national safety and quality health service standards ...nov 13, 2013 · health care standards that...

2013‐14 Key Performance Indicators – Attribute Sheet

National Safety and Quality Health Service Standards Compliance Full KPI Title: Hospital and Health Service (HHS) National Safety and Quality Health Service (NSQHS) Standards

Compliance

KPI number: 1.1

KPI Category: Effectiveness – Safety and Quality

Tier: 1

Description: HHS compliance against the National Safety and Quality Health Service (NSQHS) Standards

Definition: Assessment of whether the facility has NSQHS Standards compliance and is currently accredited (i.e. met all actions) or does not have NSQHS Standards compliance and is not accredited (i.e. not met all actions) based on the most recent accreditation event. Accreditation is against the ten clinical NSQHS Standards and any other standards imposed by the accrediting agency employed by the HHS. In HHSs accreditation may be achieved on a HHS wide basis or on an individual facility basis. The data is self‐reported but reflects the assessment by an external, independent accrediting agency. Note: If any individual facility does not meet all actions, the HHS compliance will be flagged as did not meet all actions.

Calculation: Not applicable

Target: Met all actions

Target Rationale: The Australian Commission on Safety and Quality in Health Care (ACSQHC) has established National Health Care Standards that provide a nationally consistent and uniform set of measures of safety and quality. They also form part of a framework for health care which are consumer centred, driven by information and organised to create a safe hospital environment for patients. The targets set are those used by the ACSQHC and accrediting agencies approved by the ACSQHC. Strategic Links • NSQHS Standards, ACSQHC • Queensland Health Strategic Plan 2012‐2016 • Queensland Government Blueprint for better healthcare in Queensland • HHS Performance Management Framework

Target Triggers: July‐December 2013 • Green – met all actions • Amber – not met all actions within 120 days of NSQHS Standards compliance assessment event • Red ‐ not met all actions after 120 days of NSQHS Standards compliance assessment event January‐June 2014 • Green – met all actions • Amber – not met all actions within 90 days of NSQHS Standards compliance assessment event • Red – not met all actions after 90 days of NSQHS Standards compliance assessment event

Scope: All HHSs

Data source: HHSs provide Patient Safety Unit (PSU) with the outcome of NSQHS compliance of facilities within the HHS.

Reporting frequency: Quarterly

KPI owner: Patient Safety Unit, Health Service and Clinical Innovation Division

Last updated: June 2013


Shorter stays in emergency departments Full KPI Title: National Emergency Access Target (NEAT)

KPI number: 1.2

KPI Category: Equity and Effectiveness ‐ Access

Tier: 1

Description: The percentage of patients who attended an emergency department (ED) whose length of stay in the ED was within four hours.

Definition: Of the patients who arrive at an ED, the percentage of patients whose length of stay in the ED was within four hours. The ED length of stay is calculated as the difference between the date and time of the first recorded contact between the patient and ED staff (the recorded date and time of arrival at the ED), and the date and time the patient physically departed the ED (the recorded departure date and time).

Calculation: The number of patients who arrive at an ED whose length of stay in the ED was within four hours (≤ 240 minutes), as a percentage of the number of patients who arrive at the ED.

Target: July to December 2013 – 77% January to June 2014 – 83%

Target Rationale: Queensland Health is a signatory to the National Partnership Agreement on Improving Public Hospital Services, which includes the National Emergency Access Target. The NEAT sets calendar year targets for Queensland from 2012 to 2015

Target Triggers: July to December 2013 Green: ≥ 77.0% Amber: 72.0% ‐ 76.9% Red: < 72.0%

January to June 2014 Green: ≥ 83.0% Amber: 78.0% ‐ 82.9% Red: < 78.0%

Scope: Cairns and Hinterland HHS – Cairns Base Hospital Central Queensland HHS – Gladstone Hospital, Rockhampton Base Hospital Children’s Health Queensland – Royal Children’s Hospital Darling Downs HHS – Toowoomba Hospital Gold Coast HHS – Gold Coast Hospital / Gold Coast University Hospital, Robina Hospital Mackay HHS – Mackay Base Hospital Mater Health Services – Mater Adult Public Hospital, Mater Children’s Public Hospital Metro North HHS – Caboolture Hospital, Redcliffe Hospital, Royal Brisbane & Women’s Hospital, The Prince Charles Hospital Metro South HHS – Logan Hospital, Princess Alexandra Hospital, QEII Jubilee Hospital, Redland Hospital North West HHS – Mount Isa Hospital Sunshine Coast HHS – Caloundra Hospital, Gympie Hospital, Nambour Hospital Townsville HHS – Townsville Hospital West Moreton HHS – Ipswich Hospital Wide Bay HHS – Bundaberg Hospital, Hervey Bay Hospital, Maryborough Hospital

Data source: Emergency Department Information System (EDIS)

Reporting frequency: Monthly and calendar year‐to‐date

KPI owner: Clinical Access and Redesign Unit, Health Service and Clinical Innovation Division



Shorter waits for elective surgery Full KPI Title: National Elective Surgery Target (NEST)

KPI number: 1.3


Tier: 1

Description: The percentage of patients who received elective surgery who were treated within the clinically recommended time for their urgency category.

Definition: Of the patients who received elective surgery, the percentage of patients who received elective surgery within the clinically recommended time for their urgency category. Elective surgery patients treated are those who were registered on a surgical waiting list as a category 1, 2 or 3, could have their surgery delayed for at least 24 hours from when the decision for surgery was made, and were removed because they received their surgery as an elective or emergency patient.

The time to treatment is calculated as the difference between the date the patient was placed on the waiting list and the date the patient was removed from the waiting list, excluding any periods the patient was not ready for care and any periods that the patient was waiting in a less urgent category.

Calculation: Numerator: The number of patients who received elective surgery who were treated within 30 days (≤ 30 days) if a category 1, within 90 days (≤ 30 days) if a category 2, or within 365 days (≤ 365 days) if a category 3

Denominator: number of patients who received elective surgery Formula: (Numerator ÷ Denominator) x 100

Target: July to December 2013 Category 1‐ 100% Category 2 ‐ 87% Category 3 ‐ 94%

January to June 2014 Category 1‐ 100% Category 2 ‐ 94% Category 3 ‐ 97%

Target Rationale: Queensland Health is a signatory to the National Partnership Agreement on Improving Public Hospital Services, which includes the National Elective Surgery Target. The NEST sets calendar year targets for Queensland from 2012 to 2015.

Target Triggers: July to December 2013 Green: Amber: Red: Cat 1 100.0% 95.0% ‐ 99.9% < 95.0% Cat 2 ≥ 87.0% 82.0% ‐ 86.9% < 82.0% Cat 3 ≥ 94.0% 89.0% ‐ 93.9% < 89.0%

January to June 2014 Green: Amber: Red: Cat 1 100.0% 95.0% ‐ 99.9% < 95.0% Cat 2 ≥ 94.0% 89.0% ‐ 93.9% < 89.0% Cat 3 ≥ 97.0% 92.0% ‐ 96.9% < 92.0%

Scope: Cairns and Hinterland HHS – Atherton Hospital, Cairns Base Hospital, Innisfail Hospital Central Queensland HHS – Emerald Hospital, Gladstone Hospital, Rockhampton Base Hospital Children’s Health Queensland – Royal Children’s Hospital Darling Downs HHS – Kingaroy Hospital, Toowoomba Hospital Gold Coast HHS – Gold Coast Hospital / Gold Coast University Hospital, Robina Hospital Mackay HHS – Mackay Base Hospital Mater Health Services – Mater Adult Public Hospital, Mater Children’s Public Hospital, Mater Mothers’ Public Hospital Metro North HHS – Caboolture Hospital, Redcliffe Hospital, Royal Brisbane & Women’s Hospital, The Prince Charles Hospital Metro South HHS – Beaudesert Hospital, Logan Hospital, Princess Alexandra Hospital, QEII Jubilee Hospital, Redland Hospital North West HHS – Mount Isa Hospital Sunshine Coast HHS – Caloundra Hospital, Gympie Hospital, Nambour Hospital, Noosa Hospital Townsville HHS – Townsville Hospital West Moreton HHS – Ipswich Hospital

Wide Bay HHS – Bundaberg Hospital, Hervey Bay Hospital, Maryborough Hospital

Data source: HBCIS Elective Admission Module (EAM)

Reporting frequency: Monthly and calendar year‐to‐date



2013-14 Key Performance Indicators – Attribute Sheet

Maintain surgical activity

Full KPI Title: Elective Surgery Volume

KPI number: 1.4

KPI Category: Equity and Effectiveness - Access

Tier: 1

Description: The number of elective surgery patients treated

Definition: The number of patients who were removed from the elective surgery waiting list. Elective surgery

patients treated are those who were registered on a surgical waiting list as a category 1, 2 or 3, could

have their surgery delayed for at least 24 hours from when the decision for surgery was made, and were

removed because they received their surgery as an elective or emergency patient.

Calculation: The number of patients who received elective surgery.

Target:

HHS 2010 baseline

Cairns & Hinterland 6,420

Central Queensland 3,708

Children's Health Queensland 4,176

Darling Downs 4,236

Gold Coast 12,180

Mackay 2,244

Mater Public 10,011

Metro North 25,944

Metro South 27,084

North West 624

Sunshine Coast 8,196

Townsville 7,260

West Moreton 7,176

Wide Bay 4,164

*Total (includes Surgery Connect privately outsourced) 129,927

Target Rationale: Queensland Health is a signatory to the National Partnership Agreement on Improving Public Hospital

Services, which includes the National Elective Surgery Target. During each year from 2012 to 2015, to

be eligible to achieve the NEST, Queensland must maintain elective surgery activity levels from the 2010

baseline.

Target Triggers: Green: ≥ 5% above 2010 volume

Amber: < 5% above 2010 volume and ≥ 2010 volume

Red: < 2010 volume

Scope: Cairns and Hinterland HHS – Atherton Hospital, Cairns Base Hospital, Innisfail Hospital

Central Queensland HHS – Emerald Hospital, Gladstone Hospital, Rockhampton Base Hospital

Children’s Health Queensland – Royal Children’s Hospital

Darling Downs HHS – Kingaroy Hospital, Toowoomba Hospital

Gold Coast HHS – Gold Coast Hospital / Gold Coast University Hospital, Robina Hospital

Mackay HHS – Mackay Base Hospital

Mater Health Services – Mater Adult Public Hospital, Mater Children’s Public Hospital, Mater Mothers’

Public Hospital

Metro North HHS – Caboolture Hospital, Redcliffe Hospital, Royal Brisbane & Women’s Hospital, The

Prince Charles Hospital

Metro South HHS – Beaudesert Hospital, Logan Hospital, Princess Alexandra Hospital, QEII Jubilee

Hospital, Redland Hospital

North West HHS – Mount Isa Hospital

Sunshine Coast HHS – Caloundra Hospital, Gympie Hospital, Nambour Hospital, Noosa Hospital

Townsville HHS – Townsville Hospital

West Moreton HHS – Ipswich Hospital



Reporting frequency: Monthly and calendar year-to-date




Fewer long waiting patients

Full KPI Title: Number of category 1 elective surgery patients waiting more than the clinically recommended

timeframe for their category

KPI number: 1.5


Tier: 1

Description: The number of category 1 patients waiting for elective surgery at a monthly census date who were

ready for care and were waiting longer than the clinically recommended time for their category.

Definition: � Of the patients who were waiting for elective surgery at a census date and who were ready for care,

the number of patients who were waiting for elective surgery longer than the clinically

recommended time of 30 days for category 1.

� Elective surgery patients waiting are those who were registered on a surgical waiting list as a

category 1, 2 or 3, could have their surgery delayed for at least 24 hours from when the decision for

surgery was made, and were listed as waiting or booked at the census date.

� The waiting time is calculated as the difference between the date the patient was placed on the

waiting list and the census date, excluding any periods the patient was not ready for care and any

periods that the patient was waiting as a less urgent category.

Calculation: � Numerator (green and amber trigger): The number of category 1 patients who were waiting longer

than 30 days (≥ 31) and less than or equal to 60 days at the census date and were ready for care.

� Numerator (red trigger): The number of category 1 patients who were waiting (longer than 30 days

and less than or equal to 60 days) OR (greater than 60 days) at the census date and were ready for

care.

� Denominator: The number of category 1 patients who were waiting for elective surgery and ready

for care at the census date.

� Formula: (Numerator ÷ Denominator) x 100

Target: 0% to ≤ 2.0% with no patients waiting longer than 60 days


Services, which includes the National Elective Surgery Target. The NEST sets calendar year targets for

Queensland from 2012 to 2015. In order for Queensland to reach the target of 100% of patients

treated within the clinically recommended time by 2015, there must be no patients waiting longer than

the clinically recommended time.

Target Triggers: For each category:

Green: 0% to ≤ 2.0% with no patients waiting longer than 60 days

Amber: ≥ 2.1% to < 5.0% with no patients waiting longer than 60 days

Red: (≥ 5.0% with no patients waiting longer than 60 days) OR (patients waiting > 60 days)








Public Hospital











Reporting frequency: Monthly (month of census date)




Full-year Forecast Operating Position

Full KPI Title: Full-year Forecast Operating Position

KPI number: 1.6

KPI Category: Efficiency – Efficiency and Financial Performance

Tier: 2

Description: The Hospital and Health Service (HHS) full-year forecast operating position

Definition: Operating position = revenue less expenditure

Calculation: Full year forecast revenue less full year forecast expenditure

Target: Balanced or surplus

Target Rationale: Key indicator of financial viability

� Financial Accountability Act 2009

� Financial & Performance Management Standard 2009

Target Triggers: Green: Balanced or surplus

Amber: > 0 to 1.0% unfavourable variance to budget

Red: > 1.0% unfavourable variance to budget

Scope: All HHSs

Data source: DSS Panorama – Finance module

Reporting frequency: Monthly

KPI owner: Finance Branch, System Support Services



Purchased activity variance

Full KPI Title: Variance between Year-To-Date purchased activity and actual activity

KPI number: 1.7


Tier: 1

Description: Year-To-Date (YTD) variance between recorded Activity Based Funding (ABF) Queensland Weighted

Activity Units (QWAU) and the purchased ABF QWAUs established via the Healthcare Purchasing

Framework contained within individual HHS service agreements

Definition: � A forecast threshold or tolerance for each type of activity (service stream) will be set to function as

an early warning of where the actual performance level varies from the forecast threshold.

� QWAU is a single standardised unit used to measure healthcare services (activities) within the

Queensland ABF model.

� Activity will be monitored and reported against the following service streams (as outlined in

itemised activity schedule within the HHS service agreement):

o Inpatients;

o Outpatients;

o Interventions and procedures;

o Emergency Department;

o Subacute; and

o Mental Health.

Notes:

� Does not include the reporting of estimates. Data will be reported at a two month lag to ensure

sufficient time for coding of activity data.

Calculation: Numerator: Recorded YTD QWAUs

Denominator: Purchased YTD QWAUs (target)

Formula: Variance between numerator and denominator, expressed as both a number and percentage

Target: � 0% to ± 1-2%

� Tolerance threshold set at 1% of purchased levels (overall or on any service stream) for Metro

North and Metro South, and 2% threshold for all other HHS.

� Management of activity outside of the activity thresholds is defined in the HHS Performance

Management Framework.

Target Rationale: � QWAU targets are set as part of the funding and budget allocation process in line with the 2013-14

Purchasing Framework.

� Monitoring of any deviations from the forecast threshold allows relevant parties to promptly

review activity and trigger a requirement for an activity management plan.

� Strategic Plan 2012-16 (2013 update) Objective 4.1: Develop funding models to drive increased

efficiency and accountability in the delivery of publicly funded health services.

Target Triggers:

Metro HHS Other HHS

Green: Within ± 1% overall or service stream Within ± 2% overall or service stream

Amber: Within ± 1.01 - 1.99% overall or service

stream Within ± 2.01 - 2.99% overall or service

stream

Red: Greater than or equal ± 2 % overall or

service stream

Greater than or equal ± 3% overall or

service stream

Scope: All HHSs

Data source: DSS Scorecard – Fixed EOM “Var between purchased ABF activity and recorded ABF activity”


KPI owner: Activity Based Funding Model Team, System Policy and Performance Division



Healthcare-associated infections Full KPI Title: Healthcare Associated staphylococcus aureus (including MRSA) bacteraemia

KPI number: 2.1


Tier: 2

Description: Rate of healthcare associated Staphylococcus aureus bacteraemia in acute care public hospitals per 10,000 patient days.

Definition: A Staphylococcus aureus bacteraemia (SAB) will be considered to be healthcare associated if either: Criterion A ‐ the patient’s first SAB positive blood culture was collected more than 48 hours after

hospital admission or less than 48 hours after discharge, or Criterion B ‐ the patient’s first positive SAB blood culture was collected less than or equal to 48

hours after hospital admission AND one or more of the following key clinical criteria was met for the patient‐episode of SAB: 1. SAB is a complication of the presence of an indwelling medical device (for example,

intravascular line, haemodialysis vascular access, cerebrospinal fluid shunt, urinary catheter) 2. SAB occurs within 30 days of a surgical procedure where the infection is related to the surgical

site 3. An invasive instrumentation or incision related to the SAB was performed within 48 hours 4. SAB is associated with neutropenia (<1 x 109) contributed to by cytotoxic therapy.

Only the first isolate per patient is counted, unless at least 14 days has passed without a positive culture, after which an additional episode is recorded.

Calculation: Numerator: Number of cases of healthcare‐associated S. aureus bloodstream infections Denominator: Number of patient bed days Formula: (Numerator ÷ Denominator) x 10,000

Target: The rate of Staphylococcus aureus (including MRSA) bacteraemia is no more than 2.0 per 10,000 occupied bed days.

Target Rationale: The rate of healthcare‐associated Staphylococcus aureus bacteraemia is a robust outcome measure for the control of healthcare‐associated infection.

The target rate was established in 2011 as part of the National Healthcare Agreement (agreed by the Council of Australian Governments) as per the Australian Commission on Safety and Quality in Healthcare.

The target triggers are consistent with the Queensland Department of Health Blueprint for better healthcare in Queensland report and are consistent with the targets in the service delivery statements.

Target Triggers: Green: ≤ 2.0 per 10,000 occupied bed days Amber: N/A Red: > 2.0 per 10,000 occupied bed days

Scope: All HHSs

Data source: Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP) Queensland Hospitals Admitted Patient Data Collection (QHAPDC)

Reporting frequency: Every 6 months

KPI owner: CHRISP, Chief Health Officer



28 day mental health readmission rate Full KPI Title: Proportion of readmissions to an acute mental health inpatient unit within 28 days of discharge

KPI number: 2.2


Tier: 2

Description: Proportion of in‐scope overnight separations from the Hospital and Health Service’s (HHS) acute mental health inpatient unit(s) that are followed by readmission to the same or to another acute mental health inpatient unit within 28 days of the initial discharge.

Definition: The indicator does not differentiate between planned and unplanned readmissions. The following separations, as identified through separation modes, are included:

- 01: Home / Usual residence. - 12: Correctional facility. - 15: Residential Aged Care Facility.

The following separations are excluded: - Same day separations (defined as episodes where admission and discharge dates are the

same). This includes the index separation and subsequent readmission. - Separations, where duration is one night only and where the procedure code Electroconvulsive

Therapy Block 1907 (ACHI 6th Edn) is present. Acute is defined based upon the standard unit code at the time of admission to the mental health

unit. The standard unit code are utilised in HBCIS to describe the unit to which the patient was admitted.

Numerator: Number of in‐scope overnight separations from the HHS’ acute mental health inpatient unit(s) that are followed by a readmission to the same or another acute mental health inpatient unit within 28 days of the initial discharge.

Denominator: Number of in‐scope overnight separations from the HHS’ acute mental health inpatient unit(s).

Formula: (Numerator ÷ Denominator) x 100

Target: ≤ 12%

Target Rationale: The Measurement Strategy of the Fourth National Mental Health Plan identified a national target of 12% based upon outcomes of a national benchmarking project and state and territory performance.

Target Triggers: Green: ≤ 12% Amber: > 12% to ≤15% Red: > 15%

Scope: All HHS excluding Cape York, Central West, North West, South West and Torres Strait ‐Northern Peninsular

Data source: Queensland Hospital Admitted Patient Data Collection (QHAPDC)


KPI owner: Mental Health Alcohol and Other Drugs Branch, Health Services and Clinical Innovation Division



Home Based Renal Dialysis

Full KPI title: Home Based Renal Dialysis

KPI number: 2.3


Tier: 2

Description: Home based renal dialysis treatments as a percentage of total renal dialysis treatments

Definition: Home renal dialysis:

� The Statewide Renal Clinical Network has endorsed home dialysis as patients participating in one of

the following:

o Home haemodialysis (standard and extended hours)

o Peritoneal dialysis (APD and CAPD)

o Practicing self care in a facility without assistance from paid healthcare professionals

� The approved prescribing norms of 30 treatments per month for Peritoneal Dialysis patients, 20

treatments per month for extended home haemodialysis and 15 treatments per month for self-care

and standard home haemodialysis will be used for monitoring.

In-centre admitted renal dialysis:

� Haemodialysis (DRG L61Z) and Peritoneal dialysis (DRG L68Z).

� The following HHSs are defined as ‘North Queensland’:

o Cairns and Hinterland

o Townsville

o Mackay

o Central Queensland.

� Out-of-HHS-area activity refers to renal dialysis provided to residents of another HHS.

Calculation: � Numerator = # renal dialysis treatments at home

� Denominator = Total renal dialysis treatments (home and in-centre)

� Formula = (Numerator ÷ Denominator) * 100

Two sub-categories will also be monitored in order to improve overall understanding however no

targets will be applied.

a) Home based renal dialysis treatments as a percentage of total renal dialysis treatments excluding out

of area treatments (2013/14 will be the first year that patient flow data is available for non-admitted

patients)

� Numerator = # renal dialysis treatments at home excluding out-of-area HHS activity

� Denominator = Total renal dialysis treatments (home and in-centre) excluding out-of-area HHS

activity


b) Patients on renal dialysis receiving treatments at home as a percentage of all patients receiving renal

dialysis (to enable inter-jurisdictional comparisons)

� Numerator = # patients receiving home dialysis (MAC census)

� Denominator = # patients receiving home and in-centre dialysis (MAC census and QHAPDC patient

URs)


Target: � All HHS (excluding North Queensland* and West Moreton) – 50% YTD

� North Queensland *- 40% YTD

Target Rationale: � This initiative aims to promote the delivery of home based renal dialysis.

� The primary goal of the Queensland Statewide Renal Health Services Plan (2008-2017) is to

implement a coordinated and evidence-based approach to renal health service delivery in

Queensland where equity of access to treatment, service capability and sustainability, patient

outcomes and cost effectiveness are maximised.

� A shift in the current modality pattern away from inpatient activity to well-supported outpatient,

self-care/home-based activity is a key strategy in the Plan. This shift in the service modality mix is

cited as addressing patient access issues and improving patient quality of life by minimising the need

for travel and relocation. Home-based therapy is also considered to foster a self-care approach to

end-stage kidney disease. The plan also advises that significant cost efficiencies can be obtained by

moving renal dialysis into home and community settings.

Target Triggers:

All HHS (excl. North Queensland*) North Queensland*

Green: > 50% YTD > 40% YTD

Amber: 49.9% - 30.0% YTD 39.9% - 20.0% YTD

Red: < 30.0% YTD < 20.0% YTD

Scope: � ABF facilities who deliver renal dialysis activity

Data source: � Monthly Activity Collection (MAC) for non-admitted and home dialysis (including APD, CAPD, Self

Care and Haemodialysis)

� Hospital Admitted Patient Data Collection (QHAPDC) for admitted inpatients



Last updated: August 2013


Shorter waits for emergency departments Full KPI Title: Emergency department patients seen within the clinically recommended time.

KPI number: 2.4


Tier: 2

Description: The percentage of patients who attended an emergency department (ED) whose treatment began within the clinically recommended time for their triage category.

Definition: Of the patients who arrive at an ED, the percentage of patients whose treatment began within the clinically recommended time for their triage category.

Clinically recommended time for each category: o Category 1: Immediately life‐threatening. Patient should be seen by a treating doctor

or nurse within 2 minutes of arriving. o Category 2: Imminently life‐threatening. Patient should be seen by a treating doctor

or nurse within 10 minutes of arriving. o Category 3: Potentially life‐threatening. Patient should be seen by a treating doctor or

nurse within 30 minutes of arriving. o Category 4: Potentially serious. Patient should be seen by a treating doctor or nurse

within 60 minutes of arriving. o Category 5: Less urgent. Patient should be seen by a treating doctor or nurse within

120 minutes of arriving. The time to treatment commencing is calculated as the difference between the date and time of

the first recorded contact between the patient and ED staff, and the date and time of the first contact between the patient and the treating clinician.

Calculation: Numerator: number of patients who arrive at an ED whose treatment commenced within clinically recommended time (by category)

Denominator: number of patients who arrive at the ED (by category) Formula: (Numerator ÷ Denominator) x 100

Target: Category 1 ‐ 100% Category 2 ‐ 80% Category 3 ‐ 75% Category 4 ‐ 70% Category 5 ‐ 70%

Target Rationale: Targets are based on recommendations from the Australasian College for Emergency Medicine.

Target Triggers: Green: Category 1: 100% Category 2: > 80% Category 3: > 75% Category 4: > 70% Category 5: > 70%

Amber: Category 1: 90.0% ‐ 99.9% Category 2: 70.0% ‐ 79.9% Category 3: 65.0% ‐ 74.9% Category 4: 60.0% ‐ 69.9% Category 5: 60.0% ‐ 69.9%

Red: Category 1: < 90.0% Category 2: < 70.0% Category 3: < 65.0% Category 4: < 60.0% Category 5: < 60.0%

Scope: Cairns and Hinterland HHS – Cairns Base Hospital Central Queensland HHS – Gladstone Hospital, Rockhampton Base Hospital Children’s Health Queensland – Royal Children’s Hospital Darling Downs HHS – Toowoomba Hospital Gold Coast HHS – Gold Coast Hospital / Gold Coast University Hospital, Robina Hospital Mackay HHS – Mackay Base Hospital Mater Health Services – Mater Adult Public Hospital, Mater Children’s Public Hospital Metro North HHS – Caboolture Hospital, Redcliffe Hospital, Royal Brisbane & Women’s Hospital, The Prince Charles Hospital Metro South HHS – Logan Hospital, Princess Alexandra Hospital, QEII Jubilee Hospital, Redland Hospital North West HHS – Mount Isa Hospital

Sunshine Coast HHS – Caloundra Hospital, Gympie Hospital, Nambour Hospital Townsville HHS – Townsville Hospital West Moreton HHS – Ipswich Hospital Wide Bay HHS – Bundaberg Hospital, Hervey Bay Hospital, Maryborough Hospital

Data source: Emergency Department Information System (EDIS)





Treating elective surgery patients in turn

Full KPI Title: Percentage of elective surgery patients who were treated in turn

KPI number: 2.5


Tier: 2

Description: The percentage of category 2 and 3 patients who received elective surgery who were within the longest

waiting cohort of patients for that month.

Definition: � Of the patients who received elective surgery, the percentage of category 2 and 3 patients who

were within the longest waiting cohort of patients for that month. For this measure, elective

surgery patients treated are those who were registered on a surgical waiting list as a category 1, 2

or 3, could have their surgery delayed for at least 24 hours from when the decision for surgery was

made, and were removed because they received their surgery as an elective patient.

� The longest waiting cohort of patients represents those patients waiting the longest for their

surgery who would have received their surgery as an elective patient if all patients treated during

the month were treated strictly in waiting time order. To be eligible for inclusion in the longest

waiting cohort of patients, the patient must be ready for care at the start of the month and not re-

categorised or removed from the waiting list for any other reason than receiving their surgery as an

elective patient.



periods that the patient was waiting as a less urgent.

Calculation: � Numerator: category 2 and 3 patients who were within the longest waiting cohort of patients for

that month

� Denominator: category 2 and 3 patients who received elective surgery


Target: 60%

Target Rationale: Patients with the same clinical need should, where practical, be treated on a first-in first-out basis. The

Checklist modelling tool recommends that 60% of patients are treated in turn to reduce the maximum

waiting time and the number of ‘long wait’ patients. This target allows sufficient flexibility in booking

practice to cater for patients within each category who require treatment quicker.

Target Triggers: Green: ≥ 60.0%

Amber: 50.0% - 59.9%

Red: <50.0%


















Shorter maximum wait for elective surgery

Full KPI Title: Maximum waiting time of elective surgery patients waiting

KPI number: 2.6


Tier: 2

Description: The maximum waiting time in days of the longest waiting patient in each surgical specialty for elective

surgery patients waiting at a monthly census date who are ready for care.

Definition: � The waiting time in days of the patients who were waiting for elective surgery at a monthly census

date who were ready for care at the census date and whose waiting time was the greatest number

of days in each surgical specialty. Elective surgery patients waiting are those who were registered

on a surgical waiting list as a category 1, 2 or 3, could have their surgery delayed for at least 24

hours from when the decision for surgery was made, and were listed as waiting or booked at the

census date.




� Surgical specialities include cardiothoracic, ear nose and throat, general, gynaecology,

ophthalmology, orthopaedic, neurosurgery, plastic and reconstructive, urology and vascular.

Calculation: The waiting time in days of the patients who were waiting for elective surgery who were ready for care

at the census date and whose waiting time was the greatest number of days in each surgical specialty.

Target: 365 days for each surgical specialty listed above.

Target Rationale: With a focus on treating the longest waiting patients in 2013-2014, the target is set to the maximum

clinically recommended waiting time for the least urgent category, category 3.

Target Triggers: Green: ≤ 365 days

Amber: 365 – 400 days

Red: > 400 days

















Reporting frequency: Monthly (the census snapshot is taken at midnight on the last calendar day of each month)




Shorter waits for specialist outpatient clinics

Full KPI Title: Specialist outpatients waiting within the clinically recommended time.

KPI number: 2.7


Tier: 2

Description: The percentage of patients who were, at a monthly census date, waiting within the clinically

recommended time for their urgency category for an initial specialist outpatient appointment

Definition: Of the patients who were waiting at the census date for an initial service event at a specialist outpatient

clinic, the percentage of patients who were waiting within the clinically recommended time for their

urgency category, being 30 days for category 1, 90 days for category 2 and 365 days for category 3. An initial service event is the first appointment following a referral receipt date, where the appointment

is recorded as the patient has been seen; seen and listed as an elective surgery patient; or discharged.

A specialist outpatient clinic is one whose Corporate Clinic Code is in (150, 155, 160, 170, 175, 185, 186,

187, 195, 196, 197, 198, 199, 245, 246, 250, 255, 256, 280, 281, 282, 285, 290, 305, 315, 320, 330, 331,

332, 333, 335, 340, 341, 345, 346, 350, 351, 355, 360, 370, 371, 375, 380, 390, 395, 400, 410, 420, 421,

430, 431, 435, 445, 446, 447, 448, 465, 466, 467, 468, 475, 476, 480, 490, 545, 555, 560, 565, 566, 568,

569, 570, 580, 590, 605, 615, 616, 617, 620, 625, 626).

Waiting time is calculated as the days wait between the date the referral was received and the census

date, excluding any periods the patient was not ready for care and any periods that the patient was

waiting as a less urgent category.

Calculation: � Numerator: number of patients who were waiting for an initial service event at a specialist

outpatient clinic and were waiting within clinically recommended time (by category)

� Denominator: number of patients who were waiting for an initial service event at a specialist

outpatient clinic (by category)


Target: Category 1 - 95%

Category 2 - 90%

Category 3 - 90%

Target Rationale: The targets are set as a reasonable community expectation of access to specialist hospital services. The

category 1 target of 95% has been retained from the 2012-2013 KPIs. The category 3 target is set in the

Blueprint for better healthcare in Queensland.

Target Triggers: Green:

Category 1: ≥ 95.0%



Amber:

Category 1: 85.0% - 94.9%

Category 2: 70.0% - 89.9%

Category 3: 70.0% - 89.9%

Red:

Category 1: < 85.0%

Category 2: < 70.0%

Category 3: < 70.0%









Metro South HHS – Beaudesert Hospital, Logan Hospital, QEII Jubilee Hospital, Redland Hospital






Data source: HBCIS Elective Admission Module (EAM), ASIM (Logan) and Cerner-OSIM (RBWH)





Fewer long waiting patients

Full KPI Title: Number of category 2 and 3 elective surgery patients waiting more than the clinically recommended

timeframe for their category

KPI number: 2.8


Tier: 2

Description: The number of category 2 and 3 patients waiting for elective surgery at a monthly census date who

were ready for care and were waiting longer than the clinically recommended time for their category.

Definition: � Of the category 2-3 patients who were waiting for elective surgery at a census date and who were

ready for care, the number of patients who were waiting for elective surgery longer than the

clinically recommended time for their urgency category, being 90 days for category 2 and 365 days

for category 3.

� Elective surgery patients waiting are those who were registered on a surgical waiting list as a

category 1, 2 or 3, could have their surgery delayed for at least 24 hours from when the decision for

surgery was made, and were listed as waiting or booked at the census date.




Calculation: � The number of patients who were waiting for elective surgery who were ready for care at the

census date and who were waiting longer than 90 days (≥91 days) if a category 2, or longer than

365 days (≥ 366 days) if a category 3.

� Numerator: The number of category 2 and 3 patients who were waiting longer than the clinically

recommended time for their urgency category at the census date and were ready for care.

� Denominator: The number of category 2 and 3 patients within each urgency category who were

waiting for elective surgery and ready for care at the census date.


Target: 0% to ≤ 2.0%


Services, which includes the National Elective Surgery Target. The NEST sets calendar year targets for

Queensland from 2012 to 2015. In order for Queensland to reach the target of 100% of patients

treated within the clinically recommended time by 2015, there must be no patients waiting longer than

the clinically recommended time.

Target Triggers:

Category 2 Category 3

Green: 0% to ≤ 2.0% of patients waiting 0% to ≤ 2.0% of patients waiting

Amber: ≥ 2.1% to < 5.0% of patients waiting ≥ 2.1 to < 5.0% of patients waiting

Red: ≥ 5.0% of patients waiting ≥ 5.0% of patients waiting








Public Hospital











Reporting frequency: Monthly (the census snapshot is taken at midnight on the last calendar day of each month).




Postnatal In-home Visiting Full KPI Title: Enhanced Maternal and Child Health Service – Postnatal In‐home Visiting

KPI number: 2.9


Tier: 2

Description: The number of women with newborns that are supported by a home visiting program in the first month following birth.

Definition: The count of women supported by the home visit program include:

o Number of women who received a postnatal home visit in the first two weeks post birth o Number of women receiving a home visit between three and four weeks post birth

Notes:

The woman and baby are to be recorded as one unit For the purposes of reporting on this commitment, a mother and baby can only be recorded as

having two home visits (they may have received more home visits) Calculation: N/A

Target:

HHS Target 2013‐2014 Cairns and Hinterland 4,189 Cape York 207 Central Qld 3,105 Central West 187 Darling Downs 3,742 Gold Coast 7,474 Mackay 3,231 Metro North 13,262 Metro South 19,248 North West 620 South West 402 Sunshine Coast 3,730 Torres Strait ‐ Northern Peninsula 199 Townsville 5,993 West Moreton 4,882

Wide Bay 3,633

Target Rationale: As one of its election commitments the Queensland Government committed to giving mums and bubs the best possible start to life through providing enhanced access to maternal and child health services. This commitment:

• Seeks to provide additional access to home visits and community clinics in the first 12 months of birth

• Builds on services already provided by Hospital and Health Services (HHS) which include access to a home visit (for women birthing in the public system through the Universal Postnatal Contact Service) and community clinics in the first 12 months of life.

The Enhanced Maternal and Child health service is to be available to all mothers who birth in Queensland (both in the public and private).

Target Triggers: Green: ≥ 85% HHS target Amber: ≥ 70% ‐ 84.9% HHS target Red: < 70% HHS target

Scope: All HHSs except Mater Health Service and Children’s Health Queensland

Data source: Queensland Health approved appointment scheduling system

Reporting frequency: Quarterly and year‐to‐date

KPI owner: Policy and Planning Branch, System Policy and Performance Division



Aboriginal and Torres Strait Islander Potentially Preventable Hospitalisations

Full KPI Title: Aboriginal and Torres Strait Islander – Potentially Preventable Hospitalisations

KPI number: 2.10

KPI Category: Equity and Effectiveness – Access

Tier: 2

Description: The number and proportion of Aboriginal and Torres Strait Islander hospitalisations that could have potentially been prevented through the provision of appropriate non‐hospital health services.

Definition: The number of Aboriginal and Torres Strait Islander potentially preventable hospitalisations as proportion of total Aboriginal and Torres Strait Islander separations. Notes / Limitations: Department of Health Selected Potentially Preventable Hospitalisation ICD‐10‐AM definition (Table

1), adapted from NHISSC Potentially Preventable Hospitalisation definition. Separations are reported by the jurisdiction of usual residence of the patient, not the jurisdiction of

hospitalisation. Separations for renal dialysis (DRG V50 L61Z) are excluded. Separations exclude unqualified neonates, boarders, organ procurements and non‐Queensland

residents. Patients with an Indigenous status of ‘not‐stated’ are included in non‐Indigenous counts. The sum of PPH sub‐categories Total Vaccine Preventable, Total Chronic and Total Acute does not

necessarily add to Total PPH, as a single person can be counted in multiple sub‐categories. Similarly, the sum of conditions within each sub‐category does not necessarily add to the total for that sub‐category.

After July 2010, there was a significant change in coding standards for diabetes, which is a substantial contributor to chronic and total preventable hospitalisations. Between 2009‐10 and 2010‐11 this change resulted in a 56% decrease in the number of hospitalisations where diabetes with complications was coded as a principal diagnosis. The number of hospitalisations with diabetes as other (additional) diagnosis decreased by 41%. These coding changes, and further diabetes coding changes from 1 July 2012, have impacted on the comparability of numbers and proportions across years. This means that previous trajectory computations can not be used to observe trends or to develop targets.

Calculation: Numerator: Number of Aboriginal and Torres Strait Islander potentially preventable hospitalisations for the reporting quarter.

Denominator: Total number of Aboriginal and Torres Strait Islander separations for the reporting quarter.


Target: Queensland Aboriginal and Torres Strait Islander average for potentially preventable hospitalisations derived from the first 3 quarters of the 2012‐13 financial year is 17.7%. Changes in coding practices prior to the 2012‐13 financial year prevent the use of separations prior to this period being used in the development of a Queensland average.

Target Rationale: Due to unavailability of comprehensive primary health care data, this indicator is a proxy measure of the prevalent number of cases in the community of conditions that are deemed preventable or treatable outside of the acute hospital setting. It can also serve as a useful indicator of the availability and quality of non‐hospital care.

Strategic Linkages Making Tracks: toward closing the gap in health outcomes for Indigenous Queenslanders by 2033 ‐

Policy and Accountability Framework National Healthcare Agreement

Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report

Target Triggers: Green: ≤ 17.7% Amber: ≤ 18.7% and > 17.7% Red: > 18.7%

Scope: All HHS (excluding Children’s Health Queensland HHS)



KPI owner: Aboriginal and Torres Strait Islander Health Unit, System Policy and Performance Division


Table 1.

Department of Health selected preventable hospitalisations definitions Category

ICD‐10‐AM codes

Vaccine‐preventable

Influenza and pneumonia

J10, J11, J13, J14, J15.3, J15.4, J15.7, J15.9, J16.8, J18.1, J18.8 in any diagnosis field, excludes cases with additional diagnosis of D57 (sickle‐cell disorders) and people under 2 months

Other vaccine‐preventable conditions

A35, A36, A37, A80, B05, B06, B16.1, B16.9, B18.0, B18.1, B26, G00.0, M01.4 in any diagnosis field

Chronic

Asthma

J45, J46 as principal diagnosis only

Congestive cardiac failure

I50, I11.0, J81 as principal diagnosis only, exclude cases with the following procedure codes: 33172‐00, 35304‐00, 35305‐00, 35310‐02, 35310‐00, 38281‐11, 38281‐07, 38278‐01, 38278‐00, 38281‐02, 38281‐01, 38281‐00, 38256‐00, 38278‐03, 38284‐00, 38284‐02, 38521‐09, 38270‐01, 38456‐19, 38456‐15, 38456‐12, 38456‐11, 38456‐10, 38456‐07, 38456‐01, 38470‐00, 38475‐00, 38480‐02, 38480‐01, 38480‐00, 38488‐06, 38488‐04, 38489‐04, 38488‐02, 38489‐03, 38487‐00, 38489‐02, 38488‐00, 38489‐00, 38490‐00, 38493‐00, 38497‐04, 38497‐03, 38497‐02, 38497‐01, 38497‐00, 38500‐00, 38503‐00, 38505‐00, 38521‐04, 38606‐00, 38612‐00, 38615‐00, 38653‐00, 38700‐02, 38700‐00, 38739‐00, 38742‐02, 38742‐00, 38745‐00, 38751‐02, 38751‐00, 38757‐02, 38757‐01, 38757‐00, 90204‐00, 90205‐00, 90219‐00, 90224‐00, 90214‐00, 90214‐02. E10–E14.9 as principal diagnoses and E10–E14.9 as additional diagnoses where the principal diagnosis was:

– hypersmolarity (E87.0)

– acidosis (E87.2)

– transient ischaemic attack (G45)

– nerve disorders and neuropathies (G50–G64)

– cataracts and lens disorders (H25–H28)

– retinal disorders (H30–H36)

– glaucoma (H40–H42)

– myocardial infarction (I21–I22)

– other coronary heart diseases (I20, I23–I25)

– heart failure (I50)

– stroke and sequelae (I60–I64, I69.0–I69.4)

– peripheral vascular disease (I70–I74)

– gingivitis and periodontal disease (K05)

– kidney diseases (N00–N29) [including end‐stage renal disease (N17–N19)]

Diabetes complications

COPD J20, J41, J42, J43, J44, J47 as principal diagnosis only, J20 only with additional diagnoses of J41, J42, J43,J44, J47

Angina I20, I24.0, I24.8, I24.9 as principal diagnosis only, exclude cases with procedure codes not in blocks [1820] to [2016]

Iron deficiency anaemia

D50.1, D50.8, D50.9 as principal diagnosis only.

Hypertension

I10, I11.9 as principal diagnosis only, exclude cases with procedure codes according to the list of procedures excluded from the Congestive cardiac failure category above.

Nutritional deficiencies

E40, E41, E42, E43, E55.0, E64.3 as principal diagnosis only.

Rheumatic heart disease

I00 to I09 as principal diagnosis only. (Note: includes acute rheumatic fever)

Acute

Dehydration and gastroenteritis

A09.9, E86, K52.2, K52.8, K52.9 as principal diagnosis only.

Pyelonephritis

N10, N11, N12, N13.6, N39.0 as principal diagnosis only.

Perforated/bleeding ulcer

K25.0, K25.1, K25.2, K25.4, K25.5, K25.6, K26.0, K26.1, K26.2, K26.4, K26.5, K26.6, K27.0, K27.1, K27.2, K27.4, K27.5, K27.6, K28.0, K28.1, K28.2, K28.4, K28.5, K28.6 as principal diagnosis only.

Cellulitis

L03, L04, L08, L88, L98.0, L98.3 as principal diagnosis only, exclude cases with any procedure except those in blocks 1820 to 2016 or if procedure is 30216‐02, 30676‐00, 30223‐02, 30064‐00, 34527‐01, 34527‐00, 90661‐00 and this is the only listed procedure

Pelvic inflammatory disease

N70, N73, N74 as principal diagnosis only.

Ear, nose and throat infections

H66, H67, J02, J03, J06, J31.2 as principal diagnosis only.

Dental conditions

K02, K03, K04, K05, K06, K08, K09.8, K09.9, K12, K13 as principal diagnosis only.

Appendicitis with generalised peritonitis*

K35.0 (pre 2010/2011), K35.2 (2010/2011 onwards) in any diagnosis field

Convulsions and epilepsy

G40, G41, O15, R56 as principal diagnosis only

Gangrene

R02 in any diagnosis field

* From ICD‐10AM version 7, the ICD‐10AM code K35.0 has been removed. In order to best estimate a number of episodes of care that is comparable across different time periods, K35.2 has been used to define Appendicitis with generalised peritonitis episodes of care from 2010‐11.


Potentially Preventable Hospitalisations Chronic conditions

Full KPI Title: Potentially Preventable Hospitalisations (PPH) – Chronic Conditions

KPI number: 2.11


Tier: 2

Description: The number and proportion of admissions for chronic conditions that could have potentially been prevented through the provision of appropriate non‐hospital health services.

Definition: The number of potentially preventable hospitalisations (for chronic conditions only) as proportion of total Queensland admissions.

Potentially Preventable Hospitalisations are conditions where the hospitalisation is believed to be avoidable through the provision of timely access and adequate non‐hospital care (primary and community health services). PPHs are grouped into 3 broad categories: vaccine‐preventable conditions, acute conditions and chronic conditions. This indicator focuses on chronic conditions only.

Department of Health PPH ‐ ICD‐10‐AM codes for chronic conditions include: Asthma J45, J46 as principal diagnosis only Congestive cardiac failure

I50, I11.0, J81 as principal diagnosis only, exclude cases with the following procedure codes (33172‐00, 35304‐00, 35305‐00, 35310‐02, 35310‐00, 38281‐11, 38281‐07, 38278‐01, 38278‐00, 38281‐02, 38281‐01, 38281‐00, 38256‐00, 38278‐03, 38284‐00, 38284‐02, 38521‐09, 38270‐01, 38456‐19, 38456‐15, 38456‐12, 38456‐11, 38456‐10, 38456‐07, 38456‐01, 38470‐00, 38475‐00, 38480‐02, 38480‐01, 38480‐00, 38488‐06, 38488‐04, 38489‐04, 38488‐02, 38489‐03, 38487‐00, 38489‐02, 38488‐00, 38489‐00, 38490‐00, 38493‐00, 38497‐04, 38497‐03, 38497‐02, 38497‐01, 38497‐00, 38500‐00, 38503‐00, 38505‐00, 38521‐04, 38606‐00, 38612‐00, 38615‐00, 38653‐00, 38700‐02, 38700‐00, 38739‐00, 38742‐02, 38742‐00, 38745‐00, 38751‐02, 38751‐00, 38757‐02, 38757‐01, 38757‐00, 90204‐00, 90205‐00, 90219‐00, 90224‐00, 90214‐00, 90214‐02)

Diabetes complications

E10–E14.9 as principal diagnoses and E10–E14.9 as additional diagnoses where the principal diagnosis was: hypersmolarity (E87.0); acidosis (E87.2); transient ischaemic attack (G45); nerve disorders and neuropathies (G50–G64); cataracts and lens disorders (H25–H28); retinal disorders (H30–H36); glaucoma (H40–H42); myocardial infarction (I21–I22); other coronary heart diseases (I20, I23–I25); heart failure (I50); stroke and sequelae (I60–I64, I69.0–I69.4); peripheral vascular disease (I70–I74); gingivitis and periodontal disease (K05); kidney diseases (N00–N29).

COPD J20, J41, J42, J43, J44, J47 as principal diagnosis only, J20 only with additional diagnoses of J41, J42, J43,J44, J47

Angina I20, I24.0, I24.8, I24.9 as principal diagnosis only, exclude cases with procedure codes not in blocks 1820‐2016

Iron deficiency anaemia

D50.1, D50.8, D50.9 as principal diagnosis only

Hypertension I10, I11.9 as principal diagnosis only, exclude cases with procedure codes according to the list of procedures excluded from the Congestive cardiac failure category above

Nutritional deficiencies

E40, E41, E42, E43, E55.0, E64.3 as principal diagnosis only

Rheumatic heart disease

I00 to I09 as principal diagnosis only

Calculation: Numerator: Number of chronic potentially preventable hospitalisations within the HHS for the reporting quarter.

Denominator: Total number of separations within the HHS for the reporting quarter. Formula: (Numerator / Denominator) * 100 Notes / Limitations: Department of Health Selected Potentially Preventable Hospitalisation ICD‐10‐AM definition for

chronic conditions (Table 1), adapted from NHISSC Potentially Preventable Hospitalisation definition.

Separations are reported by the jurisdiction of usual residence of the patient, not the jurisdiction of hospitalisation.

Separations for renal dialysis (DRG V5.0 L61Z) are excluded. Separations excludes care types unqualified neonates, boarders, organ procurements, as well as

non‐Queensland residents. After July 2010, there was a significant change in coding standards for diabetes, which is a

substantial contributor to chronic and total preventable hospitalisations. Between 2009‐10 and 2010‐11 this change resulted in a 56% decrease in the number of hospitalisations where diabetes with complications was coded as a principal diagnosis. The number of hospitalisations with diabetes as other (additional) diagnosis decreased by 41%. These coding changes, and further diabetes coding changes from 1 July 2012, have impacted on the comparability of numbers and proportions across years.

Target: Queensland average of 4.9. This average is based on chronic PPHs for July 2012‐March 2013 (period selected due to coding changes).

Target Rationale: Due to unavailability of comprehensive primary health care data, this indicator is a proxy measure of the prevalent number of cases in the community of conditions that are deemed preventable or treatable outside of the acute hospital setting. It can also serve as a useful indicator of the availability and quality of non‐hospital care.

As per the National Health Reform Agreement, the Department of Health is contributing to the development of a National Primary Health Care Strategic Framework to “Increase the focus on prevention, screening and early intervention”. The Commonwealth is in initial discussions with the Department about a Queensland Plan.

This indicator focuses on chronic conditions only as this is the area in which it is considered that there is greatest opportunity for the in‐scope HHSs to influence either through effective community care and/or through collaboration with other primary/community care providers. Chronic conditions make up approximately 50% of all potentially preventable hospitalisations by Queensland residents.

Target Triggers: Green: ≤ 4.9% Amber: ≤ 5.9% and > 4.9% Red: > 5.9%

Scope: All HHS (excluding Children’s Health)



KPI owner: Healthcare Purchasing, System Policy and Performance Division



Aboriginal and Torres Strait Islander Discharge against Medical Advice

Full KPI Title: Aboriginal and Torres Strait Islander patients who discharged themselves against medical advice

KPI number: 2.12


Tier: 2

Description: The proportion of Aboriginal and Torres Strait Islander patients who discharged themselves against medical advice (DAMA)

Definition: The number of Aboriginal and Torres Strait Islander DAMA inpatients as a proportion of total Aboriginal and Torres Strait Islander separations. Notes / Limitations: Patients with discharge status of ‘episode change’ or ‘died’ excluded Admissions for Renal Dialysis (DRG L61Z) are excluded Patients with an Indigenous status of ‘not‐stated’ are included in non‐Indigenous counts Included interstate and overseas patients who utilised Queensland public acute facilities.

Calculation: Numerator: Number of Aboriginal and Torres Strait Islander separations who are recorded as discharging against medical advice for the reporting quarter.

Denominator: Total number of Aboriginal and Torres Strait Islander separations for the reporting quarter.


Target: HHS Jul‐Sep13 Oct‐Dec13 Jan‐Mar14 Apr‐Jun14 Cairns and Hinterland 2.6% 2.2% 1.8% 1.4% Cape York 2.0% 1.7% 1.4% 1.1% Central Queensland 3.1% 2.8% 2.4% 2.1% Central West 1.4% 1.3% 1.2% 1.1% Children’s Health Services Better than Qld non‐Indigenous target rate ‐

maintain current rate across all quarters Darling Downs 3.5% 2.9% 2.4% 1.8% Gold Coast 1.6% 1.3% 1.1% 0.9% Mackay 1.4% 1.4% 1.4% 1.4% Metro North 3.7% 3.2% 2.6% 2.1% Metro South 2.8% 2.4% 2.0% 1.6% North West 5.2% 4.4% 3.5% 2.7% South West 4.6% 3.6% 2.6% 1.6% Sunshine Coast 1.7% 1.5% 1.4% 1.2% Torres Strait‐Northern Peninsula

Better than Qld non‐Indigenous target rate ‐ maintain current rate across all quarters

Townsville 4.1% 3.4% 2.7% 2.0% West Moreton 2.5% 2.2% 1.8% 1.5% Wide Bay 2.3% 2.0% 1.7% 1.4%

Target Rationale: Research highlights that discharge against medical advice is associated with increased patient morbidity and the risk of hospital readmission. Strategic Linkages: Aboriginal and Torres Strait Islander Health Performance Framework (3.08) Chronic Disease Indigenous Health [Queensland Health Indigenous Health Funding Package] Council of Australian Governments [COAG] Closing the Gap in Indigenous Health Outcomes

National Partnership Agreement [IHONPA] Making Tracks: toward closing the gap in health outcomes for Indigenous Queenslanders by 2033 ‐

Policy and Accountability Framework

Target Triggers: Green: ≤ HHS quarterly target Amber: ≤ 0.5% above HHS quarterly target Red: > 0.5% above HHS quarterly target

Scope: All HHS






Aboriginal and Torres Strait Islander Low Birthweight Babies Full KPI Title: Low birthweight babies (weighing less than 2500 grams at birth) born to Aboriginal and Torres Strait

Islander women

KPI number: 2.13


Tier: 2

Description: Proportion of singleton liveborn low birthweight babies born to Aboriginal and Torres Strait Islander women.

Definition: The incidence of low birthweight among liveborn babies of Aboriginal and Torres Strait Islander mothers as a proportion of liveborn babies of Aboriginal and Torres Strait Islander mothers.

Low birthweight is defined as less than 2500 grams. Calculation: Numerator: Number of low birthweight (<2500g) liveborn singleton babies born to Aboriginal and

Torres Strait Islander women in the financial year. Denominator: Total number of liveborn singleton babies born to Aboriginal and Torres Strait

Islander women in the financial year. Formula: (Numerator ÷ Denominator) x 100 Notes: Includes live births of 20 weeks gestation or 400 grams or more birthweight Babies of unknown birthweight are excluded Multiple births and stillborns are excluded

Target:

HHS 2013‐14 target Cape York 11.7% Central West 13.9% North West 10.2% South West 8.4% Torres Strait‐Northern Peninsula 5.5%

Target Rationale: Low birthweight is associated with increased risk of poor health and death during infancy and increased prevalence of a number of chronic diseases in adulthood. Low birthweight is a particular issue for Indigenous Australians.

Straight line trajectories from the current Indigenous baseline to the non‐Indigenous projected target were used to enable an estimate of the percentage or rate point change required per year.

Targets for the first 10 years (2008‐09 to 2017‐18) were based on halving the gap between Indigenous and non‐Indigenous low birthweight rates.

Strategic linkages: National Indigenous Reform Agreement National Partnership Agreement for Indigenous Early Childhood Development Agreement National Healthcare Agreement

Target Triggers: Green: ≤ HHS quarterly target Amber: ≤ 1.0% above HHS quarterly target > Red: > 1.0% above HHS quarterly target

Scope: North West HHS, Cape York HHS, Central West HHS, South West HHS, and Torres Strait‐Northern Peninsula HHS

Data source: Perinatal Data Collection (PDC)

Reporting frequency: Annual



Rate of post discharge community contact Full KPI Title: Rate of community follow up within 1 to 7 days following discharge from an acute mental health

inpatient unit

KPI number: 2.14


Tier: 2

Group A ‐ Discharging Hospital Proportion of in‐scope separations from the Hospital and Health Services’ (HHS) acute mental health inpatient unit(s) for which an ambulatory mental health service contact, in which the consumer participated (in person or via videoconference), was recorded in the one to seven days following that separation.

Description:

Group B ‐ Usual residence of discharged patient Proportion of in‐scope separations from an acute mental health inpatient unit(s) for patients usually resident in the HHS, for which an ambulatory service contact, in which the consumer participated (in person or via videoconference), was recorded in one to seven days following that separation.

Definition: An ambulatory mental health service contact is the provision of a clinically significant service by one or more specialised mental health service providers for consumer/s where the nature of the service would normally warrant a dated entry in the clinical record of the consumer in question.

A contact is where the consumer participates either in person or via videoconference The following separations, as identified through separation modes, are included:

o 01: Home / Usual residence. o 12: Correctional facility. o 15: Residential Aged Care Facility.

Same day separations (defined as episodes where admission and discharge dates are the same) are excluded. This covers the index separation and subsequent readmission.

Acute is defined based upon the standard unit code at the time of admission to the mental health unit. The standard unit code which is attached to the unit from which the patient was discharged.

The following ambulatory mental health service contacts are excluded: o contact on the day of separation. o contacts where the consumer did not participate either in person or by videoconference.

Calculation: Group A ‐ Discharging Hospital Numerator: Number of in‐scope separations from the HHS’ acute mental health inpatient unit(s),

for which an ambulatory mental health service contact in which the consumer participated (in person or via videoconference), was recorded in the one to seven days following that separation.

Denominator: Number of in‐scope overnight separations from the HHS’ acute mental health inpatient unit(s) occurring within the reference period.

Formula: (Numerator ÷ Denominator) x 100 Group B ‐ Usual residence of discharged patient Numerator: Number of in‐scope separations from an acute mental health inpatient unit for patients

usually resident in the HHS, for which an ambulatory service contact, in which the consumer participated (in person or via videoconference), was recorded in one to seven days following that separation.

Denominator: Number of in‐scope separations from an acute mental health inpatient unit for patients usually resident in the HHS occurring within the reference period.


Target: ≥ 60%

Target Rationale: The Measurement Strategy of the Fourth National Mental Health identified a national target of 75% based upon outcomes of a national benchmarking project and state and territory performance. Since 2006‐07, Queensland has made incremental improvements towards the national target and the 2013‐

Rate of post discharge community contact 14 target is reflective of this approach.

Target Triggers: Green: ≥ 60% Amber: < 60% to 55% Red: < 55%

Scope: Group A‐ discharging hospital: • Cairns and Hinterland, Central Queensland, Children’s Health Queensland, Darling Downs,

Gold Coast, Mackay, Mater Health Service, Metro North, Metro South, Sunshine Coast, Townsville, West Moreton, Wide Bay.

Group B ‐ place of usual residence of discharged patient: • Cape York, Central West, , North West, South West and Torres Strait‐Northern Peninsula

Data source: Queensland Hospital Admitted Patient Data Collection (QHAPDC) and Mental Health Activity Data Collection (MHADC)





Ambulatory mental health activity

Full KPI Title: Progress towards duration of ambulatory mental health service contacts annual target

KPI number: 2.15

KPI Category: Equity and Effectiveness – Access

Tier: 2

Description: Proportion of ‘total duration of ambulatory mental health service contacts’ target provided by the

Hospital and Health Service (HHS) mental health service organisation.

Definition: � An ambulatory mental health service contact is the provision of a clinically significant service by one

or more specialised mental health service providers for consumer/s where the nature of the service

would normally warrant a dated entry in the clinical record of the consumer in question.

� The ‘total duration’ annual target is based upon a standard methodology that considers the

investment in community mental health services as well as locality factors of the HHS. The total

duration target is expressed in hours of in-scope services that a consumer receives and is the figure

included in each service agreement.

� The indicator and target for monitoring performance considers progress towards meeting the ‘total

duration’ target.

� Inclusive of mental health service contacts in scope for the National Minimum Data Set Community

Mental Health Care.

� However group service contacts (and associated duration), in which the consumer did not

participate and the following interventions were recorded, are excluded:

- Case Review.

- Other Review (including MHRT Hearing, Medical Review, Limited Community Treatment Review

and Intake meeting).

- Intake.

- Liaison with other professionals (including interagency stakeholder meeting, second opinion,

referral feedback, provision of advice and provide collateral information).

� Duration is the time from the start to finish of a service contact (in hours or part thereof) and is

calculated from the perspective of the consumer. Travel to or from the location at which the

service is provided, for example to or from outreach facilities or private homes, is not reported as

part of the duration of the service contact.

� Group service contacts are defined as services delivered concurrently to two or more consumers.

For group service contacts the duration is the time recorded for each consumer, regardless of the

number of consumers or third parties participating or the number of service providers providing

the service.

� Numerator: Year To Date (YTD) total in-scope ambulatory mental health service contact hours

provided by the HHSs mental health service organisation(s).

� Denominator: YTD target ambulatory mental health service contact hours identified for the HHSs

mental health service organisation(s).


Target: 100%

� The following table outlines the ambulatory mental health service contact hours target identified

for each HHS. To align to reporting requirements of the Queensland State Budget Service Delivery

Statement an upper and lower range was identified. The 100% target for monitoring relates to the

lower target of the range.

HHS Lower Upper

Cairns and Hinterland 74,157 91,010

Cape York 2,796 3,494

Central Queensland 39,724 48,752

Central West 1,886 2,358

Children's Health Queensland 42,536 51,043

Darling Downs 56,492 69,331

Ambulatory mental health activity

Gold Coast 92,483 110,979

Mackay 27,461 33,702

Mater Health Services 32,884 39,461

Metro North 165,454 198,545

Metro South 194,252 233,102

North West 7,584 9,480

South West 5,016 6,270

Sunshine Coast 61,220 75,133

Torres Strait and Northern Peninsula 3,260 4,076

Townsville 68,759 84,386

West Moreton 51,033 61,240

Wide Bay 34,393 42,210

Total 961,388 1,164,572

Target Rationale: � A key element of national and state mental health plans has been the expansion of treatment and

support services to assist people affected by mental illness living in the community. In 2010-11,

51.7% (or $377.2 million) of expenditure on direct mental health care was on specialised

community mental health services.

� Access to timely and appropriate mental health services and support remains a key priority of

national strategies aimed at improving mental health service delivery and more recently identified

as a key area for action by the National Mental Health Commission.

� The total duration target was set at the HHS level, utilising a standardised approach to enable

services to be compared on a level playing field (with adjustments for variation expected due to

geographic locality) and more clearly articulates performance expectations from current

investment.

� The indicator and target for monitoring performance considers progress towards meeting the ‘total

duration’ target.

� For some services, the target will represent a ‘stretch’ in relation to current practices for recording

information.

� This target reflects the service contact duration in the Queensland State Budget Service Delivery

Statement.

Target Triggers: Green: > 95%

Amber: ≤ 95 to 90%

Red: < 90%

Scope: All HHSs

Data source: Mental Health Activity Data Collection (MHADC)





BreastScreen Queensland Screening Activity

Full KPI Title: Proportion of the annual breast screening target achieved

KPI number: 2.16


Tier: 2

Description: Progression towards the annual screening target for each BreastScreen Queensland Service.

Definition: Proportion of screening target achieved by the BreastScreen Queensland Service catchment in the 2013/14 financial year.

Calculation: Numerator: Number of women screened by the BreastScreen Queensland Service catchment in a given period. Denominator: Screening target for the BreastScreen Queensland Service catchment in a given period. Formula: (Numerator ÷ Denominator) x 100

Target: Annual screening target (for BreastScreen Queensland for the defined catchment areas in 2013‐14 financial year): HHS Screening Target Cairns and Hinterland 15,450 Central Queensland 12,000 Darling Downs 18,000 Gold Coast 29,050 Mackay 8,400 Metro North 38,550 Metro South 46,200 Sunshine Coast 31,700 Townsville 14,800 West Moreton 10,700 Wide Bay 13,050

Target Rationale: Annual screening targets are based on the number of women screened in the previous financial year., Service screening capacity and the additional number of women required to be screened to reach the BreastScreen Australia participation rate target

Target Triggers: Green: ≥ 98% Amber: ≥ 96 ‐97.9% Red: < 96%

Scope: All HHSs which host a BreastScreen Queensland Service

Data source: BreastScreen Queensland


KPI owner: Preventive Health Unit, Chief Health Officer Branch



Dental Waiting Lists Full KPI Title: Number of patients waiting more than the clinically recommended maximum time on the General Care

dental waiting list

KPI number: 2.17


Tier: 2

Description: The number of patients waiting on the General Care dental waiting list for more than the clinically recommended maximum time of two years

Definition: Includes all patients on the General Care dental waiting list with a waiting list status of waiting, appointment made, or contacted who have not yet commenced treatment

Calculation excludes any days the client was not ready for care. Month relates to patients waiting on the first day of the following month.

Calculation: Numerator: The number of patients who are ready for care on the General Care dental waiting list and have been waiting longer than the clinically recommended maximum time of two years (730 days)

Denominator: The number of patients who are ready for care on the General Care dental waiting list Formula: (Numerator ÷ Denominator) x 100

Target: 0

Target Rationale: This target is consistent with Dental Waiting List published data on the Queensland Health web site and clinical recommendations.

Target Triggers: For the General Care dental waiting list: Green: 0% Amber: > 0% ‐ 5.0% Red: > 5.0%

Scope: All HHSs except South West, Central West, Cape York and Torres Strait. Public Non‐School Dental Service Oral Health Dental Clinics which maintain a dental waiting list

Data source: Oral Health QHERS sourced from the Information System for Oral Health (ISOH)


KPI owner: Office of the Chief Dental Officer, Health Service and Clinical Innovation Division



Year To Date Operating Position

Full KPI Title: Year to date (YTD) operating position

KPI number: 2.18


Tier: 2

Description: Year to date (YTD) operating position as recorded in the Finance module on DSS Panorama

Definition: Operating position = revenue less expenditure

Calculation: Formula: YTD revenue less YTD expenditure

Target: Balanced or surplus

Target Rationale: Key indicator of financial viability

� Financial Accountability Act 2009

� Financial & Performance Management Standard 2009

Target Triggers: Green: YTD surplus or balanced

Amber: YTD deficit within 0.5% of YTD budget

Red: YTD deficit greater than 0.5% of YTD budget

Scope: All HHSs

Data source: DSS Panorama – Finance module





External labour

Full KPI Title: Expenditure on locum and agency staff

KPI number: 2.19


Tier: 2

Description: Reduction in expenditure on external labour Year To Date (YTD)

Definition: -

Calculation: Numerator: Expenditure on external labour YTD 2013/14

Denominator: Expenditure on external labour YTD 2012/13

Formula: (1 - (Numerator ÷ Denominator)) x 100

Target: YTD: 20% reduction on prior year

Target Rationale: � Target based on Fiscal Recovery requirements

Target Triggers: Green: YTD result showing a 20% reduction on prior year

Amber: YTD result showing a reduction of between 5% and <20% on prior year

Red: YTD result showing a less than 5% reduction on prior year or increase in YTD expenditure

Scope: Cape York, Central West, North West, South West, Torres Strait-Northern Peninsula

Data source: DSS





Average QWAU cost Full KPI Title: Year to date average cost per Queensland Weighted Activity Unit (QWAU)

KPI number: 2.20


Tier: 2

Description: Year To Date (YTD) Cost per QWAU for the in‐scope ABF facilities

Definition: Costing refers to the allocation of costs for the services or activity provided to a patient. Total cost includes expenditure from cost centres as per HHS determined split of the ABF proportions for ABF facilities.

QWAU is a single standardised unit used to measure healthcare services (activities) within the Queensland ABF model.

Calculation: Numerator: YTD ABF related expenditure Denominator: YTD ABF QWAU Formula: Numerator ÷ Denominator

Target: At or below the Queensland ABF price

Target Rationale: The Queensland ABF price is set to reflect the costs of delivering the many different services provided by hospitals, and the target provides a performance indicator of cost relativity to price.

Costing of services is essential for cost comparison and benchmarking at a national, state and HHS level.

Strategic Plan objective 4.3.1: Develop an annual budget plan which delivers outcomes within the allocated resources

Strategic Plan objective 4.3.2: Contribute to a nationally consistent approach to activity based funding

Target Triggers: Green: ≤ 4660 Amber: ≥ 4661 ‐ 4753 Red: ≥ 4754

Scope: All HHSs with ABF facilities (excludes Cape York, Central West, South West, Torres Strait‐Northern Peninsula)

Data source: DSS Scorecard ‐ Fixed EOM “Expenses per WAU for ABF facilities”


KPI owner: Activity Based Funding Model Team, System Policy and Performance Division



Year To Date MOHRI FTE

Full KPI Title: Minimum Obligatory Human Resource Information (MOHRI) FTE – number of MOHRI FTE year to date

KPI number: 2.21


Tier: 2

Description: Comparison of Year to date (YTD) MOHRI Occupied Full-Time Equivalents (FTE) to targets specified for

each HHS

Definition: Minimum Obligatory Human Resource Information (MOHRI) is an Queensland Government standard

defined for Whole of Government HR reporting. The MOHRI process collects data on the Queensland

Public Service (QPS) Service Delivery. This includes both employees who provide corporate and non-

corporate (front-line and support) services.

Calculation: n/a

Target: Specific for each HHS as specified in their service agreements

Target Rationale: Key indicator of financial viability and Indicates likelihood of achieving full year target

Target Triggers: Green: YTD result is less than or equal target

Amber: YTD result is greater and within 1% of target

Red: YTD result is greater than 1% of target

Scope: All HHSs

Data source: DSS





WorkCover Absenteeism

Full KPI Title: Hours Lost (WorkCover) vs Occupied FTE

KPI number: 2.22


Tier: 2

Description: WorkCover hours lost as a proportion of Occupied FTE (staff currently working in a position)

Definition: This KPI captures all statutory workers’ compensation absenteeism, including time lost claims and

partial paid days. The calculation in DSS is rounded to two decimal places for the purposes of reporting.

Calculation: Numerator: Hours Lost (FTE)

• DSS recorded Unscheduled Leave – WorkCover: (Hours: Paid and unpaid hours derived from

DSS payroll table, including both staff paid via the payroll and external contractors paid via

invoices).

• These fields include (but may not be limited to) the following SAP classifications:

o 7W01 – WorkCover – Day of Injury

o 7W02 – NP WorkCover

o 7W03 – FP WorkCover

Denominator: Occupied FTE (MOHRI)

• FTE of staff currently working in a position. Excludes the FTE of staff on extended unpaid leave.

• Minimum Obligatory Human Resource Information – WoG. Endorsed by Treasury, Office of the

Public Service Commissioner and nationally. Approved by Cabinet in 1995. [MOHRI].

• For the purposes of this KPI calculation MOHRI data is averaged over a year or quarter.

• Occupied Hours (derived from Employees Contracted Hours in HR Job History) divided by

Fortnightly Standard Award Hours where the employee has a pay status of Active or Paid

(Extended Paid Leave) and for Casuals when they worked (Actual Ordinary Hours worked).


Target: 0.40

Target Rationale: This measure is indirectly linked to the Queensland Health Strategic Plan 2012 – 2016: Contributing

Actions 5.1, 6.2 and 6.4.

Target Triggers:

Green: ≤ 0.40

Amber: > 0.40 and < 0.50

Red: ≥ 0.50

Scope: All HHSs

Data source: DSS and HR Panorama


KPI owner: Organisational Health, HR Services Branch



Emergency Department Patient Experience Full KPI Title: Emergency Department Patient Experience Survey (EDPES)

KPI number: 2.23

KPI Category: Effectiveness – Patient Experience

Tier: 2

Description: Survey patients provided with information against the survey measure as a percentage of the HHSs EDPES participants.

Definition: HHSs will be assessed against four individual measures that will be reported separately.

A telephone survey will be undertaken of a random selection of patients who attended Emergency Department (ED) during May and June 2013. The survey will be conducted during August and September 2013. Only facilities who achieve a valid sample size will be included.

Calculation: Numerator = # Patients within HHS informed or given information per measure Denominator = # Patients within HHS participating in EDPES

Target: Measure Target

State average

Patients who had to wait to be examined were told how long they might have to wait to be examined

40% 15%

Patients who had to wait to be examined were told why they had to wait to be examined

40% 26%

*Patients who were discharged from the ED were given written or printed information about their condition or treatment

60% 35%

*Patients who were discharged from the ED were advised who to contact if they were worried about their condition or treatment after leaving the ED

90% 73%

*This question does not apply to those patients who were admitted or transferred to another hospital. The target(s) will be measured at a HHS, independent of the Quality Improvement Payment measured at the facility level.

Target Rationale: Consumer‐centred care is the first of the three dimensions of a safe and high‐quality standard of care identified in the Australian Safety and Quality Framework. It is also one of the 10 national safety and quality health service standards.

This initiative also complements the focus on timely treatment within the Emergency Department, with the aim of ensuring that treatment is not only timely but also of good quality in terms of patient experience.

Target Triggers: Green: ≥ target in two or more measures and does not activate red trigger Amber: does not meet green or red trigger criteria Red: ≤ state average in two or more measures

Scope: All HHSs with facility EDs participating in the 2013 Emergency Department Patient Experience Survey (EDPES).

Data source: 2013 Emergency Department Patient Experience Survey (EDPES) http://www.health.qld.gov.au/psq/hemt/webpages/patsat_emerg.asp

Reporting frequency: Annually, by December 2013

KPI owner: Patient Safety Unit, Health Service and Clinical Innovation Division


http://www.health.qld.gov.au/psq/hemt/webpages/patsat_emerg.asp

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