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6.0 Understanding and managing activity and key performance indicators
Learning objectives
Be able to define activity
Understand the importance of knowing the classification methodology and how the data is collected
Have an understanding of commonly used activity and KPI terms
Understand the importance of having a detailed knowledge of the PMF KPIs that affect your work areas and how to influence them
Understand what to consider when managing towards activity targets
6.1 What is activity?
Activity refers to everything that a health system does for, with and to patients, residents, clients and their families and carers and the community. In order to understand and fund activity, Health Services need to have systems in place to be able to collect, count, code or classify and cost activity appropriately.
6.2 How is activity classified?
Activity is classified using various systems based on the care setting of the patient.
The table below outlines the activity type and correlating classification system.
Activity Type Classification System
Acute Inpatient Care Australian Refined – Diagnosis Related Group (AR-DRG)
Emergency Department Care Urgency Related Group (URG)
Outpatient Services National Hospital Cost Data Collection Tier 2 Clinics – Metropolitan Area Tier 1 Clinics – Country Areas Subacute Care designated
units
Australian National Subacute and Non-Acute Patient (AN-SNAP)
Subacute Care non-designated unit
AR-DRG
AR-DRG classification is a system used to relate the number and type of patients treated in a hospital (the casemix) to the resources required by the hospital to treat those patients. The Clinical Casemix Handbook 2011-12 outlines this system in greater detail. There are currently 698 DRG types.
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URG (Urgency Related Group) Classification is a 78 class Emergency Department patient classification system. The URG class is dependant on the disposition, triage category and the principal diagnosis.
Tier 2 or 1 clinic definitions classify non-admitted, non emergency department patient services. The clinic class is based on the specialty or function and whether the clinic is procedural, medical consult, diagnostic or nursing/allied health related.
There are currently 110 tier 2 type clinics.
AN-SNAP is an 83 class classification system for palliative care, rehabilitation, psycho geriatric, geriatric evaluations and management and maintenance care type patients.
6.3 How is activity labelled (activity type)?
In order to collect activity data correctly managers need to understand the rules and criteria to count and label activity consistently and appropriately.
The Admissions, Readmissions, Discharge and Transfer Policy for WA Health (Operational Directive 0343/11) provides this framework. It is the responsibility of Health Services to ensure the rules described in this policy are applied consistently and accurately.
http://www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12823
6.4 Understanding the Key Performance Indicator (KPI) definitions
The annual Performance Management Framework establishes the KPI to be used, the reporting obligations, the processes for monitoring and review of health service performance, and the thresholds for rewards and potential remediation for poor performance during that year. This framework forms the basis of the Performance Agreements for the Chief Executives. In conjunction with the PMF the DoH will publish the Performance Management Report Definitions Manual which details the KPI descriptions and definitions. A link is provided below:
http://activity/?tag=/performance-management-framework
The State Health Information Standards Committee (SHISC) formerly the WA Health Management Information Group (WAHMIG), provides detailed definitions of numerous commonly used reporting indicators. Their definitions outline
descriptions, guide for use, limitations, formulas, inclusions, exclusions, scope, data source and more. A link to WAHMIG’s definitions page is provided below however over time SHISC will adopt and rename policies, definitions and websites.
http://intranet.health.wa.gov.au/wahmig/home
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6.5 How can I influence KPI outcomes?
In order to influence the KPI outcomes, managers need to be able to answer the below questions about their KPI.
What is the KPI definition?
What variables are being used to calculate the KPI?
What is the process from input of data to output of KPI?
Who is collecting the information?
What application is being used for data inputs?
When is the data being collected?
What is current performance?
Why is there variance in the KPI?
For example:
Hospital ‘A’ is a Metropolitan hospital with an emergency department. It is aiming to meet its wait time target for triage 1 type patient presentations which is currently performing at 77%. Firstly, the emergency department team need to understand triage 1 wait time KPI definition and performance target which is 100% of all emergency department triage 1 patients seen immediately (less than 2 minutes).
The KPI is calculated by dividing the total number of patients seen by a Doctor within 2 minutes of arrival by the total number of triage 1 type patients presenting.
Then it would be important to map the processes from start to finish. So for this example, the processes and issues from patient arrival until the point in time the Doctor has seen the patient and entered the data into the application as seen below.
Patient arrives via ambulance Priority 1 response
team (senior nurse and senior doctor) make preparations for patient arrival
Team stabilises patient
Response team Doctor inputs “seen time” post event
This basic map shows that the key staff are the senior nurse and senior doctor who are inputting the data. The map indicates that a potential cause for variance could be data entry beyond the time of the event, as stabilising the patient would usually take longer than 2 minutes.
Even though this example is fictitious and simplified it illustrates the point that variances in performance are not always complicated. For example, in this case by getting all the stakeholders involved in the process (the response team)
a solution to this problem could be easily developed, implemented and evaluated.
The following module on service improvement will outline some more details on systematic approaches to problem solving.
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6.6 Managing towards activity targets
How future activity levels are set are outlined in the Health Activity Purchasing Intentions 2011-12, the WA Health Clinical Services Framework (CSF)
2010-2020 and the ABF 2011-2012 Budget: Model Parameters and Information on the Construction of AHS Service Level Agreements documents. Specifically, the activity growth rates specified in the ABF budget allocations are determined by the growth rates from the CSF demand modelling.(1)
Once activity targets are set, managers will need to monitor progress towards the activity target. But what can managers do to manage activity?
1) Understand CSF expectations for your Health Service – does the activity level set for your Health Service include expected changes to the activity profile and service profile. If so, is there a plan in place to transfer activity?
2) Understand your weighted activity profile – has the casemix changed from previous years due to changes in service profile? Which activities are expanding and which are contracting?
3) Understand current progress towards your activity target – is the health service projected to be above, at or below target?
4) Understand the Area’s progress overall – are all the health services at, above or below target across the Area?
5) Can activity and funding be moved to adjust between services –
can services be moved to where there is more capacity or be offset by another health service within the Area?
6) Can there be an increase in use of community alternatives or hospital substitution – can activity be controlled by utilising community based alternatives?
7) Review application of Admissions, Readmissions, Discharge and Transfer policy – is the policy being applied accurately for admissions and care type changes?
8) Review activity coding – is activity produced by the health service reflected in the code or classification given?
9) Review patient length of stay and over high boundaries – are patients staying over the high boundaries unnecessarily incurring higher weights?
10) Review adverse events – is poor quality causing patients to stay longer than necessary incurring higher weights?
It is important to note that these strategies are examples only. Managing towards activity targets should not be reviewed in isolation but reviewed in the context of costs and quality of service. Over boundary cases are often high weighted which does mean more revenue for that activity but often it incurs an even greater cost in quality and expenditure. In 2011-2012, WA Health introduced the Quality Incentive Program (QuIP) which is designed to support safety and quality innovation.(1)
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6.7 On reflection – understanding and managing activity and key performance indicators
Do I know what and how much activity was done by my hospital or division