agreements (Between DOH & Health Service/Hospitals) Service Providers (Undertake routine activity within the parameters of the SA) Performance Reporting (KPIs reported by PAQ) Performance Management (Incentives, remediation, penalties) Personal Performance Agreements (CEs) Performance Monitoring & Evaluation (Performance evaluated against targets and thresholds) 2.3 Reporting of KPIs Consistent with previous years, the KPIs approved for the PMF cover the domains and dimensions of performance as depicted in Figure 3. Figure 3: s and dimensions of the PMF Effectiveness Efficiency Equity Sustainability Processes Dimension Access Appropriateness Quality Inputs per output unit Access Workforce Facilities & Equipment Coding Finance 10

12 The first three domains relate specifically to patient care and outcomes delivered and achieved by Service Providers. The Sustainability performance domain is to ensure the system s ongoing viability is not compromised by short-term expediency. The inclusion of the 'Processes' domain is to maintain the integrity of the ABF/ABM system, particularly in relation to the accurate and timely coding of patient cases and enabling the development of more efficient and effective corporate services within WA Health. These are pivotal to performance measurement, payments to Service Providers and financial integrity. The KPIs within the five domains are reported against the Health Services and Statewide Services. Within Statewide Services, the ongoing inclusion of the Statewide Support Services (e.g. HIN and HCN) supports an integrated framework that covers all aspects of WA Health. The Health Services are as follows: Child and Adolescent Health Service North Metropolitan Health Service South Metropolitan Health Service WA Country Health Service. While the reporting obligations for all KPIs within the PMF apply broadly to all Service Providers 3, the indicators are defined by the scope, to suit the specific circumstances and clinical service obligations of each Service Provider. Some indicators in relation to mental health and public health reflect shared responsibilities between inpatient (admitted) and community/ambulatory services. Schedule A identifies the KPIs and Health Service Measures within the domains and dimensions along with the reporting frequency and scope of indicator. 3 Policy Drivers The Annual PMF continues to be aligned with the Strategic Intent iv for the WA health system and is consistent with the strategic policies and priorities of the DOH, state priorities negotiated with the WA Government, and agreements negotiated by the WA Government via the COAG. 3.1 WA Health Strategic Direction At a State level, WA Health is responsible for the health and wellbeing of all people residing within WA. This responsibility cascades down through the core policy drivers that impact on health service delivery, effectiveness and efficiency. WA Health s Strategic Intent iv provides four strategic priorities under which programs, initiatives and targets are outlined. Within each of these strategic priority areas are a suite of specific or targeted policy initiatives such as the 'National Emergency Access Targets', (formerly implemented in WA, prior to 2012, as The Four Hour Rule) and delivery of care closer to home. 3 Note: the new Fiona Stanley Hospital is planned to open mid 2014, and as data becomes available, will be transitioned into the PMR. 11

13 In addition to these, there are also two DOH outcomes specified in the Western Australian State Government Budget Papers published by the Department of Treasury, including: Outcome 1: Restoration of patients health, provision of maternity care to women and newborns and support for patients and families during terminal illness; and Outcome 2: Enhanced health and well-being of West Australians through health promotion, illness and injury prevention and appropriate continuing care. Funding of the WA Health system will be guided by the higher level policy objectives outlined above and the suite of programs that are aligned to them. 3.2 National Health Reform The ABF/ABM program is part of the broader policy context for the WA health system. This includes the COAG agreement v which has four elements that are primarily related to the PMF: 1. The Intergovernmental Agreement on Federal Financial Relations 2. The National Partnership Agreements (NPAs) including the Improving Public Hospital Services agreement which contains National Emergency Access Targets and National Elective Surgery Targets 3. The National Healthcare Agreement 2011 which contains many of the previous Specific Purpose Payments and NPA indicators 4. The NHRA which has ABF. This is not an exhaustive list as many other NPAs and Specific Purpose Payments between the Commonwealth and WA Health exist v. NHRA and governance A key component of NHRA is the introduction of Local Hospital Networks (LHNs). In WA these are called Health Services (as listed in Section 2.3) and were established on 1 July To add to this system wide planning and control, on 1 July 2012, Western Australia officially established five new Health Service Governing Councils made up of community members and clinicians selected by the Minister for Health. These high-level governing councils have an important role to play in planning, monitoring and reporting on our public health services, and engaging with clinical and community stakeholders. Their establishment has made the State s public health system even more responsive and accountable to the community. WA Country Health Service is served by two governing councils (the Southern Country Governing Council and the Northern and Remote Country Governing Council) each with its own set of unique health service delivery challenges and needs. National performance reporting The recently established National Health Performance Authority (NHPA) is one of the independent agencies established under the National Health Reform Act As part of its 12

14 role, the NHPA are responsible for publicly reporting on the performance of all LHNs, public and private hospitals. The Hospital Performance reports will be delivered in line with the Performance and Accountability Framework (PAF), which aims to increase accountability and drive continuous improvement in delivery of health care services. The NHPA s inaugural Hospital Performance report: Time patients spent in emergency departments in vi, was published in December This was the first hospital PAF indicator to be reported showing the performance of all emergency departments in Australia that provided services to public patients. The NHPA s Healthy Communities report was subsequently published in March 2013; reporting the first Medicare Locals PAF indicators. This report examines the use, patient experiences and the perceived health of populations living in each national Medicare Local area against a range of indicators including: General Practitioner (GP) attendances; measures of patient experiences; wait times for GP services; and after-hours GP service utilisation. The PMF continues to include the hospital PAF indicators, developed as the same indicator title or a WA Health equivalent measure until specifications for all PAF measures are developed further by the NHPA. NHRA and performance monitoring The following Clauses make up component parts of the NHRA i that specifically relate to performance monitoring. NHRA Clause D14c Local Hospital Networks will have a professional Governing Council and Chief Executive Officer, responsible for monitoring Local Hospital Network performance against the agreed performance monitoring measures in the Local Hospital Network Service Agreement, including the Performance and Accountability Framework For WA Health, the performance measures within the SAs refer to the performance measures that are specified in the Annual PMF. NHRA Clause C10 The NHPA will make regular assessments of Local Hospital Network performance against the measures in the Performance and Accountability Framework and provide advice to the Commonwealth and State governments on poor performing Local Hospital Networks. States, as system managers of the public hospital system, will act in line with Health Ministers agreed roles and responsibilities to remediate ongoing poor performance. In addressing poor performance or recognising excellent performance, the performance management criteria of the Annual PMF (Section 6) outlines staged levels of intervention and 13

15 details of incentive initiatives. While the performance management process is designed to assist the state as the manager of the public hospital system in WA, many other regulatory roles and responsibilities exist within WA Health, for example, the licensing and monitoring responsibilities of the DOH Licensing and Accreditation Regulatory Unit (LARU). ACSQHC Standards, Accreditation and LARU A key objective of the NHRA is to improve standards of clinical care through the Australian Commission on Safety and Quality in Health Care (ACSQHC). The PMF continues to include the National core hospital-level outcome indicators recommended by the ACSQHC for routine monitoring and review 4. The ACSQHS developed the National Safety and Quality Health Service (NSQHS) Standards to drive the implementation of safety and quality systems and improve the quality of health care in Australia. The 10 NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect. Under the new national accreditation scheme, state and territory health departments have agreed that public hospitals across Australia will be accredited to the NSQHS Standards from 1 January Private hospitals will need to confirm their requirements for accreditation to the NSQHS Standards with their relevant health department. WA Health s Operational Directive (OD 0410/12) requires all public and private hospitals in WA to achieve accreditation to the NSQHS Standards (in addition to existing requirements for accreditation to other standards). Hospitals must meet 100 percent of the core actions and be actively working towards the development actions to be awarded accreditation. WA Health s LARU are responsible for regulating the accreditation scheme. Following each organisational wide accreditation survey and mid-cycle assessment, health services are required to provide a copy of their written report to LARU within 10 working days. The Health Service Measure EQ6: Hospital Accreditation (established in the PMF ) requires facilities to be accredited. Therefore, this measure now requires WA hospitals to be accredited to the NSQHS Standards. Independent Hospital Pricing Authority The Independent Hospital Pricing Authority (IHPA) is responsible for critical aspects of a new nationally consistent approach to activity-based funding of public hospitals. The IHPA's primary function is to calculate and deliver an annual National Efficient Price (NEP). The NEP is a major determinant of the level of Australian Government funding for public hospital services and provides a price signal or benchmark for the efficient cost of providing public hospital services. From the Commonwealth Activity Based Funding contributions to WA Health services will be based on the NEP and budgeted activity levels set by WA. The development and implementation of the nationally consistent approach to activity-based funding may influence the future priorities of the PMF. 4 Note: hospital Identified Clostridium difficile infection (originally KPI EQ11 in the PMF ) is a national core hospital-level outcome indicator and has been removed from the PMF All other national core hospital-level outcome indicators are included. 14

16 B o th fin ancial an d non-finan cial p e rfo rman ce in d icato rs are me asu re d. P e rfo rman ce me asu re me n t take s p lace at d iffe re nt o rgan isatio n al le ve ls. Fin an cial p e rforman ce d ata is co lle cted from o p e ratio n al IT systems h o we ve r, some man u al in te rven tio n is n e e d ed. P e rfo rman ce re le van t d ata is sto re d in lo cal d ata ware h o u se s fo rmats. C le ar co mmu n icatio n stru ctu re s are e stab lish e d. No n -fin an cial figu re s are in te gral p art o f re -p o rted data. M o st re su lts are co mmu n icate d via p u sh me ch an ism. P e rfo rman ce data is u se d primarily fo r an alysis p u rp o se s an d fo r co mmu n icatin g strate gy an d go als to staff. Qu an titative go als fo r th e me asu re me n t p ro ce sse s are se t. C o n tin u ous imp ro ve me n t o f th e me asu re me n t p ro ce sse s take s p lace. Ne w te ch n ologies an d p ractice s are id e n tified. 4 Changes to the PMF Maturity Assessment Over the course of the three years that the Annual PMF has been in use it has been progressively evolved to reach a level of maturity that is more closely aligned strategically within WA and nationally, and that fosters continuous performance improvement through the provision of accessible, reliable and meaningful performance information. This level of maturity is central in supporting effective decision-making on priorities and outcomes that seek to ensure continued excellence of health activities and services, and to progress for the attainment of WA Health s mission, vision and objectives. In order to assess the level of maturity of the PMF the Four-Stage Maturity Model for Performance Measurement Systems, as provided in Schedule D, was adopted. A maturity model is a process that describes the development of an entity over time vii. These maturity models are management tools that are designed to assess performance and identify different opportunities for improvement. Therefore, maturity models are considered as essential strategic tools in assessing an organisation s current capabilities and assists in their processes to implement change and improvement in a structured way viii. The maturity of the PMF was assessed using the Four-Stage Maturity Model for Performance Management Systems. Figure 4 maps the results of this exercise. Figure 4: Assessment of the maturity of the PMF Maturity Level 4 4 Mature Quality of Performance Measurement Processes 4 Communication of Performance Results Use of Performance Measures Maturity Level 3 Grown-up 3 Scope of Measurement Storage of Data 3 Maturity Level 2 2 Adolescent Maturity Level 1 Ad-hoc 1 Both financial and non-financial performance indicators are measured. Performance measurement takes place at different organisational levels. Data Collection Financial performance data is collected from operational IT systems however, some manual intervention is needed. Performance relevant data is stored in local data warehouses using different formats. u sin g d iffe re n t Clear communication structures are established. Non-financial figures are integral part of reported data. Most results are communicated via push mechanism. Performance data is used primarily for analysis purposes and for communicating strategy and goals to staff. Quantitative goals for the measurement processes are set. Continuous improvement of the measurement processes takes place. New technologies and practices are identified

17 Through the maturity assessment, it was determined that for the PMF to continue to mature to the level required for state and national priorities, a focus should be placed on strengthening the indicator suite and making the indicator information more accessible. This focus has led to the development of data quality and outcome statements, which together add robustness and meaningfulness to the KPIs within the PMF. This coupled with the recent advancement of providing access to the Performance Management Report (PMR) to all WA Health staff through the intranet 5 helps to drive a more advanced level of maturity for the PMF by further promoting a culture of performance improvement. Section 5.2 provides more information on the content and purpose of the PMR, which is now available via a link on the PAQ webpage at In order to maximise the value of the detailed information that feeds to the PMR results, access to the data cubes will be provided to authorised users in Data Quality Statements As the PMF acts to support critical decisions concerning achievements towards agreed priorities and outcomes, it is reliant on valid and reliable KPIs. Central to a suite of valid and reliable KPIs is quality data that should be transparent enough such that users will be informed sufficiently of its quality concerning performance measurement, and be confident in the decisions that they will make. To this end, Data Quality Statements (DQS) that assess and report the quality of a data item or a collection of data items have been introduced for the PMF These quality statements allow users to make effective and informed decisions about being fit for purpose by providing quality information on seven dimensions of quality. These seven dimensions of data quality are Institutional Environment; Relevance; Timeliness; Accuracy; Coherence; Interpretability and Accessibility. The premise of implementing DQS is outlined within the Performance Reporting and Data Quality within the Performance Management Framework report. This report outlines the rationale and framework to be adopted to ensure data quality is at the forefront for ABF/ABM PMF KPIs. The report has aligned to the nationally recognised Australian Bureau of Statistics Data Quality Framework ix and with WA Health s Data Quality Policy (OD 0380/12). To make WA Health s Data Quality Policy operational, each KPI within the PMF will be accompanied by a DQS as developed by the data custodians/providers. Each KPIs DQS can be accessed from the PMR webpage, which is now available via a link on the PAQ webpage at Outcome Statements The PMF utilises outcomes measures or KPI to assess the impact of services provided through WA Health. To ensure that these KPI are meaningful and understandable, outcome statements have been developed for each KPI within the PMF The main aim of outcome statements is to answer two core questions: 1. Why has the KPI been chosen for performance monitoring? 2. Why is the KPI relevant to patients, clinicians and administrators? 5 Note: in 2013 the State Health Executive Forum approved the PMR being made available on an open access basis. 16

18 By answering these two core questions, outcome statements can assist end users in determining if the KPI is fit for purpose whilst enabling them to form a more reasonable opinion of the results presented and the relevance of these results. Outcome statements should be used in conjunction with the PMF, the PMR and the Data Quality Statements to guide end users in monitoring performance and striving for improvements in service delivery. It is important to note that the outcome statements assume that the KPI facilitates performance improvement that in turn drives the benefit to patients, clinicians and administrators. This is crucially important in order to foster a culture of performance improvement. Perhaps this importance was best articulated by leadership trainer John E. Jones who stated x : What gets measured gets done. What gets measured and fed back gets done well. What gets rewarded gets repeated. This speaks to sustainable gains in performance improvement through behavior change that fosters a culture of performance improvement. Schedule E provides outcome statements for the PMF KPIs by the relevant domains and dimensions of performance. 5 Performance Reporting, Monitoring and Evaluating 5.1 Performance Reporting Each year PMF indicator targets, thresholds (where applicable), definitions and other reporting requirements are reviewed with data custodians/providers as part of the PMF KPI Review process. This process forms one component part of the annual development cycle of the PMF and provides the basis for revised targets and thresholds and incorporates refinements while ensuring that KPIs continue to reflect the local and national priorities. KPI Targets Targets have been established for KPIs and Health Service Measures in line with previous years PMFs and with consideration of the outcomes of the PMF KPI Review process. Whilst Health Service Measures are not performance rated, targets have been established for each measure. Targets have again been established by systematically considering and adopting (where possible) the following in order of preference: 1. Existing national policy based targets 6 2. Existing WA Health state policy based targets 3. New target based on previous performance baselines, the results of the stress testing methodology, or expert advice from data custodians/providers. 6 Note: for example, the National Partnership agreement on Improving Public Hospital Services National Emergency Access Targets. 17

19 As many targets are developed as movements from baseline, consideration for potential updates to baselines formed part of the PMF KPI Review process. Baseline updates have been reviewed in conjunction with a statistical review weighing up the risks and benefits for change. Further information regarding the target source, including baseline information, is provided in Schedule C. KPI Thresholds Performance thresholds, measured against the relevant target, have been set for each KPI following rigorous stress testing and consultation with data stakeholders. These thresholds establish the levels of performance which forms the criterion for whether any action needs to be taken in relation to identifying and resolving poor performance, or acknowledging excellent performance. The agreed thresholds for each KPI are provided in Schedule B. Identifying an indicator Each KPI and Health Service Measure can be identified by an alpha-numeric domain code. The alpha-numeric system was introduced in The alpha-numeric code is based on the domains and dimensions of the framework for which the indicator relates to. In order to preserve the unique domain codes for each indicator, the ordering of the codes may not always be sequential. 5.2 Performance Monitoring and Evaluating Each month the Performance Activity and Quality (PAQ) Division provides the DG with the PMR. The PMR is a balanced scorecard report of Service Provider performance against each of the KPIs combined with appropriate detailed reporting of the Health Service Measures to support the evaluation. The performance evaluation in the PMR involves an assessment for each of the KPIs at four levels of performance: Highly Performing Performing Under-Performing Not Performing. The four level performance results will be used to calculate an overall Performance Score for facilities and Health Services. The Performance Score will be calculated each month, to provide an indicative summary of performance across all KPIs for a facility or Health Service. The performance of Service Providers will be monitored regularly against the KPIs, benchmarks and thresholds specified in the PMF in conjunction with the Performance Score. Service Providers (or their nominees) will meet regularly with DOH representatives to discuss the performance of their health service and the facilities within it. Performance concerns will be identified if the facility and/or a health service Performance Score is below a certain level. If performance concerns are identified, these meetings will occur more frequently. Details of how performance management will operate in practice are provided in the following Section. 18

20 A number of new safety and quality indicators are currently under development by WA Health s Office of Safety & Quality in Health Care. These measures will aim to provide a picture of all state and national clinical priority areas. Development and implementation timeframes for will be completed in association with Health Services. These measures will focus on individual patient clinical outcomes and will be designed to complement existing safety and quality measures in the PMF and other existing Patient Safety reports xi. 6 Performance Management 6.1 Elements of Performance Management Performance management will involve: On-going review of the performance of Service Providers Identifying a performance concern and determining the appropriate response to this concern Determining when a performance recovery plan is required and the level of intervention required Determining when the performance intervention needs to be escalated or can be deescalated Determining when a Service Provider is no longer on performance watch. Figure 5 shows schematically how performance management will operate. Figure 5: Operation of Performance Management Escalate level of intervention Yes Assessment of performance Performance concern identified? Yes Assess severity of performance concern Intervention required? Yes Implement level of intervention Performance concern persisting? No No No Performance exceeded expectations? Yes Performance recognition No Maintain monthly evaluation & review De-escalate level of intervention 19

21 6.2 Intervention Levels As in the PMF there are three intervention levels. The level of performance response and intervention dictates the action required by the Service Providers and/or the DOH. The DG has the discretion to escalate or de-escalate concerns to higher or lower levels based on an assessment of progress with the recovery plan. Details of Performance Management Processes are provided at Schedule F. Each Service Provider will: 1. Ensure timely responses to the DOH requests for performance information 2. Meet all reporting requirements specified in the PMF 3. Demonstrate that they have comparable frameworks/processes, which map as close as possible to measures included in their SA, down to facility and clinical network/cluster or division levels for monitoring performance and identifying and managing emerging performance issues 4. Identify delegates responsible for service delivery against KPIs 5. Have in place processes and procedures to identify risk including a process to report this risk to the DOH 6. Report promptly to the DOH any emerging or potential performance issue and/or performance risk including immediate actions taken and/or an early assessment of action that may be required to prevent the issue from deteriorating 7. Work in partnership with the Public Health Division to achieve performance against the population health based KPIs 8. Establish and maintain a culture of performance improvement by: Promoting the PMF at all levels within the Health Service Identifying shortfalls in relation to performance and devising and implementing appropriate support and development arrangements to facilitate long-term and sustainable delivery Providing relevant managerial staff (administrative and clinical) with training and mentoring in performance management and improvement and the tools to enable them to have an effective performance improvement role Ensuring that key staff understand their performance responsibilities and the consequences of not effectively executing these responsibilities 9. Work collaboratively with the DOH to achieve improved performance 10. Manage contractual obligations relating to performance and report these to DOH as required 11. Establish performance reporting that meets the requirements of their Governing Council/s. In these PMF requirements were added to the WA Health Operational Plan to support Health Service implementation. This will continue in the Operational Plan. 20

22 6.3 Incentives and Premium Payment Program The ABF/ABM Review of Incentives and Pay for Performance in the Health Industry is a discussion paper that examined the evidence for use of incentive schemes in the health industry across the public and private sectors, both in Australia and overseas. The move to an ABF/ABM system involves incentives and penalties based on the level of performance relative to specified targets and thresholds of performances. The PMF is based on a balanced scorecard approach addressing financial, workforce, activity, access, quality and safety domains. Key financial incentives are embedded in the ABF pricing structure. Under the funding arrangements for inpatient separations, ED attendances and outpatient occasions of service, Service Providers are paid at a rate based on the average length of stay for a given Diagnostic Related Group (DRG) 7 for cases that are within the 'length of stay' boundaries 8. Under this approach the incentive is for Service Providers to reduce the average length of stay, thereby receiving more revenue than the cost of delivering care. Where a Service Provider identifies projected efficiency savings, the revenue may continue to be expended during that financial year. Service providers are encouraged to invest in strategies that further improve productivity. No surplus generated is able to be carried over to the next financial year. In addition to the other quality improvement work already happening across the system, the Performance-based Premium Payment Program (the Program) was introduced in ii to improve sustainability of clinical practice improvements within an ABF/ABM environment; to ensure that every patient, every time, is provided with best evidence-based care. Details of the Performance-based Premium Payments Program will be provided in the Information Pack, which will be available from the activity website, in the near future. The Program has been designed to: recognise and reward services which provide a very high level of best evidence-based care reimburse service providers for any additional costs and tasks associated with participation in the scheme, including data collection and submission. Clinical areas will continue to be selected for inclusion in the Program using the following criteria: A strong evidence base and clinical consensus on the characteristics of best practice High impact, i.e. variation in practice, gap between best evidence and current practice, high volumes or significant impact on outcomes Availability and quality of data. The Program is open to ABF-funded hospitals. Participation is not mandatory; sites and services will be eligible for payment only if the required data is submitted. 7 Note: Diagnostic Related Group coded under the AN-DRG Version 6. 8 Note: this approach ensures that exceptional episodes will be identified and appropriately funded. 21

23 Each year, the performance-based premium payments and incentive models are reviewed and assessed for their effectiveness in creating and maintaining clinical practice improvements in high priority care areas. This review will result in adjustments to existing payments, and the introduction of new payments for priority clinical areas. In Health Services will continued to receive funding for the Safety and Quality Investment for Reform (SQuIRe) program. It is expected that Health Services will apply their SQuIRe funding to: Continue to develop and maintain clinical governance systems and processes Incorporate safety and quality activities into permanent roles Continue to roll out the eight evidence-based clinical practice improvement initiatives Implement State and National safety and quality policies and programs, including those initiatives developed by the Australian Commission on Safety and Quality in Health Care and endorsed by the Standing Council on Health Continue existing clinical governance activity and reporting arrangements in line with the WA Health Operational Plan and the WA Strategic Plan for Safety and Quality in Health Care xii. 6.4 Service Provider Governance Accountabilities The Service Provider will continue to ensure structures and processes are in place to fulfil all statutory obligations and to ensure good corporate governance, as outlined in: relevant legislation; WA Health s Integrity and Ethical Governance Framework; WA Health operational directives; and policy and procedure manuals and technical bulletins. From January 2013 this includes accreditation against the ACSQHC ten National Safety and Quality Health Service Standards xiii. 6.5 ABF- funded hospitals Additional to the NHRA Clauses referred to in Section 3.2 National Health Reform, Clause D8b states: NHRA Clause D8b The Local Hospital Network Service Agreement will include at a minimum: the quality and service standards that apply to services delivered by the Local Hospital Network, including the Performance and Accountability Framework Although the quality and service standards of the SAs is undertaken as prescribed in the Annual PMF, only ABF- funded hospitals are included in the PMF along with the Statewide Services. Other services, including the small country hospitals and public hospitals operated by third parties, are managed by the relevant Health Services through individual arrangements. Figure 6 depicts the structure and processes for safeguarding quality standards within WA Health. 22

24 Figure 6: Performance Governance within WA Health Service Agreements Contracts Management Performance Management Framework Regulation (accreditation) M Planning, Monitoring & Reporting Ministerial accountability as exercised through the DOH PMF Health Services CM SA M Governing Councils ABF- funded public hospitals Public hospitals operated by third parties Other non ABFfunded public hospitals R R R WA Health Licensing and Accreditation Regulatory Unit Although the PMF applies to ABF- funded hospitals only, it is anticipated that the scope will be extended to include public hospitals operated by third parties in Next Steps 7.1 Vertical Equity The domain Equity has a low volume of KPIs when compared to the other patient outcome domains of Effectiveness and Efficiency. Therefore, the introduction of more equity indicators would support the WA Health policy of better health outcomes for every patient, every time, everywhere. Equity measures can also be introduced vertically through KPIs within other domains and dimensions. The NHPA s PAF indicators are planned to be reported in this manner by Aboriginal 9 and non-aboriginal status where statistically possible and as such, are also planned to be included in the PMF when developed. 9 Within Western Australia, the term Aboriginal is used in preference to Aboriginal and Torres Strait Islander, in recognition that Aboriginal people are the original inhabitants of Western Australia. No disrespect is intended to our Torres Strait Islander colleagues and community. 23

25 A national audit: Indigenous Identification in Hospital Separations Data Quality Report xiv was recently conducted by the Australian Institute of Health and Welfare to review the quality of Indigenous identification in hospital separation data. For WA, it concluded that 98% of Indigenous persons and 99% of non-indigenous persons were correctly identified taken over an audit of 966 records. To date, a lack of confidence in the quality of the data captured for Aboriginal status has stood as a barrier to introducing vertical equity across KPIs from other domains and dimensions (together with other barriers such as potential statistical limitations due to small numbers and data not being captured). Schedule G provides the Recommendations from the Indigenous Identification in Hospital Separations Data Quality Report. A review of the ability to report PMF indicators by Aboriginality was completed as part of the PMF KPI Review; a summary of which can be found in Schedule H. Based on these findings the following KPIs are planned to be split by Aboriginality for the PMF : EAP1: Rate of selected potentially preventable chronic condition hospitalisations (for specified chronic conditions) EQ1: Age-adjusted rate of avoidable deaths EQ10: Rate of total hospital readmissions within 28 days to a designated mental health inpatient unit. Along with the following HSM: EQ12: Rate of community follow up within first 7 days of discharge from psychiatric admission. 7.2 Gaps in Performance Reporting Whilst some HSMs within the PMF have stronger causational linkages to KPIs than others, it is envisaged that the PMF will continue to be evaluated to identify the most appropriate measures. This process should identify further gaps in reporting. Facilities and Equipment There are limited measures capturing the expenditure and/or required funds for improvement in facilities and equipment to maintain an effective and efficient Health Service. The importance of asset management is recognised by the WA Department of Treasury xv and also by Professor Bryant Stokes AM in the recent special Inquiry examining the delivery of public health services at the Peel Health Campus xvi. Further, the Queensland Health Department have established this as a priority area by monitoring the following KPIs within their performance framework: maintenance expenditure; facility condition; and planned maintenance expenditure ratio xvii. Opportunities to include similar indicators will be further explored in future PMFs. Employee measures A balanced scorecard approach generally has the four inter-dependent perspectives of finance, internal business process, learning and growth (including employee engagement) and customer xviii. 24

26 The recent UK inquiry into the serious failings at the Mid Staffordshire NHS Foundation Trust identified that the Trust lacked a sufficient sense of collective responsibility or engagement for ensuring that quality care was delivered at every level xix. As the KPIs within the PMF predominantly relate to the perspectives of finance, internal business process and customer, future strategies to expand on employee engagement will be considered. 25

27 26 Schedule A. Outcome Measures & Health Service Measures, Scope and Reporting Frequency Key: * Proposed PAF indicator developed as the same indicator title or a WA Health equivalent measure ^ National core hospital-level outcome indicators recommended by the ACSQHC developed as the same indicator or a WA Health equivalent measure new! Indicator is new to PMF changed! Indicator, reporting level and/or reporting frequency changed from PMF to PMF deferred! Indicator deferred until ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT MEASURES OUTCOME MEASURE REPORTING LEVEL REPORTING FREQUENCY EFFECTIVENESS Access EA1 * Proportion of emergency department patients seen within Facility Monthly recommended times a) % Triage Category 1-2 minutes b) % Triage Category 2-10 minutes c) % Triage Category 3-30 minutes d) % Triage Category 4-60 minutes e) % Triage Category 5-2 hours EA2 * NEAT % of ED Attendances with LOE <=4 hours Facility Monthly EA3 Average overdue wait time of elective surgery cases waiting beyond Facility Monthly the clinically recommended time, by urgency category a) beyond 30 days for urgency category 1 b) beyond 90 days for urgency category 2 c) beyond 365 days for urgency category 3 EA4 * Elective surgery patients treated within boundary times: Facility Monthly a) % Category 1 within 30 days b) % Category 2 within 90 days c) % Category 3 within 365 days EA5 * Percentage of selected elective cancer surgery cases treated within boundary time: a) Bladder Cancer b) Bowel Cancer c) Breast cancer Facility Quarterly

28 27 ABF/ABM Framework Dimension Appropriateness Quality 10 Code DOH PERFORMANCE MANAGEMENT MEASURES REPORTING LEVEL REPORTING FREQUENCY HEALTH SERVICE MEASURE EA7 Percentage of ED Mental Health patients admitted within 8 hrs Facility Monthly EA8 Theatre activity Facility Monthly EA9 Ambulance Diversion Facility Monthly EA10 Access Block Facility Monthly EA11 Admissions from ED Facility Monthly OUTCOME MEASURE EAP1 EAP2 EAP3 Rate of selected potentially preventable chronic condition hospitalisations (for specified chronic conditions) HEALTH SERVICE MEASURE Adult immunisation: percentage of people aged 65 years and over immunised against Influenza Obesity: percentage of population who are overweight or obese: a) Adults b) Children Whole of population (reported at Health Service level) Whole of population (reported at Health Service level) Whole of population (reported at Statewide level EAP4 Tobacco: percentage of adults who are current smokers Whole of population (reported at Statewide level OUTCOME MEASURE EQ1 Age-adjusted rate (AAR) of avoidable deaths Whole of population (reported at Health Service level) EQ3 *^ Staphylococcus aureus bacteraemia infections per 10,000 patient Facility days Annually Annually Annually Annually Annually Annually 10 KPI EQ11: Hospital identified Clostridium difficile infections has been removed from Schedules A and C.

29 28 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT MEASURES REPORTING LEVEL REPORTING FREQUENCY EQ5 *^ Hospital standardised mortality ratio Facility Annually EQ7 *^ Death in low-mortality DRGs Facility Annually EQ8 *^ In hospital mortality rates (for acute myocardial infarction, stroke, Facility Annually fractured neck of femur & pneumonia) EQ10 Rate of total hospital readmissions within 28 days to a designated mental health inpatient unit Facility Quarterly EQ2 HEALTH SERVICE MEASURE Percentage of Emergency Department attendances which are unplanned re-attendances in less than or equal to 48 hours of previous attendance. Facility Monthly EQ4 Rate of Severity Assessment Code (SAC) 1 clinical incident investigation reports received by Patient Safety Surveillance Unit within 45 working days of the event notification date Health Service Quarterly EQ6 Hospital accreditation Facility Annually EQ9 *^ Unplanned hospital readmissions of patients discharged following management of (knee replacement, hip replacement, tonsillectomy & adenoidectomy, hysterectomy, prostatectomy, cataract surgery and appendicectomy) changed! Facility Quarterly EQ12 EQ13 * Rate of community follow up within first 7 days of discharge from Facility Quarterly psychiatric admission * Measures of patient experience (including satisfaction) with hospital Facility Annually services EQ14 Hand Hygiene Compliance Facility Tri-annually

30 29 ABF/ABM Framework Dimension EFFICIENCY Inputs per output unit Code DOH PERFORMANCE MANAGEMENT MEASURES REPORTING LEVEL REPORTING FREQUENCY OUTCOME MEASURE EI1 Volume of weighted activity year-to-date: Facility Monthly a) Inpatients (variance from target) b) ED attendances (variance from target) c) Outpatients (variance from target) EI3 Average cost per test panel for PathWest Statewide Monthly EI6 * YTD distance of net cost of service to budget Health Service Monthly EI8 * Ratio of actual cost of specified public hospital services compared Health Annual with the state efficient price deferred! Service HEALTH SERVICE MEASURE EI2 * Elective surgery day of surgery admission rates Facility Monthly EI4 YTD Distance of Expenditure to Budget Health Service Monthly EI5 YTD Distance of Own Sourced Revenue to Budget Health Service Monthly EI7 School Dental Service ratio of examinations to enrolments Whole of Annually population (reported at Health Service level) EI9 Number of separations (unweighted) Facility Monthly EI10 * Coded acute multiday average length of stay Facility Quarterly EI11 YTD Distance of Salaries Expenditure to Budget new! Health Service Monthly EQUITY Access EQA1 EQA4 OUTCOME MEASURE Standardised Mortality Ratio (SMR) of deaths among Aboriginal children (0-4 years) and non-aboriginal children (0-4 years) Proportion of eligible population receiving dental services from subsidised dental programs by group: changed! a) Aged 16 years and over b) Aged 65 years and over c) Total Aboriginal population Whole of population (reported at Health Service level) Whole of population (reported at Health Service level) Annually Quarterly

31 30 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT MEASURES HEALTH SERVICE MEASURE EQA2 Standardised Rate Ratio of Hospitalisations of : a) Aboriginal People compared to non-aboriginal People. b) Aboriginal children (0-4 years) compared to non-aboriginal children (0-4 years) EQA3 Childhood immunisation: percentage of children fully immunised at months: a) Aboriginal b) Total REPORTING LEVEL Whole of population (reported at Health Service level) Whole of population (reported at Health Service level) REPORTING FREQUENCY Annually Quarterly EQA5 WA Health Aboriginal employment headcount Health Service changed! Monthly changed! OUTCOME MEASURE SW3 Staff turnover Facility Monthly SW1 HEALTH SERVICE MEASURE Proportion of medical graduates (and other categories of medical staff) to total medical staff a) Interns (graduate) b) Resident Medical Officers c) Registrars d) Consultants e) Other Facility Quarterly SUSTAINABILITY Workforce SW2 Proportion of nursing graduates (and other categories of nursing staff) to total nursing staff a) Graduate b) Junior c) Experienced d) Senior e) SRN and above Facility Quarterly SW4 Injury management: a) Lost time injury severity rate b) Percentage of managers and supervisors trained in occupational safety and health (OSH) and injury management responsibilities changed! Health Service Bi-annually

32 31 ABF/ABM Framework Dimension PROCESSES Facilities & Equipment Coding Finance Code DOH PERFORMANCE MANAGEMENT MEASURES REPORTING LEVEL REPORTING FREQUENCY SW5 Leave Liability Facility changed! Monthly SW6 Actual and Budget FTE Health Service Monthly PC2 OUTCOME MEASURE Percentage of cases coded within boundary a) Cases within 2 weeks of discharge b) Remaining cases within 4 weeks of discharge HEALTH SERVICE MEASURE Facility Monthly PC1 Percentage of cases coded by end of month closing date Facility Monthly OUTCOME MEASURE PF2 Manually corrected payroll errors (underpayments) HCN Service Monthly PF3 Availability of Information Communication Technology (ICT) services: HIN Service Monthly percentage of Service calls resolved at first point of contact HEALTH SERVICE MEASURE PF1 Patient fee debtors Health Service Monthly PF4 NurseWest shifts filled Statewide Monthly PF5 Accounts payable payment within terms HCN Service Monthly

33 32 Code Schedule B. Outcome Measures Targets and Thresholds Key: new! Target and/or thresholds are new to PMF changed! Target and/or thresholds changed from PMF to PMF deferred! Indicator deferred until Key Performance Indicator Target Thresholds Not Performing Under Performing Performing Highly Performing EA1a EA1b EA1c EA1d EA1e Proportion of triage category 1 emergency department patients seen within 2 minutes Proportion of triage category 2 emergency department patients seen within 10 minutes Proportion of triage category 3 emergency department patients seen within 30 minutes Proportion of triage category 4 emergency department patients seen within 60 minutes Proportion of triage category 5 emergency department patients seen within 2 hours EA2 NEAT % of ED Attendances with LOE <=4 hours changed! 76% 100% < 95% >= 95% and < 100% 100% 80% < 75% >= 75% and < 80% >= 80% and < 85% >= 85% 75% < 70% >= 70% and < 75% >= 75% and < 80% >= 80% 70% < 65% >= 65% and < 70% >= 70% and < 75% >= 75% 70% < 65% >= 65% and < 70% >= 70% and < 75% >= 75% < 71% >= 71% and < 76% >= 76% and < 81% >= 81% 81% < 71.3% >= 71.3% and < 78.5% >= 78.5% and < 81% >= 81% EA3a Elective surgery: average time beyond 30 days for urgency category 1 changed! 85% 0 days < 71.3% >= 27 >= 71.3% and < 83% >= 14 and < 27 >= 83% and < 85% > 0 and < 14 >= 85% 0 0 days (2013 and 2014 calendar yr) >= 27 (2013 and 2014 calendar yr) > 0 and < 27 (2013 and 2014 calendar yr) 0 (2013 and 2014 calendar yr)

34 33 Code Key Performance Indicator Target Thresholds Not Performing Under Performing Performing Highly Performing EA3b Elective surgery: average time beyond 90 days for urgency category 2 changed! 68 days >= 90 >= 80 and < 90 > 68 and < 80 <= 68 days 45 days >= 90 >= 68 and < 90 > 45 and < 68 <= 45 EA3c Elective surgery: average time beyond 365 days for urgency category 3 changed! 23 days 65 days >= 90 >= 87 days >= 45 and < 90 >= 77 and < 87 > 23 and < 45 > 65 and < 77 <= 23 <= days >= 87 >= 65 and < 87 > 44 and < 65 <= 44 EA4a Elective surgery patients treated within boundary times: % of category 1 cases within 30 days changed! 22 days 94% >= 87 < 87.4% >= 44 and < 87 >= 87.4% and < 90.7% > 22 and < 44 >= 90.7% and < 94% <= 22 >= 94% 100% < 87.4% >= 87.4% and < 97% >= 97% and < 100% 100% EA4b Elective surgery patients treated within boundary times: % of category 2 cases within 90 days changed! 100% 84% < 87.4% < 79.2% >= 87.4% and < 100% >= 79.2% and < 81.6% 100% >= 81.6% and < 84% >= 84% 88% < 79.2% >= 79.2% and < 86% >= 86% and < 88% >= 88% 95% < 79.2% >= 79.2% and < 91.5% >= 91.5% and < 95.0% >= 95.0%

35 34 Code Key Performance Indicator Target Thresholds Not Performing Under Performing Performing Highly Performing EA4c Elective surgery patients treated within boundary times: % of category 3 cases within 365 days changed! 98% < 97.2% >= 97.2% and < 97.6% >= 97.6% and < 98% >= 98% 98% < 97.2% >= 97.2% and < 98% >= 98% EA5a Percentage of selected elective cancer surgery cases treated within boundary time: Bladder Cancer changed! 98.5% 94% < 97.2% >= 97.2% and < 98.25% < 90% >= 98.25% and < 98.5% >= 90% and < 94% >= 98.5% >= 94% 97.2% < 88.3% (2013. calendar yr) >= 88.3% and < 94.9% >= 94.9% and < 97.2% >= 97.2% EA5b Percentage of selected elective cancer surgery cases treated within boundary time: Bowel Cancer changed! 98.4% 94% < 88.3% >= 88.3% and < 97.8% < 90% >= 97.8% and < 98.4% >= 90% and < 94% >= 98.4% >= 94% 98.6% < 86.8% >= 86.8% and < 95.8% >= 95.8% and < 98.6% >= 98.6% EA5c Percentage of selected elective cancer surgery cases treated within boundary time: Breast Cancer changed! 99.3% 94% < 86.8% >= 86.8% and < 99.0% < 90% >= 99.0% and < 99.3% >= 90% and < 94% >= 99.3% >= 94% 99.3% < 87.2% >= 87.2% and < 96.4% >= 96.4% and < 99.3% >= 99.3% EAP1 Rate of selected potentially preventable chronic condition hospitalisations (for specified chronic conditions) changed! 99.6% Baseline < 87.2% >= 87.2% and < 99.5% Significant 11 increase compared to baseline >= 99.5% and < 99.6% No significant 11 change compared to baseline >= 99.6% Significant 11 decrease compared to baseline 11 The term significant refers to an interpretation of statistical data that indicates that an occurrence was not simply a chance result.

36 35 Code Key Performance Indicator Target Thresholds Not Performing Under Performing Performing Highly Performing EQ1 Age-adjusted rate (AAR) of avoidable deaths changed! Baseline Significant 11 increase compared to baseline EQ3 Staphylococcus aureus bacteraemia infections per 10,000 patient days EQ5 Hospital standardised mortality ratio National Peer Rate EQ7 Death in low-mortality DRGs National Peer Rate EQ8 EQ10 EI1a EI1b EI1c In hospital mortality rates (for acute myocardial infarction, stroke, fractured neck of femur & pneumonia) Rate of total hospital readmissions within 28 days to a designated mental health inpatient unit Volume of weighted activity year-to-date: inpatients (variance from target) changed! Volume of weighted activity year-to-date: ED attendances (variance from target) changed! Volume of weighted activity year-to-date: outpatients (variance from target) changed! 2 > 2 per 10,000 patient days National Peer Rate National Peer Rate < Lower 95% Confidence Interval National Peer Rate < Lower 95% Confidence Interval National Peer Rate < Lower 95% Confidence Interval No significant 11 change compared to baseline <= 2 per 10,000 patient days and > 0 per 10,000 patient days National Peer Rate >= Lower 95% Confidence Interval, and <= Upper 95% Confidence Interval National Peer Rate >= Lower 95% Confidence Interval, and <= Upper 95% Confidence Interval National Peer Rate >= Lower 95% Confidence Interval, and <= Upper 95% Confidence Interval Significant 11 decrease compared to baseline = 0 per 10,000 patient days National Peer Rate > Upper 95% Confidence Interval National Peer Rate > Upper 95% Confidence Interval National Peer Rate > Upper 95% Confidence Interval 12% > 14% > 12% and <= 14% >= 10% and <= 12% < 10% +/- 1% < -1% or > 1% >= -1% and <= 1% +/- 1% < -1% or > 1% >= -1% and <= 1% +/- 1% < -1% or > 1% >= -1% and <= 1% EI3 Average cost per test panel for PathWest 24 > 30 > 26 and <= 30 >= 20 and <= 26 < 20 EI6 YTD distance of net cost of service to budget Actual equals Budget < -2% >= -2% and < -0.75% >= -0.75% and <= 0% > 0%

37 36 Code Key Performance Indicator Target Thresholds Not Performing Under Performing Performing Highly Performing EI8 EQA1 EQA4a EQA4b EQA4c Ratio of actual cost of specified public hospital services compared with the state efficient price deferred! Standardised Mortality Ratio (SMR) of deaths among Aboriginal children (0-4 years) and non-aboriginal children (0-4 years) changed! Proportion of eligible population receiving dental services from subsidised dental programs by group: Aged 16 years and over Proportion of eligible people receiving dental services from subsidised dental programs by group: Aged 65 years and over Proportion of eligible people receiving dental services from subsidised dental programs by group: Total Aboriginal population Baseline Significant 12 increase compared to baseline No significant 12 change compared to baseline 100% of baseline < 100% of baseline >= 100% of baseline 100% of baseline < 100% of baseline >= 100% of baseline 100% of baseline < 100% of baseline >= 100% of baseline Significant 12 decrease compared to baseline SW3 Staff turnover 1.2% > 1.7% <= 1.7% and > 1.2% <= 1.2% and > 1.0% <= 1.0% PC2a Percentage of cases coded within boundary cases within 2 weeks of discharge PC2b Percentage of cases coded within boundary remaining cases within 4 weeks of discharge changed! 80% < 75% >= 75% and < 80% >= 80% and < 85% >= 85% 100% (12/13 financial yr) < 85% (12/13 financial yr) >= 85% and < 95% (12/13 financial yr) >= 95% and < 98% (12/13 financial yr) >= 98% (12/13 financial yr) 100% (13/14 financial yr) < 85% (13/14 financial yr) >= 85% and < 99% (13/14 financial yr) >= 99% and < 100% (13/14 financial yr) PF2 Manually corrected payroll errors (underpayments) < 1% >= 1% < 1% 100% (13/14 financial yr) PF3 Availability of Information Communication Technology (ICT) services: percentage of Service calls resolved at first point of contact 105% of baseline <= 95% of baseline > 95% of baseline and <= 100% of baseline > 100% of baseline and <= 105% of baseline > 105% of baseline 12 The term significant refers to an interpretation of statistical data that indicates that an occurrence was not simply a chance result.

38 37 Schedule C. Outcome Measures and Health Service Measures Target Source Key: * Proposed PAF indicator developed as the same indicator title or a WA Health equivalent measure ^ National core hospital-level outcome indicators recommended by the ACSQHC developed as the same indicator or a WA Health equivalent measure new! Indicator is new to PMF changed! Target and/or target source changed from PMF to PMF deferred! Indicator deferred until ABF/ABM Framework Dimension EFFECTIVENESS Access Code EA1 DOH PERFORMANCE MANAGEMENT INDICATORS OUTCOME MEASURE * Proportion of emergency department patients seen within recommended times a) % Triage Category 1-2 mins b) % Triage Category 2-10min c) % Triage Category 3-30 min d) % Triage Category 4-60 min e) % Triage Category 5-2 hours TARGET SOURCE (NB. targets for established indicators are subject to annual review) National: Australasian College for Emergency Medicine: Policy on the Australasian Triage Scale. State: N/A New: N/A Target (a) = 100% Target (b) = 80% Target (c) = 75% Target (d) = 70% Target (e) = 70% EA2 * NEAT % of ED Attendances with LOE <=4 hours changed! National: NPA on Improving Public Hospital Services (National Emergency Access Target). State: N/A New: N/A EA3 Average overdue wait time of elective surgery cases waiting beyond the clinically recommended time, by urgency category changed! a) average time beyond 30 days for urgency category 1 b) average time beyond 90 days for urgency category 2 c) average time beyond 365 days for urgency category 3 Target = 2013: 81%; 2014: 85% National: NPA on Improving Public Hospital Services (National Elective Surgery Target). State: N/A New: N/A Target (a) = 0 days Target (b) = 2013: 45 days; 2014: 23 days Target (c) = 2013: 44 days 2014: 22 days

39 38 ABF/ABM Framework Dimension Code EA4 EA5 DOH PERFORMANCE MANAGEMENT INDICATORS * Elective surgery patients treated within boundary times: changed! a) % Category 1 within 30 days b) % Category 2 within 90 days c) % Category 3 within 365 days * Percentage of selected elective cancer surgery cases treated within boundary time: changed! a) Bladder Cancer b) Bowel Cancer c) Breast Cancer TARGET SOURCE (NB. targets for established indicators are subject to annual review) National: NPA on Improving Public Hospital Services (National Elective Surgery Target). State: N/A New: N/A Target (a) = 2013: 100%; 2014: 100% Target (b) = 2013: 88%; 2014: 95% Target (c) = 2013: 98%; 2014: 98.5% National: NPA on Improving Public Hospital Services. State: N/A New: N/A Target (a) = 2013: 97.2%; 2014:98.4% Target (b) = 2013: 98.6%; 2014: 99.3% Target (c) = 2013: 99.3%; 2014: 99.6% HEALTH SERVICE MEASURE EA7 Percentage of ED Mental Health patients admitted within 8 hrs National: Nil Relevant. State: Nil Relevant. New: NSW Department of Health Key Performance Indicators and Service Measures for Service Agreement from September Target = 80% EA8 Theatre activity National: Nil Relevant. State: Nil Relevant. New: NSW Department of Health Key Performance Indicators and Service Measures for Service Agreement from September Target = 80% EA9 Ambulance Diversion National: Nil Relevant. State: Western Australia Policy on Ambulance Diversion for the Health Services of the Perth Metropolitan Area (OD 0295/10).

40 39 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) New: N/A Target = 0 EA10 Access Block National: Nil Relevant. State: Nil Relevant. New: Established for PMF Target = Decrease from the previous year. EA11 Admissions from ED National: Nil Relevant. State: Nil Relevant. New: Nil Relevant. EAP1 OUTCOME MEASURE Rate of selected potentially preventable chronic condition hospitalisations (for specified chronic conditions) No target - data displayed as trend. National: Nil Relevant. State: Established for PMF New: N/A Target = Baseline. Baseline = age standardised rate by Health Service. Appropriateness EAP2 HEALTH SERVICE MEASURE Adult immunisation: percentage of people aged 65 years and over immunised against Influenza National: Nil Relevant. State: Established for PMF with advice from Communicable Disease Control. New: N/A EAP3 Obesity: percentage of population who are overweight or obese: a) Adults b) Children Target = 70% National: National Partnership Agreement on Preventative Health State: Established for PMF with advice from Chronic Disease Prevention.

41 40 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) New: N/A Target = No more than 105% of baseline. Baseline = 2006 to 2010 annual State average. EAP4 Tobacco: percentage of adults who are current smokers changed! National: National Partnership Agreement on Preventative Health 2008 and 2007 National Drug Strategy Household Survey (NDSHS). State: Established for PMF in line with advice from Chronic Disease Prevention. New: N/A Target up to 2012 data = 15.5% (2% reduction from 2007 NDSHS) Target from 2013 data onwards = 14% (3.5% reduction from 2007 NDSHS). OUTCOME MEASURE EQ1 Age-adjusted rate (AAR) of avoidable deaths National: Nil Relevant. State: Established for PMF with advice from Epidemiology Branch. New: N/A Quality EQ3 *^ Staphylococcus aureus bacteraemia infections per 10,000 patient days Target = Baseline. Baseline = 2009 Health Service rate. National: MyHospitals national benchmark for SAB. State: N/A New: N/A Target = 2 EQ5 *^ Hospital standardised mortality ratio National: Nil Relevant. State: Established for PMF 2011-

42 41 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) 12. New: N/A Target = National peer rate. EQ7 *^ Death in low-mortality DRGs changed! National: Nil Relevant. State: Established for PMF New: N/A EQ8 EQ10 EQ2 EQ4 *^ In hospital mortality rates (for acute myocardial infarction, stroke, fractured neck of femur & pneumonia) changed! Rate of total hospital readmissions within 28 days to a designated mental health inpatient unit HEALTH SERVICE MEASURE Percentage of Emergency Department attendances which are unplanned re-attendances in less than or equal to 48 hours of previous attendance. Rate of Severity Assessment Code (SAC) 1 clinical incident investigation reports received by Patient Safety Surveillance Unit within 45 working days of the event notification date Target = National peer rate. National: Nil Relevant. State: Established for PMF New: N/A Target = National peer rate. National: The Fourth National Mental Health Plan (May 2011) produced by the Mental Health Information Strategy Subcommittee, AHMAC Mental Health Standing Committee. State: N/A New: N/A Target = 12% National: Nil Relevant. State: Established for PMF New: N/A Target = Baseline. Baseline = Facility monthly average for the period Nov 08 to Oct 09. National: Nil Relevant. State: DOH Operational Directive 0104/08: Sentinel Events to be reported to the Director, Office of Safety and Quality in Healthcare.

43 42 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) New: N/A Target = 100% EQ6 Hospital accreditation National: Will be reviewed in light of the National Safety & Quality Health Service (NSQHS) Standards effective 1 Jan State: Established for PMF New: N/A EQ9 *^ Unplanned hospital readmissions of patients discharged following management of (knee replacement, hip replacement, tonsillectomy & adenoidectomy, hysterectomy, prostatectomy, cataract surgery, and appendicectomy) changed! Target = Full Accreditation. National: Nil Relevant. State: Nil Relevant. New: Established for PMF Target: assessment period <= baseline EQ12 * Rate of community follow up within first 7 days of discharge from psychiatric admission Assessment period = moving 4 quarter period. e.g., Data shown for March 2013 represents the assessment period April 2012 to March Baseline = moving baseline representing the previous years peer group average for the corresponding 4 quarter period. e.g., Baseline data shown for March 2013 represents the period April 2011 to March Each hospital is assessed against its peer group baseline. National: The Fourth National Mental Health Plan (May 2011) produced by the Mental Health Information Strategy Subcommittee, AHMAC Mental Health Standing Committee.

44 43 ABF/ABM Framework Dimension EFFICIENCY Inputs per output unit Code EQ13 DOH PERFORMANCE MANAGEMENT INDICATORS * Measures of patient experience (including satisfaction) with hospital services TARGET SOURCE (NB. targets for established indicators are subject to annual review) State: N/A New: N/A Target = 75% National: Nil Relevant. State: State report produced by the Epidemiology branch titled "Patient Evaluation of Health Services: All Western Australian Public Hospitals, Admitted Adults, 2010/11". New: N/A Target = Rating of 80 (higher is better). EQ14 Hand Hygiene Compliance National: MyHospitals national benchmark for HHC. State: WA Health identified statewide benchmark for HHC. New: N/A EI1 Volume of weighted activity year-to-date: a) Inpatients (variance from target) b) ED attendances (variance from target) c) Outpatients (variance from target) changed! OUTCOME MEASURE Target = 70% National: Nil Relevant. State: Established for PMF New: N/A Targets (a) to (c) = +/- 1% EI3 Average cost per test panel for PathWest National: Nil Relevant. State: Established for PMF with advice from PathWest. New: N/A. Target = 24 EI6 * YTD distance of net cost of service to budget National: Nil Relevant. State: Established for PMF New: N/A Target = Actual equals Budget

45 44 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) EI8 * Ratio of actual cost of specified public hospital services compared with the 'state efficient price' deferred! HEALTH SERVICE MEASURE EI2 * Elective surgery day of surgery admission rates National: Nil Relevant. State: 2006/07 & 2007/08 WA Health Operational Plan. New: N/A Target = 95% EI4 YTD Distance of Expenditure to Budget National: Nil Relevant. State: Established for PMF New: N/A Target = Actual equals Budget. EI5 YTD Distance of Own Sourced Revenue to Budget National: Nil Relevant. State: Established for PMF New: N/A Target = Actual equals Budget. EI7 School Dental Service ratio of examinations to enrolments changed! National: Nil Relevant. State: Nil Relevant. New: Nil Relevant. No target - data displayed as trend. EI9 Number of separations (unweighted) National: Nil Relevant. State: Service Level Agreements between the DoH and Health Service. New: N/A Target = Agreement between DoH and Health Service. EI10 * Coded acute multiday average length of stay National: Nil Relevant. State: Nil Relevant. New: Established for PMF Target = 95% of baseline.

46 45 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) Baseline = Average 2009/10 financial year data. EI11 YTD Distance of Salaries Expenditure to Budget new! TBC New: Established for PMF with advice from Health Finance Target = TBC. EQA1 OUTCOME MEASURE Standardised Mortality Ratio (SMR) of deaths among Aboriginal children (0-4 years) and non-aboriginal children (0-4 years) National: Nil Relevant. State: Established for PMF New: N/A Target = Baseline. EQUITY Access EQA4 Proportion of eligible population receiving dental services from subsidised dental programs by group d) Aged 16 and over e) Aged 65 years and over f) Total Aboriginal population Baseline = 2009 Health Service rate. National: Nil Relevant. State: Nil Relevant. New: Established for PMF with advice from Dental Health Services. Targets (a) to (c) = 100% of baseline. HEALTH SERVICE MEASURE EQA2 Standardised Rate Ratio of Hospitalisations of : a) Aboriginal People compared to non-aboriginal People. b) Aboriginal children (0-4 years) compared to non-aboriginal children (0-4 years) Baseline = Average 2009/10 financial year data. National: Nil Relevant. State: Established for PMF New: N/A Targets (a) & (b) = Baseline. Baseline = 2009/10 Health Service rate.

47 46 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS EQA3 Childhood immunisation: percentage of children fully immunised at months: a) Aboriginal b) Total TARGET SOURCE (NB. targets for established indicators are subject to annual review) National: Nil Relevant. State: Established for PMF with advice from Communicable Disease Control. New: N/A Targets (a) & (b) = 90% EQA5 WA Health Aboriginal employment headcount National: Nil Relevant. State: Nil Relevant. New: Established for SLAs and PMF with advice from Aboriginal Health Division. Target = Statewide annual increase of 100* Aboriginal employees from the baseline. *The target has been apportioned for each budget holder, based on the proportion of WA Health employees within each budget holder (based on headcount as at February 2013). The annual target is divided by 12, then summed cumulatively for monthly reporting. Health Services reported in PMR Annual Targets to increase from baseline: NMHS = 26 SMHS = 33 WACHS = 20 (Note: There are other health services/entities not reported in PMR which make up the total statewide target of 100.) Baseline = headcount as at June 2013.

48 47 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) OUTCOME MEASURE SW3 Staff turnover National: Nil Relevant. State: Established for PMF New: N/A Target = 1.2% SUSTAINABILITY Workforce SW1 HEALTH SERVICE MEASURE Proportion of medical graduates (and other categories of medical staff) to total medical staff a) Interns (graduate) b) Resident Medical Officers c) Registrars d) Consultants e) Other National: Nil Relevant. State: Established for PMF with advice from Postgraduate Medical Council of WA. New: N/A Targets (a) to (e) = +/- 10% of baseline. SW2 Proportion of nursing graduates (and other categories of nursing staff) to total nursing staff a) Graduate b) Junior c) Experienced d) Senior e) SRN and above Baseline = Facility average 2011/12 financial year data. National: Nil Relevant. State: Established for PMF with advice from Chief Nursing and Midwifery Office. New: N/A Targets (a) to (e) = +/- 10% of baseline. SW4 Baseline = Facility average 2011/12 financial year data. Injury management: National: Nil Relevant. a) Lost time injury severity rate State: Occupational safety, health b) Percentage of managers and supervisors trained in occupational and injury management annual safety and health (OSH) and injury management responsibilities reporting guidelines for 2011 to 2014.

49 48 ABF/ABM Framework Dimension Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) New: N/A Target (a): - 10% of baseline. Baseline for 2013/14 = 2011/12 results. PROCESSES Facilities & Equipment Coding Target (b): 80% SW5 Leave Liability National: Nil Relevant. State: Nil Relevant. New: Established for PMF Target = Decrease from previous year. SW6 Actual and Budget FTE National: Nil Relevant. State: Nil Relevant. New: Established for PMF PC2 OUTCOME MEASURE Percentage of cases coded within boundary c) Cases within 2 weeks of discharge d) Remaining cases within 4 weeks of discharge Target = Budgeted FTE. National: Nil Relevant. State: DOH Operational Directive 0137/08: Hospital Morbidity Data Cycle. New: N/A Target (a) = 80% Target (b) = 100% HEALTH SERVICE MEASURE PC1 Percentage of cases coded by end of month closing date National: Nil Relevant. State: Established for PMF New: N/A Target = 100%

50 49 ABF/ABM Framework Dimension Finance Code DOH PERFORMANCE MANAGEMENT INDICATORS TARGET SOURCE (NB. targets for established indicators are subject to annual review) OUTCOME MEASURE PF2 Manually corrected payroll errors (underpayment) National: Nil Relevant. State: Health Corporate Network Service Level Agreement New: N/A PF3 Availability of Information Communication Technology (ICT) services: percentage of Service calls resolved at first point of contact Target = < 1% National: Nil Relevant. State: Nil Relevant. New: Established for PMF Target = 105% of baseline. Baseline = Average of 2009 calendar year. HEALTH SERVICE MEASURE PF1 Patient fee debtors National: Nil Relevant. State: Established for PMF with advice from Health Finance. New: N/A Target = 60 days PF4 NurseWest shifts filled National: Nil Relevant. State: Health Corporate Network Service Level Agreement New: N/A Target = 75% PF5 Accounts payable payment within terms changed! National: Nil Relevant. State: Section 608 of the Health Accounting Manual, which is based on the Treasurer s Instruction 323 Timely Payment of Account New: N/A Target = 100%

51 Schedule D. Maturity Assessment The four-stage Maturity Model for Performance Measurement Systems xx, below, makes it possible to determine the overall maturity of performance measurements systems. Maturity Level 1 Ad-hoc Only financial performance indicators are considered. Maturity Level 2 Adolescent Maturity Level 3 Grown-up Both financial and non-financial performance indicators are measured. Performance measurement takes place at different organizational levels. Maturity Level 4 Mature Scope of Measurement Financial performance indicators are measured. In addition, a few nonfinancial indicators are measured as well. Financial and nonfinancial indicators are measured on a regular basis. The indicators in place reflect the stakeholders interests. Key processes are measured in an integral way. Data Collection Most performancerelevant data is collected manually. Financial performance data is collected from operational IT systems; however, some manual intervention is needed. Collection of financial performance data is fully automated; collection of nonfinancial data needs some manual handling. Internal and external data sources are exploited. The various operational IT systems are integrated. Thus, data collection does not require manual intervention. Storage of Data Performance data is stored in various formats (ring binder, spreadsheets, databases, etc.). Financial performance data is stored in a central database; nonfinancial data is dispersed over different units. Performance relevant data is stored in local data warehouses using different formats. Performance data is stored in an integrated IT system. Communication of Performance Results Performance results are disseminated on an ad-hoc basis. Performance results are disseminated periodically to the upper and middle management. Clear communication structures are established. Nonfinancial figures are integral part of reported data. Most results are communicated via push mechanism. Financial and nonfinancial performance results are transmitted to the stakeholders electronically (push option). Additionally, performance results can be accessed electronically (pull option) at different level of aggregation. Use of Performance Measures The use of the performance results is not defined. Performance data is used primarily for internal reporting. Performance data is used primarily for analysis purposes and for communicating strategy and goals to staff. Performance results are used (1) as a central managerial and planning instrument, (2) to support company- external communication, and (3) to get people involved. Quality of Performance Measurement Processes The measurement processes are not defined; success depends on individual effort. A certain degree of process discipline exists; successful execution of the measurement processes can be repeated. The measurement processes are documented and standardized. The execution of the processes is compliant to the description. Quantitative goals for the measurement processes are set. Continuous improvement of the measurement processes takes place. New technologies and practices are identified. 50

52 Schedule E. Outcome Statements for PMF KPIs 13 Effectiveness/Access Key Performance Indicators EA1 - Proportion of emergency department patients seen within recommended times PMF Code: Indicator Title: EA1 Proportion of emergency department patients seen within recommended times: a) % Triage Category 1 2 mins; b) % Triage Category 2 10mins; c) % Triage Category 3 30 mins; d) % Triage Category 4 60 mins and e) % Triage Category 5 2 hours Strategic Linkages: National Health Reform Performance and Accountability Framework xxi Rationale: Relevance: Emergency departments (ED) are specialist multidisciplinary units with expertise in managing acutely unwell patients for the first few hours in hospital. When patients first enter an emergency department, they are assessed by specially trained nursing staff on how urgently treatment should be provided. The aim of this process, known as triage, is to ensure treatment is given in the appropriate time and should prevent adverse conditions arising from deterioration in the patient s condition. Treatment within recommended times should assist in the restoration to health, either during the emergency visit or the admission to hospital which may follow emergency department care. A patient is allocated a triage code between one (most severe Resuscitation) and five (least severe Non-Urgent) that indicates their level of urgency. This code provides an indication of how quickly patients should be reviewed by clinical staff. The triage process and scores are recognised by the Australasian College for Emergency Medicine (ACEM) and recommended for prioritising those who present to an emergency department. In a busy emergency department when several people present at the same time, the service aims for the best outcome for all. Treatment should commence within the recommended time of the triage category allocated. To patients: Provides improved timely access to quality emergency department care for the benefit of the patient s health. To clinicians: Drives better clinical outcomes and provides efficiency gains that may reduce the workload on clinical staff. To administrators: Better management and delivery of emergency department care, which could lead to more cost-effective service delivery. 13 Note: outcome statements have been developed in consultation with data custodians/providers. 51

53 EA2 - National Emergency Access Target percentage of ED attendances with length of episode less than or equal to 4 hours PMF Code: Indicator Title: EA2 National Emergency Access Target percentage of ED attendances with length of episode less than or equal to 4 hours Strategic Linkages: The National Health Reform Agreement National Partnership Agreement on Improving Public Hospital Services xxii Rationale: Relevance: Emergency departments are specialist multidisciplinary units with expertise in managing acutely unwell patients for the first few hours in hospital. Queuing for initial care in emergency departments is managed by triage, which classifies patients by urgency and ensures the most time critical cases are seen first. Timely movement of patients from the ED is important as it potentially reduces adverse incidents that may result from overcrowding or access block (patients waiting for 8 hours or more for admission). Once it has been determined that a patient needs to be admitted, the time until admission usually depends on the availability of a bed in the appropriate ward, for example cardiology, orthopaedic surgery, or plastic surgery. Most patients who require a bed will benefit from early transfer to the inpatient unit which can best treat their condition. Under the National Health Reform Agreement National Partnership Agreement on Improving Public Hospital Services, the Commonwealth, States and Territories have agreed to the implementation of the National Emergency Access Target (NEAT). To patients: Improves patient experience and reduces mortality linked to overcrowding and access block. To clinicians: Drives better clinical outcomes and improves the effectiveness of health care delivery. To administrators: Better management and delivery of care. Additionally, financial payments can be awarded through achieving the National Emergency Access Target, which is put back into the health system. 52

54 EA3 - Average overdue wait time of elective surgery cases waiting beyond the clinically recommended time, by urgency category PMF Code: Indicator Title: EA3 Average overdue wait time of elective surgery cases waiting beyond the clinically recommended time, by urgency category: a) beyond 30 days for urgency category 1; b) beyond 90 days for urgency category 2 and c) beyond 365 days for urgency category 3 Strategic Linkages: The National Health Reform Agreement National Partnership Agreement on Improving Public Hospital Services xxii Rationale: Elective surgery describes all non-emergency surgery where admission to hospital can be safely delayed for at least 24 hours. Timely access to required surgical procedures is a measure of the public health system s capacity to perform elective surgery. Under the National Health Reform Agreement National Partnership Agreement on Improving Public Hospital Services, the Commonwealth, States and Territories have agreed to the implementation of the National Elective Surgery Target (NEST). This KPI aims to reduce the number of patients who have waited longer than the clinically recommended time and reduce long waits. Under the NEST, the States and Territories will report the average wait time of elective surgery cases remaining over boundary by category. The category boundary times are: Category 1 = admission within 30 days Category 2 = admission within 90 days Category 3 = admission within 365 days Relevance: To patients: Provides improved timely access to quality elective surgery for those patients who have already waited past clinically recommended times, to the overall benefit of the patient s health. To clinicians: Drives better clinical outcomes and improved case load management. To administrators: Better management and delivery of care. Additionally, financial payments can be awarded through achieving the National Elective Surgery Target, which is put back into the health system. 53

55 EA4 - Elective surgery patients treated within boundary times by urgency category PMF Code: EA4 Indicator Title: Elective surgery patients treated within boundary times: a) % Category 1 within 30 days; b) % Category 2 within 90 days and c) % Category 3 within 365 days Strategic Linkages: The National Health Reform Agreement National Partnership Agreement on Improving Public Hospital Services xxii Rationale: Relevance: Elective surgery describes all non-emergency surgery where admission to hospital can be safely delayed for at least 24 hours. After surgery, some types of patients will be restored to health, while for others; surgery will improve their quality of life. Therefore, timely access to required surgical procedures is a measure of the public health system s capacity to perform elective surgery. Patients who are referred for elective surgery are classified into clinically recommended times which are assigned by a clinician and based on clinical need. The categories, one to three, are grouped into urgency categories. This is based on the likelihood of the condition becoming an emergency if not seen within the recommended time frame, known as the boundary. Under the National Health Reform Agreement National Partnership Agreement on Improving Public Hospital Services, the Commonwealth, States and Territories have agreed to the implementation of the National Elective Surgery Target (NEST). To patients: Provides improved timely access to quality elective surgery for the benefit of the patient s health. To clinicians: Drives better clinical outcomes and improved case load management. To administrators: Better management and delivery of care. Additionally, financial payments can be awarded through achieving the National Elective Surgery Target, which is put back into the health system. 54

56 EA5 - Percentage of selected elective cancer surgery treated within boundary times PMF Code: Indicator Title: EA5 Percentage of selected elective cancer surgery cases treated within boundary time: a) bladder cancer; b) bowel cancer and c) breast cancer Strategic Linkages: National Health Reform Performance and Accountability Framework xxi Rationale: Relevance: Cancer is a diverse group of diseases in which some of the body s cells become defective and multiply out of control xxiii. These abnormal cells invade and damage the tissues around them, and sooner or later spread (metastasise) to other parts of the body and can cause further damage xxiii. Cancer is estimated to be the leading cause of burden of disease in Australia and in 2012 cancer accounted for approximately 19 per cent of the total disease burden xxiii. After surgery, some types of patients will be restored to health, while for others; surgery may improve their quality of life, extend their life span or reduce the risk of the disease spreading. Bowel, breast and bladder cancers are some of the most commonly reported cancers in Australia. Thus, it is vital that the elective surgery waiting times for cancer surgery are closely monitored to ensure reduced mortality and better patient outcomes. Patients who are referred for elective surgery are classified into clinically recommended times which are assigned by a clinician and based on clinical need. The categories, one to three, are grouped into urgency categories. This is based on the likelihood of the condition becoming an emergency if not seen within the recommended time frame, known as the boundary. To patients: Provides timely access to quality cancer elective surgery that can either restore health, improve quality of life, extend life span or reduce the risk of the disease spreading. To clinicians: Drives better clinical outcomes for cancer patients and assist them to manage their workload based on clinical priorities. To administrators: Better provision of cancer related care that ultimately fosters a better health system. 55

57 Effectiveness/Appropriateness Outcome Measures EAP1 - Rate of selected potentially preventable chronic condition hospitalisations (for specified chronic conditions) PMF Code: Indicator Title: EAP1 Rate of selected potentially preventable chronic conditions hospitalisation (for specified chronic conditions) Strategic Linkages: WA Chronic Health Conditions Framework xxiv Western Australian Health Promotion Strategic Framework xxv Rationale: Relevance: Preventable chronic condition hospitalisations are hospitalisations due to chronic conditions that could be managed by means other than hospitalisation, such as through primary and community health care services and population-based health promotion strategies. Most chronic conditions do not resolve spontaneously, and are generally not cured, but can be responsive to preventative measures. Chronic disease are generally characterised by: complex causality multiple risk factors long latency periods a prolonged course of illness functional impairment or disability Chronic conditions can pose a significant burden on health care in Australia and should be monitored in order to reduce morbidity and mortality rates from these conditions and to improve the delivery of primary and community health care services. To patients: Better prevention and/or management of chronic conditions that can improve the patient s quality of life and avoid hospitalisations. To clinicians: Drives better clinical outcomes, enables improved monitoring of effectiveness of care pathways and reduces work load pressures. To administrators: Enables better state-wide services policy development and planning for the continuum of community, primary and hospital care. 56

58 Effectiveness/Quality Key Performance Indicators EQ1 - Age-Adjusted Rate of avoidable deaths PMF Code: Indicator Title: EQ1 Age-Adjusted Rate (AAR) of avoidable deaths Strategic Linkages: Rationale: Relevance: Avoidable deaths refer to the number of premature deaths (persons aged under 75 years) from conditions considered to be potentially preventable through the application of existing effective public health or medical interventions. Thus, avoidable deaths are unnecessary untimely deaths. Measuring the number of deaths and the cause of these deaths each year is one of the most important means of monitoring and evaluating the effectiveness, quality and productivity of health systems. The data obtained from this indicator can assist health systems managers to determine the public health actions that are required in order to reduce the number of preventable deaths and improve the effectiveness and quality of health care delivery. To patients: Avoidance of premature deaths that could potentially be preventable. To clinicians: Drives better clinical outcomes and enables improved monitoring of effectiveness of care pathways. To administrators: Supports the provision of high quality and safe health care services that ultimately fosters a better health system. 57

59 EQ3 - Staphylococcus aureus bacteraemia (SAB) infections per 10,000 patient days PMF Code: Indicator Title: EQ3 Staphylococcus aureus bacteraemia (SAB) infections per 10,000 patient days Strategic Linkages: National Health Reform Performance and Accountability Framework xxi Australian Commission on Safety and Quality in Health Care, National Core, Hospital-Based Outcome Indicator xxvi Rationale: The Staphylococcus aureus is a common bacterium that lives harmlessly on the skin of about half the adult population. Sometimes, however, it can get inside the body and cause serious and life threatening infections. Some strains of S.aureus are resistant to commonly used antibiotics (this means the antibiotics are no longer effective) and these are known as methicillinresistant Staphylococcus aureus or MRSA. S.aureus infections caused by the provision of healthcare (healthcare associated infections or HAIs) are generally preventable infections and healthcare workers (HCWs) need to ensure all infection prevention management practices are implemented to prevent these infections occurring. Bacteria can be transferred to patients on the hands of HCWs, through the use of contaminated medical equipment or environmental surfaces. The Health Services and the Department of Health have implemented significant infection prevention management practices to minimise the risk of a patient acquiring HAIs including S.aureus bacteraemia (SAB), which is an infection in a patient s bloodstream. Measuring the rate of these types of infections occurring in public hospitals providing acute care is a method of assessing the effectiveness of the infection prevention practices in place as well as indicating a measure of the healthcare facilities quality and safety standards for its patients. Relevance: To patients: Avoidance of a potentially serious or life threatening infection that can reduce time spent in hospital and mitigate the undue stress of acquiring the infection and any resultant complications including a longer stay in hospital. To clinicians: Drives better clinical outcomes, enables improved monitoring of effectiveness of care pathways and reduces work load pressures. To administrators: Better management and delivery of safe high quality care that could lead to more cost-effective service delivery. 58

60 EQ5 - Hospital standardised mortality ratio PMF Code: Indicator Title: EQ5 Hospital standardised mortality ratio Strategic Linkages: National Health Reform Performance and Accountability Framework xxi Australian Commission on Safety and Quality in Health Care, National Core, Hospital-Based Outcome Indicator xxvi Rationale: Hospital mortality indicators should be used as screening tools, rather than being assumed to be definitively diagnostic of poor quality and/or safety. Mortality ratios are often used as a partial indicator of the safety and quality of practice within hospitals. They can also be used as a measure of effectiveness. As a measure of safety and quality, mortality is useful because hospital deaths are a well-defined and generally accurately reported outcome. This indicator is intended to signal that a problem may exist and that further detailed investigation is required. Missed signals can potentially lead to fatal outcomes that could have been avoided had the signals been identified and acted on. Through reviewing and analysing mortality rates, targeted strategies can be developed that aim at reducing mortality in identified areas. Thus, this indicator can potentially assist hospitals in monitoring changes over time and in improving quality of care and patient outcomes. Relevance: To patients: Could improve the likelihood that the patient s hospital stay does not result in fatality. To clinicians: Drives better clinical outcomes and enables improved monitoring of effectiveness of care pathways. To administrators: Supports the provision of high quality and safe health care services that ultimately fosters a better health system. 59

61 EQ7 - Death in low-mortality Diagnostic Related Groups PMF Code: Indicator Title: EQ7 Death in low-mortality Diagnostic Related Groups Strategic Linkages: National Health Reform Performance and Accountability Framework xxi Australian Commission on Safety and Quality in Health Care, National Core, Hospital-Based Outcome Indicator xxvi Rationale: Hospital mortality indicators should be used as screening tools, rather than being assumed to be definitively diagnostic of poor quality and/or safety. This indicator is intended to identify in-hospital deaths in patients unlikely to die during hospitalisation (identified through low-mortality Diagnostic Related Groups (DRGs) - e.g. J60B: Skin Ulcers). The underlying assumption is that when a patient admitted for an extremely low-mortality condition or procedure dies, a health care error is more likely to be responsible. This indicator is intended to signal that a problem may exist and that further detailed investigation is required. Missed signals can potentially lead to fatal outcomes that could have been avoided had the signals been identified and acted on. Measuring the number of deaths and the cause of these deaths through targeted investigation allows for the determination of actions that are required in order to reduce the number of unlikely deaths and improve the effectiveness and quality of health care delivery. Relevance: To patients: Could improve the likelihood that a patient who is admitted to hospital with a low-mortality condition, survives. To clinicians: Drives better clinical outcomes and enables improved monitoring of effectiveness of care pathways and clinical practices. To administrators: Supports the provision of high quality and safe health care services that ultimately fosters a better health system. 60

62 EQ8 In hospital mortality rates PMF Code: Indicator Title: EQ8 In-hospital mortality rates (for acute myocardial infarction, stroke, fractured neck of femur & pneumonia) Strategic Linkages: National Health Reform Performance and Accountability Framework xxi Australian Commission on Safety and Quality in Health Care, National Core, Hospital-Based Outcome Indicator xxvi Rationale: Hospital mortality indicators should be used as screening tools, rather than being assumed definitively diagnostic of poor quality and/or safety. Mortality rates are often used as a partial indicator of the safety and quality of practice within hospitals. They can also be used as a measure of effectiveness. As a measure of safety and quality, mortality is useful because hospital deaths are a well-defined and generally accurately reported outcome. In-hospital mortality rates are measured for specified conditions these include acute myocardial infarction; stroke; fractured neck of femur and pneumonia. This indicator is intended to signal that a problem may exist and that further detailed investigation is required. Missed signals can potentially lead to fatal outcomes that could have been avoided had the signals been identified and acted on. Through reviewing and analysing mortality rates, targeted strategies can be developed that aim at reducing mortality in identified areas. Thus, this indicator can potentially assist hospitals in monitoring changes over time and in improving quality of care and patient outcomes. Relevance: To patients: Ensures optimal health outcomes for patients who are admitted to hospital with a diagnosis of one of these conditions. To clinicians: Drives better clinical outcomes and enables improved monitoring of effectiveness of care pathways and clinical practices. To administrators: Supports the provision of high quality and safe health care services that ultimately fosters a better health system. 61

63 EQ10 - Rate of total hospital readmissions within 28 days to a designated mental health inpatient unit PMF Code: Indicator Title: EQ10 Rate of total hospital readmissions within 28 days to a designated mental health inpatient unit Strategic Linkages: Fourth National Mental Health Plan xxvii Rationale: Relevance: Readmission rate is considered a global performance measure, as it potentially points to deficiencies in the functioning of the overall health care system. Admissions to a psychiatric facility following a recent discharge may indicate that inpatient treatment was either incomplete or ineffective, or that follow-up care was inadequate to maintain the person out of hospital. These readmissions necessitate patients spending additional periods of time in hospital as well as utilising additional hospital resources. A high percentage of readmissions may indicate that improvements could be made to discharge planning or to aspects of inpatient therapy protocols. Appropriate therapy, together with good discharge planning will decrease the likelihood of hospital readmissions. To patients: Reducing the incidence of incomplete or ineffective treatment and resultant stress that will decrease the time a patient spends in mental health inpatient unit. To clinicians: Identifies potential areas for improvement in relation to mental health intervention, treatment and discharge planning to ensure safe highquality clinical outcomes. To administrators: Better management and delivery of safe and high quality care, with a reduced requirement for additional resources. 62

64 Efficiency/Inputs per output unit Key Performance Indicators EI1 - Volume of weighted activity year-to-date PMF Code: Indicator Title: EI1 Volume of weighted activity year-to-date: a) inpatients (variance from target); b) emergency department attendances (variance from target) and c) outpatients (variance from target) Strategic Linkages: Rationale: Relevance: The measurement of the percentage variance between the estimated weighted activity and the weighted activity target enables health system managers to assess their performance against budget allocation and ensure accurate forecasting. The monitoring of service provisions and complexity of cases treated can assist in determining if people are getting the right care, at the right time, and in the right place. To patients: Can improve timely access to quality hospital care by ensuring patients receive the right care, at the right time, and in the right place. To clinicians: Drives improved case load management. To administrators: Better management, planning and forecasting of hospital service provision. 63

65 EI3 - Average cost per test panel for PathWest PMF Code: Indicator Title: EI3 Average cost per test panel for PathWest Strategic Linkages: Rationale: Relevance: This indicator can be used as a management tool to measure efficiency through determining the costs associated with PathWest services. This can then be utilised to facilitate the implementation of strategies to drive efficiency gains both in the area of cost savings and the provision of high quality health care. To patients: Improved efficiency and cost savings that could be put back into the health system to ensure the ongoing provision of high quality health care is received. To clinicians: Improved efficiency and cost savings that could be put back into the health system to ensure optimal clinical outcomes are maintained. To administrators: Better management of pathology services that could lead to more cost-effective service delivery. 64

66 EI6 - Year-to-date distance of net cost of service to budget PMF Code: Indicator Title: EI6 Year-to-date distance of net cost of service to budget Strategic Linkages: National Health Reform Performance and Accountability Framework xxi (WA equivalent measure) Financial Management Act 2006 xxviii Rationale: Relevance: Through measuring the distance of year to date (YTD) actual net cost of service to the YTD budget, health system managers are provided with the ability to assess their performance against budget allocations and ensure accurate forecasting. This can enable improved monitoring and control of expenditure, which drives efficiency gains that are financial in nature and ultimately leads to better service provision. To patients: Improved efficiency and cost savings that could be put back into the health system to ensure that the ongoing provision of high quality health care is received. To clinicians: Improved efficiency and cost savings that could be put back into the health system to ensure optimal clinical outcomes are maintained. To administrators: Drives accountability, better financial management, planning and forecasting of hospital services that could lead to more costeffective service delivery. 65

67 EI8 - Ratio of actual cost of specified public hospital services compared with the state efficient price PMF Code: EI8 14 Indicator Title: Rate of actual cost of specified public hospital services compared with the state efficient price Strategic Linkages: National Health Reform Performance and Accountability Framework xxi (WA equivalent measure) Rationale: Relevance: This indicator is a measure of the relative cost of services provided by a hospital compared with the state efficient price set each year in the WA Activity Based Funding Operating Model. The state efficient price provides a price signal or benchmark for the efficient cost of providing quality public hospital services in WA. This measure promotes improved efficiency in public hospitals by providing a more transparent understanding of costs for associated activity. To patients: Improved efficiency and cost savings that could be put back into the health system to ensure that the ongoing provision of high quality health care is received. To clinicians: Improved efficiency and cost savings that could be put back into the health system to ensure optimal clinical outcomes are maintained. To administrators: Drives accountability, better financial management, planning and transparency of hospital services that could lead to more costeffective service delivery. 14 EI8 has been deferred for reporting as data was not provided to progress the indicator. This indicator will be further considered in

68 Equity/Access Key Performance Indicators EQA1 - Standardised Mortality Ratio of deaths among Aboriginal children and non- Aboriginal children PMF Code: EQA1 Indicator Title: Standardised Mortality Ratio (SMR) of deaths among Aboriginal children (0 4 years) and non-aboriginal children (0 4 years) Strategic Linkages: National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes xxix Rationale: Infant mortality is a long established measure of child health as well as the overall health of the population and its physical and social environment xxx. Infant and child mortality rates are used internationally as key measures of population and child health. They reflect the effect of structural factors on population health and are strongly associated with social and economic disadvantage. Indigenous Australians experience the worst health of any one identifiable cultural group in Australia. The standardised mortality ratio of deaths of children aged 0-4 comparing Aboriginal children to non-aboriginal children shows the gap in mortality rates in these two populations in early childhood. Under the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, the Commonwealth, States and Territories have committed to halving the gap in mortality rates for Indigenous children under 5 years, by Hence improvements in this measure are vital to improving Indigenous health and achieving the Closing the Gap strategy. Relevance: To patients: Promotes equitable access to health care and ensures optimal health outcomes for all WA children. To clinicians: Drives better clinical outcomes and practices. To administrators: Supports the provision of high quality, equitable and safe health care services that ultimately foster a better health system. 67

69 EQA4 - Proportion of eligible population receiving dental services PMF Code: Indicator Title: EQA4 Proportion of eligible adults receiving dental services from subsidised dental programs by group: a) aged 16 years and over; b) aged 65 years and over and c) total Aboriginal population Strategic Linkages: National Partnership Agreement for Adult Public Dental Services xxxi (due to commence 1 July 2014) Rationale: Relevance: Non-specialist dental treatment services (including both emergency care and non-emergency care) are provided through subsidised dental programs to eligible concession card holders. This KPI measures the equity of access to these services by monitoring the proportion of all eligible adults receiving dental services compared to eligible adults 65 year and over and eligible Aboriginal adults. To patients: Can ensure awareness of entitlements and promote equitable access to dental services for the financially disadvantaged people, which can lead to better dental health. To clinicians: Identifies the targeted populations that are eligible to access dental services for treatment, thereby, driving better clinical outcomes and practices. To administrators: To increase the emphasis on equitable access to dental services that ultimately fosters a fairer health system. 68

70 Sustainability/Workforce Key Performance Indicators SW3 - Staff turnover PMF Code: Indicator Title: SW3 Staff turnover Strategic Linkages: Rationale: Relevance: Staff turnover is the total number of permanent employee-initiated resignations as a proportion of the total number of permanent employees at a hospital. If a hospital is said to have a high turnover it means that employees of that hospital have a shorter average tenure than those of other hospitals. A high staff turnover may be harmful to a hospital s productivity if experienced employees are frequently leaving and the employee population contains a higher percentage of workers that are new to the environment. Further, employee engagement has a positive impact on employee attraction and retention. Since engaged employees are less likely to leave a hospital, the hospital benefits from retaining its high performers and lower turnover costs (some studies have shown that it costs at least times the annual salary to replace an employee) xxxii. To patients: Able to receive timely high quality care from engaged staff who could assure confidence in the services provided. To clinicians: Ensures continuum of care for their patients and can promote work fulfilment. To administrators: Drives cost-efficiencies and supports a stable health system that can continue to deliver high quality care to Western Australians. 69

71 Processes/Coding Key Performance Indicators PC2 - Percentage of cases coded within boundary PMF Code: Indicator Title: PC2 Percentage of cases coded within boundary: a) cases within 2 weeks of discharge and b) remaining cases within 4 weeks of discharge Strategic Linkages: Department of Health WA Operation Directive 0137/08: Hospital Morbidity Data Reporting Cycle xxxiii Rationale: Relevance: This KPI measures the timeliness of clinical coding at public hospitals, that is, the percentage of all inpatient discharge records which have been clinically coded, transmitted to the Hospital Morbidity Data System (HMDS) and cleared from a range of quality edit processes within expected times. Coding information is regularly utilised in budgetary allocations (including Commonwealth funding), performance reporting, hospital statistics, resource utilisation, clinical auditing and research. Therefore significant delays in coding may adversely affect the timeliness of decisions being made in these areas. To patients: Promotes timely decision-making that can assure the patient receives safe and high quality health care. To clinicians: Can facilitate timely clinical research and audits that can drive improvements in clinical outcomes. To administrators: Better reporting, planning and timely decision-making that could lead to a more effective health system. 70

72 Processes/Finance Key Performance Indicators PF2 - Manually corrected payroll errors (underpayments) PMF Code: Indicator Title: PF2 Manually corrected payroll errors (underpayments) Strategic Linkages: Health Corporate Network Service Level Agreement xxxiv Rationale: Relevance: With 70 per cent of costs to WA Health comprising the payment of salaries and wages to its 48,000+ employees, payroll processing accuracy is important to reflect correct costs and is vital to the morale of the workforce. Thus the percentage of payroll errors corrected by a manual payment prior to the next pay run is monitored to ensure the Health Corporate Network s payroll processing accuracy is acceptable. To patients: Able to receive quality care from more fulfilled staff. To clinicians: Can promote work fulfilment. To administrators: Drives accountability and improves cost management processes that support a robust health system. 71

73 PF3 - Percentage of service calls resolved at first point of contact PMF Code: Indicator Title: PF3 Availability of Information and Communication Technology (ICT) services: percentage of service calls resolved at first point of contact Strategic Linkages: Rationale: Relevance: ICT service calls are comprised of IT service faults and difficulties reported by WA Health staff. The Service Desk is the first and single point of contact for WA Health staff to engage (by phone or ) the IT Services offered by the Health Information Network (HIN). This KPI is also referred to as First Contact Resolution (FCR) within the contact centre industry and the aim is to provide a high quality service in order to resolve the callers issue on the first call or . FCR is one of the most critical KPIs for the quality of the customer experience as well as an organisation s overall operational efficiency. To patients: Able to receive timely high quality and safe care from clinicians who have immediate access to critical patient information. To clinicians: Drives better clinical outcomes and practices through having the ability to access critical patient information when required. To administrators: Drives accountability and improves ICT service delivery that supports an effective health system. 72

74 Schedule F. Performance Management Processes Principles of Performance Management Processes Transparency: Clear, agreed KPIs, targets and responses to poor performance. Accountability: Clear roles and responsibilities at DOH and Service Provider level for delivering services to agreed standards and volumes; supporting and implementing performance improvement. Recognition: Sustained and outstanding performance is recognised and rewarded. Consistency: Responses to performance concerns are appropriate to the issue being addressed. Integrated: The PMF is linked to clinical planning, budget, activity and safety and quality. Focus on service improvement: The PMF enables a clear mechanism for health care improvement. These principles are appropriate for the current governance model where the DG is accountable for the overall functioning of the health system. Process for Escalation in Response to Performance Concerns The performance of Service Providers will be monitored regularly against the KPIs, benchmarks and thresholds specified in the PMF in conjunction with the Performance Score. Service Providers (or their nominees) will meet regularly with DOH representatives to discuss the performance of their Health Service and the facilities within it. Performance concerns will be identified if the facility and/or the Health Service Performance Score is below a certain level. If performance concerns are identified, these meetings will occur more frequently. The following outlines the DOH intervention levels that will be in place to respond to performance concerns identified through the reporting/monitoring process. The DOH response to a performance concern is based on three levels of intervention. 1. The lowest level requires the Service Provider to account for under performance in relation to achievement against the performance evaluation thresholds. 2. The intermediate level requires the Service Provider to undertake an in-depth assessment and provide the DOH with a detailed recovery plan and timetable for resolution. 3. The intervention methodology applied at the highest level will be at the discretion of the DG based on an assessment of the performance concern for the particular Service Provider. 73

75 The PMF will be subject to annual review. The review will encompass KPIs, targets and thresholds, intervention processes and service agreements. It is possible that a fourth level of intervention could be introduced into the future. At this level the DOH assumes control of the Service Provider. This is a feature of the Performance Frameworks operating in other Australian jurisdictions and has already been applied to address chronic under-performance. Level 1 Intervention: Under Review The Service Provider will be required to provide formal advice on the reasons that led to the performance concern, and whether any action is required and if so, the intended action. Level 2 Intervention: Underperforming The Service Provider will be required to undertake an in-depth assessment and formally meet with the DOH and present options to redress the problem and a detailed recovery plan and timetable for resolution. The plan will be approved by the DG. Level 3 Intervention: Seriously Underperforming The DG will determine the appropriate course of action to be taken to redress the problem on a case by case basis. The course of action will be tailored to the specific circumstances of the non-performing area and may involve one or more of the following actions. 1. Assigning a DOH lead to work collaboratively with the Service Provider to develop and implement a recovery plan as well as direct Service Provider staff as required. A joint taskforce will be established by the DOH to oversee the work and a schedule of meetings set to monitor progress. 2. Assigning an expert advisor appointed by the DOH to review the root cause(s) of the problem and provide a series of recommendations for implementation by the Service Provider. 3. Implementing a peer collaboration model whereby Service Providers within the peer group who are rated as performing or highly performing provide support and assistance to the Service Provider. It is important to note that escalation and de-escalation through the levels outlined above may not be sequential: The initial level of intervention and the level of escalation will be based on the seriousness of the performance concern, the likelihood of rapid deterioration and the magnitude of the problem There may be circumstances where the level of intervention moves directly from Level 1 to Level 3, for example, a Service Provider breaches a designated KPI that warrants a Level 1 intervention but which on further assessment, reveals serious misreporting of multiple performance issues that warrants a Level 3 intervention The rate of de-escalation will be determined by an assessment of the complexity of the underlying issues and of the likelihood that the recovery plan will be sustained The period for KPIs to show improvement after implementation of improvement plan may require more than one month's data before direct intervention of penalties apply. 74

76 There will always be a period of monitoring following the Service Provider returning to an acceptable level of performance before they are taken off performance watch. 75

77 Schedule G. Recommendations from the Indigenous identification in hospital separations data quality report, February 2010 Recommendations The 2005 report recommended that data only for Queensland, South Australia, Western Australia, and the Northern Territory (public hospitals only) should be included in national analyses of Indigenous admitted patient care, based on an agreed acceptable level of 80% Indigenous identification. This acceptable level of identification was determined for the purpose of allowing a reasonably precise quantification of hospital use for a majority of the Indigenous population (AIHW 2005a). Based on the results studies reported here, the National Health Information Standards and Statistics Committee, and the National Aboriginal and Torres Strait Islander Advisory Group on Health Information and Data have endorsed the following amendments to the analysis guidelines published in 2005 (AIHW 2005a). The complete set of recommendations is in Chapter 5 of this report. For the use of state and territory data: When using Indigenous status information for analytical purposes, the data for only New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory (public hospitals only) should be used, individually or in aggregate. It is also acceptable to use data from hospitals in all states and territories to undertake analyses by the state or territory of the patient s area of usual residence, for patients usually resident in New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory, individually or in aggregate. Analyses based on data for New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory in aggregate should be accompanied by caveats about limitations imposed by jurisdictional differences in data quality, and about the data not necessarily being representative of the jurisdictions that are not included. Caution should be exercised in time series analysis of data for New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory (public hospitals only) (individually or in aggregate). Caveats should include the possible contribution of changes in ascertainment of Indigenous status for Indigenous patients to changes in hospitalisation rates for Indigenous people. For the use of regional data: Analysis of data by remoteness area of the hospital s location can be undertaken for New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory (public hospitals only), in aggregate. It is also acceptable to use data from hospitals in all states and territories to undertake analysis by the remoteness area of the patient s area of usual residence, for patients usually resident in New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory, in aggregate. 76

78 Analyses based on remoteness area should be accompanied by caveats about limitations imposed by jurisdictional differences in data quality, and about the data not necessarily being representative of the jurisdictions that are not included. It is also recommended that ongoing studies be conducted to assess the data quality and to encourage improvement in the reporting of these data 77

79 Schedule H. Ability to report PMF KPIs by Aboriginality split 78