Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/ space space
2015/16 Service Agreement Key Performance Indicators and
Service Measures Data Dictionary
space
Document Number IB2015_053 Publication date 08-Sep-2015
Functional Sub group Corporate Administration - Information and data Clinical/ Patient Services - Information and data Population Health - Health Promotion
Personnel/Workforce - Workforce planning
Summary The 2015/16 Key Performance Indicator and Service Measure Data Dictionary has been developed to support the NSW Ministry of Health and Local Health Districts in monitoring and reporting on the 2015/16 Service Agreements by providing the relevant information concerning the definitions for the numerators and denominators, as well as inclusion and exclusion notes for each of the Performance Measures located within Schedule E of the Service Agreement.
Replaces Doc. No. 2014/15 Service Agreement Key Performance Indicators and Service Measures Data Dictionary [IB2014_055]
Author Branch Health System Information & Performance Reporting Branch contact Health System Information & Performance 02 9391 9388
Applies to Local Health Districts, Board Governed Statutory Health Corporations, Chief Executive Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Affiliated Health Organisations, Public Health System Support Division, NSW Ambulance Service, Ministry of Health
Audience Administration, Performance Units, Data collection and Data Provision staff
Distributed to Public Health System, Ministry of Health Review date 08-Sep-2016
2015-16 SERVICE AGREEMENT KEY PERFORMANCE INDICATORS
AND SERVICE MEASURES DATA DICTIONARY
PURPOSE
The purpose of this information bulletin is to support monitoring and reporting on the
2015-16 Service Agreements between the Local Health Districts and the NSW Ministry
of Health. The Service Agreement is a key component of the Performance Framework
for Health Services, providing a clear and transparent mechanism for assessment and
improvement of performance.
The definitions provided in the 2015-16 Service Agreement Key Performance
Indicators and Service Measures Data Dictionary (refer to Attachment section below)
will assist Health Services and other data users with the calculation and interpretation of
the Key Performance Indicators and Services Measures referenced in the Service
Agreements for 2015-16.
This information bulletin supersedes IB2014_055 - 2014/15 Service Agreement Key
Performance Indicators and Service Measures Data Dictionary.
KEY INFORMATION
The definitions provided in the Data Dictionary will assist Health Services and other data
users with the calculation and interpretation of the Key Performance Indicators and
Services Measures referenced in the Service Agreements for 2015-16. It should be
noted that some KPIs may be calculated differently when applied to different purposes
outside the management of the Service Agreements. The KPIs and Service Measures
contained in this document have been defined specifically with the intent to meet the
reporting requirements under 2015-16 agreements and to align to the Ministry of
Health’s monthly performance monitoring reports. Should you require further assistance
with the definitions or have comments regarding them please contact either the Health
System Information and Performance Reporting Branch or the Data / Policy contacts
listed in the KPI documentation.
The Service Agreement document covers both the Tier 1 and 2 KPIs and Service
Measures. Key Performance Indicators (KPIs), if not met, may contribute to escalation
under the Performance Framework processes. Performance against these KPIs will be
reported regularly to Health Services in the Health System Performance Report
prepared by the Department.
These KPIs have been designated into two categories:
• Tier 1 - Will generate a performance concern when the organisation’s
performance is outside the tolerance threshold for the applicable reporting
period.
• Tier 2 - Will generate a performance concern when the organisation’s
performance is outside the tolerance threshold for more than one reporting
period.
to improve provision of safe and efficient patient care and to provide the contextual
information against which to assess performance.
Note that the KPIs and Service Measures listed above are not the only measures
collected and monitored by the NSW Health System. A range of other measures are
used for a variety of reasons, including monitoring the implementation of new service
models, reporting requirements to NSW Government central agencies and the
Commonwealth, and participation in nationally agreed data collections. Relevant
measures specified in the National Health Reform Performance and Accountability
Framework, and in NSW 2021: A Plan to Make NSW Number One, have been assigned
as NSW Health KPIs, Service Measures or Monitoring Measures, as appropriate.
This year the KPIs and Service Measures are grouped under the six reporting domains
of:
• Safety and Quality
• Service Access and Patient Flow
• Integrated Care
• Finance and Activity
• People and Culture
• Population Health.
The performance of LHDs, other Health Services and Support Organisations is
assessed in terms of whether it is meeting the performance targets for individual KPIs:
Highly Performing - Performance at, or better than, target
Underperforming - Performance within a tolerance range
Not performing - Performance outside the tolerance threshold.
As in previous years, the 2015-16 KPI and Service Measure data elements are also
located on the NSW Health Information Resource Directory and are accessible via the
following link:
http://internal4.health.nsw.gov.au/hird/view_data_resource_data_elements.cfm?ItemID=
20731&sortby=2&SelInit=&Page=1
Each individual indicator and service measure may be viewed and downloaded via this
portal. Further, additional documentation (where available) for each of the indicators
and service measures (such as specific identification of which fields from the data
warehouse are used for the calculation, sample .sas code, detailed calculation
formulae, etc) may be found under the “Ext Info” tab for each individual indicator and
REVISION HISTORY
Version Approved by Amendment notes September 2015
(IB2015_053)
Director, Health System Information and
Performance
New version of the Data Dictionary to align with the 2015/16 Service Agreements.
September 2014 (IB2014_055)
Director, Health System Information and
Performance Reporting
Introduced a Data Dictionary for Local Health Districts to support the Key Performance Indicators and Service Measures as agreed to in Schedule E of the 2014/15 Service Agreements.
ATTACHMENT
1. Data Dictionary for 2015-16 Service Agreement Key Performance Indicators and
Service Measures
Key Performance Indicators
and Service Measures for
the 2015-16 Service
Agreements
(Schedule E)
Version 1.07 7 September 2015
Contact:
Further information regarding this document can be obtained from the Health System Information & Performance Reporting Branch.
• For queries relating to the documentation, including clarification of definitions:
• For queries relating to how the Service Agreement data is calculated and reported:
Date ID Item Change
01/12/2014 SSA113, SSA114
Surgery for Children – Proportion of children (0 to 16 years) treated within their LHD of residence
Added Justice Health / Forensic Mental Health Network as an exclusion
01/12/2014 KQS204 Mental Health: Acute Post Discharge Community Care
Updated Data Collection Source / System details; Updated note for denominator, clarifying selection criteria
01/12/2014 KSA202 ED Presentations staying in ED > 24 hours (Mental Health) (number)
Name change, revised indicator definition for mode of separation values in Departure Time, and changes to SNOMED CT map 01/12/2014 KQS203 Mental Health: Acute Readmission
within 28 days
Added note to denominator definition
01/12/2014 SSA106 Patients with total time in ED <= 4 hrs (%): Mental Health Patients (admitted to a ward from ED)
Changed title (previously Emergency Admission Performance (Mental Health)), changed indicator definition to align with the Patients with Total time in ED <= 4hrs Service Measure. Updated (i) Data Collection
Source/System details; (ii) Primary data source for analysis; (iii) Denominator source
01/12/2014 SFA113 Sub and Non Acute Admitted Patient Episodes – grouped to an AN-SNAP Class
Scope change to Sub and non acute admitted patient episodes completed in 2014/15 in ABF in-scope facilities, excluding mental health services provided in designated mental health units and children <18 years of age. Exclusions (point 3) change to Sub and Non Acute Episodes of care provided to children (<18 years age) 01/12/2014 SFA106,
SFA107, SFA108, SFA109
ED Records unable to be grouped Revised definition and indicator to remove E4 and E5 codes; expanded scope for numerator and
denominator to include NEC facilities, revised Primary Point of Collection
01/12/2014 SFA110 ED coding completeness RETIRED for 2015-16 01/12/2014 SSQ117 Patient Experience Survey – Adult
Admitted Patients: overall rating of care
Change to the Service Agreement Type, indicator definition, scope, numerator, inclusions and
exclusions, useable data available from and time lag to available data
01/12/2014 KSA201 ED Presentations staying in ED > 24 hours
Significant revision to Departure Time in indicator definition; Name change; minor refinement to the indicator definition, updated desired outcome and related policies and programs, updated target timeframe parameters.
01/12/2014 SSA104 ED presentations treated within benchmark times
Updated indicator definition, numerator definition, inclusions and context, related programs and policies
01/12/2014 KSA102 Emergency Treatment
Performance: Patients with Total time in ED <= 4hrs
Revised title of indicator, reflecting cessation of NEAT. Updated indicator definition, related policies and programs. Updated Targets. 01/12/2014 PI-03,
SSA117, SSA118
Hospital in the home – Admitted Activity (%)
DELETED sub-items SSA117 (Admitted Activity – Number) and SSA118 (Non-Admitted Activity – Number. Minor clarification to scope and outcome, change to
Performance Area. 01/12/2014 SSA111 Elective Surgery: Activity change
YTD compared to previous
Minor clarification to indicator definition, updated Context, Inclusions, Exclusions. 01/12/2014 SPC107 Recruitment: Improvement on
baseline average time taken from request to recruit to decision to approve/decline/defer recruitment
Updated title, indicator definition, target
01/12/2014 SFA105 Coding timeliness Updated target, clarified denominator definition, Updated Time Lag to Available Data
01/12/2014 PH-011B Get Healthy Information and Coaching Service – Health Professional Referrals
NEW for 2015-16
01/12/2014 PH-008B Healthy Children’s Initiative – Children’s Healthy Eating and Physical Activity Program (primary school sites) – Adopted
Transformed from KPI to SM; updated title from “Primary school sites adopting the Children’s Healthy Eating and Physical Activity Program in Primary School to agreed
standard”, minor amendment to indicator definition, updated target figures
01/12/2014 PH-008A Healthy Children’s Initiative – Children’s Healthy Eating and Physical Activity Program (centre based children’s service sites) – Adopted
Transformed from KPI to SM; updated title from “Primary school sites adopting the Children’s Healthy Eating and Physical Activity Program in centre-based children’s services to agreed standard”, minor amendment to indicator definition, updated target figures, updated Related Policies/ Programs.
01/12/2014 PH-010A HIV testing increase within publicly-funded HIV and sexual health services
Changed indicator from Occasions of Service to number of tests. Revised indicator definition, numerator and denominator, updated under-performing and nor under-performing targets. Updated primary point of collection, Data Collection Source/System, Numerator and denominator source and availability, inclusions and targets.
01/12/2014 PH-008C Healthy Children’s Initiative: Children 7-13 years who Enrolled in the Targeted Family Healthy Eating and Physical Activity Program
MOVED TO SCHEDULE D for 2015-16
01/12/2014 PH-008D Healthy Children’s Initiative: Children 7-13 years who complete the Targeted Family Healthy Eating and Physical Activity Program
MOVED TO SCHEDULE D for 2015-16
01/12/2014 PH-010E STI testing/treatment/management – occasions of service within publicly-funded sexual health services: All persons
MOVED TO SCHEDULE D for 2015-16
01/12/2014 PH-010F STI testing/treatment/management – occasions of service within publicly-funded sexual health services: Aboriginal people
MOVED TO SCHEDULE D for 2015-16
01/12/2014 PH-010H STI testing/treatment/management – occasions of service within publicly-funded sexual health services: Sex workers
MOVED TO SCHEDULE D for 2015-16
01/12/2014 PH-010G STI testing/treatment/management – occasions of service within publicly-funded sexual health services: Gay men and other homosexually active men
MOVED TO SCHEDULE D for 2015-16
01/12/2014 SPH008 HIV testing occasions of service within publicly-funded HIV and sexual health services: All people
RETIRED for 2015-16
01/12/2014 PH-010B HIV testing occasions of service within publicly-funded HIV and sexual health services: Aboriginal people
RETIRED for 2015-16
01/12/2014 PH-010C HIV testing occasions of service within publicly-funded HIV and
01/12/2014 PD-001 Variation against purchased volume (%) Public Dental Clinical Service
Updated indicator definition, exclusions, scope, goals, desired outcome.
01/12/2014 KFA105 Recurrent Trade Creditors Updated indicator definition with an exclusion note.
01/12/2014 SPC104 Premium Staff Usage – Allied Health
RETIRED for 2015-16
01/12/2014 SSQ103 Clostridium Difficile Infections (per 1,000 separations)
MOVED TO SCHEDULE D for 2015-16
01/12/2014 SSQ104 Root Cause Analysis – completed in 70 days
MOVED TO SCHEDULE D for 2015-16
01/12/2014 SSQ105 Complaints Management – resolved within 35 days
RETIRED for 2015-16
01/12/2014 SSA103 ED attendances admitted to ward / Intensive Care Unit / Operating Theatre (%)
RETIRED for 2015-16
01/12/2014 SSA105 Emergency Admission
Performance – Patients admitted to an inpatient bed within 8 hours of arrival in the ED
RETIRED for 2015-16
01/12/2014 SSA107 National Elective Surgery Target (NEST) Part 2.1: 10% of Longest waiting patients as at 31 December 2013 treated by 31 December 2014
RETIRED for 2015-16
01/12/2014 SSA115 Separations (number) RETIRED for 2015-16 01/12/2014 SSA119 Avoidable Admissions for targeted
conditions
RETIRED for 2015-16; Replaced by proposed new Service Measure SIC001
01/12/2014 SSA120 Available beds (number) RETIRED for 2015-16 01/12/2014 SSA121 Bed Occupancy RETIRED for 2015-16 01/12/2014
SSA122-SSA125
Connecting Care Program: • Aboriginal people enrolled (number)
• People identified as eligible for 48Hr Follow Up (number) • People identified as eligible for Chronic Care Rehab (number) • People identified as requiring an Aged Care Assessment (ACAT Evaluation Unit) (number)
RETIRED for 2015-16
01/12/2014 SFA104 Cost per NWAU RETIRED for 2015-16 01/12/2014 SFA114 Red Tape Reduction savings RETIRED for 2015-16 01/12/2014 KQS205 Hospital Acquired Pressure Injuries NEW for 2015-16 01/12/2014 SSQ120 Hospital Acquired Venous
thromboembolism NEW for 2015-16 01/12/2014 SIC101, SIC102, SIC103, SIC104 Potentially Preventable Hospitalisations NEW for 2015-16
01/12/2014 SIC105, SIC106
Discharge Summaries: Number and percentage electronically delivered to patient’s General Practitioner (Number and %)
NEW for 2015-16
01/12/2014 PH-013B Quit for New Life Program: Referred to the Quitline
Transferred from Schedule D for 2015-16
01/12/2014 PH-013C Quit for New Life Program: Provided Nicotine Replacement Therapy (NRT)
Transferred from Schedule D for 2015-16
01/12/2014 PH-013D Quit for New Life Program: Booked follow-up Appointment
Transferred from Schedule D for 2015-16
01/12/2014 PH-014A Publically funded Hepatitis C related services – HCV Treatment Assessment
NEW for 2015-16
01/12/2014 SPC102, SPC103
Premium Staff Usage – Medical / Nursing
Updated numerator and denominator definitions.
01/12/2014 SFA112 NAP data completeness: Valid Health Establishment Registration Online identification (%)
RETIRED for 2015-16
01/12/2014 SFA115-SFA117
Wait List Enterprise Data Warehouse data errors, disaggregated by error source
NEW for 2015-16
08/12/2014 SPH002, SPH004
Children fully 7mmunized at four years of age
Updated indicator definition to clarify apparent discrepancy between indicator title and definition. 10/02/2015 SPC108 Aboriginal Workforce as a
proportion of total workforce
Updated numerator and denominator sources, Documentation of Indicator Source, data collection and data source fields, usable data available from field, applied consistent labeling to Aboriginal people, added note to indicator definition.
10/02/2015 SPC105 Leave Liability: Annual reduction in the total number of days in respect of accrued leave balances of more than 30 days
Updated title and definition of indicator (change from 40 days to 30 days). Updated numerator source, data collection and data source fields, related programs and policies and related national indicators 10/02/2015 KPC201 Staff who have had a performance
review within the last 12 months
Updated data contact, minor revision (clarification) of numerator definition, updated performing, non-performing and under-performing targets. 20/02/2015 SSQ101 Deteriorating Patients – Rapid
Response Calls
Clarified indicator to clear up
reporting of data for both the total as well as reporting for each subgroup. 20/02/2015 SSQ102 Deteriorating patients – unexpected Clarified indicator to clear up
10/03/2015 SSQ115 Restoration Treatment Revised Frequency of Reporting 10/03/2015 SSQ116 Denture remakes – unplanned
returns
Revised Frequency of Reporting
10/03/2015 CC-001 Connecting Care Program: people currently enrolled (number)
MOVED TO SCHEDULE D for 2015-16
12/03/2015 KSA104 National Elective Surgery Target Part 2.2: Average overdue waiting time (days)
RETIRED FOR 2015-16
27/03/2015 SPC101 Workplace Injuries Revised title to align with the actual measure. Minor amendment to indicator definition, exclusions, and usable data available from
27/03/2015 KQS201 ICU Central Line Associated Bloodstream (CLAB) Infections
Changed from KPI to Service Measure, removed target 01/04/2015 SSA108,
SSA109, SSA110
Overdue Elective Surgery Patients Changed from Service Measure to KPI; Minor update to indicator definition, inclusions, and Primary point of collection.
02/04/2015 SSA112 Elective Surgery Theatre Utilisation Corrected numerator definition, updated inclusions, exclusions, related policies/programs 09/04/2015 PH-009 Needles and syringe Program –
Sterile needles and syringes distributed
Updated title (previously “Needles and syringes distribution – in the public sector “) and indicator
definition, related policies/programs, contact – policy, contact – data 09/04/2015 SSQ112,
SSQ113, SSQ125
Unplanned and emergency re-presentations to same ED within 48 hours
Amended numerator definition (removed visit type ‘11’ in the subsequent record criteria). Updated Denominator source and
denominator availability, updated performance area. Added documentation re: calculation of NWAU rate for ABF hospitals as a separate subset.
09/04/2015 SSQ114, SSQ118
Inpatients who were discharged against medical advice
Updated indicator splits, added note to indicator definition, updated time lag to available data, and Business owners.
17/04/2015 KSA103a, KSA103b, KSA103c
Elective Surgery Access Performance: Elective Surgery Patients Treated on Time (%)
Revised title of indicator, reflecting cessation of NEST. Minor updates to numerator definition and Primary point of Collection. Updated targets. 21/04/2015 SSA101,
SSA102
Patients with total time in ED <= 4 hrs
Updated indicator definition, numerator definition, inclusions, Related Policies and Programs 23/04/2015 KSA204 Non-Urgent Patients waiting more
than 365 days for an initial specialist outpatient services appointment
Updated Tier 2 Clinic classification, updated under-performing and non-performing targets.
23/04/2015 SFA101, SFA102
Specialist Outpatient Services (Service Events)
Updated Tier 2 Clinic classification
07/05/2015 KQS206 Mental Health: Acute Seclusion rate
07/05/2015 SSQ121 Mental Health: Outcome Readiness – HoNOS Completion Rates
NEW for 2015-16
07/05/2015 SSQ122 Mental Health Consumer Experience Measure (YES) Completion Rate
NEW for 2015-16
07/05/2015 SSQ123 Mental Health: Average duration of seclusion
NEW for 2015-16
07/05/2015 SSQ124 Mental Health: Frequency of seclusion
NEW for 2015-16
27/05/2015 NA-001 Variation Against Purchased Volume (%) of Non-admitted Patient Service National Weighted Activity Units (NWAUs)
Finalised – updated 2015-16 NWAU details, inclusions and exclusions
05/06/2015 SPC112, SPC113, SPC114
Workplace Injuries: Return to Work Experience
NEW for 2015-16
11/06/2015 SSQ106, SSQ107, SSQ126
Unplanned hospital readmission: all unplanned admissions within 28 days of separation
Major revision to the indicator, including changes to the indicator definition, numerator, denominator, inclusions and exclusions. Updated Denominator source and
denominator availability, updated performance area, and comments. Added documentation re: calculation of NWAU rate for ABF hospitals as a separate subset.
19/06/2015 KSA101 Transfer of Care – patients transferred from Ambulance to ED < 30 minutes (%)
Minor amendment to the title of the indicator – previously “Transfer of care time from ambulance to ED < 30 minutes (%)”
06/07/2015 SSA101 Patients with total time in ED <= 4 hrs – Admitted.
Corrected numerator and inclusions – removed reference to separation modes 2, 3, 12 and 13
06/07/2015 SSA106 Patients with total time in ED <= 4 hrs – Admitted Mental Health.
Corrected numerator and inclusions – removed reference to separation modes 2, 3, 12 and 13
09/07/2015 SFA111 Non-Admitted Patient level data completeness: Patient Level
Updated and clarified denominator definition and calculation
17/07/2015 PH-011B Get Healthy Information and Coaching Service – Health Professional Referrals
Modified target, updated Comments, Context, Related Policies/Programs, Business Owners (Contact Data) and deleted Related National Indicators. 04/08/2015
MHDA-005
Variation against purchased volume (%): Mental Health Non-Admitted Patient (NWAU)
Updated numerator source from WebNAP to CHAMB.
24/08/2015 SSQ122 Mental Health Consumer Experience Measure (YES) Completion Rate
Minor update to numerator & denominator definitions (added community residential to ambulatory; specified non-acute units for
inpatient) 25/08/2015 SIC001, SIC002, SIC003, SIC004 Potentially Preventable
Hospitalisations (Rate per 100,000)
Updated indicator definition to clarify the use of principal diagnosis, confirm ICD codes applicable to 7th, 8th and 9th editions, and clarified where 4th digit codes are included. 26/08/2015 PH-011B Get Healthy Information and
Coaching Service – Health Professional Referrals
Updated target for HNE LHD
28/08/2015 SSA106 Patients with Total time in ED <= 4hrs: Mental health patients admitted (to a ward/ICU/theatre from ED)
MAJOR REVISION – amended title (previously “Patients with Total time in ED <= 4hrs: Admitted to a mental health ward”); amended numerator definition, removing link to bed type, instead identifying the cohort via ED diagnosis; adjusted inclusions. 31/08/2015 PH-010A HIV testing increase within
publicly-funded HIV and sexual health services
Updated targets for WS LHD; updated comments section for SESLHD.
31/08/2015 PH-008A Healthy Children’s Initiative - Children’s Healthy Eating and Physical Activity Program (centre based children’s service sites) - Adopted
Updated 30 June 2016 target from 80% to 70%
31/08/2015 PH-008B Healthy Children’s Initiative - Children’s Healthy Eating and Physical Activity Program (primary school sites) - Adopted
Updated 30 June 2016 target from 80% to 70%
31/08/2015 PH-014A Publicly Funded Hepatitis C Related Services - Hepatitis C Virus (HCV) Treatment Assessment
Updated target, removing reference to a 10% increase.
03/09/2015 KSA101 Transfer of Care – patients transferred from Ambulance to ED <= 30 minutes
Updated indicator name and
numerator to clarify what is meant by within 30 minutes.
03/09/2015 KSA201 ED Presentations staying in ED > 24 hours
Updated indicator definition to clarify relevant modes of separation. Updated target period from annually to monthly.
03/09/2015 KSA202 ED Presentations staying in ED > 24 hours (Mental Health)
Updated target period from annually to monthly.
SUMMARY OF KEY PERFORMANCE INDICATORS AND SERVICE MEASURE
TARGETS ... 14
Summary of Indicators and Targets for 2015-16 Service Agreements ... 16
SAFETY AND QUALITY – TIER 1 ... 22
Staphylococcus aureus bloodstream infections (SA-BSI): ... 22
SAFETY AND QUALITY – TIER 2 ... 24
Patient Experience Survey – Adult Admitted Patients: overall rating of care (%) ... 24
Hospital Acquired Pressure Injuries: Stage 3, 4 and Unstageable pressure injuries (number) ... 26
Mental Health: Acute Readmission within 28 days (%) ... 29
Mental Health: Acute Post Discharge Community Care ... 32
Mental Health: Acute Seclusion rate (number) ... 36
SAFETY AND QUALITY – SERVICE MEASURES ... 38
Deteriorating Patients – Rapid Response Calls ... 38
Deteriorating patients – unexpected cardiopulmonary arrest rate ... 41
Unplanned hospital readmission rates for patients discharged following management of targeted conditions (%) ... 44
ICU Central Line Associated Bloodstream (CLAB) Infections (Number) ... 48
Incorrect Procedures: Operating Theatre ... 50
Hospital Acquired Venous Thromboembolism (rate per 1000 separations) ... 52
Inpatients who were discharged against medical advice (%) ... 56
Restoration treatment ... 59
Denture remakes – unplanned returns:... 62
Patient Experience Survey – Emergency Department Patients: overall rating of care (%) 64 Mental Health: Outcome Readiness – HoNOS Completion Rates (%) ... 66
Mental Health Consumer Experience Measure (YES) Completion Rate (%) ... 70
Mental Health: Average duration of seclusion (number) ... 73
Mental Health: Frequency of seclusion (%)... 75
SERVICE ACCESS AND PATIENT FLOW – TIER 1 ... 77
Transfer of Care – patients transferred from Ambulance to ED <= 30 minutes (%) ... 77
Emergency Treatment Performance: Patients with Total time in ED <= 4hrs (%) ... 80
Elective Surgery Access Performance: Elective Surgery Patients Treated on Time (%) .. 84
ED presentations treated within benchmark times (%) ... 101
Elective Surgery: Activity change YTD compared to previous (number) ... 104
Elective Surgery Theatre Utilisation: Operating Room Occupancy (%) ... 106
Surgery for Children - Proportion of children (0 to 16 years) treated within their LHD of residence: ... 108
Average Length of Episode Stay - Overnight Patients (days) ... 110
Acute to Aged-Related Care Services (AARCS) patients seen (number) ... 112
Aged Care Services in Emergency Teams (ASET) patients seen (number)... 114
Breast Screen Participation Rates: ... 116
INTEGRATED CARE – SERVICE MEASURES ... 119
Unplanned hospital readmission: all unplanned admissions within 28 days of separation (%): ... 119
Unplanned and emergency re-presentations to same ED within 48 hours (%) ... 123
Hospital in the home: ... 126
Potentially Preventable Hospitalisations (Rate per 100,000) ... 128
Discharge Summaries: Number and percentage electronically sent to patient’s General Practitioner (Number and %) ... 133
FINANCE AND ACTIVITY – TIER 1 ... 135
Variation against purchased volume (%) Acute Inpatient Services (NWAU) ... 135
Variation against purchased volume (%) Emergency Department Services (NWAU) ... 137
Variation against purchased volume (%) sub and non-acute inpatient services (NWAU) 139 Variation Against Purchased Volume (%) of Non-admitted Patient Service National Weighted Activity Units (NWAUs)... 141
Variation against purchased volume (%) Mental Health Acute Inpatient Services (NWAU) ... 146
Variation against purchased volume (%): Mental health Inpatient Activity Non Acute Inpatients (NWAU) ... 148
Expenditure Matched to Budget:... 150
Own Source Revenue Matched to Budget: ... 152
Recurrent Trade Creditors ... 154
Small Business Creditors... 156
FINANCE AND ACTIVITY – TIER 2 ... 158
Variation against purchased volume (%): Mental Health Non-Admitted Patient (NWAU) 158 Variation against purchased volume (%) Public Dental Clinical Service (DWAU)... 160
FINANCE AND ACTIVITY – SERVICE MEASURES ... 163
Specialist Outpatient Services (Service Events) (Number) ... 163
Patient Fee Debtors... 166
Coding timeliness (%) ... 168
ED Records unable to be grouped: ... 170
PEOPLE AND CULTURE – TIER 2 ... 181
Staff who have had a performance review within the last 12 months ... 181
PEOPLE AND CULTURE – SERVICE MEASURES ... 184
Workplace Injuries: Claims (rate per 100 FTEs) ... 184
Workplace Injuries: Return to work experience (days): ... 186
Premium staff usage: average paid hours per FTE ... 188
Leave Liability: Annual reduction in the total number of days in respect of accrued leave balances of more than 30 days ... 190
Recruitment: Improvement on baseline average time taken from request to recruit to decision to approve/decline/defer recruitment (days) ... 192
Aboriginal Workforce as a proportion of total workforce (%) ... 194
YourSay Staff Culture Survey Results ... 197
POPULATION HEALTH – TIER 2 ... 199
HIV testing increase within publicly-funded HIV and sexual health services (%) ... 199
Get Healthy Information and Coaching Service – Health Professional Referrals (% increase) ... 201
POPULATION HEALTH – SERVICE MEASURES ... 203
Quit for new life program: ... 203
Publicly Funded Hepatitis C Related Services - Hepatitis C Virus (HCV) Treatment Assessment (Number) ... 206
Healthy Children’s Initiative - Children’s Healthy Eating and Physical Activity Program (centre based children’s service sites) - Adopted (% cumulative) ... 208
Healthy Children’s Initiative - Children’s Healthy Eating and Physical Activity Program (primary school sites) - Adopted (% cumulative) ... 211
Needle and Syringe Program – Sterile needles and syringes distributed (Number) ... 214
Children fully immunised at one year of age: ... 216
Children fully immunised at four years of age: ... 218
Human papillomavirus vaccine: ... 220
Antenatal visits for mothers of Aboriginal babies: ... 222
SUMMARY OF KEY PERFORMANCE INDICATORS AND SERVICE ME AS URE TARGETS
The NSW Performance Framework (PF) applies to the 15 geographical NSW Local Health Districts, the
Ambulance Service NSW, Sydney Children’s Hospitals Network, the St Vincent’s Health Network, the
Forensic Mental Health Network and Justice Health. In this document, these organisations are referred to
collectively as Health Services, except where particular reference to Local Health Districts is required.
The definitions provided in this document will assist Health Services and other data users with the
calculation and interpretation of the Key Performance Indicators and Services Measures referenced in the
Service Agreements for 2015-16. It should be noted that some KPIs may be calculated differently when
applied to different purposes outside the management of the Service Agreements. The KPIs and Service
Measures contained in this document have been defined specifically with the intent to meet the reporting
requirements under 2015-16 agreements and to align to the Ministry of Health’s monthly performance
monitoring reports. Should you require further assistance with the definitions or have comments regarding
them please contact either the Health System Information & Performance Reporting Branch or the
Data/Policy contacts listed in the KPI documentation.
The Service Agreement is a key component of the Performance Framework for Health Services –
providing a clear and transparent mechanism for assessment and improvement of performance. The
Service Agreement document covers both the Tier 1 & 2 KPIs and Service Measures.
Key Performance Indicators (KPIs), if not met, may contribute to escalation under the Performance
Framework processes. Performance against these KPIs will be reported regularly to Health Services in
the Health System Performance Report prepared by the Department. These KPIs have been designated
into two categories:
•
Tier 1 - Will generate a performance concern when the organisation’s performance is outside the
tolerance threshold for the applicable reporting period.
•
Tier 2 - Will generate a performance concern when the organisation’s performance is outside the
tolerance threshold for more than one reporting period.
Service Measures: A range of Service Measures are identified to assist the organisation to improve
provision of safe and efficient patient care and to provide the contextual information against which to
assess performance.
Note that the KPIs and Service Measures listed above are not the only measures collected and monitored
by the NSW Health System. A range of other measures are used for a variety of reasons, including
monitoring the implementation of new service models, reporting requirements to NSW Government
central agencies and the Commonwealth, and participation in nationally agreed data collections.
Relevant measures specified in the National Health Reform Performance and Accountability Framework,
and in NSW 2021: A Plan to Make NSW Number One, have been assigned as NSW Health KPIs, Service
Measures or Monitoring Measures, as appropriate.
This year the KPIS and Service Measures are grouped under the six reporting domains of:
•
Safety and Quality
•
Service Access and Patient Flow
•
Integrated Care
•
Finance and Activity
•
People and Culture
•
Population Health
whether it is meeting the performance targets for individual KPIs:
Highly Performing - Performance at, or better than, target
Underperforming - Performance within a tolerance range
Not performing - Performance outside the tolerance threshold
As in previous years, the 2015-16 KPI and Service Measure data elements are also located on the NSW
Health Information Resource Directory and are accessible via the following link: TBA
Each individual indicator and service measure may be viewed and downloaded via this portal. Further,
additional documentation (where available) for each of the indicators and service measures (such as
specific identification of which fields from the data warehouse are used for the calculation, sample .sas
code, detailed calculation formulae, etc) may be found under the “Ext Info” tab for each individual
indicator and service measure, which may be downloaded as well.
The following table below provides a summary of the performance measures and targets against the Tier
1 & 2 KPIs as well as listing the Service Measures for each of the domains.
Summary of Indicators and Targets for 2015-16 Service Agreements
ID Key Performance Indicator Target
Not Performing X Under Performing Performing Safety and Quality
KQS 101
Tier 1
Staphylococcus aureus bloodstream infections (SA-BSI) (per 10,000 occupied bed days) < 2 > 2.0 N/A < 2 SSQ 117 Tier 2
Patient Experience Survey following treatment: Overall care received - good and very good (%)
Increase Decrease from previous Year No change Increase from previous Year KQS 205 Tier 2
Hospital acquired pressure injuries (rate per 1,000 completed inpatient stays) Decrease Increase from previous Year No change Decrease from previous Year KQS 203 Tier 2
Mental Health: Acute readmission
within 28 days (%) < 13 > 20 > 13 and < 20 < 13 KQS 204 Tier 2
Mental Health: Acute Post-Discharge Community Care - follow up within seven days (%)
> 70 < 50 > 50 and < 70 > 70 KQS 206 Tier 2
Mental Health: Acute Seclusion
rate (episodes per 1,000 bed days) < 6.8 > 9.9
> 6.8 and
< 9.9 < 6.8 Service Access and Patient Flow
KSA 101
Tier 1
Transfer of Care – patients
transferred from Ambulance to ED < 30 minutes (%) > 90 < 80 > 80 and < 90 > 90 KSA 102 Tier 1 Emergency Treatment
Performance - Patients with total time in ED <= 4 hrs (%) > 81 < 71 > 71 and < 81 > 81 KSA 201 Tier 2 Presentations staying in ED > 24
hours (number) 0 >5 >1 and <5 0
Elective Surgery Access Performance: Elective Surgery Patients Treated on Time (%):
KSA 103a Tier 1 • Category 1 100 < 100 N/A 100 KSA 103b • Category 2 > 97 < 93 > 93 and < 97 > 97 KSA 103c • Category 3 > 97 < 95 > 95 and < 97 > 97
ID Key Performance Indicator Target Not Performing X Under Performing Performing Service Access and Patient Flow
Overdue Elective Surgery Patients (number)
SSA 108 Tier 1 • Category 1 0 > 1 N/A 0 SSA 109 • Category 2 0 > 1 N/A 0 SSA 110 • Category 3 0 > 1 N/A 0 KSA 202 Tier 2
Mental Health: Presentations
staying in ED > 24 hours (number) 0 > 5 > 1 and < 5 0
KSA 204
Tier 2
Non-Urgent Patients waiting > 365 days for an initial specialist outpatient services appointment (Number) 0 Increase from previous Year Decrease from previous Year 0
Finance and Activity
Variation against purchased volume (%)
AI-001 Tier 1 Acute Inpatient Services (NWAU)
See Schedule D > +/- 2.0 variation from target +/ >1.0 -<2.0 variation from target +/- 1.0 variation from target ED-001 Tier 1
Emergency Department Services (NWAU) See Schedule D > +/- 2.0 variation from target +/ >1.0 -<2.0 variation from target +/- 1.0 variation from target SA-001 Tier 1
Sub and Non Acute Inpatient Services (NWAU) See Schedule D > +/- 2.0 variation from target +/ >1.0 -<2.0 variation from target +/- 1.0 variation from target NA-001 Tier 1
Non Admitted Patient Services – Tier 2 Clinics (NWAU) See Schedule D > +/- 2.0 variation from target +/ >1.0 -<2.0 variation from target +/- 1.0 variation from target MHD A-001
Tier 1 Mental Health Inpatient Activity Acute Inpatients (NWAU) See Schedule D > +/- 2.0 variation from target +/- >1.0 -< 2.0 variation from target +/- 1.0 variation from target
ID Key Performance Indicator Target Not Performing X Under Performing Performing Finance and Activity
Expenditure matched to budget (General Fund):
KFA 101
Tier 1
a) Year to date - General Fund (%) On budget or Favourable > 0.5 Unfavourable > 0 but < 0.5 Unfavourable On budget or Favourable KFA 102 Tier 1
b) June projection - General Fund (%) On budget or Favourable > 0.5 Unfavourable > 0 but < 0.5 Unfavourable On budget or Favourable
Own Source Revenue Matched to budget (General Fund):
KFA 103
Tier 1
a) Year to date - General Fund (%) On budget or Favourable > 0.5 Unfavourable > 0 but < 0.5 Unfavourable On budget or Favourable KFA 104 Tier 1
b) June projection - General Fund (%) On budget or Favourable > 0.5 Unfavourable >0 but < 0.5 Unfavourable On budget or Favourable Liquidty: KFA 105 Tier 1
Recurrent Trade Creditors > 45 days correct and ready for payment ($) 0 > 0 N/A 0 KFA 106 Tier 1
Small Business Creditors paid within 30 days from receipt of a correctly rendered invoice (%)
100 < 100 N/A 100
People and Culture KPC
201
Tier 2
Staff who have had a
performance review (%) 100 < 85 > 85 and < 90 > 90 Population Health PH-010A Tier 2
HIV testing increase within publicly-funded HIV and sexual health services (% increase) See Schedule D > 5.0 % variation below Target < 5.0 % variation below Target Met or exceeded Target PH-011B Tier 2
Get Healthy Information and Coaching Service – Health Professional Referrals (% increase) See Schedule D > 10.0 % variation below Target < 10.0 % variation below Target Met or exceeded Target
SSQ101 SSQ102
Deteriorating Patients (rate per 1,000 separations): • Rapid response calls
• Cardio respiratory arrests
SSQ108 SSQ109 SSQ110 SSQ111
Unplanned hospital readmission rates (%) for patients discharged following management of: • Acute Myocardial Infarction
• Heart Failure
• Knee and hip replacements
• Pediatric tonsillectomy and adenoidectomy
KQS201 ICU Central Line Associated Bloodstream (CLAB) Infections (number)
KQS202 Incorrect procedures: Operating Theatre - resulting in death or major loss of function (number)
SSQ120 Hospital Acquired Venous thromboembolism (rate per 1000 separations)
SSQ114 SSQ118
Inpatients who were discharged against medical advice (%): • Aboriginal
• Non-Aboriginal
SSQ115
Re-treatment following restorative treatment: Number of permanent teeth re-treated within 6 months of an episode of restorative treatment. Performance target: less than 6% (less than 6 teeth re-treated per 100 teeth restored).
SSQ116 Denture remakes: Number of same denture type (full or partial) and same arch remade within 12
months. Performance target: less than 3% (less than 3 per 100 dentures).
SSQ119 Patient Experience Survey – Emergency Department Patients: Overall rating of care
(Percentage of patients rating care as “good” or “very good”) (%)
SSQ121 SSQ122 SSQ123 SSQ124
Mental Health:
• Outcomes readiness (HoNOS completion rates) (% of mental health episodes with completed HoNOS outcome measures)
• Consumer Experience Measure (YES) Completion Rate (% of episodes) • Average duration of seclusion (Hours)
• Frequency of seclusion (% of acute mental-health admitted care episodes with seclusion)
Service Access and Patient Flow
SSA101SSA102 SSA106
Patients with total time in ED <= 4 hrs (%): • Admitted (to a ward/ICU/theatre from ED) • Not Admitted (to an Inpatient Unit from ED)
• Mental Health Patients (admitted to a ward from ED)
SSA104
ED attendances treated within benchmark times (%): • Triage 1
• Triage 2 • Triage 3 • Triage 4 • Triage 5
SSA126 SSA127 SSA128 SSA129 SSA130 SSA131
Breast Screen Participation Rates, disaggregated by Aboriginality and cultural and linguistic diversity (%): • Women, aged 50-69 • Women, aged 70-74
Integrated Care
SSQ106 SSQ107 SSQ126Unplanned hospital readmissions: all admissions within 28 days of separation (%): • All persons
• Aboriginal persons
• ABF hospitals (rate in NWAU)
SSQ112 SSQ113 SSQ125
Unplanned and Emergency Re-Presentations to same ED within 48 hours (%): • All persons
• Aboriginal persons
• ABF hospitals (rate in NWAU)
PI-03
Hospital in the Home: • Admitted activity (%)
SIC001 Potentially Preventable Hospitalisations (Rate per 100,000 population)
SIC002 Discharge Summaries: Number and percentage electronically delivered to patient’s General Practitioner (Number and %)
Finance and Activity
SFA101SFA102
Specialist Outpatient Services (Service events) • Initial
• Subsequent
SFA103 Patient Fee Debtors > 45 days as a percentage of rolling prior 12 months Patient Fee Revenues
(%)
SFA105 Coding timeliness: % uncoded acute separations
SFA106 SFA107 SFA108 SFA109
ED records unable to be grouped:
• to URG with a breakdown for error codes: E1, E2, E3, E6, E7 and E8 (number and %) • to UDG with a breakdown for error codes: E1 and E2 (number and %)
SFA111
NAP data completeness: • Patient Level (%)
SFA115 SFA116 SFA117
Wait List Enterprise Data Warehouse data errors, reported separately and disaggregated by error source (%):
• Source System error (issues related to the EDW extract or mappings defects) • Data collection error (issues related to the actual data collected or reported) • System Vendor error (issues related to source system defects)
SFA113 Sub and Non Acute Inpatient Services - Grouped to an AN-SNAP class (%)
People and Culture
SPC101 SPC112 SPC113 SPC114
Workplace injuries:
• Claims (rate per 100 FTEs)
• Return to work experience - Continuous Average Duration (days)
SPC102 SPC103
Premium staff usage - average paid hours per FTE (Hours): • Medical
days (Number)
SPC107 Recruitment: improvement on baseline average time taken from request to recruit to decision to
approve/decline recruitment (days)
SPC108 Aboriginal Workforce as a proportion of total workforce (%)
SPC109 SPC110 SPC111
YourSay Survey (%):
• Estimated Response Rate • Engagement Index • Workplace Culture Index
Population Health
PH-013B PH-013C PH-013D
Quit for New Life Program (%) • Referred to the Quitline
• Provided Nicotine Replacement Therapy (NRT) • Booked follow-up Appointment
PH-014A Publically funded Hepatitis C related services – HCV Treatment Assessment (Number)
PH-008A Healthy Children’s Initiative - Children’s Healthy Eating and Physical Activity Program (centre based children’s service sites) - Adopted (% cumulative)
PH-008B Healthy Children’s Initiative - Children’s Healthy Eating and Physical Activity Program (primary school sites) - Adopted (% cumulative)
PH-009 Needle and Syringe Program – Sterile needles and syringes distributed (Number)
SPH003 SPH001 SPH004 SPH002
Children fully immunised (%)
• At one year of age: Non- Aboriginal children • At one year of age: Aboriginal children • At four years of age: Non- Aboriginal children • At four years of age: Aboriginal children
PH-006 Human papillomavirus vaccine – year 7 students receiving the third dose through the NSW
Adolescent Vaccination Program (%)
SPH005 SPH006
First comprehensive antenatal visit provided < 14 weeks gestation for all women who: • Identify the baby as Aboriginal
• Identify the baby as Non-Aboriginal
PH-013a SPH007
Women who smoked at any time during pregnancy (%): • Aboriginal women
S AFETY AND QUALITY – TIER 1
INDICATORS: KQS101
Previous IDs: 9A15, 9A16,
0005
Staphylococcus aureus bloodstream infections (SA-BSI):
• A1 – C2 facilities (per 10,000 occupied bed days) • D1a – F8 facilities (per 10,000 occupied bed days) Service Agreement Type
Performance Area Status
Version number
Key Performance Indicator Safety and Quality (Tier 1) Final
1.1
Scope All patients in hospitals
Goal To minimize the risks and unnecessary morbidity and mortality from healthcare associated infections (HAI) in NSW public healthcare facilities through
implementation of infection control practices.
Desired outcome Reduction in the number of Staphylococcus aureus bloodstream infections
Primary point of collection Health staff in all NSW public healthcare facilities
Data Collection Source/System HAI Monthly Data Collection, NSW Health Primary data source for
analysis HAI Monthly Data Collection, NSW Health
Indicator definition The number of SA-BSI as a rate of the number of occupied bed days Numerator
Numerator definition Number of Staphylococcus aureus bloodstream infections (SA-BSI)
Numerator source NSW public healthcare facilities
Numerator availability Monthly, available from 1 January 2009 Denominator
Denominator definition Number of occupied bed days
Denominator source Health System Information and Performance Reporting Branch, NSW Health Denominator availability Monthly
Inclusions • Healthcare associated inpatient bloodstream infections caused by
Staphylococcus aureus:
- Methicillin sensitive Staphylococcus aureus (MSSA) - Methicillin resistant Staphylococcus aureus (MRSA)
• Healthcare associated non-inpatient MSSA and MRSA bloodstream infections
Exclusions • Community associated MSSA and MRSA bloodstream infections
Next report due Monthly from data availability
Targets
Target Less than or equal to 2 SA-BSI per 10,000 occupied bed days
hygiene and aseptic technique requirements.
Context • Staphylococcus aureus, a bacterium that commonly colonises human skin
and mucosa, is amongst the commonest and more serious causes of community and healthcare associated sepsis.
• Incidence of healthcare associated SA-BSI is used as an outcome marker for hand hygiene compliance of healthcare workers.
Related Policies/ Programs • NSW Health Hand Hygiene Policy
• Healthcare Associated Infection: Clinical Indicator Manual, version 2.0 November 2008
Useable data available from 2009 Frequency of Reporting Monthly
Time lag to available data Reporting data available one month post last reporting period Business owners Clinical Excellence Commission
Contact - Policy Director, Clinical Governance, Clinical Excellence Commission (Dr Paul Curtis) Contact - Data Director, Clinical Governance, Clinical Excellence Commission (Dr Paul Curtis),
and
Executive Director, Health System Information and Performance Reporting (Dr Zoran Bolevich)
Representation
Data type Numeric
Form Number, presented as a rate per 10,000 occupied bed days
Representational layout X.X
Minimum size 1
Maximum size 2
Date effective January 2009
Related National Indicator
Indicators National Healthcare Agreement: PI 22-Healthcare associated infections, 2015
http://meteor.aihw.gov.au/content/index.phtml/itemId/559022
Meteor ID: 559022
S AFETY AND QUALITY – TIER 2
INDICATOR:
SSQ117
Previous IDs: 9A20, 9A21
Patient Experience Survey – Adult Admitted
Patients: overall rating of care (%)
Percentage of patients rating care as “good” or “very good”
Service Agreement Type Performance Area Status
Version number
Key Performance Indicator Safety and Quality (Tier 2) Final
5.0
Scope Sample of adult patients who are admitted to hospitals in peer groups A1, A3, B, C1 and C2. These hospitals contribute to the LHD total in
proportion to the total number of admitted patients for all A1, A3, B, C1 and C2 hospitals in that LHD.
Goal Improve patients’ experience of care
Desired outcome Increase proportion of patients rating their overall care as “good” or “very good”
Primary point of collection Postal survey of recent admitted patients with up to two reminders and alternative completion online
Data Collection Source/System NSW Patient Survey Program data
Primary data source for analysis Responses to Adult Admitted Patient Survey
Indicator definition Weighted percentage of survey respondents who rate their overall care as “good” or “very good”.
Numerator
Numerator definition Number of survey respondents who rate their overall care as “good” or “very good”
Data are weighted to represent the age and stay type (overnight or same day) profile of patients at each hospital.
Numerator source NSW Patient Survey Program data
Numerator availability Available
Denominator
Denominator definition Total number of survey respondents answering this question.
Data are weighted to represent the age and stay type (overnight or same day) profile of patients at each hospital.
Denominator source NSW Patient Survey Program data
Denominator availability Available
Inclusions All patients surveyed during the target period.
Facilities in peer groups A1, A3, B, C1 and C2
Patients aged 17 years or older until Dec 2013, then 18 years or older from Jan 2014 onwards
Valid Australian postal address
Exclusions • As per inclusions above
• Same day admissions less than 3 hours
• Same day episodes with a mode of separation of transfer
• Maternity admissions (incl. stillbirths, miscarriages and termination of pregnancy procedures)
• Patients treated for contraceptive management • Haemodialysis patients
• Admitted patients treated in a mental health setting • Maltreatment codes (incl. sexual and physical abuse) • Patients that have died
Targets
Target Increase over previous year.
Context Health services should not only be of good clinical quality but should also
provide a positive experience for the patient.
Related Policies/ Programs
Useable data available from Quarterly data is available for January to March 2013 onwards. Previous
data from 2007-2011 exists however direct comparisons are not advisable due to changes in the question wording.
Frequency of Reporting Quarterly reporting at LHD level
Time lag to available data Eight months from the end of each quarter
Business owners Directorate, Patient Based Care, Clinical Excellence Commission
Contact - Policy Directorate, Patient Based Care, Clinical Excellence Commission
Contact - Data Director Surveys and Quarterly Reports, Bureau of Health Information
Representation
Data type Numeric
Form Number, presented as a percentage
Representational layout NNN
Minimum size 1
Maximum size 3
Data domain
Date effective 2014
INDICATOR: KQS205
Previous IDs:
Hospital Acquired Pressure Injuries: Stage 3, 4
and Unstageable pressure injuries (number)
Service Agreement TypePerformance Area Status
Version number
Key Performance Indicator Safety and Quality (Tier 2) Final
1.0
Scope All overnight inpatients in public hospitals
Goal To minimize the number and severity of hospital acquired pressure injuries in NSW public health facilities through promotion of a
comprehensive, systematic approach to pressure injury prevention and management.
Desired outcome Improved quality and safety processes by timely risk assessment which guides prevention strategies and management of existing pressure injuries, resulting in a reduction in the number and severity of hospital acquired pressure injuries.
Primary point of collection Patient Medical Record
Data Collection Source/System Hospital PAS systems, Admitted Patient Data Collection
Primary data source for analysis HIE
Indicator definition The rate of age standardized overnight admitted patient stays with stage 3, 4 and Unstageable hospital acquired pressure injuries within a financial year.
Numerator
Numerator definition The total number of stage 3, 4 and Unstageable hospital acquired pressure injuries, disaggregated by pressure injury stage.
Stage 3, 4 and Unstageable hospital acquired pressure injuries are identified where:
• ICD10AM 9th edition codes L89.2x, L89.3x, and L89.4x are
recorded; AND
• Condition Onset Flag is set to ‘1’, OR
• The ‘condition onset flag’ is “9” AND the condition is NOT a principal diagnosis code.
Numerator source HIE
Numerator availability Available
Denominator
Denominator definition The total number of completed inpatient stays with separation dates within the reporting period
Denominator source HIE
Denominator availability Available
Inclusions • Stays where the presence of a pressure injury is not specified as
numbers.
Exclusions • Pressure injuries present on admission (Community acquired
pressure injuries). • Same day inpatient stays.
Targets
Target Reduction from the previous financial year’s rate of hospital acquired
pressure injuries.
Performing: Reduction from the previous financial year’s rate of hospital acquired pressure injuries.
Under performing: No change from the previous financial year’s rate of hospital acquired pressure injuries.
Not performing: Increase on the previous financial year’s rate of hospital acquired pressure injuries.
Context The rate of hospital acquired pressure injury varies between patient
populations. Facilities with a low hospital acquired pressure injury rate may be able to demonstrate good preventative practices; facilities with a high hospital acquired pressure injury rate may indicate a problem with clinical care and risk assessment processes
Related Policies/ Programs • NSW Health Pressure Injury Prevention and Management policy PD 2014_007 sets out best practice for the prevention of pressure injuries
• NSQHSS – Standard 8 Preventing and Managing Pressure Injuries • CEC Pressure Injury Prevention Project
Useable data available from 1 September 2015 Frequency of Reporting Monthly
Time lag to available data 1 month
Business owners Clinical Excellence Commission
Contact - Policy Director, Clinical Governance, Clinical Excellence Commission (Dr Paul
Curtis)
Contact - Data Executive Director, Health Systems Information and Performance
Reporting (Dr Zoran Bolevich)
Representation
Date effective 1 July 2015
Related National Indicator
INDICATOR: KQS203
Previous IDs: 0008, 9A9
Mental Health: Acute Readmission within 28 days
(%)
Service Agreement Type Performance Area Status
Version number
Key Performance Indicator Safety and Quality (Tier 2) Final
3.0
Scope Mental health Services
Goal To reduce the number of acute public sector mental health readmissions to same or another public sector acute mental health unit within 28 days of discharge.
Desired outcome Improved mental health and well-being through effective inpatient care and adequate and proper post-discharge follow up in the community.
Primary point of collection Administrative and clinical staff at designated facilities (including stand-alone psychiatric hospitals) with mental health units/beds.
Data Collection Source/System Inpatient data: Patient Administration Systems.
Primary data source for analysis Admitted Patient Data Collection - HIE/IQ server; State Unique Patient Identifier (SUPI) - HIE/IQ server.
Indicator definition Percentage of overnight separations from a NSW acute Mental Health unit followed by an overnight readmission to any NSW acute Mental Health unit within 28 days.
Numerator
Numerator definition Overnight separations from a NSW mental health acute psychiatric inpatient unit(s) occurring within the reference period, that are followed by an overnight readmission to the same or another acute psychiatric inpatient unit within 28 days.
Numerator source Admitted Patient Data Collection (NSW HIE).
Readmission between facilities detected by (i) SUPI where available or
(ii) Local identifier (combination of facility identifier and person identifier) where SUPI not available.
Numerator availability Availability of Admitted Patient data is good; however, time must be allowed for readmissions to occur and be recorded in systems.
Numerator is therefore only available after a lag of 3 months, e.g. a June report will measure readmissions following separations in March. Since 2007/2008, SUPI coverage has been close to 99% for separations from NSW mental health inpatient units.
Denominator availability Available.
Inclusions Numerator: Overnight separations, where the last ward is a designated
acute mental health unit, which are followed by an overnight admission to any designated acute mental health unit within 28 days.
Exclusions
Denominator: Separations following overnight acute care where the last
ward is a designated acute mental health unit.
Denominator:
• Excludes separations where “mode of separation” = death (6, 7), discharge at own risk (2) transfer (4, 5) or type change (9). • Excludes same day separations. This exclusion applies to each
separation in the denominator and any subsequent readmission. • Separations where the purpose of admission was for
maintenance ECT and length of stay is one night only. This exclusion applies to each separation in the denominator and any subsequent readmission.
Target
Comment
Less than or equal to 13% (10% for readmission to same facility and 3% readmission to other facility/Area).
Performing: <= 13%
Under Performing: > 13% and < 20% Not Performing: >= 20%
The methodology for constructing this indicator was revised in August 2008. The revision was followed by the publication of a Technical Report describing the rationale and methodology for the revised indicator which was distributed widely in AHS and the Department (MHDAO).
An electronic copy of the report, “Technical Paper: Transition to a Revised 28 Day Readmission Indicator for Mental Health, November 2008”, based on the definitions and methodology published in the National Mental Health KPIs (November 2004), is available from Associate Director Performance Analysis and Reporting, InforMH (Tel: 02 8877 5121).
In September 2012, the Technical Paper was revised. The revised “Technical Paper: Revised Acute 28 Days Readmission, Indicator for
Mental Health 2005/2006 – 2011/201” is based on the new definitions
and methodology published in the National Mental Health KPIs (second edition 2011). An electronic copy is available from Associate Director Performance Analysis and Reporting, InforMH (Tel: 02 8877 5121).
Context Readmission to Hospital within 28 days of discharge has become one of
the most widely used Key Performance Indicators in Australian health care.
Within mental health care, 28 Day Readmission is reported in all Australian jurisdictions. The Australian national mental health KPI set
includes the indicator in the domains of effectiveness and continuity, stating “high levels of readmissions within a short timeframe are widely regarded as reflecting deficiencies in inpatient treatment and/or follow-up care and point to inadequacies in the functioning of the overall system”.
Source: Key Performance Indicators for Australian Public Mental Health Services, second edition 2011. Australian Govt, Canberra. P 29.
Related Policies/ Programs The NSW Health Policy Directive “Transfer of Care from Mental Health Inpatient Services” (PD2012_060), articulates the roles and
responsibilities for safe, efficient and effective transfer of care between inpatient settings and from hospital to the community. The policy aims to address two key state targets to improve mental health outcomes:
• Reduce re–admissions within 28 days to any facility
• Increase the rate of community follow–up within 7 days from a NSW public mental health unit
Useable data available from Financial year 2002/03
Frequency of Reporting Monthly: HSP report; Biannual: NSW MH Performance Report;
Annual/Financial: NSW Health Annual Report, NSW 2021, COAG Health
Council, National Healthcare Agreement (NHA) Performance Indicator Report.
Time lag to available data Admitted Patient reporting is required by the 13th calendar day of each month for previous month. Data available in HIE/IQ Server by following Tuesday.
Business owners
Contact - Policy Director, Mental Health and Drug & Alcohol Office (Peter Carter; Tel: 02 9391 9262)
Contact - Data Associate Director Performance Analysis and Reporting, InforMH
(Sharon Jones; Tel: 02 8877 5121)
Representation
Data type Numeric
Form Number, presented as a percentage (%)
Representational layout NNN
Minimum size 1
Maximum size 3
Data domain HIRD (Health Information Resource Directory), Indicator specifications in