dhb non-financial quarterly reporting for 2010/11 · web viewprior to 2010/11, the dhb...

2016/17District Health Board (DHB) Non-Financial Quarterly Reporting

DHB Guide to DHB Non-Financial Quarterly Reporting Process and Assessments

Update: 14 Dec 2016

Contents1. Introduction.......................................................................................................................................................32. 2016/17 Monitoring Framework........................................................................................................................4

2.1. Overview...................................................................................................................................................42.2. Indicators in the framework......................................................................................................................4

3. Crown Funding Agreement (CFA) variation reporting........................................................................................54. Process for Quarterly Reporting.........................................................................................................................65. Timeframes........................................................................................................................................................7

5.1. Standard timeframe 2016/17....................................................................................................................85.2. Delayed health target timeframe 2016/17................................................................................................9

6. DHB Quarterly Reporting Website...................................................................................................................107. Reporting Templates........................................................................................................................................118. Resources for Reporting...................................................................................................................................129. Assessment Criteria/Ratings............................................................................................................................13

9.1. Health targets & performance measures................................................................................................139.2. CFA Variations.........................................................................................................................................149.3. Initial and Confirmed ratings...................................................................................................................14

10. Poor Performance Reporting...........................................................................................................................1511. Quarterly Performance Dashboards................................................................................................................1712. Contact Information.........................................................................................................................................18Appendix 1: Non-financial performance measure reporting calendar for 2016/17..................................................19Appendix 2: CFA Variation Reporting calendar for 2016/17.....................................................................................20

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1. Introduction As part of their Crown Funding Agreements, DHBs are required to supply the Ministry with regular reports on their non-financial performance. These are submitted on a quarterly basis for the indicators agreed in each DHB’s Annual Plan as part of the 2016/17 monitoring framework.

Section 13.3 of the Ministry’s Operational Policy Framework 2016/171 details the requirement to provide these reports and sets out the process by which these reports are submitted and assessed.

This document details the process for non-financial quarterly reporting, including the types of measures reported on, the two stage assessment process, the reporting timeframes for 2016/17, what the different ratings mean and how DHBs and the Ministry are expected to work together to address issues with reporting.

1 http://nsfl.health.govt.nz/accountability/operational-policy-framework-0/operational-policy-framework-201617

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2. 2016/17 Monitoring Framework 2.1. OverviewPrior to 2010/11, the DHB non-financial monitoring framework was designed primarily to assess DHB contribution towards implementation of the Health Strategies. Cabinet decisions from 2000 directed that the focus be weighted towards key priorities identified in formal strategy documents, with less emphasis on activity, output and impacts monitoring. With the current Government’s increased focus on productivity and value for money, the balance has shifted to an increasingly close interest in DHB provider arm activity. This is due to the high level of financial investment in DHB provider arms and their impact on overall health spending.

The 2016/17 monitoring framework is based on the 2014/15 monitoring framework and is intended to provide the Minister with a rounded view of performance. The four dimensions of DHB performance, that reflect DHBs’ functions as owners, funders and providers of health and disability services are:

Policy Priorities achieving Government’s priority goals/objectives and targets

System Integration meeting service coverage requirements and supporting sector inter-connectedness

Outputs purchasing the right mix and level of services within acceptable financial performance

Ownership providing quality services efficiently.

2.2. Indicators in the frameworkUntil the end of the 2009/10 financial year, non-financial reporting was based on a three tier system of indicators. These were health targets, indicators of DHB performance (IDPs), and additional reporting. With the introduction of the dimensions of performance in 2010/11 and the work done to reduce the reporting burden on DHBs, there are now only two tiers of measures: health targets and performance measures.All health targets are contained within the Policy Priorities dimension and their titles are preceded by the code HT. Performance measures are spread across the Policy Priorities, System Integration, Outputs and Ownership dimensions. The code at the beginning of their title identifies which dimension they fit into, as set out below:

Code Dimension

PP Policy Priorities

SI System Integration

OP Outputs

OS Ownership

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3. Crown Funding Agreement (CFA) variation reporting The non-financial quarterly reporting process is also used to collect and assess reports on CFA variations. This is in line with the Ministerial Review Group’s recommendation in October 2009 to provide more centralised collection of reporting on the accountability arrangements and to reduce the reporting burden.All CFA variations with a reporting component, and created since the 2009/10 year, are required to have their reports collected as part of the non-financial quarterly reporting process. However, there is a small group of CFA variations which will not be reported on via the non-financial quarterly reporting process for the following reasons:

Reporting is done directly to a specific Ministry team (i.e. reports for Very Low Cost Access and Zero Fees for Under Sixes and Under Thirteens are emailed to the Primary Care team)

The reporting is required at specific timeframes that do not align with the quarterly reporting process timelines and which cannot be moved.

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DHB Quarterly Reporting Website

District Health Boards

DHB Quarterly Reporting Database II

2. DHBs submit Quarterly Reports through the website

3. Ministry Initial Assessment rating and feedback

4. DHBs respond to Ministry feedback.

1. Database reset for new quarter and reporting template sent to DHBs

Ministry of Health

5. Ministry provides Confirmed Assessment

Ministry reports sent to the Minister of Health

Copies of Minister’s dashboard reports sent to DHB Chairs and CEOs

4. Process for Quarterly Reporting The DHB Quarterly Non-Financial Reporting process involves two formal rounds of Ministry assessment and feedback on DHB reports against the monitoring framework. The process uses the DHB Quarterly Reporting system which is a web based interface between DHBs and the Ministry.

The process has five main steps:1. The Ministry populates the reporting website with the list of reports required for the quarter, and sends

the reporting template to DHBs2. DHB reporting is uploaded to the site (by the 20th of the month following the end of the quarter)3. DHB reports are assessed by the Ministry and initial ratings and feedback are provided via the website4. DHBs access the initial results and respond to Ministry’s feedback via the website5. The Ministry assesses the responses and supplies a final rating.

The process is the same for each quarter and is set out in Figure One below. Timeframes for each quarter are provided in the Timeframes section of this document.

Figure One: DHB Quarterly Reporting Process Flow Chart

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5. Timeframes The timeframes for each quarter are based on working days from the date specified in section 13.3.1 in the OPF:‘Each DHB will deliver its quarterly report information by the 20th day of the month following the end of a quarter’.This remains the same for each quarter during the year, as set out below.

Step Timeframe

1 Website activated & template sent to DHBs One month before reporting is due

2 DHB Reports Due 20th of the month following the end of the quarter

3 Ministry Initial rating and feedback posted 8-10 working days from receiving reports

4 DHB Response due 5 working days from receiving initial ratings

5 Confirmed rating and feedback posted 4-5 working days from receiving DHB feedback

There are two timeframes for each quarter; the first is the standard timeframe for all reporting, the second is the delayed health target timeframe. This is used for the Electives health target, the CVD health target, the Smoking health target (primary care component) and the Electives CFA variation due to the nature of these measures and the up-to-date data required.

When normal reporting dates fall on non-business days during 2016/17, the due dates have been extended to the next business day. The dates that final PHO PP data will be available are approximate, as the Ministry cannot discount the possibility of delays in the provision of the data by DHB Shared Services.

To ensure that all stages of the reporting process can be completed on time, it is essential that DHBs endeavour to provide complete reports by the due date each quarter. The Ministry will track the proportion of each DHB’s reports that are provided by the due date and assessment reports on the timeliness of DHB reporting will be provided to both the Minister and DHB’s CEO on an exceptional basis when any issues occur. Allowances will be made where the DHB has sought and been granted an extension (prior to the due date) for reports unable to be provided in time.

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5.1. Standard timeframe 2016/17

Quarter One

Website activated & template sent to DHBs Friday, 16 September 2016

DHB Reports Due Thursday, 20 October 2016

Ministry Initial rating and feedback posted Monday, 31 October 2016

DHB Response due Monday, 7 November 2016

Confirmed rating and feedback posted Monday, 14 November 2016

Quarter Two

Website activated & template sent to DHBs Friday, 16 December 2016

DHB Reports Due Friday, 20 January 2017

Ministry Initial rating and feedback posted Tuesday, 31 January 2017

DHB Response due Wednesday, 8 February 2017

Confirmed rating and feedback posted Wednesday, 15 February 2017

Quarter Three

Website activated & template sent to DHBs Friday, 17 March 2017

DHB Reports Due Thursday, 20 April 2017

Ministry Initial rating and feedback posted Monday, 1 May 2017

DHB Response due Monday, 8 May 2017

Confirmed rating and feedback posted Monday, 15 May 2017

Quarter Four

Website activated & template sent to DHBs Friday, 16 June 2017

DHB Reports Due Thursday, 20 July 2017

Ministry Initial rating and feedback posted Tuesday, 1 August 2017

DHB Response due Tuesday, 8 August 2017

Confirmed rating and feedback posted Tuesday 15, August 2017

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5.2. Delayed health target timeframe 2016/17

Quarter One

Final Electives/ Preliminary PHOPP data available to DHBs Tuesday, 1 November 2016 (approximately)

Ministry Initial rating Tuesday, 1 November 2016DHB Response due Monday, 7 November 2016

Final PHO PP available to DHBs Monday, 7 November 2016 (approximately)

Confirmed rating and feedback posted Monday, 14 November 2016

Quarter Two

Preliminary Electives and PHOPP data available to DHBs Tuesday, 31 January 2017 (approximately)

Ministry Initial rating Tuesday, 31 January 2017

Final Elective and PHO PP available to DHBs Tuesday, 7 February 2017 (approximately)

DHB Response due Wednesday, 8 February 2017 Confirmed rating and feedback posted Wednesday, 15 February 2017

Quarter Three

Final Electives/ Preliminary PHOPP data available to DHBs Monday, 1 May 2017 (approximately)

Ministry Initial rating Monday, 1 May 2017 DHB Response due Monday, 8 May 2017

Final PHO PP available to DHBs Monday, 8 May 2017 (approximately)

Confirmed rating and feedback posted Monday, 15 May 2017

Quarter Four

Final Electives/Preliminary PHO PP data available to DHBs Tuesday, 1 August 2017 (approximately)

Ministry Initial rating Tuesday, 1 August 2017

Final PHO PP available to DHBs Monday, 7 August 2017 (approximately)

DHB Response due Tuesday, 8 August 2017Confirmed rating and feedback posted Tuesday 15, August 2017

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6. DHB Quarterly Reporting Website The DHB Quarterly Reporting website is designed to facilitate the process of DHBs reporting to the Ministry. All information on reporting for each quarter can be found on this site, including resources and data sets provided from the Ministry to DHBs. Where some datasets are not contained on the website, links will be provided to other sites where the information is located for reporting purposes.

The website is password protected and log-on information is below.

URL: http://www.moh.govt.nz/apps/dhbq.nsf/Logon?OpenFormUser Name: this is your DHB name (e.g. Auckland)Password: Initially supplied by the Ministry but can be changed.

If you do not know your password, please contact the Ministry’s Quarterly Reporting (Contact details in section 12)

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7. Reporting Templates The reporting template is updated each quarter and provided to DHBs when the website has been activated at the start of each reporting period. The reporting template consolidates all the requirements for reports (health targets, performance measures and CFA variations) that are due to be submitted that quarter.

The order in which these appear in the reporting template reflects how they are set out on the DHB Quarterly Reporting website.

Template DHB Quarterly Reporting Website

Section 3 - Health targets A HT <Health target title>

Sections 4 - 8 - Performance measures B <Performance measure title>

Section 9 - CFA variations C CFA <CFA variation title>

This reporting template also contains: the timetable for the current reporting quarter; any updated changes to reporting requirements for the quarter being reported on; and changes that affect the reporting for the reporting year.

The reporting template can be found in the General Toolkit section of the DHB Quarterly Reporting Website.

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8. Resources for Reporting Resources that are required for reporting include:

Data sets provided from the Ministry Templates for reporting Reporting requirement documentation

The DHB Quarterly Reporting website provides all resource information on reporting for each quarter, including resources and data sets provided from the Ministry to DHBs. Where some datasets are not contained on the website, links will be provided to other sites where the information is located for reporting purposes.

The 2016/17 Performance Measure Technical Definitions, found under Accountability Documents on the Nationwide Service Framework Library (NSFL) website, provide details on the reporting required for each health target and performance measure. Links to related non sensitive data sets and reporting templates will be listed alongside individual technical document (rather than with the larger indicator dictionary for each performance dimension).

DHBs’ nominated contacts for quarterly reporting will be advised by email once data sets are available either on the NSFL or the Quarterly Reporting website for each quarter.

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9. Assessment Criteria/Ratings There are two sets of Assessment Criteria/Ratings for reporting, one for health targets and performance measures, and another for CFA Variations. Both of these are outlined below.

9.1. Health targets & performance measuresProgress towards each target or measure will be assessed and reported to the Minister of Health according to the reporting frequency outlined in the indicator dictionary for each performance dimension (found on the NSFL). Health Target progress will be publicly reported on the Ministry’s website.

A resolution plan, that outlines the actions being taken to address poorer than planned performance, must be supplied where performance is not meeting the agreed expectation. For further information, see Section 10 Poor Performance ReportingIn some cases, specific assessment criteria are set out for each target or measure. These can be found in the relevant pages of the indicator dictionary or the technical definition document for the measure (both on the NSFL). Where a target/measure description does not include specific assessment criteria, the following criteria will apply:

Rating Abbrev Criteria

Outstanding performer/sector leader

O

1. This rating indicates that the DHB achieved a level of performance considerably better than the agreed DHB and/or sector expectations.

2. For those measures, included in the Maori health plan, this rating is applied when the DHB has met the target agreed in its Annual Plan and has achieved the target level of performance for the Maori population group, and the Pacific population group.

Note: this rating can only be applied in the fourth quarter for measures that are reported quarterly or six-monthly. Measures reported annually can receive an ‘O’ rating, irrespective of when the reporting is due.

Achieved

A

1. Deliverable demonstrates targets / expectations have been met in full.

2. In the case of deliverables with multiple requirements, all requirements are met.

3. For those measures, included in the Maori health plan, this rating is applied when the DHB has met the target agreed in its Annual Plan and has achieved significant progress for the Maori population group, and the Pacific population group.

4. Data, or a report confirming expectations have been met, has been provided through a mechanism outside the Quarterly Reporting process, and the assessor can confirm.

Partial achievement

P

1. Target/expectation not fully met, (including not meeting expectations for Maori and Pacific population groups) but the resolution plan satisfies the assessor that the DHB is on track to compliance.

2. A deliverable has been received, but some clarification is required.3. In the case of deliverables with multi-requirements, where all

requirements have not been met at least 50% of the requirements have been achieved.

Not achieved N 1. The deliverable is not met.

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– escalation required 2. There is no resolution plan if deliverable indicates non-compliance.

3. A resolution plan is included, but it is significantly deficient.4. A report is provided, but it does not answer the criteria of the

performance indicator.5. There are significant gaps in delivery. 6. It cannot be confirmed that data or a report has been provided

through channels other than the quarterly process.

Note: 1) ‘NR’ refers to ‘No report has been received’.2) ‘NA’ refers to Not Applicable.

9.2. CFA VariationsThe assessment criteria for CFA variation reporting are different to the criteria applied to health targets and performance measures. The progress and developmental reporting nature for CFA variations is more compliance based, and therefore the target-oriented nature of health target and performance measure assessment is not considered appropriate. The assessment criteria detailed below reflect the more qualitative nature of this component.

Category Abbrev CriteriaSatisfactory S 1. The report is assessed as up to expectations

2. Information as requested has been submitted in full

Further work required B 1. Although the report has been received, clarification is required2. Some expectations are not fully met

Not Acceptable N 1. There is no report 2. The explanation for no report is not considered valid.

Note: ‘NA’ refers to Not Applicable.

9.3. Initial and Confirmed ratingsDHB reports will be rated, using the criteria in 9.1 and 9.2 above, in both the initial and confirmed assessment rounds each quarter.

If a DHB receives a rating of P, B or N for a particular measure or CFA Variation, the Ministry’s assessor will outline the reasons in the Ministry feedback section and the DHB will be expected to submit an updated report/further comment during the confirmed reporting round. Supplying the requested information may result in the DHB receiving an improved score in the Confirmed assessment round. However, this is not guaranteed.

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10. Poor Performance Reporting If a DHB fails to submit a required report against any health target, performance measure or CFA Variation, receives an ‘N’ rating in the Confirmed assessment round, or is determined to have significant emerging performance issues or service coverage issues, these issues will be highlighted to the Minister in the Performance Issues section of the DHB’s quarterly dashboard performance report. If reports against the measure or variation are not due to be submitted in the following quarterly, the DHB will be asked to report in the following quarter. These requirements will be outlined in the Poor Performance Reporting section of each quarter’s Reporting Template (see section 7 above). If all the appropriate information is provided to meet all the expectations of the requirement in the following quarter, then this will no longer be considered to be a Poor Performance Reporting issue.However, if all the appropriate information to meet all the expectations of the requirement is not provided in the following quarter, then further escalation may follow and the DHB will be required to continue to report on a quarterly basis until the issue(s) has been resolved, and the issue(s) will continue to be escalated via the ‘Ministry/DHB Relationship Protocol’ (see Figure Two below).

Figure Two: Ministry/DHB Relationship Protocol

Condition Responsibility Action by Ministry Suggested timeframe

MoH DHB

0 Either:

Seeking to resolve an outstanding issue, or non-compliance of an already agreed deadline. Lack of compliance may include only partial completion of the total requirement

Regional DHB Relationship

Manager (RM)

DHB Contact Raise the issue and seek to effect an early resolutionIf issue involves a missed deadline, DHB to be reminded as soon as possible that deadline is missed and compliance is required or reason for non-compliance supplied

If reason for delay is not considered reasonable, advise that escalation will occur.

ASAP

1 If no satisfactory resolution

DHB PAMF Manager

Director – DHB Performance

GM/CEO Manager initially seeks to resolve problem with appropriate DHB Manager

If timeline involved, agree a new timeline

Manager to secure a resolution plan in writing; OR

If DHB does not comply, advise that escalation will continue after this period.

24–48 hours

2 Disagreement at Level 1, or if no response from DHB within new agreed timeline (if appropriate), or 24 hours if no change to original requirement

Service Commissioning Director / DG

CEO Letter prepared by responsible manager/ RM for National Director including options that are available to the Ministry and/or DHBNational Director to either speak to or forward letter to CEONational Director to decide whether or not DG to release letterCEO should be given sufficient time to reply in writing

National Director/DG

decision

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Condition Responsibility Action by Ministry Suggested timeframe

MoH DHB

3 If National Director unable to reach resolution with DHB CEO

Minister Chair Brief prepared by responsible manager/RM for Minister providing background to escalation including draft letter to be forwarded by the Minister to the ChairThe Minister may wish to initiate discussion with the DHB Chair rather than sending a note of censure.

If the Minister agrees to sign-off the letter to the Chair, the National Director should formally advise the appropriate CEO of this action prior to the Chair’s receipt of the Minister’s letter

Minister’s decision

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11. Quarterly Performance Dashboards At the conclusion of the reporting process each quarter, the Ministry will produce a dashboard summarising each DHB’s performance. The dashboard displays performance against the health targets, a selection of performance measures, ESPIs and financial performance. An example of previous year dashboard format is displayed below:

These dashboards will be produced concurrently with the public health target reporting and will be provided to DHBs shortly after the embargoed package of health target results.

The dashboards are designed to inform performance conversations between the Minister, the Ministry and DHBs. They will not be published on the Ministry’s website.

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12. Contact Information If you have any queries about the DHB Quarterly Reporting process, the reporting requirements, or any issues with the DHB Quarterly Reporting Website please contact:

Darryl Oldfield Jane Wang Senior Analyst Senior AnalystHealth Target Non-Financial DHB Performance MonitoringMonitoring MonitoringDHB Performance DHB PerformanceService Commissioning Service CommissioningMinistry of Health Ministry of HealthDDI: 04 816 2699 DDI: 04 816 2657Email: :[email protected] Email: [email protected]

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Appendix 1: Non-financial performance measure reporting calendar for 2016/1 7 The table below sets out the quarters in which non-financial performance measures are due to be reported in 2016/17. DHBs will be notified if there are any changes to the reporting requirements during the year.

Code Performance Measure FrequencyQuarter Due MoH to supply

Data DHB to Supply data

1 2 3 4 (from National collections)

Health Targets

HT1 Shorter stays in Emergency Departments Quarterly HT2 Improved access to elective surgery Quarterly HT3a Faster cancer treatment Quarterly HT4 Increased Immunisation Quarterly HT5 Better help for smokers to quit Quarterly HT7 Raising healthy kids Quarterly

Policy Priorities

PP6 Improving the health status of people with severe mental illness through improved access Six-Monthly - - PP7 Improving mental health services using transition (discharge) planning Quarterly PP8 Shorter waits for non-urgent mental health and addiction services for 0-19 year olds Quarterly PP10 Oral Health- Mean DMFT score at Year 8 Annual - - - PP11 Children caries-free at five years of age Annual - - - PP12 Utilisation of DHB-funded dental services by adolescents from School Year 9 up to and including age 17 years Annual - - - PP13 Improving the number of children enrolled in DHB funded dental services Annual - - - PP20 Improved management for long term conditions (CVD, Acute heart health, Diabetes, and Stroke) Quarterly PP21 Immunisation coverage FA1 (2 and 5 years old) Quarterly PP21 Immunisation coverage FA2 (HPV) Annually - - - PP22 Improving system integration and SLMs Quarterly PP23 Improving Wrap Around Services – Health of Older People Quarterly PP25 Prime Minister’s youth mental health project Quarterly PP26 Rising to the Challenge: The Mental Health and Addiction Service Development Plan Quarterly PP27 Supporting Vulnerable Children Quarterly PP28 Reducing Rheumatic fever Quarterly PP29 Improving waiting times for diagnostic services Quarterly PP30 Faster cancer treatment (31 day indicator) / Shorter waits for cancer treatment (radiotherapy and chemotherapy) Quarterly PP31 Better help for smokers to quit in public hospitals (previous health target) Quarterly

System Integration

SI1 Ambulatory sensitive hospitalisations (ASH) Six-Monthly - - SI2 Delivery of Regional Service Plans Quarterly SI3 Ensuring delivery of Service Coverage Six-Monthly - - SI4 Standardised Intervention Rates (SIRs) Quarterly SI5 Delivery of Whānau Ora Annual - - -

Ownership

OS3 Inpatient Average Length of Stay (ALOS) Quarterly OS8 Reducing Acute Readmissions to Hospital Quarterly OS10 Improving the quality of identity data within the National Health Index (NHI) and data submitted to National Collections Quarterly

Outputs OP1 Mental health output Delivery against Plan Quarterly Developmental DV4 Improving patient experience Quarterly Progress update HS Supporting delivery of the New Zealand Health Strategy Quarterly

Update: 14 Dec 2016

Appendix 2: CFA Variation Reporting calendar for 2016/1 7

The table below lists the CFA Variation reports scheduled for 2016/17, as at 1 st July 2016. This list is subject to change as new Variations are agreed throughout the financial year.

Variation Name FrequencyQuarter Due All DHBs

reporting?1 2 3 4

Appoint Cancer Nurse Coordinators Six-Monthly - - Appoint cancer psychological and social support workers Six-Monthly - - xAppoint regional cancer centre clinical psychologists Six-Monthly - - xB4 School Check Quarterly Disability Support Services (DSS) Increase of Funding Quarterly Electives Initiative and Ambulatory Initiative Quarterly Green Prescription Initiative Quarterly xImmunisation Coordination Service Annually - - - National Immunisation Register (NIR) Ongoing Administration Services Annually - - - National Patient Flow Annually - - - Health Services for Emergency Quota Refugees Quarterly xWell Child/Tamariki Ora Services Quarterly

Update: 14 Dec 2016