SERVICE AGREEMENT PERFORMANCE FRAMEWORK

Transcription

1 Version 1.0 Final Amended December SERVICE AGREEMENT PERFORMANCE FRAMEWORK Activity Based Funding and Management

2 Contents 1 Executive Summary 3 2 Background 5 Overview of the Department s Performance Framework 5 3 Purpose of the Service Agreement Performance Framework 7 4 Service Agreement Performance Monitoring and Reporting Process 8 Service Agreement Performance Monitoring 8 Exceptional Events 8 Service Agreement Performance Reporting 8 Service Agreement Quarterly Performance Review Meetings Changes to KPIs 10 New KPIs 10 Changes to Existing KPIs 10 Removal of KPIs 10 6 Service Agreement Performance Management Process 11 Principles of the Service Agreement Performance Management Process 11 Elements of Service Agreement Performance Management 12 Performance Intervention Levels Key Performance Indicators Data Summary 16 8 Service Agreement Key Performance Indicator Definitions 20 2

3 Executive Summary 1 Executive Summary This document presents the Service Agreement Performance Framework and consolidates work commenced and progressed in the and versions. The version reinforces the focus on Activity Based Funding (ABF) and management and has matured to include: Specific activity Key Performance Indicators (KPIs) that are directly aligned to the funded outputs of the Tasmanian Activity Based Funding Model. Selected process KPIs that recognise the importance of accurate and timely coding of patient data in maintaining the integrity of the ABF system. Furthermore, while mental health services transferred to THOs from 1 July 2013, no specific KPIs were included in Service Agreements, thus enabling the services to consolidate within THO structures before the introduction of formal management processes. The version addresses this previous gap through the inclusion of three specific KPIs that enable a broad analysis of the of the mental health service system across a number of domains, including quality, effectiveness, efficiency and access. Drawing on lessons learned, the version retains the monitoring and management processes outlined in These processes were practically applied by both the Department of Health and Human Services (the Department) and THOs throughout , providing clarity to both parties in relation to the identification, escalation and de-escalation of identified issues. The version reinforces the over-arching objective of facilitating long term, sustainable improvement in areas where a concern has been identified. While escalations remain a central feature, they will generally only be recommended in circumstances where a THO is unable to demonstrate to the Department that: The concern is being actively managed and monitored by the THO. A robust and transparent plan for sustainable improvement is in place within the THO. It possesses the necessary skills to achieve sustainable improvement in the area of concern. In 2014 the Minister approved delegation of certain Ministerial powers and functions that enables the Secretary to escalate or de-escalate concerns for; Level 1 (unsatisfactory ), requesting a Performance Improvement Plan from THOs. Level 2 (sustained unsatisfactory ), ability to appoint a Performance Improvement Team. The Minister retains the power to appoint a Ministerial Representative to assist the Governing Council, if considered necessary, as part of a Level 2 escalation. The Minister also retains the power to approve a Level 3 escalation. The version moves to address any previous uncertainty regarding the carryover of existing escalations from one Service Agreement year to the next. Whereas previously escalations ceased at 30 June of the Service Agreement year in which they were initiated (regardless of whether the issue had been remediated at that time or not), escalations will now remain in place until such time as the requirements of any associated escalation are met. 3

4 Executive Summary Where possible, the version continues to be aligned to state and national strategic priorities. The annual (rolling) Statement of Purchaser Intent, which signals purchaser intentions over the coming five years, provides detail on the annual purchasing priorities and policy drivers for the Department. 4

5 Background 2 Background Overview of the Department s Performance Framework Under the Tasmanian Health Organisations Act 2011 (the Act), the Minster for Health (the Minister) enters into annual Service Agreements with THO Governing Councils. The development of, and advice regarding these Agreements originates from the Department (acting on behalf of the Minister as the Purchaser). The Department s purchasing function is supported by a number of governing instruments, including the Purchasing Framework, which outlines the process followed in purchasing services, and this document, the Service Agreement Performance Framework, which codifies the process of monitoring THO against the requirements of Service Agreements. In addition to its role as the Purchaser, the Department has a broader responsibility as System Manager to undertake such strategic, planning and monitoring functions and activities as necessary to enable it to provide assurance to the responsible Ministers (the Minister for Health and the Treasurer have joint responsibilities under the Act) that the Tasmanian health system is being managed effectively and efficiently. There are many activities that occur in the Tasmanian health system, outside of those that are purchased directly from THOs through Service Agreements that should be subject to ongoing monitoring. The Monitoring Suite (currently under review as part of the One Health System reform programme), governed by the Monitoring Suite Operational Guidelines, enables the System Manager to gain an understanding of the state of Tasmania s publicly funded health services, supplementing the quasi contractual arrangements of Service Agreements. Should there be a patient safety issue that requires an urgent response, it will be guided by the Clinical Governance Framework. The functions of Purchaser and System Manager cannot be viewed in isolation of each other - the nature and volume of services purchased will impact on the effectiveness and efficiency of the Tasmanian health system and the primary mechanism for effective system management is through informed, appropriate purchasing. Purchasing is a necessarily transactional process, and so must be contextualised to be effective as a mechanism to enact Government policy in health and to ensure that purchasing decisions reflect the longer term application of strategy. An annual (rolling) Statement of Purchaser Intent (currently under review as part of the One Health System reform programme), which signals purchaser intentions over the coming five years, will act as the bridge between the functions of the Purchaser and System Manager. This will be the translational implement linking the activities of the Purchaser to the priorities of the System Manager and will be released in the first quarter of every calendar year. The dual role of the Department as both Purchaser and System Manager is represented graphically in Figure 1. 5

6 Background Figure 1: Inter-relationship of compliance and monitoring. 6

7 Purpose of the Service Agreement Performance Framework 3 Purpose of the Service Agreement Performance Framework Annual Service Agreements between the Minister and THO Governing Councils set out the expectations of each THO in terms of the volume and quality of services to be delivered and the funding provided in relation to the delivery of those services. It is the responsibility of Governing Councils to ensure that THOs deliver the requirements of Service Agreements once established. It is the responsibility of the Department to ensure that THO against those requirements is monitored and managed to ensure that where necessary, the intervention options available to the Minister under the Act are effectively implemented. The Service Agreement Performance Framework codifies the process of monitoring THO against the requirements of Service Agreements to ensure that where determined necessary, the management options available to the Minister under the Act are effectively implemented. It describes an integrated process for the monitoring and of THO against the requirements of Service Agreements and provides both the Department and THOs with a clear delineation of roles, responsibilities and expectations in response to identified Service Agreement issues. It should be read in conjunction with the following key documents: THO Service Agreements; State-wide Clinical Governance Framework; and THO Funding Guidelines - Activity Based Funding and Management (yet to be released). In addition, a number of key system management frameworks have been committed to under the One Health System reform programme. These include: Statement of Purchaser Intent; Purchasing Framework; and Monitoring Suite of Indicators. These frameworks are currently in the early stages of review and development and are due for completion by 31 January

8 Service Agreement Performance Monitoring and Reporting Process 4 Service Agreement Performance Monitoring and Reporting Process Service Agreement Performance Monitoring Annual Service Agreements between the Minister and THO Governing Councils include specific KPIs and associated targets. KPIs and targets are systematically considered and adopted in the following order of preference where practical: Existing national policy based targets. Existing Tasmanian health policy based targets. New targets based on previous baselines. s establish the levels of that determine whether any action is required regarding the identification and management of Service Agreement issues. Not all national or state based targets form part of Service Agreements. Some have been determined as better placed within the Monitoring Suite as broader markers of the effective and efficient management of the Tasmanian health system. Further information regarding the target source is provided in Section 8. Exceptional Events There may be circumstances beyond the reasonable control of THOs which may prevent the achievement of s and it is important that such circumstances are recognised. At its discretion, and on a case-by-case basis, the Department will consider requests from THOs to consider such circumstances as part of the ongoing monitoring process. The intention is to recognise extraordinary and generally unforseen events beyond the reasonable control of the THO, but not planned service interruptions such as capital works or ad hoc operational difficulties. THOs are expected to provide the Department with timely advice of such circumstances and to actively mitigate any risk(s) to achieving s. Service Agreement Performance Reporting At the end of each quarter, the Department provides the responsible Ministers with THO Quarterly Service Agreement Performance Reports, outlining Service Agreement against all KPIs over the preceding quarter and, where necessary, recommended interventions. The reports are compiled by the System Purchasing and Performance (SPP) Unit of the Department following completion of quarterly Service Agreement review meetings with THOs. 8

9 Service Agreement Performance Monitoring and Reporting Process Service Agreement Quarterly Performance Review Meetings Quarterly review meetings are co-ordinated by SPP. Meetings are characterised by: Common standard agenda for all meetings, varied for specific local issues and the escalation status. THO led discussion that enables THO representatives to describe their proactive management from an operational-level perspective. Aiming to reduce the need for further escalation of the response. Clear recording and communication of actions and requirements of the THO and the Department. Core attendance is kept to a minimum to facilitate smooth and efficient conduct of business ensuring coverage of each domain. Additional attendees may be included where attention to specific areas of requires the involvement of staff with specialist expertise and knowledge. Each meeting will have the following core attendees: The Department: SPP Deputy Secretary and the Chief Financial Officer will attend all meetings. Other Departmental Directors or their representatives will attend as required. Generally, representatives of SPP will also attend and provide secretariat support if required. THOs: The attendance of the THO Chair is required. Attendance by other members of the Governing Council and/or senior executives is at the discretion of the Chair, unless attendance of a specified executive is requested by the Secretary or delegate. It is anticipated that the THO Chief Executive Officer will attend. The Secretary of the Department may attend if and when a issue has been escalated and is unsatisfactory. 9

10 Changes to KPIs Changes to KPIs New KPIs Finance and Activity Based Management THO cash liquidity. Acute admitted raw separations. Admitted patient episode (clinical coding) including contracted care timeliness. Admitted patient episode (clinical coding) including contracted care accuracy. Mental Health 28 Day re-admission rates. Acute 7 day post discharge community care. Seclusion rates. Primary Health and Aged Care Aged Care Assessment Team (ACAT) priority category one clients seen on time in all settings. Aged Care Assessment Team (ACAT) priority category two clients seen on time in all settings. Aged Care Assessment Team (ACAT) priority category three clients seen on time in all settings. Changes to Existing KPIs Finance and Activity Based Management Acute admitted weighted separations (replaced by the following KPI); Acute admitted inlier weighted units (same day and multi-day). Emergency Department Ambulance offload delay (replaces the following two KPIs); Incidence of ambulance presentations to emergency departments experiencing offload delay. Total time (hours) spent by ambulance presentations in offload delay. Removal of KPIs Alcohol & Drug Number of individual clients accessing the Pharmacotherapy Program (removed from Service Agreement to be included in Monitoring Suite). 10

11 Service Agreement Performance Management Process 6 Service Agreement Performance Management Process Principles of the Service Agreement Performance Management Process The Department s approach to monitoring, and response is shaped by the principles outlined in Table 1 below. Table 1: Principles of the Performance Framework Realistic Performance and funding expectations will be balanced with the resources and capacity of the health system and the current fiscal environment. Consistency and Transparency The Department will apply a consistent and transparent method for assessing against clear, agreed s, and responding where appropriate. The default response to the non-achievement of targets will be escalation, with the Minister (or delegate) maintaining discretion to waive such escalations. Accountability The Department and THOs have distinct and separate roles and accountabilities as Purchaser and Provider respectively. The Department, on behalf of the Minister, will negotiate Service Agreements with THOs and monitor against the requirements of those agreements. THOs are accountable for delivering services to the agreed standards outlined in Service Agreements and ensuring that an effective internal framework is in place that demonstrates processes to actively monitor the requirements of those agreements. Informed Purchasing The Department s System Manager role will inform the establishment of purchasing priorities and KPIs, in turn shaping negotiation of Service Agreements. Integration The Department recognises change or variation in a particular aspect of may require changes to other, interdependent, elements of the system. The Department acknowledges that influences outside the control of THOs may affect and such factors will be considered when is assessed. Recognition Superior will be recognised and reviewed by the Department for lessons to be shared across THOs. 11

12 Service Agreement Performance Management Process Elements of Service Agreement Performance Management Service Agreement management will involve: On-going monitoring and review of THO against the requirements of Service Agreements. Identifying a concern and determining the appropriate response. Determining when a intervention is necessary and the level of intervention required. Determining when the intervention needs to be escalated or can be de-escalated. Performance Intervention Levels As in , there are four levels in the Service Agreement Performance Framework. The level of response and intervention dictates the action required by THOs and/or the Department. In 2014 the Minister approved delegation of certain Ministerial powers and functions that enables the Secretary to escalate or de-escalate concerns for; Level 1 (unsatisfactory ), requesting a Performance Improvement Plan from THOs. Level 2 (sustained unsatisfactory ), ability to appoint a Performance Improvement Team. The Minister retains the power to appoint a Ministerial Representative to assist the Governing Council, if considered necessary, as part of a Level 2 Performance Escalation. The Minister also retains the power to approve a Level 3 Performance Escalation. The non-achievement of any individual Service Agreement will lead to the immediate identification of a concern and application of the intervention process outlined below. Service Agreement KPIs require compliance and the achievement of assigned targets within the specified period. Generally, a escalation will only be recommended in circumstances where a THO is unable to demonstrate to the Department that: The concern is being actively managed and monitored by the THO. A robust and transparent plan for sustainable improvement is in place within the THO. The THO possesses the necessary skills to achieve sustainable improvement in the area of concern. The Minister may waive any recommendation received from the Department to proceed with a escalation. Based on the response provided by THOs to concerns, an issue may be escalated or deescalated in a non-sequential fashion. Service Agreement KPIs are viewed independently of each other - that is, escalation or de-escalation is managed on the basis of each KPI, without mitigation by in other KPIs. Performance Escalation Level 0 (Satisfactory Performance) If a Service Agreement is achieved by a THO, the KPI will be assigned Level 0 (satisfactory ). Satisfactory will be noted in the THO Quarterly Service Agreement Performance Reports provided to the Minister and may be reviewed for lessons to be shared across THOs. Performance Escalation Level 1(Unsatisfactory Performance) The non-achievement of a Service Agreement will lead to the immediate identification of a concern and the application of the intervention process. In the event of non- 12

13 Service Agreement Performance Management Process achievement, the Secretary will consider escalating the issue to Level 1 (unsatisfactory ). Before taking this action, the Chair and CEO will be advised of the intention to escalate and be provided with an opportunity to provide more information to the Department in relation to the issue. In such circumstances, CEOs must provide supporting information within 7 days from receipt of the request. Performance Escalation Level 2 (Sustained Unsatisfactory Performance) At Level 2, direct intervention will occur due to sustained unsatisfactory. Formal notification of the intention to escalate to Level 2 will be provided by the Secretary to the Chair and the CEO. Depending on the nature of the concern, at Level 2, the Secretary may appoint a Performance Improvement Team or the Minister may appoint a Ministerial Representative to assist the Governing Council in its oversight of the THO s functions. Performance Escalation Level 3 (Challenged and Failing) For sustained concerns that have not been resolved, the Secretary may recommend to the Minister that a higher level of response be initiated (Level 3 challenged and failing). Formal notification of the intention to recommend to the Minister that escalation to Level 3 should occur will be provided by the Secretary to the Chair and the CEO. Table 2 summarises the escalation/de-escalation response process. Figure 2 demonstrates the escalation/de-escalation decision process. 13

14 Service Agreement Performance Management Process Table 2: Performance Escalation/De-escalation Response Framework Level of Response Point of Escalation Response Level 0 Satisfactory Performance No action required Not applicable. Satisfactory noted in monthly Service Agreement Performance Report. Performance that exceeds expectations recognised. Point of De-escalation Not applicable. THO Act reference Not applicable. Level 1 Unsatisfactory Performance Performance Improvement Plan (PIP) required Non-achievement of a Service Agreement KPI target. 0 The Secretary formally requests the Governing Council to: o Provide a PIP for approval; o Comply with the requirements of the PIP, and o Meet with the Department to formally monitor the PIP. The Department prepares an Escalation Notice for the THO. The requirements of the PIP are met. Part 7, Division 3 (sections 60-62) Level 2 Sustained Unsatisfactory Performance Performance Improvement Team OR Appointment of a Ministerial Representative to assist the Governing Council. PIP targets are not achieved and the Department is of the opinion that the concern is unlikely to be resolved without: The involvement of a Performance Improvement Team OR The appointment of a ministerial representative to assist the Governing Council to improve. The Secretary will: o Formally notify the Governing Council that a Performance Improvement Team is to be appointed in respect of the THO. The THO will provide all reasonable assistance to the Performance Improvement Team OR o Recommend that the Minister give notice to the Governing Council of the appointment of a representative to the Governing Council. The instrument of appointment of the Ministerial Representative will specify the terms and conditions of the appointment. The period for which the Performance Improvement Team was formed expires OR The terms and conditions of the ministerial representative s appointment have been met. Part 7, Division 4 and Division 5 (sections 63-68) Level 3 Challenged and failing Changes to the governance of the THO may be required The Department is of the opinion the Governing Council has ceased to perform satisfactorily and no other action may be taken other than to dissolve the Governing Council. The Secretary will recommend that the Minister appoint an administrator who has the functions and powers of the Governing Council. The period and conditions specified in the administrator s instrument of appointment are complete. Part 7, Division 6 (sections 69-73) 14

15 Service Agreement Performance Management Process Figure 2: Performance Intervention Decision Process 15

16 Key Performance Indicators Data Summary Key Performance Indicators Data Summary Domain Code Finance and Activity Based Management KPI Source of KPI Target F&ABM_1 Variation from budget - full year projected DHHS-Budget and Finance F&ABM_2 THO cash liquidity DHHS-Budget and Finance F&ABM_3 Acute admitted raw separations Tasmanian Activity Based Funding Model (DHHS SPP). Negotiated with THOs. Recognises prevailing State Government policy directions Balanced budget THO Operating Account has a favourable balance As per individual THO Service Agreements F&ABM_4 Acute admitted inlier weighted units (same day and multi-day) Tasmanian Activity Based Funding Model (DHHS SPP). Negotiated with THOs. Recognises prevailing State Government policy directions As per individual THO Service Agreements F&ABM_5 F&ABM_6 Admitted patient episode coding (clinical coding) including contracted care - timeliness Admitted patient episode coding (clinical coding) including contracted care - accuracy DHHS (SPP) 100% within 42 days of separation DHHS (SPP) 100% within 30 days of advice from SPP Domain Code Safety and Quality KPI Source of KPI Target 16

17 Key Performance Indicators Data Summary S&Q_1 Hand Hygiene compliance ACSQHC 70% S&Q_2 Healthcare associated staphylococcus aureus (including MRSA) bacteraemia infection rate National Standard 2.0 per 10,000 patient days Domain Code Emergency Department KPI Source of KPI Target ED_1 Percentage of Triage 1 emergency department presentations seen within recommended time Australasian College for Emergency Medicine 100% ED_2 Percentage of Triage 2 emergency department presentations seen within recommended time Australasian College for Emergency Medicine 80% ED_3 Percentage of all emergency department presentations seen within recommended triage time NPA Hospital and Health Workforce Reform 80% ED_4 Percentage of emergency department did not wait presentations DHHS (SPP) </= 5% ED_5 Time until most admitted patients (90%) departed emergency department National Health Performance Authority As per individual THO Service Agreements AMB_1 Ambulance offload delay Australasian College for Emergency Medicine 85%</= 16 minutes 100%</= 31 minutes Domain Code Elective Surgery KPI Source of KPI Target ES_1 Elective surgery quarterly admission targets. This KPI excludes activity associated with any additional Commonwealth or State Government funded activity as outlined in Schedules E and F (Schedules F and G for the North West) Tasmanian Activity Based Funding Model (SPP). Negotiated with THOs. Recognises prevailing State Government policy directions As per individual THO Service Agreements 17

18 Key Performance Indicators Data Summary ES_2 Percentage of category 1 patients admitted within the recommended time DHHS SPP. Negotiated with THOs. Recognises prevailing State Government policy directions As per individual THO Service Agreements ES_3 Number of over boundary, category 1 patients on the waiting list ES_4 Number of over boundary, category 2 patients on the waiting list ES_5 Number of over boundary, category 3 patients on the waiting list DHHS SPP. Negotiated with THOs. Recognises prevailing State Government policy directions DHHS SPP. Negotiated with THOs. Recognises prevailing State Government policy directions DHHS SPP. Negotiated with THOs. Recognises prevailing State Government policy directions As per individual THO Service Agreements As per individual THO Service Agreements As per individual THO Service Agreements ES_6 Number of patients on the waiting list waiting longer than 365 days DHHS SPP. Negotiated with THOs. Recognises prevailing State Government policy directions As per individual THO Service Agreements Domain Mental Health KPI Source of Target 18

19 Key Performance Indicators Data Summary Code KPI MH_1 28 Day re-admission rate NMDS </= 14.7% MH_2 Acute 7 day post discharge community care NMDS 75% MH_3 Seclusion rates To be included in NMDS < 9.6 per 1,000 patient days Domain Code Oral Health KPI (THO South only) Source of KPI Target OH_1 Number of Dental Weighted Activity Units (DWAUs) delivered between 20 December 2012 and 30 June 2015 NPA on Treating More Public Dental Patients Sep14: 80,945 Dec14: 91,794 Mar15: 102,470 Jun15: 111,868 OH_2 Proportion of 'Emergency' clients managed on the same day that they are triaged THO South (OHST) >/= 75% Domain Code Primary Health and Aged Care KPI Source of KPI Target PH_1 Aged Care Assessment Team (ACAT) - Priority Category one clients seen on time in all settings PH_2 Aged Care Assessment Team (ACAT) - Priority Category two clients seen on time in all settings PH_3 Aged Care Assessment Team (ACAT) - Priority Category three clients seen on time in all settings ACAP Minimum Data Set ACAP Minimum Data Set ACAP Minimum Data Set >85% >85% >85% The timeframes for data collection are specified against each KPI in the following Section 8 Service Agreement Key Performance Indicator Definitions. 19

20 8 Service Agreement Key Performance Indicator Definitions Finance and Activity Based Management Variation from budget full year projected Definition This measures the variance between full year budget and full year projected actual on a cash basis for all funding types. source Frequency of data collection and For Service Agreement monitoring, this indicator applies to the THO as a whole. Calculated by subtracting the full year projected cash forecast from the full year cash budget on an all funds basis including carry forwards. Balanced budget. Data Source Finance 1 DHHS Budget and Finance. This KPI will be monitored by Budget and Finance on a monthly basis. Performance will be assessed on a quarterly basis. THO cash liquidity Definition This KPI is a measure of a THOs ability to meet all their financial commitments when they fall due. If a THO is unable to meet their financial commitments within a given month, an advance of future funding is required to ensure the THO complies with Treasurer s Instruction (TI) 402. This KPI is an early indicator that there is the potential for a liquidity problem impacting on the THOs ability to meet financial commitments within the current financial year. source Frequency of data collection and Data Source Finance 1 This indicator is calculated by subtracting the total of the advance from the closing balance of the THO Operating Account at the end of the month to demonstrate what the unadjusted position would have been. THO Operating Account has a favourable balance. DHHS Budget and Finance. This KPI will be monitored by Budget and Finance on a monthly basis. Performance will be assessed on a quarterly basis. In the instance where a THO requires an advance of funds in one month, quarterly will enable a THO to take corrective action in the following month(s) to return the Operating Account to a favourable position. 20

21 Acute admitted raw separations Definition This indicator measures acute admitted raw separations. Service Agreement Key Performance Indicator Definitions For Service Agreement monitoring, this indicator: source Frequency of data collection and Data source applies to Tasmania s four major hospitals only (the Royal Hobart Hospital, Launceston General Hospital, North West Regional Hospital and Mersey Community Hospital). excludes activity associated with any additional Commonwealth or State Government funded activity as outlined in Schedules E and F (F and G for THO NW). Calculated using the total number of acute admitted raw separations Acute Inpatient Activity (Care Type 1), including acute mental health inpatient activity, but excluding Outside Referred Patients and activity associated with any additional Commonwealth or State Government funded activity as outlined in Schedules E and F (F and G for THO NW). Numerator: Acute admitted raw separations reported for acute care public hospitals (as specified above). Denominator: No denominator As per individual THO Service Agreements. Tasmanian Activity Based Funding Model (DHHS SPP). Negotiated with THOs. Recognises prevailing State Government policy directions. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed year-to-date targets. Performance is assessed on a year-to-date basis. Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm 21

22 Acute admitted inlier weighted units (same day and multi day) Definition This indicator measures acute admitted inlier weighted units (same day and multi day) which indicate the costliness of an Australian Refined Diagnosis Related Group (AR-DRG) relative to all other AR-DRGs such that the average cost weight for all separations in A separation for an AR-DRG with a cost weight of 5.0, therefore, on average costs 10 times as much as separations with a cost weight of 0.5. For Service Agreement monitoring, this indicator: source Frequency of data collection and applies to Tasmania s four major hospitals only (the Royal Hobart Hospital, Launceston General Hospital, North West Regional Hospital and Mersey Community Hospital). excludes activity associated with any additional Commonwealth or State Government funded activity as outlined in Schedules E and F (F and G for THO NW). Calculated using the total number of inlier weighted units for Acute Inpatient Activity (Care Type 1), including acute mental health inpatient activity, but excluding Outside Referred Patients and activity associated with any additional Commonwealth or State Government funded activity as outlined in Schedules E and F (F and G for THO NW). The average cost weight used to construct this indicator is calculated from the National Hospital Morbidity Database, using AR-DRG public cost weights published by the Department of Health and Ageing. However the following costs are excluded as the Tasmanian funding model funds these separately (with the exception of depreciation); Depreciation ICU Mechanical ventilation ED Casemix adjustment is based on the round of cost weights attributed to the AR- DRG assigned to each separation. National Hospital Cost Data Collection (NHCDC) Round 16 ( ) AR-DRG v6.0x public sector estimated cost weights will be applied to calculate inlier unit separations for Numerator: Acute admitted inlier weighted units reported for acute care public hospitals. Denominator: No denominator. As per individual THO Service Agreements. Tasmanian Activity Based Funding Model (DHHS SPP). Negotiated with THOs. Recognises prevailing State Government policy directions. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against 22

23 agreed year-to-date targets. Performance is assessed on a year-to-date basis. Data source Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm Admitted patient episode coding (clinical coding) including contracted care timeliness Definition This KPI measures the percentage of admitted patient episodes coded within 42 source Frequency of data collection and Data source days of the episode separation. This KPI is measured as a percentage. All admitted patient episode separations within the specified period are within scope. The coding date (considered to be the date recorded against the principal diagnosis field in ipm) will be compared with the separation date. All records not coded within 42 days of the separation date will be considered to fail. 100% within 42 days of separation. DHHS System Purchasing and Performance (SPP). Data collection is continuous. Performance against this KPI will be assessed on a quarterly basis, based on over the most recent quarter against which the 42 day period can be applied (e.g. the December 2014 quarterly will be based on the percentage of admitted patient episodes coded within 42 days of the episode separation for all episode separations dated between 1 July 2014 and 30 September 2014). Performance will be based on data collected through Health Central from ipm on the 4 th working day of the month (e.g. the December 2014 quarterly for all episode separations dated between 1 July 2014 and 30 September 2014 will be based on data collected from Health Central through ipm on the 4 th working day in January 2015). ipm 23

24 Admitted patient episode coding (clinical coding) including contracted care - accuracy Definition This KPI measures the percentage of fatal data errors (as specified in the schedule below) that are corrected within 30 days of being reported by DHHS to THOs. source Frequency of data collection and This KPI is measured as a percentage. At the end of each month, DHHS will provide THOs with a list of fatal data errors detected over the previous month. Errors not corrected by THOs within 30 days of receipt of the list will be considered to fail. The date of receipt will be considered to be the date upon which the list of fatal data errors is ed to THO CEO s by SPP. The list will clearly indicate the date by which the correction of fatal data errors is to occur. 100% within 30 days of advice. DHHS System Purchasing and Performance (SPP). Data collection is continuous. Performance against this KPI will be assessed on a quarterly basis, based on over the most recent quarter against which the 30 day period can be applied (e.g. the December 2014 quarterly will be based on the percentage of fatal data errors corrected within 30 days of receipt of the monthly list of fatal data errors for the months of July 2014, August 2014 and September 2014). Performance will be based on data collected through Health Central from ipm on the 4 th working day of the month (e.g. the December 2014 quarterly for the months of July 2014, August 2014 and September 2014 will be based on data collected from Health Central through ipm on the 4 th working day in January 2015). Data source ipm Schedule: Coding accuracy fatal validations Number Name Rule Rationale Action to Fix ICDF1 Unspecified reason for admission Principal diagnosis must not be R69 Unknown and unspecified causes of morbidity in any admitted episode. Every admitted episode must have the reason for admission identified by the Clinician and coded in accordance with Australian Coding Standards. It is expected that after study, this would normally be a condition, symptom, sign, health problem or status that is described more specifically by other codes within the Notify SPP of any episode where it is verifiable that, after study, the patient was admitted for an unknown or unspecified cause of morbidity; in any instance where this occurs SPP will manually remove the fatal validation from the episode. Assign PD in accordance with ACS 0001 Principal Diagnosis. 24

25 classification. Number Name Rule Rationale Action to Fix ICDF2 Other illdefined and unspecified causes of mortality R99 Other ill-defined and unspecified causes of mortality must not be coded in any admitted episode (unless verifiable that the patient died and that the cause of death is ill defined or unable to be specified). A code reflecting mortality is only compatible in the episode in which a patient dies. In an episode where a patient dies, the cause of death should be coded (where this meets Australian Coding Standards). Notify SPP of any episode where it is verifiable that the patient died and that the cause of death is ill defined or unable to be specified; in any instance where this occurs SPP will manually remove the fatal validation from the episode. For all other episodes: If the patient has not died, delete R99 from coding string and check that coding is accurate and complete. If the patient has died, check episode notes and any autopsy report for cause of death and code accordingly. Number Name Rule Rationale Action to Fix ICDCF3 Qualified (acute) singleton newborn without morbidity codes A newborn episode ( nine days) must not have a qualified (acute) status if the only ICD code is Z38.0 Singleton, born in hospital. Singleton newborns can only be qualified if they remain in hospital without their mother or are admitted to an intensive care facility in a hospital, being a facility for provision of special care. Check code assignment and qualification status and amend as necessary. In these instances there must be at least one other code that reflects the patient s conditions or relevant status. Number Name Rule Rationale Action to Fix 25

26 ICDCF4 ICD code/ admission weight conflict ICD codes in the range P07.01 Extremely low birth weight to P07.13 Other low birth weight must be assigned in accordance with Australian Coding Standards and directives (NCCH). Where a preterm baby has a low birth weight, a code in the range P07.01 Extremely low birth weight to P07.13 Other low birth weight must be assigned in the birth episode. Combinations of reported admission weight < 2500g and ICD codes are valid in the birth episode only as follows: In accordance with Australian Coding Standards 1618 Low Birth Weight and Gestational Age and NCCH Coding Rule Low Birth weight and Prematurity, (ref Q 2648 published 15-Dec 2012) codes P07.01 P07.13 should be assigned in the birth episode for preterm babies who have a low birth weight. For preterm newborns there must be correlation between the admission weight recorded and the ICD code assigned in the birth episode. Check code assignment and reported admission weight and amend as necessary. P07.01 Extremely low birth weight 499g or less is only valid for admission weight range 0 to 499g P07.02 Extremely low birth weight g is only valid for admission weight range 500 to 749g P07.03 Extremely low birth weight g is only valid for admission weight range 750 to 999g P07.11 Other low birth weight g is only valid for 26

27 admission weight range 1000 to 1249g P07.12 Other low birth weight g is only valid for admission weight range 1250 to 1499g P07.13 Other low birth weight g is only valid for admission weight range 1500 to 2499g Supporting Notes: ICDF1 The responsibility for recording accurate diagnoses and procedures, in particular principal diagnosis, lies with the clinician, not the clinical coder. 1 The principal diagnosis is defined as: The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment, as represented by a code (METeOR: ) (Australian Institute of Health and Welfare 2012). The phrase after study in the definition means evaluation of findings to establish the condition that was chiefly responsible for occasioning the episode of care. Findings evaluated may include information gained from the history of illness, any mental status evaluation, specialist consultations, physical examination, diagnostic tests or procedures, any surgical procedures, and any pathological or radiological examination. The condition established after study may or may not confirm the admitting diagnosis. The circumstances of inpatient admission will always govern the selection of principal diagnosis. In determining principal diagnosis, the coding directives in the ICD-10-AM manuals take precedence over all other guidelines (see ICD-10-AM Tabular List: Conventions used in the Tabular List of Diseases and ICD-10-AM Alphabetic Index: Conventions used in the Alphabetic Index of Diseases). The importance of consistent, complete documentation in the clinical record cannot be overemphasised. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task. 2 1 Extracted from EIS ebook, July 2013, Introduction. 2 Extracted from EIS ebook, July 2013, General Standards for Diseases. (ACS 0001) 27

28 Safety and Quality Hand Hygiene compliance Definition This indicator measures the compliance rate as the percentage of correct hand hygiene performed by hospital staff. For Service Agreement monitoring, this indicator applies to Tasmania s four major hospitals only (the Royal Hobart Hospital, Launceston General Hospital, North West Regional Hospital and Mersey Community Hospital). Data is collected by authorised Hand Hygiene auditors in accordance with the Hand Hygiene Australia, Hand Hygiene Manual. Numerator: Number of times hand hygiene was performed correctly at the correct time. Denominator: Number of hand hygiene opportunities that were observed. 70%. source Frequency of data collection and Data source An interim national benchmark of 70% for hand hygiene reporting on MyHospitals has been advised by the Australian Commission on Safety and Quality in Health Care. Data is submitted by each of the hospitals individually and is entered directly onto the Hand Hygiene Australia database via the Hand Hygiene Australia website through a secure portal. TIPCU give final approval before the data is available to Hand Hygiene Australia. Data is submitted to Hand Hygiene Australia three times per annum: March 31st June 30th October 31st Publically identified hospital data is published quarterly by the Tasmanian Infection & Control Unit and is available on the TIPCU DHHS website. TIPCU 28

29 Healthcare associated staphylococcus aureus (including MRSA) bacteraemia infection rate Definition This indicator measures the rate of Healthcare Associated Staphylococcus aureus bacteraemia infection. This indicator is concerned with cases of this infection which are associated with a patient receiving healthcare. source Frequency of data collection and Data source For Service Agreement monitoring, this indicator applies to Tasmania s four major hospitals only (the Royal Hobart Hospital, Launceston General Hospital, North West Regional Hospital and Mersey Community Hospital). The definitions applied are consistent with national definitions which are published by the Australian Commission on Safety and Quality in Healthcare Data set specification Surveillance of Healthcare Associated Infections: Staphylococcus aureus bacteraemia and Clostridium difficile infection (Version 4.0). Numerator: Number of cases of healthcare associated Staphylococcus aureus bacteraemia. Denominator: Number of patient days for the given period (matching the numerator period). No more than 2.0 cases per 10,000 patient days. The national benchmark for states and territories (public hospitals) is no more than 2 cases per 10,000 patient days. In line with the TIPCU Staphylococcus aureus Bacteraemia Surveillance Protocol V3, 2011 data is collected and reported on as per the following process: TIPCU TIPCU receive notification of a SAB from the Communicable Diseases Prevention Unit (CDPU). Participating hospitals will receive notification of a SAB from TIPCU and are requested to provide additional information via a SAB Surveillance Form. All SAB which were collected before the end of the month should have completed surveillance information submitted to TIPCU by the 10th calendar day of the following month or nearest work day. The TIPCU obtain a monthly summary report detailing all SABs from the participating laboratories. This data will is used TIPCU to validate that all forms received by the IC Teams and GPs correspond with the individual reports of SABs provided by the laboratories. Publically identified hospital data is published quarterly by the Tasmanian Infection & Control Unit and is available on the TIPCU DHHS website. 29

30 Emergency Department Access Percentage of Triage 1 emergency department presentations seen within the recommended time Definition This indicator measures the percentage of patients that are treated within the national recommended benchmark for waiting times for triage category 1 in public hospital emergency departments. 100% The definitions applied are consistent with the national definitions used for reporting against the National Partnership Agreement on Hospital and Health Workforce Reform. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are did not wait, dead on arrival or the waiting time to service delivery is invalid are excluded for the purpose of calculating this indicator. See Australasian Triage Scale from the Australasian College for Emergency Medicine for a description of each triage category, including indicative clinical descriptors. Time to treatment is calculated by subtracting the date and time the patient presented to the emergency department from the date and time treatment commenced. The time to treatment is then compared to the recommended treatment time for the allocated initial triage category. The indicator is calculated for triage category 1 and presented as a percentage. Computation: 100 x (Numerator Denominator) Numerator: Total number of presentations to emergency departments that were treated within benchmarks for triage category 1: Triage category 1: seen within seconds, calculated as less than 2 minutes (being a waiting time of 2 or below, which allows for 2:59 seconds*). * This is in line with the national reporting standards. Denominator: Total number of triage 1 presentations to emergency departments. source Frequency of data collection and Data source Australasian College for Emergency Medicine. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from EDIS on the 4th working day of the month immediately following the end of each quarter. EDIS 30

31 Percentage of Triage 2 emergency department presentations seen within the recommended time Definition This indicator measures the percentage of patients that are treated within the national recommended benchmark for waiting times for triage category 2 in public hospital emergency departments. 80% The definitions applied are consistent with the national definitions used for reporting against the National Partnership Agreement on Hospital and Health Workforce Reform. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are did not wait, dead on arrival or the waiting time to service delivery is invalid are excluded for the purpose of calculating this indicator. See Australasian Triage Scale from the Australasian College for Emergency Medicine for a description of each triage category, including indicative clinical descriptors. Time to treatment is calculated by subtracting the date and time the patient presented to the emergency department from the date and time treatment commenced. The time to treatment is then compared to the recommended treatment time for the allocated initial triage category. The indicator is calculated for triage category 2 and presented as a percentage. Computation: 100 x (Numerator Denominator) Numerator: Total number of presentations to emergency departments that were treated within benchmarks for triage category 2: Triage category 2: seen within 10 minutes (being a waiting time of 10 or below, which allows for 10:59 seconds*). * This is in line with the national reporting standards. Denominator: Total number of triage 2 presentations to emergency departments. source Frequency of data collection and Data source Australasian College for Emergency Medicine. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from EDIS on the 4th working day of the month immediately following the end of each quarter. EDIS 31

32 Percentage of all emergency department presentations seen within the recommended time Definition This indicator measures the percentage of patients that are treated within national recommended benchmarks for waiting times for each triage category in public hospital emergency departments. 80% The definitions applied are consistent with the national definitions used for reporting against the National Partnership Agreement on Hospital and Health Workforce Reform. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are did not wait, dead on arrival or the waiting time to service delivery is invalid are excluded for the purpose of calculating this indicator. See Australasian Triage Scale from the Australasian College for Emergency Medicine for a description of each triage category, including indicative clinical descriptors. Time to treatment is calculated by subtracting the date and time the patient presented to the emergency department from the date and time treatment commenced. The time to treatment is then compared to the recommended treatment time for the allocated initial triage category. The indicator is calculated for the five triage categories as a whole and presented as a percentage. Numerator: Total number of presentations to emergency departments that were treated within benchmarks for each triage category: Triage category 1: seen within seconds, calculated as less than 2 minutes (being a waiting time of 2 or below, which allows for 2:59 seconds*). Triage category 2: seen within 10 minutes (being a waiting time of 10 or below, which allows for 10:59 seconds*). Triage category 3: seen within 30 minutes (being a waiting time of 30 or below, which allows for 30:59 seconds*). Triage category 4: seen within 60 minutes (being a waiting time of 60 or below, which allows for 60:59 seconds*). Triage category 5: seen within 120 minutes (being a waiting time of 120 or below, which allows for 120:59 seconds*). * This is in line with the national reporting standards. Denominator: Total number of presentations to emergency departments. source Frequency of data collection and NPA Hospital and Health Workforce Reform. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health 32

33 Data source Central from EDIS on the 4th working day of the month immediately following the end of each quarter. EDIS Percentage of emergency department did not wait presentations Definition This indicator measures the percentage of emergency department presentations that concluded with the patient leaving the emergency department before being attended by a health care professional. </= 5% The definitions applied were set by the Emergency Care Network Steering Committee. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are dead on arrival or the waiting time to service delivery is invalid are excluded for the purpose of calculating this indicator. See Australasian Triage Scale from the Australasian College for Emergency Medicine for a description of each triage category, including indicative clinical descriptors. The indicator is presented as a percentage. Numerator: Total number of presentations who have been identified as did not wait. Denominator: Total number of presentations to emergency departments. source Frequency of data collection and Data source DHHS System Purchasing and Performance (SPP). Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from EDIS on the 4th working day of the month immediately following the end of each quarter. EDIS 33

34 Time until most admitted patients (90%) departed emergency department Definition The 90th percentile of total time for emergency department stays for patients who physically leave the emergency department for admission to hospital. source Frequency of data collection and Data source Numerator: include records with the triage categories from 1 to 5. exclude records if the Waiting time to service is invalid, i.e. - Length of stay < 0. - Presentation date or time is missing. - Physical departure date or time is missing. The 90th percentile (the ninetieth percentage value in a group of data arranged from lowest to highest value for time waited) represents the time within which 90% of patients were admitted and physically left the emergency department. For example, if there were 100 observations admitted to the hospital, the 90th percentile will correspond to the average time for the 90th and 91st observations. If there were 101 observations, the 90th percentile will correspond to the time for the 91st observation. Emergency department stay time is calculated by subtracting the date and time the patient presented to the emergency department from the date and time the patient physically left the emergency department. Denominator: Not applicable. As per individual THO Service Agreements. National Health Performance Authority. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from EDIS on the 4th working day of the month immediately following the end of each quarter. EDIS 34

35 Ambulance offload delay Definition This KPI measures the percentage of ambulance presentations to an emergency department to experience delay in complete transfer of clinical care to the emergency department, specifically due to lack of available clinical space in the emergency department. source Frequency of data collection and Data source This KPI is measured as a percentage. The definitions applied were recommended by the Australasian College for Emergency Medicine. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are 'dead on arrival' are excluded for the purpose of calculating this indicator. The definition includes presentations that arrive by ambulance (arrival modes such as police, nonemergency patient transport are out of scope). Numerator: Total number of ambulance presentations to public hospital emergency departments that were transferred to ambulance ramped location (ambulance waiting) and subsequently transferred to ED staff care within the following benchmarks: 85% of presentations transferred within 15 minutes 100% of presentations transferred within 30 minutes Denominator: Total number of ambulance presentations transferred to ambulance ramped location (ambulance waiting). 85% within15 minutes 100% within 30 minutes Australasian College for Emergency Medicine. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from EDIS on the 4th working day of the month immediately following the end of each quarter. EDIS 35

36 Elective Surgery Elective Surgery quarterly admissions Definition This indicator measures the number of patients that have been removed from the elective surgery waiting list as admitted to the hospital (or contracting hospital) and receiving their waiting list procedure. For Service Agreement monitoring, this indicator excludes activity associated with any additional Commonwealth or State Government funded activity as outlined in Schedules E and F. source Frequency of data collection and Data source The definitions applied are consistent with the national definitions used for reporting against the National Partnership Agreement on Improving Public Hospital Services. The definitions applied include admission from the elective surgery waiting list where the planned procedure was completed. This also includes patients admitted for the waiting list as an emergency. For Service Agreement monitoring, this indicator excludes weighted separations funded by the National Partnership Agreement on Improving Health Services in Tasmania. Indicator procedures as defined in the Tasmanian wait list procedure code (TWLPC) set and specify which procedures are included in the calculation of this indicator in accordance with national definitions. Numerator: Total number of admissions from the elective surgery waiting list to the hospital (or contracting hospital) where the planned procedure was completed (this includes admissions from the waiting list as an emergency). Denominator: No denominator. As per individual THO Service Agreements. Tasmanian Activity Based Funding Model (SPP). Negotiated with THOs. Recognises prevailing State Government policy directions. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed year-to-date targets. Performance is assessed on a year-to-date basis. Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm 36

37 Percentage of category 1 patients admitted within the recommended time Definition This indicator measures the percentage of category 1 elective surgery patients who are admitted to the hospital (contracting hospital) and received their waiting list procedure within national benchmark waiting time for urgency category 1. The definition applied is consistent with the national definitions used for reporting against the National Partnership Agreement on Improving Public Hospital Services. The definition includes admission from the elective surgery waiting list where the planned procedure was completed. This also includes patients admitted from the waiting list as an emergency. The number of waiting time days is calculated by subtracting the listing date for care from the removal date, minus any days the patient was 'not ready for care', and minus any days the patient was waiting with a less urgent clinical urgency category than their clinical urgency category at removal. Indicator procedures as defined in the Tasmanian wait list procedure code (TWLPC) set and specify which procedures are included in the calculation of this indicator in accordance with national definitions. The indicator is presented as a percentage. Numerator: Total number of admissions from the elective surgery waiting list to the hospital (or contracting hospital) within benchmark for urgency category 1 (this includes admissions from the waiting list as an emergency): Clinical urgency category Category 1 - Urgent National standards (desirable treatment times) Admission within 30 days (i.e. <= 30 days) source Frequency of data collection and Data source Denominator: Total number of admissions from the elective surgery waiting list to the hospital (or contracting hospital) for urgency category 1 (this includes admissions from the waiting list as an emergency). As per individual THO Service Agreements. Tasmanian Activity Based Funding Model (SPP). Negotiated with THOs. Recognises prevailing State Government policy directions. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm 37

38 Number of over boundary, category 1 patients on the waiting list. Number of over boundary, category 2 patients on the waiting list. Number of over boundary, category 3 patients on the waiting list. Definition These three indicators report the number of urgency category 1, 2 or 3 patients, ready for care, who are waiting for elective surgery longer than the recommended number of waiting days for that urgency category (30 Days, 60 Days and 365 Days, respectively). A patient may be 'ready for care' or 'not ready for care'. Ready for care patients are those who are prepared to be admitted to hospital or to begin the process leading directly to admission. Not ready for care patients are those who are not in a position to be admitted to hospital. These patients are either: Staged patients whose medical condition will not require or be amenable to surgery until some future date; for example, a patient who has had internal fixation of a fractured bone and who will require removal of the fixation device after a suitable time; or deferred patients who for personal reasons are not yet prepared to be admitted to hospital; for example, patients with work or other commitments which preclude their being admitted to hospital for a time. Not ready for care patients could be termed staged and deferred waiting list patients, although currently health authorities may use different terms for the same concepts. Staged and deferred patients should not be confused with patients whose operation is postponed for reasons other than their own unavailability, for example; surgeon unavailable, operating theatre time unavailable owing to emergency workload. These patients are still 'ready for care'. Patients who are not ready for care should be excluded from calculation. The recommended wait time before treatment, in days, for urgency category 1 patients is 30 days or less (i.e. <= 30 days). The recommended wait time before treatment, in days, for urgency category 2 patients is 60 days or less (i.e. <= 60 days). The recommended wait time before treatment, in days, for urgency category 3 patients is 365 days or less (i.e. <= 365 days). See Tasmanian wait list procedure code (TWLPC) for a list of indicator procedures. Numerator: Total number of urgency category 1, 2 or 3 patients on elective surgery waiting lists that are ready for care who have waited longer than the recommended waiting time. The recommended waiting time is: within 30 days (i.e. <= 30 days) for urgency category 1. Urgency category 1 patients who have waited 31 days or longer are considered over boundary. within 60 days (i.e. <= 60 days) for urgency category 2. Urgency category 2 patients who have waited 61 days or longer are considered over boundary. within 365 days (i.e. <= 365 days) for urgency category 3. Urgency category 2 patients who have waited 366 days or longer are considered over 38

39 source Frequency of data collection and Data source boundary. Denominator: No denominator. As per individual THO Service Agreements. Tasmanian Activity Based Funding Model (SPP). Negotiated with THOs. Recognises prevailing State Government policy directions. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed year-to-date targets. Performance is assessed on a year-to-date basis, based on a snapshot of the waiting list at a specified date. Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm 39

40 Number of patients on the waiting list waiting longer than 365 days. Definition This indicator measures the number of elective surgery patients, inclusive of all three clinical priority categories that are waiting ready for care, that have waited longer than 365 days. A patient may be 'ready for care' or 'not ready for care'. Ready for care patients are those who are prepared to be admitted to hospital or to begin the process leading directly to admission. Not ready for care patients are those who are not in a position to be admitted to hospital. These patients are either: Staged patients whose medical condition will not require or be amenable to surgery until some future date; for example, a patient who has had internal fixation of a fractured bone and who will require removal of the fixation device after a suitable time; or deferred patients who for personal reasons are not yet prepared to be admitted to hospital; for example, patients with work or other commitments which preclude their being admitted to hospital for a time. Not ready for care patients could be termed staged and deferred waiting list patients, although currently health authorities may use different terms for the same concepts. Staged and deferred patients should not be confused with patients whose operation is postponed for reasons other than their own unavailability, for example; surgeon unavailable, operating theatre time unavailable owing to emergency workload. These patients are still 'ready for care'. Patients who are not ready for care should be excluded from calculation. Waiting time is as defined in waiting time at a census date. It is calculated by subtracting the Listing date for care from the Census date, minus any days when the patient was 'not ready for care', and also minus any days the patient was waiting with a less urgent clinical urgency category than their clinical urgency category at the census date. Indicator procedures as defined in the Tasmanian wait list procedure code (TWLPC) set and specify which procedures are included in the calculation of this indicator in accordance with national definitions. The indicator is calculated separately for each of the three urgency categories and presented as an average (days). See Tasmanian wait list procedure code (TWLPC) for a list of indicator procedures. The definitions applied are consistent with the national definitions used for reporting against the National Partnership Agreement on Improving Public Hospital Services. Computation: Waiting time (at census date) [TotalWaitingDays] > 365 days. Numerator: Number of patients on elective surgery waiting lists that are ready for care who have waited longer than 365 days. Denominator: No denominator. As per individual THO Service Agreements. Tasmanian Activity Based Funding Model (SPP). Negotiated with THOs. Recognises 40

41 source Frequency of data collection and Data source prevailing State Government policy directions. Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed year-to-date targets. Performance is assessed on a year-to-date basis, based on a snapshot of the waiting list at a specified date. Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm 41

42 Mental Health Service Agreement Key Performance Indicator Definitions 28 Day re-admission rate Definition This KPI measures the percentage of overnight separations from an acute inpatient unit that are followed by readmission to the same or a similar type unit (MHS / ADS / FHS) within 28 days of discharge. This KPI is measured as a percentage. Numerator: Number of in scope overnight separations from the acute inpatient unit occurring within the reference period that are followed by a readmission to the same or similar type unit within 28 days. Denominator: Number of in scope overnight separations from the acute inpatient unit in the reference period. Coverage / scope: The following separations are excluded: Same day separations. Statistical and change of care type separations. Separations that end by transfer to another acute or psychiatric hospital. Separations that end by left against medical advice / discharge at own risk. Separations where length of stay is one night only and procedure code for ECT is recorded. </= 14.7% source Frequency of data collection and Data source The target is based on the latest nationally reported average of 14.7% (as per the National Mental Health Report 2013). Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm 42

43 Acute 7 day post discharge community care Definition This KPI measures the percentage of separations from an acute psychiatric inpatient unit for which a community ambulatory service contact, in which the consumer participated, was recorded in the 7 days immediately following that separation. 75% This KPI is measured as a percentage. Numerator: Number of overnight separations from the acute inpatient unit occurring, within the reference period, for which a community mental health service contact, in which the consumer participated, was recorded in the 7 days immediately following that separation. Denominator: Number of overnight separations from the acute inpatient unit in the reference period. source Frequency of data collection and Data source The latest nationally reported average (as per the National Mental Health Report 2013) is 54%. Based on current THO levels against this KPI (which are all above 54%) DHHS Mental Health and Alcohol and Drug Directorate consider 75% to be an appropriate target in Data collection is continuous. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed quarterly targets. A new period commences at the beginning of each quarter (i.e. is not measured on a year-to-date basis). Performance reporting and is based on data collected through Health Central from ipm on the 4th working day of the month immediately following the end of each quarter. ipm 43

44 Seclusion rates Definition This KPI measures the number of seclusion events per 1,000 patient days within an in scope unit. Unit of measurement: Count. Numerator: Number of seclusion events occurring in the mental health service s inpatient units during the reference period. source Denominator: Number of accrued mental health care days within the mental health services inpatient units during the reference period. Coverage / scope: All public health mental health admitted patient services approved for involuntary clients. <9.6 per 1000 patient days The latest Nationally reported average as per the AIHW Mental Health Services in Australia website in of 9.6 events per 1,000 patient days. Continuous improvement is expected, even in circumstances where is below the specified target. Data is collected on a monthly basis. Frequency of data collection and Data source Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed targets. Performance is assessed on a year-to-date basis. Performance reporting and is based on data collected by local services and collated in Department of Psychological Medicine (DPM) in THO South. Office of the Chief Psychiatrist Mental Health Act Forms database. 44

45 Oral Health (THO South only) Number of Dental Weighted Activity Units (DWAUs) delivered between 20 December 2012 and 30 June 2015 Definition A DWAU is a unit of activity. Each dental service item from the Australian Dental Association schedule of services is attributed a relative value based on the price paid by the Commonwealth for dental services provided under the Department of Veterans Affairs Schedule of Dental Services. The indicator is calculated by multiplying all services provided by their respective DWAU values and summing the totals. Services provided are multiplied by their respective DWAU value. The results per service are added for a total of DWAUs achieved. For THO South only: Using methodology derived from the NPA, the overall target of represents the minimum level of activity expected by 30 June Progressive targets to be achieved by the end of each quarter of are as follows: Period: Progressive target: December 2012 to September December 2012 to December December 2012 to March source Frequency of data collection and Data source December 2012 to June NPA on Treating More Public Dental Patients. Data is sourced quarterly from Titanium and reported one month in arrears. Historical totals are subject to change each quarter due to the time lag in getting treatment data back from private providers when the care has been outsourced. All totals are recalculated to ensure previously unreported treatment is picked up in subsequent reporting cycles. This indicator is reported quarterly on a year-to-date basis. The cumulative result since 20 December 2012 at the end of the quarter will be assessed against the agreed quarterly progressive targets. Titanium 45

46 Proportion of Emergency clients managed on the same day as they are triaged Definition This indicator reports the proportion of clients triaged as emergency who are managed on the same day they are triaged. >/= 75% Numerator: Total clients triaged as 'emergency' who are offered care on the same day as triage in the reporting period. Denominator: Total number of clients triaged as 'emergency' in the reporting period. source Frequency of data collection and Data source THO South (OHST) Data is sourced monthly from Titanium and reported one month in arrears. This indicator is reported monthly on an as-at-period basis for monitoring purposes. The individual quarter s result is the average of the data across the quarter, and is assessed against the level. Titanium 46

47 Aged Care Priority category one Aged Care Assessment Team (ACAT) clients seen on time in all settings Definition This KPI measures the percentage of priority category one Aged Care Assessment Team (ACAT) clients are seen on time in all settings. This KPI is measured as a percentage. Numerator: The number of s with an end of date within the specified period with a priority category of one and the period of time from referral date to first intervention date is equal to or less than 2 calendar days. Denominator: The number of s with an end of date within the specified period with a first intervention date and with a priority category of one. >85% source Frequency of data collection and Data source Commonwealth Aged Care Assessment Agreement with Tasmania. Data is collected on a monthly basis. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed targets. Performance is assessed on a year-to-date basis. Performance reporting and is based on data collected through the Aged Care Evaluation (ACE) database. Aged Care Evaluation (ACE) database. Priority category two Aged Care Assessment Team (ACAT) clients seen on time in all settings This KPI measures the percentage of priority category two Aged Care Assessment Definition Team (ACAT) clients are seen on time in all settings. This KPI is measured as a percentage. Numerator: The number of s with an end of date within the specified period with a priority category of two and the period of time from referral date to first intervention date is equal to or less than 14 calendar days. Denominator: The number of s with an end of date within the specified period with a priority category of two with a first intervention date. >85% source Frequency of data collection and Commonwealth Aged Care Assessment Agreement with Tasmania. Data is collected on a monthly basis. Performance monitoring is undertaken on a monthly basis. Performance reporting and is undertaken on a quarterly basis against agreed targets. 47

48 Performance is assessed on a year-to-date basis. Performance reporting and is based on data collected through the Aged Care Evaluation (ACE) database. Data source Aged Care Evaluation (ACE) database. Priority category three Aged Care Assessment Team (ACAT) clients seen on time in all settings This KPI measures the percentage of priority category three Aged Care Definition Assessment Team (ACAT) clients are seen on time in all settings. This KPI is measured as a percentage. Numerator: The number of s with an end of date within the specified period and a priority category of three and the period of time from referral date to first intervention date is less than or equal to 36 calendar days. Denominator: The number of s with an end of date within the specified period and a priority category of three with a first intervention date. >85% source Commonwealth Aged Care Assessment Agreement with Tasmania. Data is collected on a monthly basis. Performance monitoring is undertaken on a monthly basis. Frequency of data collection and Performance reporting and is undertaken on a quarterly basis against agreed targets. Performance is assessed on a year-to-date basis. Performance reporting and is based on data collected through the Aged Care Evaluation (ACE) database. Data source Aged Care Evaluation (ACE) database. 48