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Performance Management Policy Outcome Statements for QCPR Performance Indicators 2017-18

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© Department of Health, State of Western Australia (2017). Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia. Important Disclaimer: All information and content in this Material is provided in good faith by the WA Department of Health, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use.

VERSION DATE AUTHOR COMMENTS

3.0 12 June 2017 Anthony Jones and Julie Skevington

Approved by Assistant Director General, Purchasing and System Performance

Owner: Department of Health, Western Australia

Contact: System Performance Directorate

Approved by: Angela Kelly, Assistant Director General, Purchasing and System Performance

Approval date: 12 June 2017

Current version: 3.0

Links to: Performance Policy Framework

http://ww2.health.wa.gov.au/Our-performance/

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Contents Acronyms ................................................................................................................................... 4

Introduction ................................................................................................................................ 5

QCPR – Performance Indicators ............................................................................................... 6

P1-3: Percentage of pressure areas/burns treated in the community .............................. 6

P1-4: The percentage of clients who are discharged from the WA Quadriplegic Centre back into the community (Sub-acute Transition Care (step-down) service) .................... 7

E1-1a: Injury management: Lost time injury severity rate Error! Bookmark not defined. E1-1b: Injury management: Percentage of managers and supervisors trained in occupational safety and health (OSH) and injury management responsibilitiesError! Bookmark n

E2-2: Rate of Severity Assessment Code (SAC1) clinical incident investigation reports received by Patient Safety Surveillance Unit within 28 working days of the event notification date ............................................................................................................... 8

E2-5: Excess Leave ........................................................ Error! Bookmark not defined. E3-4: Year-to-date Expenditure to Budget ...................................................................... 9

E3-8: Cost per bed day for Quadriplegic Centre in-patient services .............................. 10

Document Control .................................................................................................................... 11

References ................................................................................................................................ 12

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Acronyms

NSQHS National Safety and Quality Health Service Standards

PI Performance Indicator

PMP Performance Management Policy

QCPR Quadriplegic Centre Performance Report

SAC Severity Assessment Code

TBD To be determined

WA Western Australia

YTD Year to date

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Introduction The Performance Management Policy (PMP) 2017-18 guides the Department of Health to perform its role as the System Manager. The PMP involves a system of reporting performance against specified performance indicators for each Health Service Provider. The PMP is aligned to the Strategic Intent 2015-2020 and has been designed to support the vision to enable all staff members work towards achieving a sustainable health system that is able to deliver safe, high quality healthcare outcomes. The PMP 2017-18 consolidates performance reporting, monitoring, evaluation, management and intervention processes. The Interim Quadriplegic Centre Performance Report (QCPR) is the performance reporting component of the PMP for the Quadriplegic Centre. Within the PMP 2017-18, each performance indicator is accompanied by an outcome statement. Outcome statements are a declaration of the performance indicators’ strategic linkages, rationale, and relevance to key stakeholders. They ensure that performance indicators are meaningful and understandable. The main purpose of each outcome statement is to answer two core questions:

1. Why has the performance indicator been chosen for performance monitoring? 2. Why is the performance indicator relevant to patients, clinicians and

administrators? By answering these two core questions, each outcome statement will assist end users to make an informed decision about the relevance of the results presented in the Interim Quadriplegic Centre Performance Report. Outcome statements should be read in conjunction with the PMP, the Interim Quadriplegic Centre Performance Report and the supporting data definitions and data quality statements to provide a better understanding of each performance indicator.

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QCPR – Performance Indicators

P1-3: Percentage of pressure areas/burns treated in the community

PI Code P1-3

Indicator Title Percentage of pressure areas/burns treated in the community

Strategic Linkages • WA Health Strategic Intent Priority 1 – Prevention and Community Care ServicesError! Bookmark not defined.

• NSQHS – Standard 8 Preventing and Managing Pressure Injuries1

Rationale Spinal cord-injured individuals have a higher propensity to experience a degradation of skin integrity and pressure related injuries.2

Pressure injuries lead to pain, alterations to sleep and mood, a reduction in the quality of life and increased infections.3

In the majority of cases, pressure injuries that result from immobility are preventable.5,6,7

Research shows that preventable pressure injuries are a significant cost burden to the Australian health system.4

Relevance To patients: Ensures the ongoing provision of safe and quality healthcare.

To clinicians: Improves efficiency to ensure optimal clinical outcomes are maintained.

To administrators: Improves safety and quality in healthcare, and drives accountability that will result in cost-effective service delivery.

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P1-4: The percentage of clients who are discharged from the WA Quadriplegic Centre back into the community (Sub-acute Transition Care (step-down) service)

PI Code P1-4

Indicator Title The percentage of clients who are discharged from the WA Quadriplegic Centre back into the community (Sub-acute Transition Care (step-down) service)

Strategic Linkages • WA Health Strategic Intent Priority 1 – Prevention and Community Care ServicesError! Bookmark not defined.

Rationale There is a shift away from medical models of care dominated by the health service delivery sector to social models in which people with disabilities are normalised into the community.5

This normalisation approach is based on the principle that everyone is entitled to the same choices and level of services as anyone else in the community.6, 7 The ultimate goal of this approach is to empower and enable people with disabilities to gain control over their lives.8

Relevance To patients: Improves timely access to sub-acute transitional care services for the benefit of patients’ health and wellbeing.

To clinicians: Improves case load management.

To administrators: Reduces resource requirements due to the timely provision of sub-acute transitional care services.

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E2-2: Rate of Severity Assessment Code (SAC) 1 clinical incident investigation reports received by Patient Safety Surveillance Unit within 28 working days of the event notification date

PI Code E2-2

Indicator Title Rate of Severity Assessment Code (SAC1) clinical incident investigation reports received by Patient Safety Surveillance Unit within 28 working days of the event notification date

Strategic Linkages • WA Health Strategic Intent Enabler 2 – AccountabilityError! Bookmark not defined.

• Clinical Incident Management Policy (2015)11

• Australian Council of Safety and Quality in Health Care: National Core Set of Sentinel Events9

Rationale The WA health system is committed to delivering safe and high quality healthcare. Although prevention is the best strategy, it is also important to investigate and address clinical incidents when they occur.10

The reporting and investigation of a clinical incident enables strategies to be put into place to improve the safety of healthcare delivery and prevent another patient being harmed.10 To further enhance the clinical incident process, Severity Assessment Codes are used to guide incident analysis, action and escalation. Clinical incidents are categorised according to the harm caused to the patient by the delivery of healthcare and not the patient’s underlying condition/illness.10 A SAC 1 rating refers to clinical incidents resulting in serious harm/death/near miss, and includes the eight nationally reported clinical incidents known as sentinel events. 11

The Clinical Incident Management Policy (2015) requires the mandatory reporting of all SAC 1 clinical incidents. The Policy requires that the investigation findings for all SAC 1 clinical incidents are reported to the Patient Safety Surveillance Unit within 28 working days of the incident notification date.

Relevance To patients: Improves the likelihood that the patient’s hospital stay will not result in clinical related harm or a fatality.

To clinicians: Ensures the timely investigation of clinical incidents so that service delivery standards are maintained.

To administrators: Improves safety and quality in healthcare, with reduced resource requirements due to unwarranted variations in care such as under, over or misuse of care.

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E3-4: YTD Expenditure to Budget

PI Code E3-4

Indicator Title YTD Expenditure to Budget

Strategic Linkages • WA Health Strategic Intent Enabler 3 – Financial ManagementError! Bookmark not defined.

• National Health Reform Performance and Accountability Framework12

• Financial Management Act 200613

Rationale Through measuring the year-to-date (YTD) expenditure to budget, health system managers are provided with the ability to assess their performance against budget allocations and ensure accurate forecasting. This can enable improved monitoring and control of expenditure, which drives efficiency gains that are financial in nature and ultimately leads to better service provision.

Relevance To patients: Improves efficiency to ensure the ongoing provision of safe and quality healthcare.

To clinicians: Improves efficiency to ensure optimal clinical outcomes are maintained.

To administrators: Drives accountability, better financial management planning and forecasting of hospital services that will result in cost-effective service delivery.

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E3-8: Cost per bed day for Quadriplegic Centre in-patient services

PI Code E3-8

Indicator Title Cost per bed day for Quadriplegic Centre in-patient services

Strategic Linkages • WA Health Strategic Intent Enabler 3 – Financial ManagementError! Bookmark not defined.

Rationale This indicator is a measure of the cost per bed day for Quadriplegic Centre in-patient services.

This measure promotes improved efficiency by providing a more transparent understanding of costs for the associated activity.

Relevance To patients: Improves efficiency to ensure the ongoing provision of safe and quality healthcare.

To clinicians: Improves efficiency to ensure optimal clinical outcomes are maintained.

To administrators: Drives accountability, better financial management, planning and transparency that may lead to more cost-effective service delivery.

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Document Control

VERSION DATE AUTHOR COMMENTS

1.0 1 July 2017 Anthony Jones and Julie Skevington

Endorsed by the Assistant Director General, Purchasing and System Performance Division

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References 1 Australian Commission of Safety and Quality in Healthcare. (2012). Standard 8

Preventing and Managing Pressure Injuries, National Safety and Quality Health Service Standards, Australian Commission on Safety and Quality in Health, Canberra. Available From: http://www.safetyandquality.gov.au/wp-content/uploads/2012/10/Standard8_Oct_2012_WEB.pdf

2 Curry, K., Casady, L. (1992). The relationship between extended periods of

immobility and decubitus ulcer formation in the acutely spinal cord-injured individual, Journal of Neuroscience Nursing, Vol. 24 No.4, 185–89.

3 Department of Health. (2013). Pressure Injury Prevention and Management Clinical

Guidelines, Department of Health, Perth. Available From: http://www.health.wa.gov.au/circularsnew/attachments/817.pdf

4 Ngyen, K., Chaboyer, W., Whitty, J. A. (2015). Pressure injury in Australian public

hospitals: a cost-of-illness study, Australian Health Review, Vol. 39, 329–36. 5 World Health Organisation. (2011). World Report on Disability, World Health

Organisation, Geneva, Switzerland. 6 Queensland Spinal Cord Injuries Service. (2015). An Enhanced Service Model for

People with Spinal Cord Injury in Western Australia, Queensland Spinal Cord Injuries Service, Perth.

7 Dorset, P. (2010). Review of Needs and Services for People with Spinal Code

Injuries in Queensland, Griffin University, Brisbane. 8 Kendall, E., Buys, N., Larner, J. (2000). Community-Based Service Delivery in

Rehabilitation: The promise and the paradox, Disability and Rehabilitation, Vol. 22 Issue.10, 435-45.

9 Department of Health. (2015). Clinical Incident Management Policy, Department of

Health, Perth. Available From: http://www.health.wa.gov.au/circularsnew/attachments/1056.pdf

10 Australian Council of Safety and Quality in Health Care. (2015). National Core Set of

Sentinel Events, Australian Council of Safety and Quality in Health Care, Canberra. Available From: https://www.health.gov.au/internet/main/publishing.nsf/content/DB6FC7B04519D195CA257BF000217B28/$File/safeap8.pdf

11 Department of Health. (2015). Clinical Incident Management Policy, Department of

Health, Perth. Available From: http://www.health.wa.gov.au/circularsnew/attachments/1056.pdf

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12 National Health Performance Authority. (2012). National Health Reform Performance

and Accountability Framework, National Health Performance Authority, Canberra. Available from: http://nhpa.gov.au/internet/nhpa/publishing.nsf/Content/PAF.

13 Financial Management Act 2006, WA [statute on the internet] c2012. Available from:

http://www.slp.wa.gov.au/legislation/statutes.nsf/main_mrtitle_333_homepage.html (Accessed 22 February 2017).

This document can be made available in alternative formats on request for a person with a disability.

© Department of Health 2017

Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.