High-performing health services Victorian health service monitoring framework 2015 16
To receive this publication in an accessible format phone 9096 7120 using the National Relay Service 13 36 77 if required, or email: mim.biondo@health.vic.gov.au Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne. State of Victoria, Department of Health & Human Services August 2015. Where the term Aboriginal is used it refers to both Aboriginal and Torres Strait Islander people. Indigenous is retained when it is part of the title of a report, program or quotation. Available at <www.health.vic.gov.au/hospital-> Printed by Doculink Australia, Port Melbourne (1508023)
Contents Introduction... 5 Section 1: Strategic directions for monitoring... 6 High-performing health services... 6 Strategic directions... 7 Section 2: Components of the monitoring framework... 11 Victorian health service governance model... 12 Strategic plans... 12 Statement of priorities... 12 Victorian health policy and funding guidelines... 13 Performance monitoring tools... 13 Section 3: Performance assessment and monitoring... 15 Using the Statement of priorities targets to assess... 15 Performance assessment score... 16 the assessment score... 17 Section 4: Contact details... 27 Appendix 1: 2015 16 changes... 28 Patient experience and outcomes... 28 Governance, leadership and culture... 28 Safety and quality... 28 Financial sustainability... 29 Access and timeliness... 29 Ambulance Victoria... 30 Appendix 2: Key indicators... 31 Statement of priorities (Part B) key indicators for 2015 16... 31 Appendix 3: Data requirements... 35 Data submission requirements for key indicators... 35 Appendix 4: Business rules... 38 Patient experience and outcomes... 38 Governance, leadership and culture... 61 Safety and quality... 62 Financial sustainability... 71 Access and timeliness key indicators... 79
Introduction High-performing health services: Victorian health service monitoring framework 2015 16 ( the monitoring framework ) is the source document for information about the Victorian Government s monitoring framework for health services. The services to which this framework applies include metropolitan health services, regional health services, subregional health services, local health services, small rural health services, Multi-Purpose Services, Ambulance Victoria, Dental Health Services Victoria and the Victorian Institute of Forensic Mental Health (also known as Forensicare). The document is intended for health service board members and chief executive officers and describes the strategic directions, implementation approach and processes involved in monitoring health service by the Department of Health & Human Services ( the department ). The document also provides detailed information about the key indicators used to monitor health service. This information is provided in appendices to the document and is of particular relevance to health services staff who are responsible for data collection, analysis and reporting to the department. High-performing health services: Victorian health service monitoring framework 2015 16 Page 5
Section 1: Strategic directions for monitoring As part of the annual review cycle, the department evaluates the strategic directions for monitoring to gauge the effectiveness of the monitoring framework, ensure alignment with government policy and directions in the healthcare sector, and measure its impact on Victorian healthcare system as a whole. Last year s experience has demonstrated the effectiveness of the framework in establishing safety and quality as key drivers for improved across the system. Continuing to build on these achievements will require a stronger focus on governance and leadership including the extent to which both patient and staff safety is embedded into the organisational culture. In addition, there is a need for higher emphasis on patient experience and sustained improvement of patient outcomes. As such, the monitoring approach for Victoria will centre on the following strategic directions: patient experience and outcomes governance, leadership and culture safety and quality financial sustainability. Underpinning these, the approach retains a core focus on access and timeliness, reflecting the criticality of these aspects of health service in delivering the healthcare experience and outcomes most important to the people of Victoria. In 2015 16 the three domains from 2014 15 (safety and quality, financial sustainability and access) will be updated to further strengthen the monitoring framework by expanding the quality and safety domain to better emphasise the importance of governance, leadership and culture, as well as the patient experience and outcomes. These changes are discussed in detail in Appendix 1. Together, the five expanded domains of will provide the overall structure for the Victorian health service monitoring framework and drive the approach to measuring and assessing health service for the coming year. In 2015 16, to further Ambulance Victoria s integration into the monitoring framework, a tailored Ambulance Victoria assessment score will be introduced. The Ambulance Victoria assessment score domains will be consistent with health services, however, in addition to range of common measures, include ambulance-specific Statement of Priorities (SoP) indicators across the access, safety and quality and patient experience and outcomes domains. Introduction of the assessment score for Ambulance Victoria will be premised on a improvement culture and provide greater accountability and transparency consistent with peer SoP health services. High-performing health services The government is committed to driving continuous improvement in the healthcare sector as an important contributor to delivering better health outcomes for all Victorians. The monitoring framework has a vital role in providing assurance regarding current health service as well as detecting and responding to concerns. It must also contribute to the goal of continuous improvement. In order to support this commitment to improvement, the framework aims to do two things: minimise the risk of healthcare system failures arising from a framework that is too narrowly focused on targets and indicators Page 6 High-performing health services: Victorian health service monitoring framework 2015 16
broaden the framework to include an understanding of, and focus on, contextual factors that drive high and lead to excellent healthcare outcomes. The monitoring framework works across a spectrum from education and persuasion through to enforced compliance. This continuum of responses is grounded in the concept of responsive regulation. Towards one end of the spectrum, the department undertakes intensive monitoring to address serious issues. At the other end of the spectrum, the focus on improvement emphasises a supportive approach that assists health services to maintain and improve. It represents a focus on collaboration rather than coercion within an environment of earned autonomy. It also involves a more preventive approach to monitoring, which draws on a wider range of information from a variety of sources and uses lead indicators and warning signs to identify potential issues before they become failures. Strategic directions 1. Patient experience and outcomes There is a strong, shared vision across the healthcare system that all aspects of care must be patientcentred. In 2014 15 the monitoring framework provided a greater emphasis on patient experience and outcomes, including the introduction of the patient experience survey and seclusion rate for people with a mental illness in the assessment score for health services. This direction is further strengthened in 2015 16, with health services now being assessed based on the experience reported by their patients. The department is also working with the Health Services Commissioner and other organisations to give greater weight to qualitative sources of information about patient experience and outcomes, including patient stories, in order to understand what health service really means to patients. Outlier results for mortality and readmission will continue to be monitored as part of the meetings. Use of outcome measures for gauging healthcare system has traditionally been a very underdeveloped area. In part, this is because the outcomes that matter most are often hard to measure or are measured inconsistently. Recent work on patient-reported outcome measures might help to address some of these challenges, as well as supporting a focus on outcomes most relevant to patients. Victoria already uses patient-reported outcome measures (PROMs) to assess health state and treatment outcomes in mental health, aged care and cancer services. PROMs are incorporated into screening tools for community-based services (through the Service coordination tool templates) and are used by health services to assess patient outcomes from procedures, clinical effectiveness and the need for follow-up care. PROMs data is also collected by clinical registries to monitor treatment approaches and patient outcomes. There are a number of options for using PROMs in monitoring, including the addition of outcome-focused questions to the patient experience survey (as has recently been done in New South Wales), the broad-based use of generic PROMs to assess health state across populations, or the use of specific PROMs to assess outcomes from care provided by health services. Each of these provides opportunities to build a stronger patient perspective into the monitoring of healthcare delivery outcomes. The monitoring framework will continue to promote monitoring across the full spectrum of healthcare provision, including monitoring patient outcomes relating to mental health, maternity, cancer and aged care. Further improvements for 2015 16 will see the introduction of new indicators for measuring advance care planning, maternity care outcomes and an updated measure for pain reduction during the ambulance care episode. High-performing health services: Victorian health service monitoring framework 2015 16 Page 7
2. Governance, leadership and culture Achieving improved healthcare outcomes relies on effective governance and leadership, including creating a culture in which clinical staff feel empowered to act in the best interests of patients. The government is committed to placing an increased emphasis on the role of effective governance and leadership and a strong patient-centred culture in delivering positive health service. These aspects of care can be difficult to measure, so a key part of this approach is stronger engagement with health service boards, reflecting boards critical role in setting directions and expectations, fostering leadership and shaping organisational culture. Boards sets the tone for the organisation. A key way to demonstrate this top-level leadership is to undertake a board assessment. Boards strive to improve organisational effectiveness through monitoring against strategic objectives. This monitoring usually leads to an improvement in and governance. It is well recognised that assessing a board s own is also a critical aspect of improving governance and board capability. The Victorian governance model also expects that the board is fully informed to discharge its functions effectively and ensures appropriate action is taken to manage and remedy issues as they arise. As such, the annual SoPs asks boards to undertake an annual board assessment to identify and develop board capability to ensure all board members are well equipped to effectively discharge their responsibilities. In support of setting the organisational tone across the organisation, a composite indicator based on eight safety culture questions from the People Matter survey was introduced for health services last year as part of the calculation of the assessment score. Ambulance Victoria will include these questions in their next survey. This measure has been further strengthened in 2015 16 by increasing the level of staff representation in the survey. The safety culture indicator is only one element of the People Matter Survey, which has been specifically chosen as a measure for reporting in the assessment score. The department has and will continue to utilise the full spectrum of the People Matter Survey results in addressing issues with health services. The department is also working with the Victorian Public Sector Commission on the potential introduction of a leadership index measure that could offer additional insight into this important area of. Other organisations involved in specific regulation or oversight of health services will also be more closely engaged, such as the Victorian WorkCover Authority and the Victorian Managed Insurance Authority, with a view to reflecting outcomes from their work with health services in the conversation. In particular, the relationship with the WorkCover Authority is building momentum in response to the need for stronger workforce safety in the healthcare industry as highlighted in the government s priorities and latest Victorian Auditor-General s reports. Implementing optimal strategies for collecting, analysing and reporting quality data on occupational violence incidents for the purpose of improving will be a priority in 2015 16. A stronger focus on governance will support rural health services, which can have varying experiences in selecting board members and fewer resources to achieve improvement outcomes. The department will continue to work with the rural health services to identify and develop tools for boards to support the discharge of their functions. 3. Safety and quality Safety and quality of healthcare is an established part of health service monitoring in Victoria and continues to be a key area of focus. This strategic direction recognises that safety and quality is core to every patient s experience and outcomes that needs to be embedded within the culture of healthcare organisations. In 2014 15 new safety and quality measures were introduced into the monitoring framework reflecting higher expectations and better alignment between health service and Page 8 High-performing health services: Victorian health service monitoring framework 2015 16
key elements of the clinical governance framework, in particular risk management associated with infection prevention and control. This approach has been particularly useful in promoting the necessary level of commitment from health services in driving sustained improvement in patient safety and quality. Considerable improvement has been demonstrated in relation to healthcare worker vaccinations. The delay in vaccine availability for the 2015 16 influenza season may pose a risk to meeting the level of immunisation achieved last year. Health services will need to instigate strategies to ensure the increased participation continues for 2015 16. Sentinel events continue to feature strongly in the conversation, ensuring that health services have adequate and effective systems are in place to address potential safety and quality concerns and that learnings from the respective reviews are implemented in a timely manner. Dr Foster s value to Victorian health services is being further enhanced by the addition of new datasets, including data on sepsis and hospital-acquired infections. Feedback from health services supports the initiative because it engages clinicians in the conversation at an operational level and provides broader benchmarking opportunities for a range of indicators and signals of clinical. In 2014 15 Victoria implemented a pricing for quality approach, providing an opportunity to incentivise by linking funding allocations to discrete measures that demonstrate a health service s success in reducing preventable harm and improving quality of care. The scheme was well supported by the sector, with excellent outcomes in both the accreditation and infection rates requirements introduced last year. The scheme is continuing in 2015 16 with a continued focus on infection and a new focus on the transitions of care, targeting improved processes relating to discharge planning from an inpatient admission, as derived from a composite of questions in the Victorian Healthcare Experience Survey. 4. Financial sustainability Delivering safe and cost-effective healthcare in a financially sustainable way will continue to be a strategy direction. Financial monitoring goes beyond operating results and also looks at liquidity and asset management. Additional financial measures will be included in the SoP regarding ongoing financial sustainability. This strategy acknowledges the significant financial challenges faced by health services, as exemplified by the concerns raised by the Auditor-General about limited cash holdings and operating margins in a number of health services. The new indicators will measure the cash reserves and financial liquidity of health services and be initially included in Part B of the SoPs until the data sources that underpin them become sufficiently mature to include as part of the assessment score. The financial sustainability focus acknowledges that prudent financial management in healthcare is not just about hitting a financial target but about how well health services are positioned to deliver the best healthcare outcomes efficiently as possible. Long-term sustainability of health services means achieving sustainable reductions in cost growth including by managing demand for high-cost care and intervening early to maintain and improve healthcare status and outcomes. 5. Access and timeliness The monitoring framework retains a strong focus on access and timeliness as a core area of health service. In line with the recommendations from the Travis review, there is a stronger focus on waiting lists for 2015 16, including the reduction in the number of long-waiting patients and closer monitoring of waiting lists clearance rates. Partnerships and other innovative solutions that can improve elective surgery will be encouraged, particularly for those health services experiencing High-performing health services: Victorian health service monitoring framework 2015 16 Page 9
theatre capacity constraints or that have increasing number of patients waiting longer than clinically recommended for treatment. Compliance with the Specialist clinics in Victorian public hospitals access policy (2013) will also feature as a future element of the conversation, based on reported average waiting time from referral to first consultation in specialist clinics. This will provide better visibility of the patient journey in accessing elective surgical and medical treatment. There will be a continued focus on improving ambulance patient transfers to emergency departments and improving overall system coordination of ambulance arrivals to hospital emergency departments. The suite of measures for Ambulance Victoria will be expanded to include a more specific measure for response to major trauma and will also include average hospital clearing time. Last year has seen some notable improvements in the emergency department, particularly in terms of ambulance transfer times, triage times and the number of patients waiting longer than 24 hours. Building on those achievements and continuing to explore strategies to address demand, including collaborative options, should continue to contribute to better. In this context, the access and timeliness indicators have been reviewed to ensure they remain relevant to policy and strike a balance between with the strategic directions for health service. A new access indicator for cancer care will be added to the Program Report for Integrated Service Monitoring (PRISM) to better capture relating to radiotherapy waiting times. With proposed changes to monitoring of critical care access in 2015 16, there will be a need to review the current indicators. Page 10 High-performing health services: Victorian health service monitoring framework 2015 16
Section 2: Components of the monitoring framework The monitoring framework encompasses the mechanisms the department uses to formally monitor health service. The monitoring framework was implemented in public health services in 2004 05 and has been incrementally expanded to cover subregional, local and small rural health services, multipurpose services, Ambulance Victoria and Forensicare. At its heart, the monitoring framework is a dialogue between the department and health services aimed at improving health service. As Figure 1 indicates, this dialogue follows an annual cycle, and the department and health services bring different aspects to the conversation at each point in the cycle. Particular components of the monitoring framework are more relevant to different stages in the cycle. Figure 1: The monitoring cycle The monitoring framework is reviewed annually and provides information on the strategic directions for monitoring, as well as detailing the components of the monitoring framework and any changes from previous years. High-performing health services: Victorian health service monitoring framework 2015 16 Page 11
Victorian health service governance model The 12 metropolitan health services and six major regional health services are defined under the Health Services Act 1988 as public health services, along with Dental Health Services Victoria, and are governed by boards of directors as set out under s. 65S. The nine subregional health services, 11 local health services and 36 small rural health services are defined as public hospitals and are governed by members who make up boards of management as set out under ss. 33 (1, 2, 2A). The seven multipurpose services are subject to a set of governance provisions similar to public hospitals and are governed by boards of management. Mildura Base Hospital is a privately operated public hospital and the three denominational hospitals are subject to similar governance provisions to public hospitals. Ambulance Victoria was created under s. 23 of the Ambulance Services Act 1986 on 1 July 2008 and is governed by a board of directors as set out under s. 17 of the Act. The Victorian Institute of Forensic Mental Health was established under s. 117B of the Mental Health Act 1986 and is continued under the Mental Health Act 2014, operating under the name Forensicare. Forensicare is governed by a board of directors as set out under s. 67 of the new Mental Health Act. Strategic plans Strategic plans aim to demonstrate how the health service will ensure it is able to meet the needs of its catchment population for safe and high-quality healthcare services, including by achieving the organisational goals of financial sustainability, innovation and service improvement. They also demonstrate how the health service will contribute to system-wide goals of efficiency, effectiveness, equity, accessibility, appropriateness, continuity and integration in the delivery of healthcare services, including addressing specific and policy priorities set by the Victorian Government. System-wide goals and health service strategic plans come together formally in the annual SoPs. Both the Health Services Act and the Ambulance Services Act states that the SoPs must be consistent with the strategic plan approved by the Minister for the operation of the service. This requirement is one of the key ways in which the direction set by the strategic plan is turned into actions that fit within the broader system context and contribute to system-wide goals. The conversation with health services aims to identify and acknowledge progress against strategic plans more broadly, including considering aspects of governance, leadership and culture and the way in which strategic plans are translated into strategic management. Statement of priorities The SoP was introduced in 2004 05 as part of a series of governance reforms enacted through changes to the Health Services Act and Ambulance Service Act to improve accountability and transparency between boards of health services and the state government. The SoP is reviewed and agreed between the Minister and health services annually. The department is committed to ensuring the suite of indicators used to monitor health service provide a balanced perspective on service provision. In line with the themes and directions set out in this document, the department works with health services to develop and refine indicators over time. Ambulance Victoria, the 12 metropolitan Melbourne health services, the three denominational health services based in Melbourne and the six regional Victorian health services all have an SoP signed by the Minister for Health and the chair of the health service board. Forensicare has an SoP as the formal funding and priority-setting agreement with the Minister for Mental Health, in accordance with the new Mental Health Act. An SoP is also in place as the formal funding and monitoring agreement between Victorian subregional, local and small rural health services and the Secretary to the Department of Health & Human Services (with the exception of multi-purpose services, which have a separate agreement with the Australian and the Victorian governments). Page 12 High-performing health services: Victorian health service monitoring framework 2015 16
Mildura Base Hospital also has an SoP as the formal funding and monitoring agreement with the Secretary to the department, in accordance with Schedule 1 of the services agreement between Ramsay Health Care and the Victorian Government. Victorian health policy and funding guidelines The Victorian health policy and funding guidelines 2015 16 outline the policy and service delivery objectives, the conditions of funding and key accountability requirements that organisations must comply with in addition to their contractual and statutory obligations. The policy and funding guidelines also provide an overview of the new initiatives and health budget for 2015 16. In the case of any inconsistencies or ambiguities between these guidelines and any legislation, regulations and contractual obligations with the state of Victoria (acting through the Department of Health & Human Services or the Secretary to the Department of Health & Human Services), the legislative, regulatory and contractual obligations will take precedence. Performance monitoring tools The Victorian Performance Monitor The Victorian Health Services Performance Monitor ( the monitor ) reports health service against key indicators (KPIs) outlined in the SoP (Part B and Part C). A similar monitoring tool is produced for Ambulance Victoria and Forensicare, as described below. Produced monthly, the monitor provides interim results of KPIs across the five domains: patient experience and outcomes; governance, leadership and culture; safety and quality; financial sustainability; and access and timeliness. Health service is reviewed monthly, but formal assessment including a assessment score and level of monitoring is determined quarterly. The monitor is distributed monthly to chief executive officers (CEOs), the Minister for Health and the Minister for Mental Health and quarterly to board chairs. The monitor is also produced annually using the consolidated annual activity data and audited financial results. This is distributed to health service CEOs, board chairs, the Minister for Health and the Minister for Mental Health. The Ambulance Victoria Monitor reports ambulance service against KPIs outlined in the SoP (Part B) and a broader set of program measures necessary to provide a more balanced perspective of Ambulance Victoria activity. Produced monthly, the Ambulance Victoria Monitor presents interim results for a range of indicators across the five domains. While some of these measures are more specific to Ambulance Victoria requirements, there are a number of common indicators, particularly in relation to financial sustainability and quality and safety, which will be included in the statewide monitor and respective peer monitor reports. This will allow for improved benchmarking across the system. The Ambulance Victoria Monitor is distributed to the Ambulance Victoria CEO and the Minister for Ambulance Services monthly and to the board chair quarterly. An annual Ambulance Victoria Monitor report is produced using the consolidated annual activity data and audited financial results. This is distributed to the CEO and board chair. A Forensicare Monitor report is being developed for 2015 16 to report on against KPIs outlined in the SoP (Part B) and a broader set of program measures specific to Forensicare requirements. Produced quarterly, it will present interim results for relevant indicators across the same five health services domains and will be distributed to the CEO, board chair and the Minister for Mental Health quarterly. An annual Forensicare Monitor will also be produced using the consolidated annual activity data and audited financial results. This will be distributed to the CEO and board chair. High-performing health services: Victorian health service monitoring framework 2015 16 Page 13
The Small Rural Health Services Monitor ( SRHS monitor ) reports small rural health service against KPIs outlined in the SoP (Part B and Part C) and a broader set of program measures to provide a more balanced perspective of health service activity. Produced monthly, it presents financial and service aspects of and activity. The SRHS monitor is also produced for the MPS. The SRHS monitor is distributed to CEOs and the Minister for Health monthly, and to board chairs quarterly. An annual SRHS monitor is produced using the consolidated annual activity data and audited financial results. This is distributed to CEOs, board chairs and the Minister for Health. The Program Report for Integrated Service Monitoring PRISM includes a broader set of measures that provides a balanced perspective of health service activity and system. It supports the monitor by providing context and key drivers of. For the small rural health services, this information is incorporated in the SRHS monitor. PRISM provides a broader range of services delivered by health services to the Victorian community and is used by health services to benchmark their against similar health services. Based on industry feedback, the department will be looking to further reform the PRISM report to ensure information currently collected and reported continues to support sector requirements. The PRISM report is distributed to CEOs and board chairs quarterly. The department encourages health services to disseminate PRISM to relevant staff within the health service. An annual PRISM report is produced using the consolidated annual activity data and audited financial results. This is also distributed to the CEOs and board chairs. The department is exploring options for future reporting of PRISM information using an online portal, thus providing a more timely solution to health services. The portal could also provide additional features including more detailed data inquiry options and reports customisation to further assist health services in tailoring information. The department will also use PRISM as a formal test-bed for metrics that are being considered for inclusion in the SoP and assessment score. Page 14 High-performing health services: Victorian health service monitoring framework 2015 16
Section 3: Performance assessment and monitoring This section sets out the approach the department uses to assess and monitor health service. The monitoring framework is centred on a conversation between the department and health services. This conversation focuses strategic directions outlined in Section 1 and draws on a wide range of information to fill out a comprehensive picture of health service. While the department is committed to working with health services to drive high, it also has a responsibility to ensure problems are detected and acted upon quickly. In some cases, issues will trigger a higher level of monitoring of health service by the department to ensure that appropriate action is being taken to address concerns. It is important that health services regularly review and improve the reliability, timeliness and accuracy of the information provided to the department to ensure that assessment accurately reflects current. The assessment score is a mechanism for determining the level of monitoring applied to health services. However, in keeping with the broad-based approach to monitoring, the assessment score is only one factor taken into account when assessing health service. Other factors considered when determining the level of monitoring include, but are not limited to, the following risk factors: accreditation outcomes where core action items are assessed as not met or significant risk of patient harm is identified persistent and emerging financial risk, including deficit operating result, low liquidity or material budget issues demonstrated deficits in other critical areas including significant unexplained variation in patient health outcomes indications of pervasive failure in leadership or culture identified failures in clinical or corporate governance, or unacceptable outcomes in the quality of patient care, occupational health and safety or human resources emerging or ongoing significant under- or deterioration in service access or timeliness indicators the level of department support required to sustain operations or manage risks. In the case of those services for which no assessment score is generated, the above risk factors are the primary means of determining whether a higher level of monitoring is required. In 2015 16 this approach applies to small rural health services and Forensicare. Using the Statement of priorities targets to assess Performance against the actions and deliverables committed to in the SoP will continue to be formally reported in the annual report at the end of the financial year as consistent with the Annual report guidelines (report of operations). In addition, health services will also be expected to provide periodic progress reports on achieving those commitments, particularly Part A action items deliverables as part of the mid-year (quarter 2) review. High-performing health services: Victorian health service monitoring framework 2015 16 Page 15
Performance against all indicators is assessed based on the target agreed in the SoP. The symbols used to indicate results are: Target achieved Target not achieved Significant non-achievement. The assessment of each SoP key indicators is reported in the monitor and thresholds as detailed in Appendix 4. Outcomes against these indicators are a key facet of the conversation and inform the assessment of against the risk factors outlined above. Performance assessment score For most health services, a subset of indicators included in Part B of the SoP is used to generate a assessment score, which in turn informs the level of monitoring applicable to individual health services. The assessment score was updated in 2014 15 to strike a better balance between financial, access and quality and safety. The 2015 16 assessment score is structured around the five domains of and the contribution they make to the health service s objectives. In keeping with this, the assessment score in 2015 16 establishes governance, leadership and culture and patient experience and outcomes as separate domains. In 2015 16 the five domains of the assessment score will be: patient experience and outcomes governance, leadership and culture safety and quality financial sustainability access and timeliness. The five domains and the indicators included in the respective domains for 2015 16 are shown in Figure 2. In 2015 16 the contribution of the domains was reviewed due to the expansion from three to five domains to reflect the increasing focus on patient outcomes and organisational governance and leadership. The patient experience and outcomes domain and the safety and quality domain have been updated to each contribute 15 per cent of the assessment score, and the governance, leadership and culture domain to 10 per cent of the total assessment score. The overall contribution that access and timeliness indicators make to the overall assessment score has been reduced from 35 to 30 per cent, due to the consolidation of two elective surgery indicators into one. Financial sustainability has reduced from 35 to 30 per cent while retaining the same KPIs. As a result, the contribution made by each access KPI to the overall assessment score has been updated proportionately (Figure 2). Page 16 High-performing health services: Victorian health service monitoring framework 2015 16
Figure 2: Performance assessment score domains and KPIs Further development of monitoring will see Ambulance Victoria monitored against a assessment score in 2015 16 for the first time. the assessment score The scoring process occurs in three steps: 1. Allocate points for each KPI based on the results and score for each domain. 2. Apply the conditional KPIs for elective surgery and emergency care, where applicable. 3. Account for accepted force majeure claims that have impacted on. Key indicator scores The result of each KPI is assessed based on the corresponding thresholds, aggregated and weighted for each domain. This means the maximum points scored for each domain does not necessarily equate with the weighting that domain receives in the assessment score. (For example, the maximum points that can be achieved in the access and timeliness domain is 21, but this score is weighted up so that it counts for 30% of the total assessment score.) Performance thresholds and points used to calculate the assessment score for each KPI are outlined in Tables 6 to 10. KPIs are assessed at the health service level unless, the assessment at campus level is required due to the nature of the being measured (such as emergency departments). Depending on the access KPI, assessment is either at campus or health service level. For health services with multiple emergency departments, a maximum weighted score is determined across all relevant campuses and the total domain score is calculated by adjusting the relative weighting of the remaining KPIs. Where a KPI does not apply to a health service (such as mental health seclusion rate), the total domain score is calculated by adjusting the relative weighting of the remaining KPIs. Where a domain is not applicable, the combined remaining domain scores are factored on a pro-rata basis to calculate a score out of 100. High-performing health services: Victorian health service monitoring framework 2015 16 Page 17
Table 1: Patient experience and outcomes Key indicator Thresholds Points Patient experience Staphylococcus aureus bacteraemia (SAB) rate Mental health seclusion Patient experience score based on the overall patient experience result and compliance with use of the Victorian Health Experience Survey (VHES) Rate of SAB infections per 10,000 occupied bed days Mental health seclusion rate per 1,000 occupied bed days Overall patient experience result greater than 95% and full compliance Overall patient experience result between 85% and 95% Overall patient experience result less than 85% or noncompliance Less than or equal to 2.0 5 2.1 to 2.5 3 2.6 to 3.5 1 Equal to or greater than 3.6 0 Less than or equal to 15 5 16 to 20 3 21 to 25 1 Equal to or greater than 26 0 5 3 0 Table 2: Governance, leadership and culture Key indicator Thresholds Points Safety culture Safety culture index based on eight safety culture questions in the People Matter survey Equal to or greater than 80% 5 Between 75% and 80% 3 Less than 75% and/or response rate for People Matter survey of less than 40% 0 Table 3: Safety and quality Key indicator Thresholds Points Hand hygiene Healthcare worker immunisation Hand hygiene compliance Rate of healthcare worker immunisation influenza Equal to or greater than 80% 5 78% to less than 80% 3 77% to less than 78% 1 Less than 77% 0 Equal to or greater than 75% 5 65% to less than 75% 3 Less than 65% 0 Page 18 High-performing health services: Victorian health service monitoring framework 2015 16
Table 4: Financial sustainability Key indicator Thresholds Points Operating result Creditors Debtors Operating result as a percentage of total operating revenue Number of trade creditors days Number of patient debtors days In surplus and achieved or ahead of budget 20 In surplus but behind budget 17 In deficit and achieved or ahead of budget 17 In deficit and within 0.1% to 1.1% unfavourable variance to budget In deficit and greater than 1.1% to 2.1% unfavourable variance to budget In deficit and greater than 2.1% to 3.1% unfavourable variance to budget In deficit and greater than 3.1% unfavourable variance to budget Less than or equal to 60 days 5 61 to 65 days 3 66 to 70 days 2 71 days or more 0 Less than or equal to 60 days 5 61 to 70 days 3 71 to 80 days 2 81 days or more 0 15 10 5 0 Table 5: Access and timeliness Key indicator Thresholds Points 40-minute transfer Triage1* Percentage of ambulance patients transferred within 40 minutes Percentage of triage category 1 patients seen immediately 4 hours Percentage of all emergency patients with a length of stay in the ED of within four hours 24 hours Number of patients with a length of stay in the ED longer than 24 hours Equal to or greater than 90% 3 85 to 89% 2 80% to 84% 1 Less than or equal to 79% 0 100% Equal to or greater than 81% 3 76% to 80% 2 66% to 75% 1 Less than or equal to 65% 0 0 3 1 to 15 2 16 to 30 1 Equal to or greater than 31 0 High-performing health services: Victorian health service monitoring framework 2015 16 Page 19
Key indicator Thresholds Points Cat 1 admitted* Cat 1, 2 and 3 admitted ESWL HiPs Percentage of urgency category 1 patients admitted within 30 days Percentage of elective patients treated within clinically recommended time frames Number of patients on the elective surgery waiting list percentage variance to target Number of hospitalinitiated postponements per 100 scheduled admissions from the elective surgery waiting list 100% Equal to or greater than 94% 3 89.0% to 93.9% 2 84.0% to 88.9% 1 Less than or equal to 83.9% 0 Target achieved 3 Between 0.1% to 2% over target 2 3% to 5% over target 1 Greater than or equal to 6% over target 0 0 to 8.0 3 8.1 to 11.0 2 11.1 to 15.0 1 Greater than or equal to 15.1 0 * Failure to meet the conditional KPIs will result in a point being deducted from each of the KPIs for the relevant program. Triage category 1 impacts on emergency care, and urgency category 1 impacts on elective surgery, unless the score is already 0. Conditional key indicators Two of the access KPIs in the assessment score will remain conditional, whereby their results only impact on the score when the KPI target is not met. The access score is first calculated for all other KPIs and in the instance where a health service does not achieve the emergency care or elective surgery conditional indicator, points are deducted. In this situation the access score is reduced by one point across each of the corresponding emergency care or elective surgery KPIs in the given quarter. If the score for a KPI is zero, no points are deducted. The conditional KPIs for 2015 16 are: percentage of triage category 1 emergency care patients seen immediately; and percentage of urgency category 1 elective surgery patients admitted within 30 days. In the event these indicators are not met health services are required to send a letter to the Director of Sector Performance, Quality and Rural Health branch within five days of the breach. The letter must: advise the department of the breach or expected breach; explain the circumstances of the breach; and outline the rectification plan and actions to be undertaken by the health service to avoid further breaches. Following receipt of the letter, the department will follow up with the health service to ascertain the health service s response to this breach and that patient safety has not been compromised. This breach will also be an item for discussion at the next health service meeting, targeting any proactive initiatives and strategies that can prevent anticipated issues or clinical risks. Overdue patients will continue to be monitored through the Elective Surgery Information System (ESIS) reporting system, with regular updates on the status of these patients. Page 20 High-performing health services: Victorian health service monitoring framework 2015 16
Force majeure The final step in determining the score is to account for any agreed force majeure claims between the department and health service. From time to time, unforeseen events may occur that adversely impact on hospital and it is critical that the assessment score reflects these bona fide concerns. The intent of the process is to address extraordinary and genuinely unforeseen events beyond the control of the organisation that affect service delivery or reporting requirements. Examples include internal disasters (e.g. burst water pipe causing flooding) and third-party-related failures leading to interrupted service delivery. Where circumstances have a significant impact on, a health service may request that the department consider a claim. The process should not be applied to ad hoc operational difficulties or for planned service interruptions such as capital works or ICT upgrades. When a hospital is reliant on services provided by a third party, the hospital is responsible for ensuring that, as far as practicable, the service is of an acceptable quality and delivered in a timely manner. For this reason, the failure of a third party to deliver a product or service is not in itself regarded as acceptable grounds for a force majeure. Difficulties related to software conversion are not a force majeure unless it can be demonstrated that reasonable steps were taken to ensure the continuity of data collection and data recovery. In applying the force majeure policy, the result of a health service will not change, but the department will consider adjusting the assessment, depending on the circumstances. Submitting a force majeure request Individual health services may make a formal request for a consideration. The request should clearly indicate the event(s) affecting against targets and include supporting data and documentation. Formal written requests from the health service CEO should be forwarded to the relevant health service lead by the end of the reporting period affected. The department will only consider issues of force majeure retrospectively. Health services should not apply for a force majeure in anticipation of poor results. The department may use its discretion in extraordinary circumstances to apply a force majeure across the sector. 2015 16 changes Ambulance Victoria In 2015 16, to further Ambulance Victoria s integration into the monitoring framework, a tailored Ambulance Victoria assessment score will be introduced (see Figure 3). The Ambulance Victoria assessment score domains will be consistent with health services, however, in addition to range of common measures, include ambulance-specific SoP indicators across the access and timeliness, safety and quality and patient experience and outcomes domains. Introduction of the assessment score for Ambulance Victoria will be premised on a improvement culture and provide greater accountability and transparency consistent with peer SoP health services. High-performing health services: Victorian health service monitoring framework 2015 16 Page 21
Figure 3: Performance assessment score domains and KPIs for Ambulance Victoria Table 6: Patient experience and outcomes thresholds and points Key indicator Thresholds Points Patient satisfaction Pain reduction Stroke patients transported Major trauma patients transported Cardiac arrest survival Percentage of emergency patients satisfied or very satisfied with the quality of care provided by paramedics Percentage of patients with a significant reduction in pain Percentage of adult stroke patients transported to definitive care within 60 minutes Percentage of major trauma patients that meet destination compliance Percentage of adult cardiac arrest patients surviving to hospital discharge Equal to or greater than 97.4% 5 Between 95.1% and 97.3% 3 Equal to or less than 95% 0 Equal to or greater than 95.0% 5 Between 92.0% and 94.9% 3 Less than or equal to 91.9% 0 Equal to or greater than 88% 5 Between 85.0% and 87.9% 3 Less than or equal to 84.9% 0 Equal to or greater than 95.0% 5 Between 90.0% and 94.9% 3 Less than or equal to 89.9% 0 Equal to or greater than 29.0% 5 Between 26.5% and 28.9% 3 Less than or equal to 26.4% 0 Page 22 High-performing health services: Victorian health service monitoring framework 2015 16
Table 7: Governance, leadership and culture thresholds and points Key indicator Thresholds Points Safety culture Composite safety culture score based on eight safety culture questions in the People Matter survey (percentage agreement) Equal to or greater than 80% 5 Between 75% and 80% 3 Less than 75% or response rate for People Matter survey of less than 40% 0 Table 8: Safety and quality thresholds and points Key indicator Thresholds Points Clinical compliance emergency cases Healthcare worker immunisation Percentage of audited cases meeting clinical practice guidelines Rate of healthcare worker immunisation influenza Equal to or greater than 98.0% 2 Between 95.0% and 97.9% 1 Less than 95.0% 0 Equal to or greater than 75% 5 65% to less than 75% 3 Less than 65% 0 Table 9: Financial sustainability thresholds and points Key indicator Thresholds Points Operating result Operating result as a percentage of total operating revenue In surplus and achieved or ahead of budget 20 In surplus but behind budget 17 In deficit and achieved or ahead of budget In deficit and within 0.1% to 1.1% unfavourable variance to budget In deficit and greater than 1.1% to 2.1% unfavourable variance to budget In deficit and greater than 2.1% to 3.1% unfavourable variance to budget In deficit and over 3.1% unfavourable variance to budget Creditors Trade creditors days Less than or equal to 60 days 5 61 to 65 days 3 66 to 70 days 2 71 days or more 0 Debtors Patient debtors days Less than or equal to 60 days 5 61 to 70 days 3 71 to 80 days 2 81 days or more 0 17 15 10 5 0 High-performing health services: Victorian health service monitoring framework 2015 16 Page 23