SERVICE AGREEMENT KEY PERFORMANCE INDICATORS AND SERVICE MEASURES DATA DICTIONARY

Transcription

1 Information Bulletin Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) Fax (02) /16 Service Agreement Key Performance Indicators and Service Measures Data Dictionary Director-General Document Number IB2015_053 Publication date 08-Sep-2015 Functional Sub group Corporate Administration - Information and data Clinical/ Patient Services - Information and data Population Health - Health Promotion Personnel/Workforce - Workforce planning space space space Summary The 2015/16 Key Performance Indicator and Service Measure Data Dictionary has been developed to support the NSW Ministry of Health and Local Health Districts in monitoring and reporting on the 2015/16 Service Agreements by providing the relevant information concerning the definitions for the numerators and denominators, as well as inclusion and exclusion notes for each of the Performance Measures located within Schedule E of the Service Agreement. Replaces Doc. No. 2014/15 Service Agreement Key Performance Indicators and Service Measures Data Dictionary [IB2014_055] Author Branch Health System Information & Performance Reporting Branch contact Health System Information & Performance Applies to Local Health Districts, Board Governed Statutory Health Corporations, Chief Executive Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Affiliated Health Organisations, Public Health System Support Division, NSW Ambulance Service, Ministry of Health Audience Administration, Performance Units, Data collection and Data Provision staff Distributed to Public Health System, Ministry of Health Review date 08-Sep-2016 Policy Manual Not applicable File No. 14/4402 Status Active

2 INFORMATION BULLETIN SERVICE AGREEMENT KEY PERFORMANCE INDICATORS AND SERVICE MEASURES DATA DICTIONARY PURPOSE The purpose of this information bulletin is to support monitoring and reporting on the Service Agreements between the Local Health Districts and the NSW Ministry of Health. The Service Agreement is a key component of the Performance Framework for Health Services, providing a clear and transparent mechanism for assessment and improvement of performance. The definitions provided in the Service Agreement Key Performance Indicators and Service Measures Data Dictionary (refer to Attachment section below) will assist Health Services and other data users with the calculation and interpretation of the Key Performance Indicators and Services Measures referenced in the Service Agreements for This information bulletin supersedes IB2014_ /15 Service Agreement Key Performance Indicators and Service Measures Data Dictionary. KEY INFORMATION The definitions provided in the Data Dictionary will assist Health Services and other data users with the calculation and interpretation of the Key Performance Indicators and Services Measures referenced in the Service Agreements for It should be noted that some KPIs may be calculated differently when applied to different purposes outside the management of the Service Agreements. The KPIs and Service Measures contained in this document have been defined specifically with the intent to meet the reporting requirements under agreements and to align to the Ministry of Health s monthly performance monitoring reports. Should you require further assistance with the definitions or have comments regarding them please contact either the Health System Information and Performance Reporting Branch or the Data / Policy contacts listed in the KPI documentation. The Service Agreement document covers both the Tier 1 and 2 KPIs and Service Measures. Key Performance Indicators (KPIs), if not met, may contribute to escalation under the Performance Framework processes. Performance against these KPIs will be reported regularly to Health Services in the Health System Performance Report prepared by the Department. These KPIs have been designated into two categories: Tier 1 - Will generate a performance concern when the organisation s performance is outside the tolerance threshold for the applicable reporting period. Tier 2 - Will generate a performance concern when the organisation s performance is outside the tolerance threshold for more than one reporting period. IB2015_053 Issue date: September of 3

3 INFORMATION BULLETIN Service Measures: A range of Service Measures are identified to assist the organisation to improve provision of safe and efficient patient care and to provide the contextual information against which to assess performance. Note that the KPIs and Service Measures listed above are not the only measures collected and monitored by the NSW Health System. A range of other measures are used for a variety of reasons, including monitoring the implementation of new service models, reporting requirements to NSW Government central agencies and the Commonwealth, and participation in nationally agreed data collections. Relevant measures specified in the National Health Reform Performance and Accountability Framework, and in NSW 2021: A Plan to Make NSW Number One, have been assigned as NSW Health KPIs, Service Measures or Monitoring Measures, as appropriate. This year the KPIs and Service Measures are grouped under the six reporting domains of: Safety and Quality Service Access and Patient Flow Integrated Care Finance and Activity People and Culture Population Health. The performance of LHDs, other Health Services and Support Organisations is assessed in terms of whether it is meeting the performance targets for individual KPIs: Highly Performing - Performance at, or better than, target Underperforming - Performance within a tolerance range Not performing - Performance outside the tolerance threshold. As in previous years, the KPI and Service Measure data elements are also located on the NSW Health Information Resource Directory and are accessible via the following link: &sortby=2&SelInit=&=1 Each individual indicator and service measure may be viewed and downloaded via this portal. Further, additional documentation (where available) for each of the indicators and service measures (such as specific identification of which fields from the data warehouse are used for the calculation, sample.sas code, detailed calculation formulae, etc) may be found under the Ext Info tab for each individual indicator and service measure, which may be downloaded as well. SUPPORTING INFORMATION Service Agreement Key Performance Indicators and Service Measures Data Dictionary: ( 731) IB2015_053 Issue date: September of 3

4 REVISION HISTORY Version Approved by Amendment notes September 2015 (IB2015_053) September 2014 (IB2014_055) Director, Health System Information and Performance Director, Health System Information and Performance Reporting INFORMATION BULLETIN New version of the Data Dictionary to align with the 2015/16 Service Agreements. Introduced a Data Dictionary for Local Health Districts to support the Key Performance Indicators and Service Measures as agreed to in Schedule E of the 2014/15 Service Agreements. ATTACHMENT 1. Data Dictionary for Service Agreement Key Performance Indicators and Service Measures IB2015_053 Issue date: September of 3

5 Key Performance Indicators and Service Measures for the Service Agreements (Schedule E) NSW Ministry of Health

6 Version September 2015 Contact: Further information regarding this document can be obtained from the Health System Information & Performance Reporting Branch. For queries relating to the documentation, including clarification of definitions: acand@doh.health.nsw.gov.au For queries relating to how the Service Agreement data is calculated and reported: agold@doh.health.nsw.gov.au

7 VERSION CONTROL Date ID Item Change 01/12/2014 SSA113, SSA114 Surgery for Children Proportion of children (0 to 16 years) treated within their LHD of residence 01/12/2014 KQS204 Mental Health: Acute Post Discharge Community Care 01/12/2014 KSA202 ED Presentations staying in ED > 24 hours (Mental Health) (number) 01/12/2014 KQS203 Mental Health: Acute Readmission within 28 days 01/12/2014 SSA106 Patients with total time in ED <= 4 hrs (%): Mental Health Patients (admitted to a ward from ED) 01/12/2014 SFA113 Sub and Non Acute Admitted Patient Episodes grouped to an AN-SNAP Class 01/12/2014 SFA106, SFA107, SFA108, SFA109 ED Records unable to be grouped Added Justice Health / Forensic Mental Health Network as an exclusion Updated Data Collection Source / System details; Updated note for denominator, clarifying selection criteria Name change, revised indicator definition for mode of separation values in Departure Time, and changes to SNOMED CT map Added note to denominator definition Changed title (previously Emergency Admission Performance (Mental Health)), changed indicator definition to align with the Patients with Total time in ED <= 4hrs Service Measure. Updated (i) Data Collection Source/System details; (ii) Primary data source for analysis; (iii) Denominator source Scope change to Sub and non acute admitted patient episodes completed in 2014/15 in ABF in-scope facilities, excluding mental health services provided in designated mental health units and children <18 years of age. Exclusions (point 3) change to Sub and Non Acute Episodes of care provided to children (<18 years age) Revised definition and indicator to remove E4 and E5 codes; expanded scope for numerator and denominator to include NEC facilities, revised Primary Point of Collection 01/12/2014 SFA110 ED coding completeness RETIRED for /12/2014 SSQ117 Patient Experience Survey Adult Admitted Patients: overall rating of care 01/12/2014 SSQ119 Patient Experience Survey Emergency Department Patients: overall rating of care Change to the Service Agreement Type, indicator definition, scope, numerator, inclusions and exclusions, useable data available from and time lag to available data NEW for

8 Date ID Item Change 01/12/2014 KSA201 ED Presentations staying in ED > 24 hours 01/12/2014 SSA104 ED presentations treated within benchmark times 01/12/2014 KSA102 Emergency Treatment Performance: Patients with Total time in ED <= 4hrs 01/12/2014 PI-03, SSA117, SSA118 Hospital in the home Admitted Activity (%) 01/12/2014 SSA111 Elective Surgery: Activity change YTD compared to previous 01/12/2014 SPC107 Recruitment: Improvement on baseline average time taken from request to recruit to decision to approve/decline/defer recruitment Significant revision to Departure Time in indicator definition; Name change; minor refinement to the indicator definition, updated desired outcome and related policies and programs, updated target timeframe parameters. Updated indicator definition, numerator definition, inclusions and context, related programs and policies Revised title of indicator, reflecting cessation of NEAT. Updated indicator definition, related policies and programs. Updated Targets. DELETED sub-items SSA117 (Admitted Activity Number) and SSA118 (Non-Admitted Activity Number. Minor clarification to scope and outcome, change to Performance Area. Minor clarification to indicator definition, updated Context, Inclusions, Exclusions. Updated title, indicator definition, target 01/12/2014 SFA105 Coding timeliness Updated target, clarified denominator definition, Updated Time Lag to Available Data 01/12/2014 PH-011B Get Healthy Information and Coaching Service Health Professional Referrals NEW for /12/2014 PH-008B Healthy Children s Initiative Children s Healthy Eating and Physical Activity Program (primary school sites) Adopted 01/12/2014 PH-008A Healthy Children s Initiative Children s Healthy Eating and Physical Activity Program (centre based children s service sites) Adopted Transformed from KPI to SM; updated title from Primary school sites adopting the Children s Healthy Eating and Physical Activity Program in Primary School to agreed standard, minor amendment to indicator definition, updated target figures Transformed from KPI to SM; updated title from Primary school sites adopting the Children s Healthy Eating and Physical Activity Program in centre-based children s services to agreed standard, minor amendment to indicator definition, updated target figures, updated Related Policies/ Programs. 4

9 Date ID Item Change 01/12/2014 PH-010A HIV testing increase within publiclyfunded HIV and sexual health services 01/12/2014 PH-008C Healthy Children s Initiative: Children 7-13 years who Enrolled in the Targeted Family Healthy Eating and Physical Activity Program 01/12/2014 PH-008D Healthy Children s Initiative: Children 7-13 years who complete the Targeted Family Healthy Eating and Physical Activity Program 01/12/2014 PH-010E STI testing/treatment/management occasions of service within publicly-funded sexual health services: All persons 01/12/2014 PH-010F STI testing/treatment/management occasions of service within publicly-funded sexual health services: Aboriginal people 01/12/2014 PH-010H STI testing/treatment/management occasions of service within publicly-funded sexual health services: Sex workers 01/12/2014 PH-010G STI testing/treatment/management occasions of service within publicly-funded sexual health services: Gay men and other homosexually active men 01/12/2014 SPH008 HIV testing occasions of service within publicly-funded HIV and sexual health services: All people 01/12/2014 PH-010B HIV testing occasions of service within publicly-funded HIV and sexual health services: Aboriginal people 01/12/2014 PH-010C HIV testing occasions of service within publicly-funded HIV and sexual health services: Gay men and other homosexually active men 01/12/2014 PH-010D HIV treatment/management occasions of service within publiclyfunded HIV and sexual health services Changed indicator from Occasions of Service to number of tests. Revised indicator definition, numerator and denominator, updated underperforming and nor performing targets. Updated primary point of collection, Data Collection Source/System, Numerator and denominator source and availability, inclusions and targets. MOVED TO SCHEDULE D for MOVED TO SCHEDULE D for MOVED TO SCHEDULE D for MOVED TO SCHEDULE D for MOVED TO SCHEDULE D for MOVED TO SCHEDULE D for RETIRED for RETIRED for RETIRED for RETIRED for

10 Date ID Item Change 01/12/2014 PD-001 Variation against purchased volume (%) Public Dental Clinical Service Updated indicator definition, exclusions, scope, goals, desired outcome. 01/12/2014 KFA105 Recurrent Trade Creditors Updated indicator definition with an exclusion note. 01/12/2014 SPC104 Premium Staff Usage Allied Health RETIRED for /12/2014 SSQ103 Clostridium Difficile Infections (per 1,000 separations) 01/12/2014 SSQ104 Root Cause Analysis completed in 70 days 01/12/2014 SSQ105 Complaints Management resolved within 35 days 01/12/2014 SSA103 ED attendances admitted to ward / Intensive Care Unit / Operating Theatre (%) 01/12/2014 SSA105 Emergency Admission Performance Patients admitted to an inpatient bed within 8 hours of arrival in the ED 01/12/2014 SSA107 National Elective Surgery Target (NEST) Part 2.1: 10% of Longest waiting patients as at 31 December 2013 treated by 31 December 2014 MOVED TO SCHEDULE D for MOVED TO SCHEDULE D for RETIRED for RETIRED for RETIRED for RETIRED for /12/2014 SSA115 Separations (number) RETIRED for /12/2014 SSA119 Avoidable Admissions for targeted conditions RETIRED for ; Replaced by proposed new Service Measure SIC001 01/12/2014 SSA120 Available beds (number) RETIRED for /12/2014 SSA121 Bed Occupancy RETIRED for /12/2014 SSA122- Connecting Care Program: RETIRED for SSA125 Aboriginal people enrolled (number) People identified as eligible for 48Hr Follow Up (number) People identified as eligible for Chronic Care Rehab (number) People identified as requiring an Aged Care Assessment (ACAT Evaluation Unit) (number) 01/12/2014 SFA104 Cost per NWAU RETIRED for /12/2014 SFA114 Red Tape Reduction savings RETIRED for /12/2014 KQS205 Hospital Acquired Pressure Injuries NEW for /12/2014 SSQ120 Hospital Acquired Venous thromboembolism NEW for /12/2014 SIC101, SIC102, SIC103, SIC104 Potentially Preventable Hospitalisations NEW for

11 Date ID Item Change 01/12/2014 SIC105, SIC106 Discharge Summaries: Number and percentage electronically delivered to patient s General Practitioner (Number and %) 01/12/2014 PH-013B Quit for New Life Program: Referred to the Quitline 01/12/2014 PH-013C Quit for New Life Program: Provided Nicotine Replacement Therapy (NRT) 01/12/2014 PH-013D Quit for New Life Program: Booked follow-up Appointment 01/12/2014 PH-014A Publically funded Hepatitis C related services HCV Treatment Assessment 01/12/2014 SPC102, SPC103 Premium Staff Usage Medical / Nursing 01/12/2014 SFA112 NAP data completeness: Valid Health Establishment Registration Online identification (%) 01/12/2014 SFA115- SFA117 08/12/2014 SPH002, SPH004 Wait List Enterprise Data Warehouse data errors, disaggregated by error source Children fully 7mmunized at four years of age 10/02/2015 SPC108 Aboriginal Workforce as a proportion of total workforce 10/02/2015 SPC105 Leave Liability: Annual reduction in the total number of days in respect of accrued leave balances of more than 30 days 10/02/2015 KPC201 Staff who have had a performance review within the last 12 months 20/02/2015 SSQ101 Deteriorating Patients Rapid Response Calls 20/02/2015 SSQ102 Deteriorating patients unexpected cardiopulmonary arrest rate 20/02/2015 KQS202 Incorrect Procedures: Operating Theatre 10/03/2015 SA-001 Variation against purchased volume (%) sub and non-acute inpatient services (NWAU) NEW for Transferred from Schedule D for Transferred from Schedule D for Transferred from Schedule D for NEW for Updated numerator and denominator definitions. RETIRED for NEW for Updated indicator definition to clarify apparent discrepancy between indicator title and definition. Updated numerator and denominator sources, Documentation of Indicator Source, data collection and data source fields, usable data available from field, applied consistent labeling to Aboriginal people, added note to indicator definition. Updated title and definition of indicator (change from 40 days to 30 days). Updated numerator source, data collection and data source fields, related programs and policies and related national indicators Updated data contact, minor revision (clarification) of numerator definition, updated performing, non-performing and under-performing targets. Clarified indicator to clear up reporting of data for both the total as well as reporting for each subgroup. Clarified indicator to clear up reporting of data for both the total as well as reporting for each subgroup. Changed from KPI to Service Measure; Updated Related Policies/ Programs Updated Primary point of collection, removing reference to per diem allocations. 7

12 Date ID Item Change 10/03/2015 SSQ115 Restoration Treatment Revised Frequency of Reporting 10/03/2015 SSQ116 Denture remakes unplanned returns 10/03/2015 CC-001 Connecting Care Program: people currently enrolled (number) 12/03/2015 KSA104 National Elective Surgery Target Part 2.2: Average overdue waiting time (days) Revised Frequency of Reporting MOVED TO SCHEDULE D for RETIRED FOR /03/2015 SPC101 Workplace Injuries Revised title to align with the actual measure. Minor amendment to indicator definition, exclusions, and usable data available from 27/03/2015 KQS201 ICU Central Line Associated Bloodstream (CLAB) Infections 01/04/2015 SSA108, Overdue Elective Surgery Patients SSA109, SSA110 Changed from KPI to Service Measure, removed target Changed from Service Measure to KPI; Minor update to indicator definition, inclusions, and Primary point of collection. 02/04/2015 SSA112 Elective Surgery Theatre Utilisation Corrected numerator definition, updated inclusions, exclusions, related policies/programs 09/04/2015 PH-009 Needles and syringe Program Sterile needles and syringes distributed 09/04/2015 SSQ112, SSQ113, SSQ125 09/04/2015 SSQ114, SSQ118 17/04/2015 KSA103a, KSA103b, KSA103c 21/04/2015 SSA101, SSA102 Unplanned and emergency representations to same ED within 48 hours Inpatients who were discharged against medical advice Elective Surgery Access Performance: Elective Surgery Patients Treated on Time (%) Patients with total time in ED <= 4 hrs 23/04/2015 KSA204 Non-Urgent Patients waiting more than 365 days for an initial specialist outpatient services appointment 23/04/2015 SFA101, SFA102 Specialist Outpatient Services (Service Events) 07/05/2015 KQS206 Mental Health: Acute Seclusion rate Updated title (previously Needles and syringes distribution in the public sector ) and indicator definition, related policies/programs, contact policy, contact data Amended numerator definition (removed visit type 11 in the subsequent record criteria). Updated Denominator source and denominator availability, updated performance area. Added documentation re: calculation of NWAU rate for ABF hospitals as a separate subset. Updated indicator splits, added note to indicator definition, updated time lag to available data, and Business owners. Revised title of indicator, reflecting cessation of NEST. Minor updates to numerator definition and Primary point of Collection. Updated targets. Updated indicator definition, numerator definition, inclusions, Related Policies and Programs Updated Tier 2 Clinic classification, updated under-performing and nonperforming targets. Updated Tier 2 Clinic classification NEW for

13 Date ID Item Change 07/05/2015 SSQ121 Mental Health: Outcome Readiness HoNOS Completion Rates 07/05/2015 SSQ122 Mental Health Consumer Experience Measure (YES) Completion Rate 07/05/2015 SSQ123 Mental Health: Average duration of seclusion 07/05/2015 SSQ124 Mental Health: Frequency of seclusion 27/05/2015 NA-001 Variation Against Purchased Volume (%) of Non-admitted Patient Service National Weighted Activity Units (NWAUs) 05/06/2015 SPC112, SPC113, SPC114 11/06/2015 SSQ106, SSQ107, SSQ126 Workplace Injuries: Return to Work Experience Unplanned hospital readmission: all unplanned admissions within 28 days of separation 19/06/2015 KSA101 Transfer of Care patients transferred from Ambulance to ED < 30 minutes (%) 06/07/2015 SSA101 Patients with total time in ED <= 4 hrs Admitted. 06/07/2015 SSA106 Patients with total time in ED <= 4 hrs Admitted Mental Health. 09/07/2015 SFA111 Non-Admitted Patient level data completeness: Patient Level 17/07/2015 PH-011B Get Healthy Information and Coaching Service Health Professional Referrals 04/08/2015 MHDA- 005 Variation against purchased volume (%): Mental Health Non- Admitted Patient (NWAU) 24/08/2015 SSQ111 Unplanned hospital readmission rates for patients discharged following management of targeted conditions (%) - Paediatric tonsillectomy and adenoidectomy NEW for NEW for NEW for NEW for Finalised updated NWAU details, inclusions and exclusions NEW for Major revision to the indicator, including changes to the indicator definition, numerator, denominator, inclusions and exclusions. Updated Denominator source and denominator availability, updated performance area, and comments. Added documentation re: calculation of NWAU rate for ABF hospitals as a separate subset. Minor amendment to the title of the indicator previously Transfer of care time from ambulance to ED < 30 minutes (%) Corrected numerator and inclusions removed reference to separation modes 2, 3, 12 and 13 Corrected numerator and inclusions removed reference to separation modes 2, 3, 12 and 13 Updated and clarified denominator definition and calculation Modified target, updated Comments, Context, Related Policies/Programs, Business Owners (Contact Data) and deleted Related National Indicators. Updated numerator source from WebNAP to CHAMB. Updated numerator and denominator with clarification of paediatric definition (patient aged under 16 years of age) 9

14 Date ID Item Change 24/08/2015 SSQ122 Mental Health Consumer Experience Measure (YES) Completion Rate 25/08/2015 SIC001, SIC002, SIC003, SIC004 Potentially Preventable Hospitalisations (Rate per 100,000) 26/08/2015 PH-011B Get Healthy Information and Coaching Service Health Professional Referrals 28/08/2015 SSA106 Patients with Total time in ED <= 4hrs: Mental health patients admitted (to a ward/icu/theatre from ED) 31/08/2015 PH-010A HIV testing increase within publiclyfunded HIV and sexual health services 31/08/2015 PH-008A Healthy Children s Initiative - Children s Healthy Eating and Physical Activity Program (centre based children s service sites) - Adopted 31/08/2015 PH-008B Healthy Children s Initiative - Children s Healthy Eating and Physical Activity Program (primary school sites) - Adopted 31/08/2015 PH-014A Publicly Funded Hepatitis C Related Services - Hepatitis C Virus (HCV) Treatment Assessment 03/09/2015 KSA101 Transfer of Care patients transferred from Ambulance to ED <= 30 minutes 03/09/2015 KSA201 ED Presentations staying in ED > 24 hours 03/09/2015 KSA202 ED Presentations staying in ED > 24 hours (Mental Health) Minor update to numerator & denominator definitions (added community residential to ambulatory; specified non-acute units for inpatient) Updated indicator definition to clarify the use of principal diagnosis, confirm ICD codes applicable to 7 th, 8 th and 9 th editions, and clarified where 4 th digit codes are included. Updated target for HNE LHD MAJOR REVISION amended title (previously Patients with Total time in ED <= 4hrs: Admitted to a mental health ward ); amended numerator definition, removing link to bed type, instead identifying the cohort via ED diagnosis; adjusted inclusions. Updated targets for WS LHD; updated comments section for SESLHD. Updated 30 June 2016 target from 80% to 70% Updated 30 June 2016 target from 80% to 70% Updated target, removing reference to a 10% increase. Updated indicator name and numerator to clarify what is meant by within 30 minutes. Updated indicator definition to clarify relevant modes of separation. Updated target period from annually to monthly. Updated target period from annually to monthly. 10

15 Table of Contents SUMMARY OF KEY PERFORMANCE INDICATORS AND SERVICE MEASURE TARGETS Summary of Indicators and Targets for Service Agreements SAFETY AND QUALITY TIER Staphylococcus aureus bloodstream infections (SA-BSI): SAFETY AND QUALITY TIER Patient Experience Survey Adult Admitted Patients: overall rating of care (%) Hospital Acquired Pressure Injuries: Stage 3, 4 and Unstageable pressure injuries (number) Mental Health: Acute Readmission within 28 days (%) Mental Health: Acute Post Discharge Community Care Mental Health: Acute Seclusion rate (number) SAFETY AND QUALITY SERVICE MEASURES Deteriorating Patients Rapid Response Calls Deteriorating patients unexpected cardiopulmonary arrest rate Unplanned hospital readmission rates for patients discharged following management of targeted conditions (%) ICU Central Line Associated Bloodstream (CLAB) Infections (Number) Incorrect Procedures: Operating Theatre Hospital Acquired Venous Thromboembolism (rate per 1000 separations) Inpatients who were discharged against medical advice (%) Restoration treatment Denture remakes unplanned returns: Patient Experience Survey Emergency Department Patients: overall rating of care (%) 64 Mental Health: Outcome Readiness HoNOS Completion Rates (%) Mental Health Consumer Experience Measure (YES) Completion Rate (%) Mental Health: Average duration of seclusion (number) Mental Health: Frequency of seclusion (%) SERVICE ACCESS AND PATIENT FLOW TIER Transfer of Care patients transferred from Ambulance to ED <= 30 minutes (%) Emergency Treatment Performance: Patients with Total time in ED <= 4hrs (%) Elective Surgery Access Performance: Elective Surgery Patients Treated on Time (%).. 84 Overdue Elective Surgery Patients SERVICE ACCESS AND PATIENT FLOW TIER ED Presentations staying in ED > 24 hours (number) ED Presentations staying in ED > 24 hours (Mental Health) (number) Non-Urgent Patients waiting more than 365 days for an initial specialist outpatient services appointment (number) SERVICE ACCESS AND PATIENT FLOW SERVICE MEASURES

16 Patients with Total time in ED <= 4hrs: ED presentations treated within benchmark times (%) Elective Surgery: Activity change YTD compared to previous (number) Elective Surgery Theatre Utilisation: Operating Room Occupancy (%) Surgery for Children - Proportion of children (0 to 16 years) treated within their LHD of residence: Average Length of Episode Stay - Overnight Patients (days) Acute to Aged-Related Care Services (AARCS) patients seen (number) Aged Care Services in Emergency Teams (ASET) patients seen (number) Breast Screen Participation Rates: INTEGRATED CARE SERVICE MEASURES Unplanned hospital readmission: all unplanned admissions within 28 days of separation (%): Unplanned and emergency re-presentations to same ED within 48 hours (%) Hospital in the home: Potentially Preventable Hospitalisations (Rate per 100,000) Discharge Summaries: Number and percentage electronically sent to patient s General Practitioner (Number and %) FINANCE AND ACTIVITY TIER Variation against purchased volume (%) Acute Inpatient Services (NWAU) Variation against purchased volume (%) Emergency Department Services (NWAU) Variation against purchased volume (%) sub and non-acute inpatient services (NWAU) 139 Variation Against Purchased Volume (%) of Non-admitted Patient Service National Weighted Activity Units (NWAUs) Variation against purchased volume (%) Mental Health Acute Inpatient Services (NWAU) Variation against purchased volume (%): Mental health Inpatient Activity Non Acute Inpatients (NWAU) Expenditure Matched to Budget: Own Source Revenue Matched to Budget: Recurrent Trade Creditors Small Business Creditors FINANCE AND ACTIVITY TIER Variation against purchased volume (%): Mental Health Non-Admitted Patient (NWAU) 158 Variation against purchased volume (%) Public Dental Clinical Service (DWAU) FINANCE AND ACTIVITY SERVICE MEASURES Specialist Outpatient Services (Service Events) (Number) Patient Fee Debtors Coding timeliness (%) ED Records unable to be grouped: Non-Admitted Patient level data completeness: Patient Level (%)

17 Wait List Enterprise Data Warehouse data errors, disaggregated by error source (%) Sub and Non Acute Admitted Patient Episodes - grouped to an AN-SNAP Class (%) PEOPLE AND CULTURE TIER Staff who have had a performance review within the last 12 months PEOPLE AND CULTURE SERVICE MEASURES Workplace Injuries: Claims (rate per 100 FTEs) Workplace Injuries: Return to work experience (days): Premium staff usage: average paid hours per FTE Leave Liability: Annual reduction in the total number of days in respect of accrued leave balances of more than 30 days Recruitment: Improvement on baseline average time taken from request to recruit to decision to approve/decline/defer recruitment (days) Aboriginal Workforce as a proportion of total workforce (%) YourSay Staff Culture Survey Results POPULATION HEALTH TIER HIV testing increase within publicly-funded HIV and sexual health services (%) Get Healthy Information and Coaching Service Health Professional Referrals (% increase) POPULATION HEALTH SERVICE MEASURES Quit for new life program: Publicly Funded Hepatitis C Related Services - Hepatitis C Virus (HCV) Treatment Assessment (Number) Healthy Children s Initiative - Children s Healthy Eating and Physical Activity Program (centre based children s service sites) - Adopted (% cumulative) Healthy Children s Initiative - Children s Healthy Eating and Physical Activity Program (primary school sites) - Adopted (% cumulative) Needle and Syringe Program Sterile needles and syringes distributed (Number) Children fully immunised at one year of age: Children fully immunised at four years of age: Human papillomavirus vaccine: Antenatal visits for mothers of Aboriginal babies: Women who smoked at any time during pregnancy: (%)

18 Summary of KPIs and Targets SUMMARY OF KEY PERFORMANCE INDICATORS AND SERVICE MEASURE TARGETS The NSW Performance Framework (PF) applies to the 15 geographical NSW Local Health Districts, the Ambulance Service NSW, Sydney Children s Hospitals Network, the St Vincent s Health Network, the Forensic Mental Health Network and Justice Health. In this document, these organisations are referred to collectively as Health Services, except where particular reference to Local Health Districts is required. The definitions provided in this document will assist Health Services and other data users with the calculation and interpretation of the Key Performance Indicators and Services Measures referenced in the Service Agreements for It should be noted that some KPIs may be calculated differently when applied to different purposes outside the management of the Service Agreements. The KPIs and Service Measures contained in this document have been defined specifically with the intent to meet the reporting requirements under agreements and to align to the Ministry of Health s monthly performance monitoring reports. Should you require further assistance with the definitions or have comments regarding them please contact either the Health System Information & Performance Reporting Branch or the Data/Policy contacts listed in the KPI documentation. The Service Agreement is a key component of the Performance Framework for Health Services providing a clear and transparent mechanism for assessment and improvement of performance. The Service Agreement document covers both the Tier 1 & 2 KPIs and Service Measures. Key Performance Indicators (KPIs), if not met, may contribute to escalation under the Performance Framework processes. Performance against these KPIs will be reported regularly to Health Services in the Health System Performance Report prepared by the Department. These KPIs have been designated into two categories: Tier 1 - Will generate a performance concern when the organisation s performance is outside the tolerance threshold for the applicable reporting period. Tier 2 - Will generate a performance concern when the organisation s performance is outside the tolerance threshold for more than one reporting period. Service Measures: A range of Service Measures are identified to assist the organisation to improve provision of safe and efficient patient care and to provide the contextual information against which to assess performance. Note that the KPIs and Service Measures listed above are not the only measures collected and monitored by the NSW Health System. A range of other measures are used for a variety of reasons, including monitoring the implementation of new service models, reporting requirements to NSW Government central agencies and the Commonwealth, and participation in nationally agreed data collections. Relevant measures specified in the National Health Reform Performance and Accountability Framework, and in NSW 2021: A Plan to Make NSW Number One, have been assigned as NSW Health KPIs, Service Measures or Monitoring Measures, as appropriate. This year the KPIS and Service Measures are grouped under the six reporting domains of: Safety and Quality Service Access and Patient Flow Integrated Care Finance and Activity People and Culture Population Health 14

19 Summary of KPIs and Targets The performance of LHDs, other Health Services and Support Organisations is assessed in terms of whether it is meeting the performance targets for individual KPIs: Highly Performing - Performance at, or better than, target Underperforming - Performance within a tolerance range Not performing - Performance outside the tolerance threshold As in previous years, the KPI and Service Measure data elements are also located on the NSW Health Information Resource Directory and are accessible via the following link: TBA Each individual indicator and service measure may be viewed and downloaded via this portal. Further, additional documentation (where available) for each of the indicators and service measures (such as specific identification of which fields from the data warehouse are used for the calculation, sample.sas code, detailed calculation formulae, etc) may be found under the Ext Info tab for each individual indicator and service measure, which may be downloaded as well. The following table below provides a summary of the performance measures and targets against the Tier 1 & 2 KPIs as well as listing the Service Measures for each of the domains. 15

20 Summary of KPIs and Targets Summary of Indicators and Targets for Service Agreements ID Key Performance Indicator Target KQS 101 Safety and Quality Tier 1 Staphylococcus aureus bloodstream infections (SA- BSI) (per 10,000 occupied bed days) Not Performing X Under Performing Performing < 2 > 2.0 N/A < 2 SSQ 117 Tier 2 Patient Experience Survey following treatment: Overall care received - good and very good (%) Increase Decrease from previous Year No change Increase from previous Year KQS 205 Tier 2 Hospital acquired pressure injuries (rate per 1,000 completed inpatient stays) Decrease Increase from previous Year No change Decrease from previous Year KQS 203 Tier 2 Mental Health: Acute readmission within 28 days (%) < 13 > 20 > 13 and < 20 < 13 KQS 204 Tier 2 Mental Health: Acute Post- Discharge Community Care - follow up within seven days (%) > 70 < 50 > 50 and < 70 > 70 KQS 206 Tier 2 Mental Health: Acute Seclusion rate (episodes per 1,000 bed days) < 6.8 > 9.9 > 6.8 and < 9.9 < 6.8 Service Access and Patient Flow KSA 101 Tier 1 Transfer of Care patients transferred from Ambulance to ED < 30 minutes (%) > 90 < 80 > 80 and < 90 > 90 KSA 102 Tier 1 Emergency Treatment Performance - Patients with total time in ED <= 4 hrs (%) > 81 < 71 > 71 and < 81 > 81 KSA 201 Tier 2 Presentations staying in ED > 24 hours (number) 0 >5 >1 and <5 0 Elective Surgery Access Performance: Elective Surgery Patients Treated on Time (%): KSA 103a Category < 100 N/A 100 KSA Tier 103b 1 Category 2 > 97 < 93 KSA 103c Category 3 > 97 < 95 > 93 and < 97 > 95 and < 97 > 97 > 97 16

21 Summary of KPIs and Targets ID Key Performance Indicator Target Service Access and Patient Flow Not Performing X Under Performing Performing Overdue Elective Surgery Patients (number) SSA 108 SSA 109 SSA 110 KSA 202 Tier 1 Tier 2 Category 1 0 > 1 N/A 0 Category 2 0 > 1 N/A 0 Category 3 0 > 1 N/A 0 Mental Health: Presentations staying in ED > 24 hours (number) 0 > 5 > 1 and < 5 0 KSA 204 Tier 2 Non-Urgent Patients waiting > 365 days for an initial specialist outpatient services appointment (Number) 0 Increase from previous Year Decrease from previous Year 0 Finance and Activity Variation against purchased volume (%) AI- 001 Tier 1 Acute Inpatient Services (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 - <2.0 variation from target +/- 1.0 variation from target ED- 001 Tier 1 Emergency Department Services (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 - <2.0 variation from target +/- 1.0 variation from target SA- 001 Tier 1 Sub and Non Acute Inpatient Services (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 - <2.0 variation from target +/- 1.0 variation from target NA- 001 Tier 1 Non Admitted Patient Services Tier 2 Clinics (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 - <2.0 variation from target +/- 1.0 variation from target MHD A- 001 Tier 1 Mental Health Inpatient Activity Acute Inpatients (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 -< 2.0 variation from target +/- 1.0 variation from target MHD A- 002 Tier 1 Mental Health Inpatient Activity Non Acute Inpatients (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 -< 2.0 variation from target +/- 1.0 variation from target MHD A- 005 Tier 2 Mental Health Non Admitted occasions of service (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 - <2.0 variation from target +/- 1.0 variation from target PD- 001 Tier 2 Public Dental Clinical Service (DWAU) 100 <100 N/A >

22 Summary of KPIs and Targets ID Key Performance Indicator Target Not Performing X Under Performing Performing Finance and Activity Expenditure matched to budget (General Fund): KFA 101 Tier 1 a) Year to date - General Fund (%) On budget or Favourable > 0.5 Unfavourable > 0 but < 0.5 Unfavourable On budget or Favourable KFA 102 Tier 1 b) June projection - General Fund (%) On budget or Favourable > 0.5 Unfavourable > 0 but < 0.5 Unfavourable On budget or Favourable Own Source Revenue Matched to budget (General Fund): KFA 103 Tier 1 a) Year to date - General Fund (%) On budget or Favourable > 0.5 Unfavourable > 0 but < 0.5 Unfavourable On budget or Favourable KFA 104 Tier 1 b) June projection - General Fund (%) On budget or Favourable > 0.5 Unfavourable >0 but < 0.5 Unfavourable On budget or Favourable Liquidty: KFA 105 Tier 1 Recurrent Trade Creditors > 45 days correct and ready for payment ($) 0 > 0 N/A 0 KFA 106 Tier 1 Small Business Creditors paid within 30 days from receipt of a correctly rendered invoice (%) 100 < 100 N/A 100 People and Culture KPC 201 Tier 2 Staff who have had a performance review (%) 100 < 85 > 85 and < 90 > 90 Population Health PH- 010A Tier 2 HIV testing increase within publicly-funded HIV and sexual health services (% increase) See Schedule D > 5.0 % variation below Target < 5.0 % variation below Target Met or exceeded Target PH- 011B Tier 2 Get Healthy Information and Coaching Service Health Professional Referrals (% increase) See Schedule D > 10.0 % variation below Target < 10.0 % variation below Target Met or exceeded Target 18

23 Summary of KPIs and Targets ID SSQ101 SSQ102 SSQ108 SSQ109 SSQ110 SSQ111 KQS201 KQS202 SSQ120 SSQ114 SSQ118 SSQ115 SSQ116 SSQ119 SSQ121 SSQ122 SSQ123 SSQ124 SSA101 SSA102 SSA106 SSA104 SSA111 Safety and Quality Deteriorating Patients (rate per 1,000 separations): Rapid response calls Cardio respiratory arrests Unplanned hospital readmission rates (%) for patients discharged following management of: Acute Myocardial Infarction Heart Failure Knee and hip replacements Pediatric tonsillectomy and adenoidectomy ICU Central Line Associated Bloodstream (CLAB) Infections (number) Incorrect procedures: Operating Theatre - resulting in death or major loss of function (number) Hospital Acquired Venous thromboembolism (rate per 1000 separations) Inpatients who were discharged against medical advice (%): Aboriginal Non-Aboriginal Re-treatment following restorative treatment: Number of permanent teeth re-treated within 6 months of an episode of restorative treatment. Performance target: less than 6% (less than 6 teeth re-treated per 100 teeth restored). Denture remakes: Number of same denture type (full or partial) and same arch remade within 12 months. Performance target: less than 3% (less than 3 per 100 dentures). Patient Experience Survey Emergency Department Patients: Overall rating of care (Percentage of patients rating care as good or very good ) (%) Mental Health: Outcomes readiness (HoNOS completion rates) (% of mental health episodes with completed HoNOS outcome measures) Consumer Experience Measure (YES) Completion Rate (% of episodes) Average duration of seclusion (Hours) Frequency of seclusion (% of acute mental-health admitted care episodes with seclusion) Service Access and Patient Flow Patients with total time in ED <= 4 hrs (%): Admitted (to a ward/icu/theatre from ED) Not Admitted (to an Inpatient Unit from ED) Mental Health Patients (admitted to a ward from ED) ED attendances treated within benchmark times (%): Triage 1 Triage 2 Triage 3 Triage 4 Triage 5 Elective Surgery: Activity compared to previous year (Number) SSA112 Elective Surgery Theatre Utilisation: operating room occupancy (%) SSA114 SSA113 SSA116 PC-001 PC-002 Surgery for Children - Proportion of children (to 16 years) treated within their LHD of residence: Emergency Surgery (%) Planned Surgery (%) Average Length of Episode Stay - Overnight patients (days) Acute to Aged-Related Care Services patients seen (number) Aged Care Services in Emergency Teams patients seen (number) 19

24 Summary of KPIs and Targets SSA126 SSA127 SSA128 SSA129 SSA130 SSA131 Breast Screen Participation Rates, disaggregated by Aboriginality and cultural and linguistic diversity (%): Women, aged Women, aged Integrated Care SSQ106 SSQ107 SSQ126 SSQ112 SSQ113 SSQ125 PI-03 SIC001 SIC002 SFA101 SFA102 SFA103 SFA105 SFA106 SFA107 SFA108 SFA109 SFA111 SFA115 SFA116 SFA117 Unplanned hospital readmissions: all admissions within 28 days of separation (%): All persons Aboriginal persons ABF hospitals (rate in NWAU) Unplanned and Emergency Re-Presentations to same ED within 48 hours (%): All persons Aboriginal persons ABF hospitals (rate in NWAU) Hospital in the Home: Admitted activity (%) Potentially Preventable Hospitalisations (Rate per 100,000 population) Discharge Summaries: Number and percentage electronically delivered to patient s General Practitioner (Number and %) Finance and Activity Specialist Outpatient Services (Service events) Initial Subsequent Patient Fee Debtors > 45 days as a percentage of rolling prior 12 months Patient Fee Revenues (%) Coding timeliness: % uncoded acute separations ED records unable to be grouped: to URG with a breakdown for error codes: E1, E2, E3, E6, E7 and E8 (number and %) to UDG with a breakdown for error codes: E1 and E2 (number and %) NAP data completeness: Patient Level (%) Wait List Enterprise Data Warehouse data errors, reported separately and disaggregated by error source (%): Source System error (issues related to the EDW extract or mappings defects) Data collection error (issues related to the actual data collected or reported) System Vendor error (issues related to source system defects) SFA113 Sub and Non Acute Inpatient Services - Grouped to an AN-SNAP class (%) People and Culture SPC101 SPC112 SPC113 SPC114 SPC102 SPC103 Workplace injuries: Claims (rate per 100 FTEs) Return to work experience - Continuous Average Duration (days) Premium staff usage - average paid hours per FTE (Hours): Medical Nursing 20

25 Summary of KPIs and Targets SPC105 SPC107 Reduction in the number of employees with accrued annual leave balances of more than 30 days (Number) Recruitment: improvement on baseline average time taken from request to recruit to decision to approve/decline recruitment (days) SPC108 Aboriginal Workforce as a proportion of total workforce (%) SPC109 SPC110 SPC111 PH-013B PH-013C PH-013D PH-014A PH-008A PH-008B PH-009 SPH003 SPH001 SPH004 SPH002 PH-006 SPH005 SPH006 PH-013a SPH007 YourSay Survey (%): Estimated Response Rate Engagement Index Workplace Culture Index Population Health Quit for New Life Program (%) Referred to the Quitline Provided Nicotine Replacement Therapy (NRT) Booked follow-up Appointment Publically funded Hepatitis C related services HCV Treatment Assessment (Number) Healthy Children s Initiative - Children s Healthy Eating and Physical Activity Program (centre based children s service sites) - Adopted (% cumulative) Healthy Children s Initiative - Children s Healthy Eating and Physical Activity Program (primary school sites) - Adopted (% cumulative) Needle and Syringe Program Sterile needles and syringes distributed (Number) Children fully immunised (%) At one year of age: Non- Aboriginal children At one year of age: Aboriginal children At four years of age: Non- Aboriginal children At four years of age: Aboriginal children Human papillomavirus vaccine year 7 students receiving the third dose through the NSW Adolescent Vaccination Program (%) First comprehensive antenatal visit provided < 14 weeks gestation for all women who: Identify the baby as Aboriginal Identify the baby as Non-Aboriginal Women who smoked at any time during pregnancy (%): Aboriginal women Non-Aboriginal women 21

26 Safety and Quality Tier One SAFETY AND QUALITY TIER 1 INDICATORS: KQS101 Previous IDs: 9A15, 9A16, 0005 Staphylococcus aureus bloodstream infections (SA-BSI): A1 C2 facilities (per 10,000 occupied bed days) D1a F8 facilities (per 10,000 occupied bed days) Service Agreement Type Performance Area Key Performance Indicator Safety and Quality (Tier 1) Status Version number Final 1.1 Scope All patients in hospitals Goal To minimize the risks and unnecessary morbidity and mortality from healthcare associated infections (HAI) in NSW public healthcare facilities through implementation of infection control practices. Desired outcome Reduction in the number of Staphylococcus aureus bloodstream infections Primary point of collection Health staff in all NSW public healthcare facilities Data Collection Source/System HAI Monthly Data Collection, NSW Health Primary data source for HAI Monthly Data Collection, NSW Health analysis Indicator definition The number of SA-BSI as a rate of the number of occupied bed days Numerator Numerator definition Number of Staphylococcus aureus bloodstream infections (SA-BSI) Numerator source NSW public healthcare facilities Numerator availability Monthly, available from 1 January 2009 Denominator Denominator definition Number of occupied bed days Denominator source Health System Information and Performance Reporting Branch, NSW Health Denominator availability Monthly Inclusions Healthcare associated inpatient bloodstream infections caused by Staphylococcus aureus: - Methicillin sensitive Staphylococcus aureus (MSSA) - Methicillin resistant Staphylococcus aureus (MRSA) Healthcare associated non-inpatient MSSA and MRSA bloodstream infections Exclusions Community associated MSSA and MRSA bloodstream infections Next report due Targets Target Comments Monthly from data availability Less than or equal to 2 SA-BSI per 10,000 occupied bed days The incidence of SA-BSI provides an indication of compliance with hand 22