Department of Health and Human Services Policy and Funding Guidelines 2016 - Volume 2

Department of Health and Human Services policy and funding guidelines 2016 Volume 2: Health operations 2016–17 Chapter 4: Conditions of funding To receive this publication in an accessible format, please phone 9096 8572 using the National Relay Service 13 36 77 if required, or email .

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne. © State of Victoria, Department of Health and Human Services July 2016. Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people. Indigenous is retained when it is part of the title of a report, program or quotation. Available at . Printed by Impact Digital, Brunswick (1605009) Contents

CHAPTER 4: CONDITIONS OF FUNDING...... 281

Introduction to Chapter 4...... 282

4.1 Standards...... 283 4.1.1 Public sector values and principles...... 283 4.1.2 Safety...... 284

4.2 Expectations, policies and performance...... 287 4.2.1 Acute and subacute...... 287 4.2.2 Mental health services...... 295 4.2.3 Alcohol and drug services...... 295 4.2.4 Ageing, aged and home care services...... 296 4.2.5 Primary, community and dental health...... 296 4.2.6 Children and Young Persons (Care and Protection) Act 1998...... 297

4.3 Accreditation...... 299 4.3.1 Australian Health Service Safety and Quality Accreditation Scheme...... 299 4.3.2 Pathology services...... 299 4.3.3 Ambulance...... 300 4.3.4 Mental health clinical and community support services...... 300 4.3.5 Alcohol and drug treatment services...... 300 4.3.6 Aged care...... 300

4.4 Clinical governance...... 302 4.4.1 Health service clinical governance...... 302 4.4.2 Community health clinical governance...... 306

4.5 Consumer rights and community participation...... 307 4.5.1 Australian Charter of Healthcare Rights in Victoria...... 307 4.5.2 Consumer, carer and community participation...... 307 4.5.3 Victoria’s health experience...... 308 4.5.4 Health service community advisory committees...... 308 4.5.5 Reporting on quality of care...... 309 4.5.6 Partnerships...... 309 4.5.7 Service coordination...... 309 4.5.8 Informed consent for receipt of services...... 310 4.5.9 Complaint management...... 310 4.5.10 Health service cultural and linguistic diversity requirements...... 310

4.6 Financial requirements...... 312 4.6.1 Health service procurement and purchasing requirements...... 312 4.6.2 Compliance with financial requirements...... 313 4.6.3 Goods and services tax...... 314 4.6.4 Strategic procurement...... 314

4.7 Asset and environmental management...... 317 4.7.1 Asset management planning...... 317

iii 4.7.2 Property portfolio management...... 319 4.7.3 Asset maintenance...... 320 4.7.4 Health service environmental management planning and reporting...... 320

4.8 Information and communication technology standards...... 321

4.9 Risk management...... 323 4.9.1 Risk management and assurance...... 323 4.9.2 Emergency management...... 324 4.9.3 Fire risk management...... 325

4.10 Legal obligations...... 327 4.10.1 Privacy...... 327 4.10.2 Intellectual property...... 327

4.11 Payments and cash flow...... 328 4.11.1 Payments to funded organisations...... 328 4.11.2 Enterprise bargaining...... 328 4.11.3 Use of contract WIES...... 329 4.11.4 Health service fees and charges...... 330 4.11.5 Private patient accommodation charges...... 330 4.11.6 Redirection of funds...... 331 4.11.7 Doctors in training secondment arrangements...... 331 4.11.8 Accountability for visiting medical officer payments...... 331 4.11.9 Long service leave...... 332 4.11.10 Medical indemnity insurance...... 332

4.12 Data collection requirements...... 333 4.12.1 Data integrity...... 333 4.12.2 Key systems...... 334 4.12.3 Acute data reporting requirements...... 345 4.12.4 Subacute data reporting requirements...... 352 4.12.5 Ambulance Victoria data reporting requirements...... 353 4.12.6 Mental health services data reporting requirements...... 354 4.12.7 Alcohol and drug services data reporting requirements...... 357 4.12.8 Aged care data reporting requirements...... 359 4.12.9 Primary, community and dental health data reporting requirements...... 362 4.12.10 Commonwealth–state reporting requirements...... 367

Appendix 4.1: Performance targets and monitoring...... 368

Appendix 4.2: Service standards and guidelines...... 380

List of tables

Acronyms and abbreviations

iv Conditions of funding

Chapter 4: Conditions of funding

Volume 2: Health operations 2016–17, Chapter 4 Page 25 Conditions of funding

Introduction to Chapter 4

Chapter 4 of Volume 2: Health operations 2016–17 details the conditions and expectations of funding that apply to funded agencies, including the relevant standards and policies. These guidelines are a functional document that articulates the performance and financial framework within which state government-funded health sector entities operate. They are a reference for funded organisations regarding the parameters that they are expected to work to and within, as well as the funding linked to various services, in order to achieve the expected outcomes of the Victorian Government. The guidelines are divided into five chapters: • Chapter 1 sets out the key changes and initiatives in 2016–17 • Chapter 2 focuses on the financial framework for providing funding • Chapter 3 outlines all the prices and associated cost weights that support the overall financial framework • Chapter 4 outlines the conditions and expectations of that funding • Chapter 5 includes the modelled budgets for organisations that receive more than $1 million in health funding. Items may be updated throughout the year. Funded organisations should always refer to the policy and funding guidelines website for the most recent version of documents and guidelines. Where these guidelines refer to a statute, regulation or contract, the reference and information provided in these guidelines is descriptive only. In the case of any inconsistencies or ambiguities between these guidelines and any legislation, regulations and contractual obligations with the State of Victoria acting through the Department of Health and Human Services or the Secretary to the department, the legislative, regulatory and contractual obligations will take precedence. A note on terminology The term ‘funded organisations’ relates to all entities that receive departmental funding to deliver services. Aspects of these guidelines referring to funded organisations are applicable to all department- funded entities. For the purposes of these guidelines, the term ‘health services’ relates to public health services, denominational hospitals, public hospitals and multipurpose services, as defined by the Health Services Act 1988, in regard to services provided within a hospital or a hospital-equivalent setting. Aspects of these guidelines that refer specifically to ‘health services’ are only applicable to these entities. The term ‘community service organisations’ (CSOs) refers to registered community health centres, local government authorities and non-government organisations that are not health services. The term ‘Aboriginal community-controlled health organisations’ (ACCHOs) refers to Aboriginal medical services that are controlled by the local Aboriginal community elected boards of management. The term ‘Aboriginal community-controlled organisations’ (ACCOs) refers to a range of other Aboriginal community services that are controlled by the local Aboriginal elected boards of management. These guidelines are also relevant to Ambulance Victoria, Health Purchasing Victoria, Ramsay Health Care and the Victorian Institute of Forensic Mental Health. The guidelines specify where aspects of the guidelines are relevant for these organisations.

Volume 2: Health Operations 2016–17, Chapter 4 Conditions of funding

4.1 Standards

4.1.1 Public sector values and principles

Responsiveness • Providing frank, impartial and timely advice to the government • Providing high-quality services to the Victorian community • Identifying and promoting best practice

Integrity • Being honest, open and transparent in their dealings • Using powers responsibly • Reporting improper conduct • Avoiding real or apparent conflicts of interest • Striving to earn and sustain public trust at the highest level

Impartiality • Making decisions and providing advice on merit without bias, caprice, favouritism or self-interest • Acting fairly by objectively considering all relevant facts and applying fair criteria • Implementing government policies and programs equitably

Accountability • Working to clear objectives in a transparent manner • Accepting responsibility for their decisions and actions • Seeking to achieve best use of resources • Submitting themselves to appropriate scrutiny

Respect • Treating others fairly and objectively • Ensuring freedom from discrimination, harassment and bullying • Using their views to improve outcomes on an ongoing basis

Leadership • Actively implementing, promoting and supporting these values

Human rights • Making decisions and providing advice consistent with the human rights set out in the Charter of Human Rights and Responsibilities Act 2006 • Actively implementing, promoting and supporting human rights Section 8 of the Public Administration Act 2004 outlines the principles of the public sector and articulates what employers must do to comply. Employers must establish employment processes to ensure: • employment decisions are based on merit • employees are treated fairly and reasonably • equal employment opportunity is provided • human rights, as set out in the Charter of Human Rights and Responsibilities Act, are upheld • public sector employees have a reasonable avenue of redress against unfair or unreasonable treatment • a career in the public service is fostered (in the case of public service bodies).

The Public Sector Standards Commissioner issues codes of conduct to reinforce the public sector values, and standards on how to apply the employment principles. The codes and standards are binding but not detailed. They enable employers to introduce policies and practices that suit their organisation while also complying with the codes and standards. Employees should consider the codes, standards and any organisational policies when deciding what action to take. Further information about public sector values is available on the Victorian Public Sector Commission’s website at .

4.1.2 Safety

4.1.2.1 Pre-employment screening The department and all funded organisations must undertake the relevant pre-employment and pre- placement police record checks on all employees to minimise the risk of employing unsuitable people. Safety screening may also include a Working with Children Check, which is a mandatory screening process for people who volunteer or work with children. Healthcare workers may be exposed to, and transmit, vaccine-preventable diseases such as influenza, measles, rubella and pertussis. Maintaining immunity in the healthcare worker population helps prevent transmission of vaccine-preventable diseases to and from healthcare workers and patients. The likelihood of contact with patients and/or blood or body substances determines vaccination recommendations. Healthcare workers should receive the vaccines they require preferably before or at minimum within the first few weeks of employment, with the exception of influenza vaccine, which should be administered annually between March and May. Work activities, rather than job title, should be considered on an individual basis to ensure an appropriate level of protection is afforded to each healthcare worker. Medical facilities are encouraged to formulate a comprehensive vaccination policy for all healthcare workers. Each worker should be individually assessed for specific vaccines, taking possible contraindications into account. Work practices should include the use of standard and additional precautions to minimise exposure to blood and body fluids. If exposure does occur, guidelines for post exposure prophylaxis should be followed. Ensure that post exposure guidelines are easily accessible 24 hours a day. Each healthcare worker should be given a personal immunisation record that documents vaccinations given and test results. These records, along with other program resources, are available from the Health Department’s immunisation program website at or telephone 1300 882 008.

4.1.2.2 Staff safety in Victorian health services All funded organisations are responsible for the safety of their staff, patients and visitors. Funded organisations must have systems and processes in place to enable them to identify, assess and control occupational health and safety risks in accordance with their obligations under the Occupational Health and Safety Act 2004. Initiatives across occupational violence, bullying and harassment and worker health and wellbeing are aimed at ensuring health services are safe, respectful and healthy places to work. Key actions in 2016– 17 will focus on promoting a culture where all staff know how to raise concerns and report incidents, staff feel supported to do so and actions are taken in response to the issues raised that improve the safety for staff, patients and the community. The improved Victorian Health Incident Management System (VHIMS) will be implemented in health services throughout 2016–17. The improved VHIMS includes an integrated occupational health and violence module, and increased occupational health and violence reporting requirements as part of the minimum dataset.

4.1.2.3 Safe environments for Aboriginal and Torres Strait Islander people Funded organisations have a responsibility to provide a culturally safe environment for their Aboriginal and Torres Strait islander patients or clients. Services should develop local policies and procedures in consultation with local Aboriginal staff and community members. This includes being respectful of cultural protocols, offering patients or clients the opportunity to access male or female staff as required and preventing stigmatism and racial discrimination. All staff should undertake cultural safety training specific to their region. The department has developed the following documents to provide guidance to services: The Aboriginal culturally informed addendum to the Department of Human Services Standards evidence guide (September 2015) is available at: . Koolin Balit: Victorian Government strategic directions for Aboriginal health 2012–2022, Enable 3: Cultural responsiveness chapter (Page 60) is available at: .

4.1.2.4 Safe environment for transgender or intersex individuals Funded organisations have a responsibility to provide a safe and inclusive environment for transgender people and people with intersex variations. Services should develop local policies and procedures to facilitate gender-sensitive practice. This includes using pronouns preferred by the individual, minimising potentially embarrassing encounters with other patients, and avoiding assumptions about gender and sex-specific health issues, such as the need for cervical screening. For transgender people, it also means providing respectful, supportive advice on access to health services associated with gender transition. The department has developed the following documents to provide guidance to services: • Rainbow e-Quality: a guide to LGBTI inclusive practice for health and human services . • Service guideline for gender sensitivity and safety, available at .

4.1.2.5 Patient and client safety All funded organisations are responsible for the safety of their patients or clients. Funded organisations should have systems and processes in place to enable them to identify, manage and respond to adverse events, reducing the risk of such events recurring in future. Health services and community service organisations (CSOs) that provide services on behalf of the department and report patient or client safety incidents through the Victorian Health Incident Management System (VHIMS) are subject to the Victorian health incident management policy. The policy is available at . Community Service Organisations that provide services on behalf of the department and do not report incidents through VHIMS are subject to the (former) Department of Health’s Incident reporting instruction 2013. The Incident reporting instruction 2013 and accompanying incident report form are available at the Funded Agency Channel. More information can be found at . The Incident reporting instruction 2013 provides guidance for reporting incidents or alleged incidents that involved or impacted patients or clients during service delivery. It does not replace an organisation’s own incident management systems and processes. Organisations’ incident management policies and

Volume 2: Health operations 2016–17, Chapter 4 Page 29 Conditions of funding processes may be reviewed as part of the departments’ routine contract and performance management arrangements. For information about the reporting instruction visit: . Supported Residential Services  Supported Residential Services (SRS) are privately operated services, not funded by the department.  Supported Residential Services are registered with the department, which has responsibility for administration of the legislation governing SRS under the Supported Residential Services (Private Proprietors) Act 2010 and a regulatory responsibility under the Supported Residential Services (Private Proprietors) Regulations 2012. • Effective from 10 April 2014, the incident reporting process for SRS is as follows: – Supported Residential Services prescribed reportable incidents are notified to Authorised Officers located in regional offices. Authorised Officer details are available at . – Prescribed reportable incidents in SRS are detailed in the Supported Residential Services Act and Regulations. Authorised Officers are responsible for recording prescribed reportable incidents through a separate and independent database, the Compliance Reporting and Monitoring System (CRAMS). – Supported Residential Services Authorised Officers are no longer required to report SRS incidents via the Category One reporting process. Mental health – reportable deaths Since 1 July 2014, the Mental Health Act 2014 has required all mental health service providers to inform the Chief Psychiatrist of all reportable deaths within the meaning of the Coroners Act 2008. Mental health service providers include all designated mental health services and all publicly funded mental health community support services (MHCSS). MHCSS are required to submit the following reports within the relevant timeframes:  VHIMS reporting community service organisations providing MHCSS are required to report the incident in accordance with the Victorian health incident management policy  non-VHIMS reporting community service organisations providing MHCSS are required to report the incident in accordance with the Incident reporting instruction 2013  complete a MHA 125 ‘Notice of Death’ form to the Office of the Chief Psychiatrist. More information on what is meant by a ‘reportable death’ and the procedures for reporting them can be found in the Chief Psychiatrist’s guideline on reportable deaths, available at .

4.2 Expectations, policies and performance

The following section outlines the non-financial performance and behavioural expectations for funded agencies. These expectations are consistent with the Victorian health service performance monitoring framework business rules 2016–17. The framework is discussed in Chapter 1, section 1.5 ‘Victorian health services performance framework’ and is available at .

4.2.1 Acute and subacute

4.2.1.1 Integrated cancer services All health services that treat cancer patients are expected to be active members of the Integrated Cancer Service (ICS) for their area and support the implementation of the clinical network’s vision to improve patient experiences and outcomes by connecting cancer care and driving best practice. The Integrated Cancer Services’ strategic goals are: • a networked cancer care system • high-quality cancer care • a research-informed cancer care system. A continuing focus for the ICS in 2016–17 is to work in collaboration with the relevant cancer centres to streamline service improvement priorities within and across the ICS areas. This is in addition to participating in statewide initiatives to support improvement in cancer outcomes. Host organisations are required to hold funds on behalf of the ICS and act as employers for ICS directorate staff. Host organisations need to ensure that appropriate human resource management, fiscal management processes and accounting procedures are in place. A senior executive should be nominated as the key management contact regarding these matters. The ICS governance groups, with clinician input, are responsible for: • decision making about using funds in accordance with both local and statewide priorities for cancer reform • accountability for the ICS funding • ensuring value for money • ensuring sound project management and evaluation processes are employed. Host organisations and the ICS governance groups must agree to any charges levied by the host for infrastructure support. These charges must be reflective of actual costs incurred and should be reported in the ICS budget. A detailed reporting schedule for Integrated Cancer Services, which identifies requirements, dates and timelines, will be provided in September 2016. The accountability requirements of the ICS governance groups are to: • provide an annual review and report of progress against the current strategic plan • provide half-yearly financial statements (for periods ending 31 December and 30 June) • participate in the department’s cancer reform meetings and workshops • provide an annual report (for 2015–16) for public dissemination • participate in processes to evaluate the impact of cancer reform activities, including reporting outcomes against targets and milestones. The department reserves the right to conduct an ICS directorate performance and financial audit. Further information about Victoria’s Integrated Cancer Services is available at .

4.2.1.2 Maternity and neonatal services The department publishes an annual report of Victorian perinatal services performance indicators. The report contains individual hospital (or campus) level data for public health services compared with the statewide public hospital average and, where available, the statewide private hospital average. Health services should use this report to: • track their own performance and trends, using raw local data more frequently if required • compare results with services of a similar profile • perform ongoing local audits, including adverse event reviews through their perinatal mortality and morbidity committees • perform local analysis of specific groups or cohorts of cases such as age profiles • identify priority areas for focus and plan for performance improvement within a continuous quality framework • evaluate improvement programs and provide feedback to relevant stakeholders • provide education and support to staff and local communities. Each indicator has a list of recommended actions that should be undertaken by health services and, in particular, outlier services to ensure ongoing performance improvement. Outlier services should undertake: • an assessment of their local capability and the processes to support regular clinical audits and the provision of performance data feedback to clinicians • a multidisciplinary review of local clinical practice guidelines and protocols to ensure they are based on current evidence and research • a review of organisational barriers that constrain continual practice improvement • benchmarking with peer group services and engage with hospitals achieving better outcomes to support local and regional improvement. Interquartile ranges (identified throughout the report as most favourable, least favourable and non- outlying) are used to identify health services whose performance on a given indicator is outlying. In 2016–17, the department will work with outlier services on identifying the areas needing attention, development of improvement plans and monitoring progress against the plans or in performance over time. Further information about the perinatal services indicators report is available at .

4.2.1.3 Blood Matters Program As part of the ongoing commitment to safe transfusion practice, the Blood Matters Program assists health services to monitor transfusion practices against guidelines and provide recommendations for best practice. Performance reporting through participating in audits and surveys on clinical practice and governance is required. Health services will be advised of the audits to be conducted in 2016–17. The Blood Matters Program serious transfusion incident reporting for serious adverse events related to blood or blood components includes near-miss incidents, events related to Rh D immunoglobulin, and cell salvage. While reporting is voluntary, participation in the program is strongly encouraged and supports national healthcare standards. Blood and blood products are provided to health services, with the expectation that product use will align with the Australian health ministers’ endorsed National Stewardship Expectations for the Supply of Blood and Blood Products and associated strategies including the National Blood and Blood Product Wastage Reduction Strategy 2013–17 and the Strategic Framework for the National Haemovigilance Program available at .

The department has helped establish the transfusion nurse/trainer/safety officer role across Victoria and continues to support this position through acute admitted funding. Activities to support compliance with the national guidelines and the National Safety and Quality Health Service (NSQHS) Standards include: • employment of an appropriately trained nurse or scientist, such as one who holds a Graduate Certificate of Transfusion Practice • ensuring the role operates within an effective health service transfusion and quality governance structure • incorporating patient blood management practices – that is, a patient-centred approach to safe and appropriate transfusion practice in line with national clinical guidelines, standards and strategies (National Blood Authority and the Australian Commission on Safety and Quality in Health Care (ACSQHC) – National Standards of Health Care or NSQHS Standard 7) • participation in Blood Matters Program audits, educational forums and other activities • annual progress reports to the Blood Matters Program. Further details on the Blood Matters Program can be found at .

4.2.1.4 Subacute and non-acute services Subacute capability and access planning framework Health services providing rehabilitation, geriatric evaluation and management (GEM) and Health Independence Program (HIP) services should ensure they align, or are working towards aligning, with their services based on their service capability level as defined in Planning the future of Victoria’s subacute service system: a capability and access planning framework (2013). The framework is available at . Performance monitoring and supporting improvements Subacute services are subject to the department’s broader monitoring of health services, which focuses on the overall activity levels of health services when compared with the target. Additional subacute activity reports have been developed to provide benchmarking and model of care information between peers and across the state to support practice and service delivery improvements and better understand patient cohorts in admitted and non-admitted subacute care types. These benchmarking reports are currently provided to health services twice yearly. Health Independence Program Health Independence Program services aim to provide hospital substitution and diversion services by supporting people in the community, in ambulatory settings and in their homes. These services focus on improving and optimising people’s function and participation in activities of daily living to allow them to maximise their independence and return to, or remain in, their usual place of residence. Health Independence Program service delivery components The components of the Health Independence Program that a client receives will be based on the client’s assessed needs and will assist the client to meet their identified goals. This may consist of one or more of the following: • rehabilitation (such as rehabilitation at home or in a community rehabilitation centre) • care coordination – short-term or complex • client self-management, education and support • access to specialist services including specialist assessment (such as linking to residential in-reach services, a specialist medical clinic or specialist subacute clinic – falls and balance or continence clinics) • short-term supports (such as post-acute care)

• complex psychosocial issues management. In 2016–17 it is expected that health services will continue to progress the Health Independence Program consolidation with the aim of providing a responsive, integrated and flexible approach to service provision. It is expected that health services will continue to provide the Health Independence Program service components for which they are funded based on their subacute service capability framework level. The Health Independence Program guidelines will continue to guide health service and departmental directions for these services in 2016–17 and are available at . In 2016–17 the department will continue to work with health services to reduce variation across services. Work to review the Health Independence Program price and service stream weights to better reflect stream costs will continue over 2016–17. Further work to improve the Health Independence Program classification data, including potential Victorian Integrated Non-Admitted Health (VINAH) dataset refinements for 2017–18, will also continue. Health Independence Program Complex Care (HIV) The Health Independence Program Complex Care (HIV) program is part of the Health Independence Program and is delivered at four health services: Barwon Health, Melbourne Health, Monash Health and St Vincent’s Health. The Health Independence Program Complex Care (HIV) (formerly HARP-HIV) provides specialist person-centred medical care, comprehensive assessment, care coordination and timely access to specialist care in the ambulatory and community setting. The program aims to provide integrated seamless care within and across the hospital and community setting and deliver greater access for people living with HIV/AIDS to HIV-specific, mainstream and specialised health and community services. Victorian Paediatric Rehabilitation Service The Victorian Paediatric Rehabilitation Service (VPRS) specifically caters for children and adolescents who, as a result of injury, medical and surgical intervention, or functional impairment, will benefit from a program of developmentally appropriate, time-limited, goal-focused multidisciplinary rehabilitation. The Victorian Paediatric Rehabilitation Service is composed of a statewide management team, two inpatient services at The Royal Children’s Hospital and Monash Children’s Hospital (Monash Health) and eight ambulatory services, as part of the Health Independence Program at Ballarat Health Services, Barwon Health, Bendigo Health Care Group, Eastern Health, Goulburn Valley Health, Latrobe Regional Hospital, Monash Health and The Royal Children’s Hospital. The Victorian Paediatric Rehabilitation Service was previously governed by a memorandum of understanding (MOU) between the participating services. Key elements of the MOU relate to the Victorian Paediatric Rehabilitation Service structure and are integral to its functioning as a statewide service. The Victorian Paediatric Rehabilitation Service is structured to provide clear guidance for the way in which the service provider partners, funding body and key referring agencies work together in the planning and provision of paediatric rehabilitation services, including the areas of quality and performance monitoring. Key components of the structure are: • a statewide director and program manager • medical directors at The Royal Children’s Hospital and Monash Health • an advisory group comprising of members of all Victorian Paediatric Rehabilitation Services and departmental representatives.

The Victorian Paediatric Rehabilitation Service is funded through the Subacute WIES for admitted activity and Health Independence Program funding for the ambulatory services. Activity is reported through the Victorian Admitted Episodes Dataset (VAED) and VINAH datasets respectively. Monash Health receives a specified grant for the statewide management-related cost of the Victorian Paediatric Rehabilitation Service. The Victorian Paediatric Rehabilitation Service statewide appointments provide support, leadership and clinical services where appropriate across the Victorian Paediatric Rehabilitation Service sites. Participating health services facilitate visiting rights for Victorian Paediatric Rehabilitation Service staff conducting clinical work. Visiting clinical staff will observe local policies and procedures enabling the safe and effective provision of specialist paediatric rehabilitation care.

4.2.1.5 Providing aids, equipment and domiciliary oxygen In 2013 the department updated Fees and charges for acute health services in Victoria: a handbook for public hospitals to clarify the responsibilities of public hospitals in providing aids, equipment and domiciliary oxygen for patients being discharged from hospital. The Victorian Aids and Equipment Program (A&EP) provides people with a permanent or long-term disability with subsidised aids, equipment, home and vehicle modifications. The program aims to enhance the independence of people with a disability in their own home, facilitate their participation in the community and provide support to families and carers. Ballarat Health Services Statewide Equipment Program (SWEP) administers the Aids and Equipment Program for items such as mobility aids, including wheelchairs and scooters, hoists, beds, commodes, continence aids, domiciliary oxygen, home modifications and vehicle modifications. Yooralla administers the Electronic Communications Devices Scheme (ECDS), which assists individuals to communicate with speech generating devices and software. Maximum subsidies apply to all items. Clients may need to provide some funding, where the maximum subsidy does not cover the full cost of an item. Information on what type of equipment can be provided; client eligibility criteria and the application process can be found in the Victorian Aids and Equipment Program Guidelines (2010). This document is available at . The guidelines have been expanded to provide additional guidance on: • domiciliary oxygen • continence aids • compensable patients • non-compensable spinal cord patients. Note: A person is not eligible to access the Victorian Aids and Equipment Program within the 30 days post-discharge period from a public hospital where the provision of aids, equipment or home modification required is related to the hospital admission. However, to ensure a smooth transition of the client (a person who has been assessed as eligible for assistance through the Victorian Aids and Equipment Program) from hospital, applications for the Victorian Aids and Equipment Program may be lodged during the 30-day period to ensure that the aid, equipment or home modification application can be processed and supplied in a timely manner. The National Disability Insurance Scheme will commence operating in North East Melbourne from 1 July 2016 and progressively rollout across the state. People with a disability under 65 years of age will have their disability-related aid and equipment needs met by the National Disability Insurance Scheme. People aged 65 years and over will continue to be able to access the Victorian Aids and Equipment Program for their aids and equipment.

4.2.1.6 Advance care planning All health services are expected to implement formal advance care planning structures and processes. Health services are supported by Advance care planning: have the conversation – a strategy for Victorian health services 2014–2018, which provides actions, outcomes and measures to guide the implementation of advance care planning in and across health services. An implementation advisory group has been established to guide advance care planning across health services. In 2016–17 (the third year of the strategy) health services should have: • executive and clinical leaders responding to advance care planning quality audits • policies and procedures to support advance care planning • reviewed existing policies for consistency with advance care planning policy • made advance care planning resources available in key clinical areas • an alert process and system to make advance care plans available to the treating team • included patient-centred care in position descriptions and induction programs • provided advance care planning training to staff • provided mentoring or peer-to-peer support for staff. Health services should be working towards: • including advance care planning and identification of substitute decision makers in communication with other providers • including advance care planning as a parameter in assessment of outcomes such as mortality and morbidity review reports, patient experience and other routine data collection. As advance care planning delivery becomes embedded into the usual care health services provide, health services should be seeing an increase in the number of both admitted and non-admitted patients with an advance care plan alert and an identified substitute decision maker. This will be measured through VAED and VINAH data items that become mandatory from July 2016 (see section 1.8.9.7). Further information on advance care planning is available at .

4.2.1.7 Palliative care services In response to the recommendations made in the 2015 Victorian Auditor-General’s (VAGO) report on palliative care, the department has identified a number of priority actions that address the recommendations. Palliative care services will be consulted and involved in the priority actions over 2016–17. Three recommendations (recommendations 4, 5 and 6) are directed at palliative care services. Affected services should become familiar with the VAGO report and recommendations and review actions relevant to their service. The report, which includes the department’s response, can be found at . In accordance with the Standards for Providing Quality Palliative Care for all Australians, the patient, their caregiver(s) and family are considered to be the unit of care. Palliative care service providers are to ensure their service models extend to providing high-quality care for carers and families. Bereavement support is an essential component of palliative care service delivery. Services are required to ensure the Bereavement support standards for specialist palliative care services are implemented at a service level and clear referral mechanisms are in place to identify complex cases requiring additional expertise and support. Palliative care service planning framework In 2016–17 the department will consider palliative care service planning in line with the end of life care framework strategic priorities relating to system integration and specialist palliative care capacity.

Regional palliative care consortia Regional palliative care consortia will continue to play a role in the planning and coordination of the end of life care framework policy’s goals in each region. In 2016–17 consortia are expected to align their projects with the strategic priorities of Victoria’s end of life care framework: • services are person-centred • engaging communities and embracing diversity • services are coordinated and integrated • end of life and palliative care is everyone’s responsibility • specialist palliative care is strengthened. All consortia role statements and business rules will be reviewed by the department in 2016–17. The ongoing role of regional consortia will be considered in the context of Victoria’s future strategic policy directions. Palliative care consortia and the Victorian Paediatric Palliative Care Program business rules These rules relate to: • funding for consortia to undertake regional planning, coordinate service provision and determine regional priorities for future service development (the business rules should be read in conjunction with the consortia role statement) • funding for the Victorian Paediatric Palliative Care Program to provide statewide consultation and liaison for children requiring paediatric palliative care, to build the capacity of health professionals to provide paediatric palliative care and to manage the paediatric palliative care flexible funds. Funding received by the fund-holders should be treated as revenue in accordance with AASB 1004. Funding distributed to consortia members and Victorian Paediatric Palliative Care Program members should be recorded under ‘22091-22100 Grant received on behalf of and paid to other agencies’ in the books of the fund-holders. Likewise, consortia members and Victorian Paediatric Palliative Care Program members are to recognise the distributions as revenue. Expenses incurred by fund-holders, consortia members and Victorian Paediatric Palliative Care Program members on this program are to be reported as salaries and wages and non-salary costs accordingly. There should be minimal unspent funding held by health services for consortia projects. These unspent funds are to be retained in the next year and used in the same program in the following year. Unspent funds held by community or non-government organisation services for consortia projects may or may not be retained for use in the following year, in line with individual consortia decisions. Consortia and Victorian Paediatric Palliative Care Program members are required to disclose any unspent funding in their special purpose financial statement to the department. After-hours palliative care Funding for community palliative care is provided to designated providers. Funding for after-hours provision and the unassigned bed program is included as part of services non-admitted palliative care funding. Funding for after-hours care is to be used for direct service delivery and not for other purposes. Business hours normally fall between 7.00 am and 4.30 pm Monday to Friday, excluding public holidays. Outside these times, it is expected that community palliative care services will provide or arrange for the following minimum level of service: • telephone advice to clients, carers and families primarily (but not only) about symptom management if required • a nursing visit if required, based on the client’s, carer’s or family’s needs (if it is safe for staff to undertake the visit)

• any other after-hours care negotiated between clients and the community palliative care service will be on an individual basis. Community palliative care services will ensure that the phone number for an appropriately staffed after- hours service is provided to all clients and carers upon admission to that service. To ensure the safe and effective delivery of after-hours services, all community palliative care services will have: • a multidisciplinary care planning process that anticipates and addresses the need for after-hours palliative care • a policy and procedures regarding after-hours access to medication • occupational health and safety procedures and equipment for staff undertaking visits after hours (in accordance with WorkCover’s Working safely in visiting health services). A review of Victoria’s after-hours palliative care model will be completed in 2016–17. This review will inform the system design of Victoria’s palliative care after hours support program in 2017–18. Unassigned bed program Non-admitted palliative care funding incorporates what was previously known as the unassigned bed program. This funding is to provide equipment or services that enable palliative care clients to remain at home with a comparable quality of care to an inpatient setting. The unassigned bed program is designed to fund services or equipment that a community palliative care service would not normally provide as part of a standard service or that are above the usual level of service provision. The inclusion of this funding into non-admitted palliative care funding does not change the eligibility criteria or type of services that should be provided to clients. Community palliative care services are expected to manage the demand for equipment and services for their clients. Palliative care services are expected to provide equipment or services to: • clients who have been assessed as meeting the admission criteria of the community palliative care service • clients who are living in their own home, in a supported residential service (SRS) or in residential care • clients who would otherwise require admission to an inpatient setting but the client’s preference is to remain at home (their care will not be compromised by this decision) • carers who require additional short-term support in order to continue their caring role for the client who remains in a home-like setting and who would otherwise require admission to an inpatient setting • clients and carers who are unable to meet the cost of the service without assistance. Where possible, regional agreement on how funds are to be distributed should be considered to ensure equity of access across the region. All other avenues of funding for the equipment or services should be explored. This includes Home and Community Care (HACC), post-acute care (PAC), Department of Veterans’ Affairs and Carer’s Choice or commonwealth respite centres. Clients in residential care services are able to access items specifically related to providing palliative care if they are not included in Schedule 1 Specified Care and Services for Residential Care Services, Part 3, which is found in the Residential care manual 2009, Edition 1. Palliative care programs The following programs should continue to be provided as part of the palliative care consultancy, community or inpatient funding arrangements: • Aged care link workers are to be appointed in each region, with the aim of improving palliative care capacity in residential aged care facilities. • Disability link workers are to be appointed in each region, with the aim of improving palliative care capacity in disability accommodation services.

• Health services will continue to support the Nurse Practitioner Program and appointed nurse practitioners in their health services. • The palliative care interpreter line providing non-government community palliative care services with telephone interpreting, on-site interpreting (both spoken and sign languages) and translation for people making significant life decisions and where essential information is being communicated. Interpreter line funding is included in the community palliative care grant lines from 1 July 2013.

4.2.2 Mental health services

4.2.2.1 Key policies and guidelines for mental health services The Chief Psychiatrist’s guidelines provide specialist advice on clinical practice, especially in those areas regulated by the Mental Health Act. The current guidelines are available at . Program management circulars articulate or clarify departmental policy on key aspects of service provision and are available at . The revised National standards for mental health services 2010 apply to all funded clinical and non- government mental health services. Accreditation frameworks for services delivering specialist mental healthcare treatment and care should reference these standards in 2016–17. The National Safety and Quality Health Service Standards commenced in January 2013 in all health services. As a condition of funding, organisations are required to adhere to the service standards and guidelines applicable to the funded activity, including program management circulars and the Chief Psychiatrist’s guidelines that have been issued by the department. Organisations can obtain copies of the relevant standards and guidelines from their department program and service advisor or, in some instances, through the department’s Funded Agency Channel. Standards and guidelines are available at . Further information on mental health services is available at .

4.2.2.2 Mental health community support services performance framework The Mental health community support services performance management framework specifies the performance requirements of the department for funded mental health community support services (MHCSS) agencies and outlines how the department will measure, monitor and assess performance at the agency, service and program levels. In this regard, the framework provides a key mechanism for monitoring whether a funded agency is delivering services consistent with the requirements of their Funding and Service Agreement. The framework also outlines the processes, roles and responsibilities of all relevant stakeholders who are involved in the performance management of the MHCSS program. The Your Experience of Service (YES) survey has been distributed in 2016 to collect information on consumer experience in adult mental health services and selected Mental Health Community Support Services. This survey will be implemented annually.

4.2.3 Alcohol and drug services

4.2.3.1 Key standards and guidelines Service standards and guidelines that apply to funded alcohol and drug services are listed at Chapter 4, 2 ‘Service standards and guidelines’. Where organisations receive funding for an activity or service, it is a

Volume 2: Health operations 2016–17, Chapter 4 Page 39 Conditions of funding condition of funding that they adhere to the service standards and guidelines listed under the relevant activity. Organisations can obtain copies of the relevant standards and guidelines from their departmental program and service advisor or, in some instances, through the department’s Funded Agency Channel. A range of additional documentation to assist services in the delivery of alcohol and other drug treatment are being developed for release in 2016–17. These include: • Alcohol and other drug treatment program guidelines • Alcohol and other drug treatment reporting guide. Standards and guidelines are available at < www.dhs.vic.gov.au/funded-agency-channel >. Information can also be obtained from the drug-related services internet site at < www.health.vic.gov.au/aod>. Organisations are required to deliver services in line with the Victorian alcohol and other drug client charter and the Victorian alcohol and drug treatment principles. Copies of the charter and principles are available at .

4.2.4 Ageing, aged and home care services Service standards and guidelines that apply to funded aged care services are listed at Chapter 4, 2 ‘Service standards and guidelines’. If organisations receive funding for an activity or service, it is a condition of funding that they adhere to the service standards and guidelines listed under the relevant activity. The performance targets and monitoring requirements for the relevant ageing, aged and home care services are outlined at Chapter 4, 1 ‘ Performance targets and monitoring ’.

4.2.4.1 Protection of residential aged care residents’ rights and interests Health services operating public sector residential aged care services (PSRACS) are required to meet commonwealth legislative requirements relating to protecting residents’ rights and interests. This includes meeting obligations for resident accommodation agreements, aged care accreditation standards, police checks for key personnel, staff and volunteers, compulsory reporting for reportable assaults and unexplained absences, and responsive management of complaints including those lodged through the Aged Care Complaints Commissioner. Supported residential services proprietors have obligations to residents under the Supported Residential Services (Private Proprietors) Act and Regulations. The department will continue supporting services to address the Accommodation and personal support standards, including through the Supporting Accommodation for Vulnerable Victorians Initiative (SAVVI), as well as working with community service organisations through a partnerships management model to implement the Pension Level Projects initiative in other pension-level supported residential services.

4.2.5 Primary, community and dental health

4.2.5.1 Community health The service standards and guidelines that apply to the community health program are listed in Chapter 4, 2 ‘Service standards and guidelines’. If organisations receive funding for an activity or service, it is a condition of funding that they adhere to the service standards and guidelines listed under the relevant activity. The performance targets and monitoring requirements for community health are outlined at Chapter 4, 1 ‘ Performance targets and monitoring ’.

4.2.5.2 Identification and management of vulnerable children In 2016–2017 the department will release new guidance to support health services to protect and promote the safety, health and wellbeing of vulnerable children and families. The framework Healthcare that counts will replace the current framework for acute services Vulnerable babies: children and young people at risk of harm: best practice framework for vulnerable children. Under the framework, all health services will be required to provide an annual self-assessment against the five action areas outlined. The action areas provide guidance to enable funded health services embed organisational governance, systems and structures focussed on improving the safety, health and wellbeing of vulnerable children and families. For health services that work with adult clients, the framework highlights the need for family sensitive and inclusive practice so that the needs of dependent children are visible and promoted. Further resources to provide education and training to the health workforce regarding the identification and response to vulnerable children at risk of abuse can be found at Department of Health and Human Services, Children at Risk Learning Portal at . Access to this portal and the courses are free for all health services. Victorian Forensic Paediatric Medical Service The Royal Children’s Hospital is the statewide governing body for Victorian Forensic Paediatric Medical Services (VFPMS). Services are provided by The Royal Children’s Hospital, Monash Medical Centre and all regional health services. A key function of the VFPMS is to provide a forensic assessment of injury and neglect to children from birth to 18 years where there is suspected child abuse and neglect. While The Royal Children’s Hospital is responsible for providing leadership and clinical guidance for the statewide service, all regional health services are expected to provide appropriate 24-hour clinical forensic services for these children. Locally-based agreements between regional health services and VFPMS, outlining roles and responsibilities are expected to be in place during 2016–17.

4.2.6 Children and Young Persons (Care and Protection) Act 1998 Every health worker has a responsibility to protect the health, safety, welfare and wellbeing of children or young people with whom they have contact. The legal responsibilities of health services and health workers are identified in the following legislation. Children, Youth and Families Act 2005 (Vic.) The main purpose of this Act is to provide for the protection of children. Child Wellbeing and Safety Act 2005 and the Commission for Children and Young People Act 2012  Collaborate with interagency partners and comply with information exchange provisions to promote the safety, welfare and wellbeing of children and young people, including taking reasonable steps to coordinate the provision of services with other agencies.  Meet requirements for mandatory reporting of children and reporting of young people (or classes/groups of children or young people) at suspected risk of significant harm (ROSH).  Report unborn children where it is suspected they may be at risk of significant harm after their birth.  Respond to the needs of children and young people after making a report to Child Protection or Victoria Police.  Assist with Children’s Court proceedings when required.

Working with Children Act 2005 (Vic.)  Meet requirements to ensure that only people with a valid Working with Children Check are engaged in child-related work (where a child is under the age of 18 years).

‘Reportable conduct’ scheme  The Victorian Government is also developing a ‘reportable conduct’ scheme. The scheme will require organisations with a very high degree of responsibility for children to report allegations of abuse to the Commission for Children and Young People.

4.3 Accreditation

Funded organisations have a range of obligations related to clinical service provision. These requirements have been put in place to ensure the quality of services and the safety of patients.

4.3.1 Australian Health Service Safety and Quality Accreditation Scheme Since 1 January 2013 accreditation of health services falls under the Australian Health Service Safety and Quality Accreditation Scheme. Under this scheme, health services are accredited against the National Safety and Quality Health Service Standards. These standards apply to all health services, including small rural health services (SRHS), clinical mental health services and public dental services housed within community health services. Under the scheme the department, as the jurisdictional regulator, is responsible for verifying the accreditation status of health services. Accreditation status is monitored by the department in accordance with the Accreditation: performance monitoring and regulatory approach business rules 2013. These business rules detail the department’s regulatory approach to accreditation outcomes and provide health services with a clear understanding of the requirements of the new scheme and reporting obligations. Performance against accreditation will be reviewed at performance meetings with health services. The regulatory response will be based on the outcome of the accreditation assessment and allow for escalation of monitoring and intervention. A revised set of standards is under development. Once released, the department will work with health services to prepare for implementation.

4.3.2 Pathology services In September 2004 Victoria entered into a memorandum of understanding (MOU) with the National Association of Testing Authorities (NATA) in recognition of their role as the national authority in Australia for accrediting laboratories and as an accreditor of inspection bodies. One of the undertakings made in the MOU is that Victoria will encourage all service providers to adhere to the principles of good laboratory practice contained in NATA’s relevant accreditation criteria. An additional MOU that specifically relates to pathology laboratories was entered into by NATA and Victoria’s chief health officer on behalf of the department. It embodies the spirit of cooperation between the department and NATA in relation to protecting public health. On the basis of these undertakings, the conditions of funding are: • Any laboratory operated by a health service whose principal function is to conduct pathology services must obtain and maintain accreditation from NATA or the Royal College of Pathologists of Australasia for the pathology services it provides. • Any pathology service required for a public, private or compensable admitted patient of a health service must only be requested from a laboratory that holds accreditation from NATA or the Royal College of Pathologists of Australasia for the type of service required. • Any pathology service required for a patient attending an outpatient clinic of a health service must only be requested from a laboratory that holds accreditation from NATA or the Royal College of Pathologists of Australasia for the type of service required. • The conduct of any pathology service provided for a health service that is not under the direct management of a pathology laboratory accredited by NATA or the Royal College of Pathologists of Australasia (for example, services provided by research laboratories, specialist clinical laboratories or

at the point of care) must be overseen by a pathology laboratory that is accredited by NATA or the Royal College of Pathologists of Australasia for the relevant scope of services.

4.3.3 Ambulance With the exception of Victoria, ambulance services in Australia are not currently part of an accreditation or external assessment process. Ambulance Victoria has organisation-wide accreditation to the business standards ISO9001. In 2016–17 Ambulance Victoria will continue work commenced in 2015–16 to self- assess against appropriate and relevant National Safety and Quality Health Service Standards and investigate broader implementation or incorporation of those standards.

4.3.4 Mental health clinical and community support services All funded clinical mental health services are required to be accredited against the National Standards for Mental Health Services 2010. In addition, as outlined above, the NSQHS standards apply to all mental health services delivered by Victorian health services. Organisations that receive funding for a Mental Health Community Support Services program are required to implement the National Standards for Mental Health Services 2010. Ongoing implementation of plans to deliver services consistent with these standards is expected of organisations that will receive funding for MHCSS in 2016–17. During transition to the National Disability Insurance Scheme, Victoria will monitor providers of defined MHCSS programs who deliver funded NDIS supports to ensure they meet the quality and safeguards described in current Service Agreements. These services are also required to continue to be accredited within existing generic accreditation frameworks by an entity certified by either the International Society for Quality in Health Care or the Joint Accreditation System of Australia and New Zealand.

4.3.5 Alcohol and drug treatment services Health services providing alcohol and drug treatment services are required to be accredited against the NSQHS standards (see Chapter 4, section 3.1 ‘Australian Health Service Safety and Quality Accreditation Scheme’). Organisations that receive funding for alcohol and drug services are required to establish and implement plans to deliver services consistent with the Victorian alcohol and other drug charter. The ongoing implementation of plans to deliver services consistent with the Victorian charter is also expected of organisations that will receive funding for alcohol and drug services in 2016–17. These services are also required to continue to be accredited within existing generic accreditation frameworks by an entity certified by either the International Society for Quality in Health Care or the Joint Accreditation System of Australia and New Zealand.

4.3.6 Aged care

4.3.6.1 Public sector residential aged care service accreditation and quality approach The Commonwealth Government has the primary responsibility for funding and regulating residential aged care services under the Aged Care Act 1997. In accordance with this legislation, all Victorian public sector residential aged care service (PSRACS) are expected to comply with minimum aged care accreditation standards at all times to receive recurrent commonwealth subsidies. Accreditation of residential aged care services against the aged care accreditation standards is undertaken by the Australian Aged Care Quality Agency. The department actively supports PSRACS to provide high-quality care to residents. The department’s Beyond compliance strategy provides the strategic framework for focusing on safety and quality in PSRACS. It aspires to broaden approaches to quality, beyond minimum commonwealth accreditation requirements, and support care excellence.

Beyond compliance programs and initiatives are designed to encourage and support PSRACS to excel in the delivery of person-centred, safe, effective, appropriate, integrated and coordinated services so that a good quality of life is experienced by every resident, every day. The focus of initiatives to be progressed in 2016–17 includes:  accreditation support  improving consumer health literacy  supporting person-centred care approaches  building nurse workforce capacity  better use of evidence in practice  continued development and support of the quality indicator program for PSRACS.

4.3.6.2 Home and Community Care Arrangements post 1 July 2016 for the Victorian Government’s Home and Community Care program for younger people will be advised.

4.4 Clinical governance

4.4.1 Health service clinical governance All health services and funded organisations are required to ensure that their clinical governance policies and frameworks comply with the provisions contained in the current Victorian clinical governance policy framework: enhancing clinical care (2008). Health services are required to measure and monitor compliance with the policy under the framework’s quality and safety domains: consumer participation, clinical effectiveness, effective workforce and risk management. Compliance at a state level is monitored through accreditation mechanisms. The framework is being refreshed to enhance the understanding and implementation of effective governance for quality and safety in Victorian health services. The refreshed framework will provide enhanced guidance in fulfilling core clinical governance obligations by clarifying the key requirements and responsibilities of health service board chairs, board members, CEOs and executive teams. Tools will also be developed to better support health services ensure that their systems are robust to assure the provision of safe and high-quality healthcare. The refreshed consumer participation policy and outcomes from the review of the effectiveness of the Australian Charter of Healthcare Rights in Victoria will assist in implementation of the framework. All health services will be required to implement the new framework and report on compliance obligations, as specified in the new policy. Links to the policy and toolkit can be found at .

4.4.1.1 Clinical risk management All health services and funded organisations are required to ensure their clinical governance policies and frameworks comply with the provisions contained in the Victorian clinical governance policy framework: enhancing clinical care (2008). Health services are required to measure and monitor compliance with the policy under the framework’s quality and safety domains: consumer participation, clinical effectiveness, effective workforce and risk management. Compliance at a state level is monitored through accreditation mechanisms. Links to the clinical governance policy and toolkit can be found at . In 2016–17 the department will work with senior medical staff and health services to develop a new integrated Credentialing: Scope of clinical practice and performance policy framework for senior medical practitioners. The new policy framework will strengthen the current policies and process, and provide greater clarification and resources to aid implementation.

4.4.1.2 Occupational violence in the Victorian health system The safety of health care workers is important and the Victorian Government has committed to address violence in healthcare settings, through a multifaceted approach including the improved reporting of incidents and public reporting by health services. A $20 million fund has been allocated to improve physical facilities and to support a focus on training, organisational prevention, management and response and increased awareness. Violence in Healthcare Taskforce The government established the Violence in Healthcare Taskforce in 2015 to examine and advise ways to address systemic issues in relation to violence in the health care sector. The taskforce recommended to the Minister for Health and the department that an integrated, comprehensive and collaborative approach that focusses on the underlying culture of the health system be taken to address violence in healthcare. The taskforce has endorsed immediate actions that focus on:

• raising awareness by engaging boards, management, staff and patients through a public awareness campaign, public reporting and shared learning • building knowledge and skills by providing guidance and training, creating a culture where violence is prevented and people take responsibility for their behaviour • responding and taking action by creating safe environments and making health service boards accountable for reducing the risk of workplace violence. The taskforce has recommended a reference group be established to inform the implementation of the endorsed initiatives. All recommendations have been accepted and the department will work with services to implement the initiatives in 2016–17. Funding The second year of funding of the Health Service Violence Prevention Fund will be provided to health services in 2016–17 to improve facilities in public health services, including mental health services and Ambulance Victoria, making them safer for staff, patients and visitors. The $20 million fund (over four years) will support minor capital works and facility improvements that reduce or prevent the risk of violence. Reporting The department will work with health services to introduce a new occupational health and safety module in the Victorian Health Incident Management System in 2016–17 to assist with addressing the under- reporting of incidents within health services. In addition, health services are required to publicly report all incidents of occupational violence in their 2015–16 annual report. The department will be working with health services and boards in 2016–17 to improve the reporting and support risk management.

4.4.1.3 Sentinel event reporting All health services and funded organisations that identify a sentinel event as defined in the Victorian health incident management policy are required to report the incident to the department’s sentinel event program as follows: • organisations must notify the department within three days of the incident occurring or the organisation becoming aware of the incident • the final de-identified root cause analysis summary report must be provided to the department within 60 days of notification via [email protected]. Report templates and additional information on the department’s sentinel event program can be accessed at . Sentinel event reporting and review processes will be reviewed in 2016–17 to strengthen reporting and accountability for implementation of recommended actions; streamline review processes and ensure more timely dissemination of learnings for continuous improvement.

4.4.1.4 Core hospital-based quality outcome indicators The hospital-based quality outcome indicators enable all health services to routinely compare results against peer services and national and state rates. The indicators reveal where patient outcomes are within the expected range for the state and peer hospitals, are significantly better than expected or where they could be improved. The indicators measure in-hospital mortality, unplanned readmissions and healthcare-associated infections. With the exception of the indicators for healthcare-associated infections, the core hospital- based outcome indicators utilise routinely collected hospital administrative data as an information source.

The healthcare-associated infections indicator relies on survey results captured by the Victorian Healthcare Associated Infection Surveillance System (VICNISS) and reported to the department. The hospital-based quality outcome indicators are: • in-hospital mortality – hospital standardised mortality ratios (HSMR) – death in low-mortality diagnostic-related groups (DRG) – death following treatment for acute myocardial infarction – death following treatment for pneumonia – death following treatment for stroke – death following treatment for fractured neck of femur • unplanned readmission – following treatment for acute myocardial infarction – following a knee replacement – following a hip replacement – following treatment for paediatric tonsillectomy and adenoidectomy • healthcare-associated infections (HAI) – Staphylococcus aureus bacteraemia – hospital-identified Clostridium difficile. The indicators are not considered as definitive measures of poor quality or safety in patient care, rather they identify areas for further investigation and analysis. Health services are required to investigate outcomes that vary significantly from state, national and peer group rates to understand whether the variation is driven by clinical practice, data capture, patient casemix or other factors.

4.4.1.5 Infection control The effective prevention, monitoring and control of infection are an integral part of the quality, safety and clinical risk management operations of any health service. A key initiative to improve infection control is Victoria’s healthcare-associated infections surveillance program and the VICNISS coordinating centre. The VICNISS coordinating centre collects and analyses data from individual hospitals on risk-adjusted, procedure-specific infection rates. All public health services are required to provide data to the VICNISS coordinating centre according to the type one (more than 100 beds) and type two (fewer than 100 beds) participation indicators. The indicators can be found at . This data is then submitted to the department for monitoring against the Victorian health service performance management framework and associated National Health Reform Agreement performance measures. As per the Victorian guideline on carbapenemase-producing Enterobacteriaceae (CPE) for health services published in December 2015, all public and private hospitals must now: • Comply with infection prevention and control recommendations made within the guideline and participate in annual compliance auditing. • Undertake screening of patients at the highest risk of carbapenemase-producing Enterobacteriaceae acquisition, including those in intensive care units, haematology and transplant wards. Two point prevalence surveys are to be completed – the first by 30 June 2016 and the second by 31 December 2016.

The Victorian guideline on carbapenemase-producing Enterobacteriaceae for health services is available at . All laboratories in Victoria are requested to refer Enterobacteriaceae displaying reduced-susceptibility to carbapenems to the Microbiological Diagnostic Unit Public Health Laboratory (MDU PHL) for further characterisation. Improved hand hygiene practices are linked to a reduction in healthcare-associated infection rates. All health services are required to participate in the ACSQHC National Hand Hygiene Initiative. This initiative was established to implement a national hand hygiene culture-change program to standardise hand hygiene practice and placement of alcohol-based hand rub in every Australian hospital. Health services are required to complete three compliance audits against the five moments of hand hygiene: • before touching a patient • before a procedure • after a procedure or body fluid exposure • after touching a patient • after touching a patient’s surroundings. Hand hygiene performance is measured against a Victorian benchmark rate of 80 per cent. For submission criteria see . Public reporting of individual hospital or health service hand hygiene compliance is via the My Hospitals and the Victorian Health Services Performance websites. The Victorian cleaning standards are a performance requirement of the department and are applicable to all relevant acute and subacute Victorian public hospitals, regardless of whether the cleaning service is outsourced or performed in-house. The Victorian cleaning standards have been changed to provide health services with the flexibility to select either a qualified auditor or a suitably experience auditor. Cleaning standards performance and reporting requirements including the updated auditor requirements are available at .

4.4.1.6 Streamlining clinical trial research The government continues to encourage clinical trial activity within health services. In particular, the department has established a framework for streamlining the ethical review of multisite clinical trials managed centrally by the Coordinating Office for Clinical Trial Research. Since January 2015 the scope of this framework also includes multisite health and medical research projects. Health services that participate in research projects involving human subjects at more than one site are required to: • Sign the standard MOU between the department and the health service for the purpose of facilitating the central ethical review system’s operation. This has extended to the initiative involving national mutual acceptance of multisite ethical review for clinical trials. Ethics committees providing intra and inter-jurisdictional ethical review are required to be accredited by the National Health and Medical Research Council. It is expected that health services will participate in the national mutual acceptance of ethical review of multisite clinical trials. • Comply with all matters agreed in the MOU, including acceptance of a single ethics review decision by an accredited and certified human research ethics committee, reporting requirements and research governance obligations associated with the conduct of a research project.

• Assist the consolidation of research activity information concerning Victoria’s public hospital sector by using the Australian Research Ethics Database to enter data for all ethics applications and research governance/site specific assessments for single and multisite studies involving human subjects. Health services hosting a human research ethics committee that conducts review of multisite clinical trials and health and medical research are required to be accredited by the National Health and Medical Research Council and are also required to conduct sufficient ethical reviews to maintain expertise. Further information is available at and .

4.4.2 Community health clinical governance Funded organisations receiving community health program funding are expected to have strong clinical governance systems and practices to ensure the quality and safety of services. Organisations are required to review their clinical governance structures and have adequate internal documentation to ensure consistency and compliance with the Victorian clinical governance policy framework. Funded organisations that receive funding through primary health output group activities must be accredited by a body or entity that is accredited by the International Society for Quality in Health Care or the Joint Accreditation System of Australia and New Zealand. All public dental services are required to be assessed against the National Safety and Quality Health Service Standards. Performance monitoring of accreditation against the national standards by the department and Dental Health Services Victoria in 2015–16 will be undertaken as per the Accreditation: performance monitoring and regulatory approach business rules (2013).

4.5 Consumer rights and community participation

4.5.1 Australian Charter of Healthcare Rights in Victoria The Australian Charter of Healthcare Rights in Victoria is based on the Australian Charter of Healthcare Rights, and is aligned with the Victorian Charter of Human Rights and Responsibilities Act. It describes and promotes the rights of patients, consumers and family members using the Victorian healthcare system. The charter specifies seven healthcare rights: access, safety, respect, communication, participation, privacy and comment. These rights are applicable across all funded organisations in Victoria, including public and private hospitals, general practice clinics, medical specialists, aged care services, disability services, mental health services, registered community health centres and allied health providers. The aim of the Australian Charter of Healthcare Rights in Victoria is to ensure that healthcare is provided in a manner that embodies the seven healthcare rights, is safe and of high quality. The Victorian charter should be distributed and available at all funded organisations. Access to the Australian Charter of Healthcare Rights in Victoria is a requirement of the NSQHS standards under the Australian Health Service Safety and Quality Accreditation Scheme. The Australian Charter of Healthcare Rights in Victoria is available in a variety of formats, including audio file, Auslan video, Braille and 25 community languages, from: . In 2016–17, a review will be undertaken to ensure that the charter is effectively promoting patient and parent rights and responsibilities.

4.5.2 Consumer, carer and community participation The consumer, carer and community participation standards and indicators are outlined in the department’s policy Doing it with us not for us: strategic direction 2010–13. An evaluation of this policy was completed in 2014 and a new consumer participation in healthcare policy is under development for 2016–17. The new policy will strengthen the elements of equity and diversity; person and family-centred healthcare, and cultural responsiveness in participation processes at direct care, service and system levels to improve Victorians participation and experience in their own healthcare. During this period health services should continue to achieve the relevant priority actions set out in Doing it with us not for us. All funded organisations are required to actively support and promote consumer, carer and community participation at all levels of healthcare, including support for community advisory committees. The policy’s comprehensive suite of participation standards and performance indicators should be reported in the annual quality of care report. In achieving the standards and indicators of the policy, health services will be ensuring that they meet the National Safety Quality Health Service Standards. The policy, standards and indicators and updates on the evaluation and new policy development are available at . Under the Carers Recognition Act 2012 people in care relationships, and the contribution of carers, need to be recognised by: • councils, within the meaning of the Local Government Act 1989 • organisations funded by government that are responsible for developing or providing policies, programs or services that affect people in care relationships.

The Act lists principles that must be respected by councils and relevant funded organisations. These principles promote understanding of the significance of care relationships, and the people in them. The Act is supported by the Victorian charter supporting people in care relationships. Councils and relevant funded organisations are required to report on how they met their obligations under the Act in their annual report; this may be as simple as including a paragraph detailing the actions taken during the year to comply with the Act. Information, including legal responsibilities and obligations of local government and organisations, is available at: .

4.5.3 Victoria’s health experience

4.5.3.1 Victorian Healthcare Experience Survey The department encourages health services to collect patient experience data and to use this information to improve patient experiences. The Victorian Healthcare Experience Survey (VHES) has been established by the department to assist health services understand how their consumers and, where appropriate, carers feel about their recent experience of care provided by a Victorian public health service. The department has contracted Ipsos Australia to conduct the survey. Health services are required to provide Ipsos with the names and addresses of people eligible to complete the survey. The VHES measures patient experiences; this focus enables identification of the areas where these experiences can be improved and the actions that enhance person- and family-centred care; it provides health services and the department with actionable results. All questionnaires were developed with funded agencies and consumer and carer working groups. They were cognitively tested with consumers (and, where appropriate, carers) and piloted through a sample of the appropriate funded agencies. They include verbatim comments thematically streamed from survey respondents. The VHES will be expanded into new setting types in 2016–17: • Community health services: for clients (primarily non-general practitioner primary healthcare clients), utilising a tool based on the National Health Service (NHS) primary care survey. • Specialist clinics: utilising a tool based on the NHS adult outpatient survey and the Picker Europe paediatric and parent/carer outpatient survey. • Other program surveys are being considered for development and implementation during 2016–17 and 2017–18, including ambulance services and palliative care services.

4.5.3.2 Ambulance patient satisfaction survey The Council of Ambulance Authorities undertakes an annual patient satisfaction survey for ambulance services across Australia. The survey investigates service quality and satisfaction ratings of Australian ambulance services, including Ambulance Victoria, by state and territory. Patients evaluate their experience of using the ambulance service across different dimensions including timeliness, telephone assistance, treatment received, paramedics’ care, journey quality and overall satisfaction. A patient experience survey for ambulance services will be developed for implementation in 2016–17.

4.5.4 Health service community advisory committees Under Schedule 5 of the Health Services Act public health services are required to have a community advisory committee. Health services should continue to work with their committee to ensure that consumer, carer and community participation are integrated into service development, quality improvement planning and other relevant activities across all levels of their organisation. Public health services have been required to develop and report to the department on their community participation plan covering a one- to five-year period as part of each scheduled public health service’s

Volume 2: Health Operations 2016–17, Chapter 4 Conditions of funding strategic plan. A part of the program to support the implementation of a new participation and equity policy, guidelines outlining the role and reporting of community advisory committees will be reviewed in 2016–17. Health services are no longer required to submit their community participation plan or progress report on implementation to the department. However, health services should continue to undertake relevant planning outlining the role of the community advisory committee, the health service’s board and executive management to ensure that consumers, carers and community members are involved in service development, planning and quality improvement. Primary care and population health advisory committees Under the Health Services Act health services are required to have a primary care and population health advisory committee. Health services should continue to work through these committees to consider the broader needs of the community.

4.5.5 Reporting on quality of care All health services, multipurpose services and registered community health services are required to produce an annual quality of care report. The department will provide guidelines on the content and submission requirements for the quality of care report covering 2015–16. Further information, including contact details and recommended reporting guidelines, is provided at .

4.5.6 Partnerships All funded organisations are required to actively participate in Primary Care Partnerships (PCPs) including encouraging staff participation in Primary Care Partnership activities where appropriate. The 2013–17 program logic guides the work and priorities of Primary Care Partnerships. It consists of three key domains: early intervention and integrated care; consumer and community empowerment; and prevention. This encompasses the system level work of Primary Care Partnerships, including service coordination, e-health, integrated disease management, integrated health promotion and strategic partnership development. Further information about Primary Care Partnerships can be found at . Partner agencies on the governing board or managing committee of the Primary care Partnership are required to sign the partnering agreement and be listed as a party to the department’s consortia agreement. In order to provide better coordinated client care all funded organisations are expected to develop effective relationships with general practitioners and other private providers. Primary Care Partnerships and Primary Health Networks provide mechanisms to facilitate systematic engagement with these private providers. In 2016-17, the department in collaboration with clinicians and service providers will seek to improve the system and will look across the health system to draw on the expertise and innovation that is already happening and invest in spreading this across our system.

4.5.7 Service coordination Primary Care Partnerships should continue to support agencies to provide coordinated services in the context of the broader reform occurring in the sector in 2016–17. Activity will include: • working with partners to facilitate service coordination for people accessing a range of health and human services, aligning with government priorities • developing local agreements to progress interagency shared-care planning • continuing to implement the common service coordination practice standards, as documented in the Victorian service coordination practice manual 2012.

4.5.8 Informed consent for receipt of services Funded organisations are required to ensure all clients receiving services have had an opportunity to discuss options regarding their care and provide full consent to the care they receive. Evidence of informed consent should be documented in the client record. All Victorian public health services have electronic access to a comprehensive suite of high-quality, plain- language, current, evidence-based, patient information brochures (in English, ‘easy read’ format and community languages) on specialist medical procedures. This information can be readily disseminated to patients, consumers and carers to assist with informed consent and consumer participation in clinical decisions.

4.5.9 Complaint management All funded organisations are required to have effective and responsive management systems in place to respond to complaints in a timely and appropriate way. Resources for organisations providing health services to manage complaints are currently provided by the Office of the Health Services Commissioner (OHSC) and can be accessed via its website at . This includes train-the-trainer modules to assist health service providers to develop and implement effective complaint handling practices as well as training and online resources to increase understanding and awareness about the Health Records Act 2001. With the commencement of the Health Complaints Act 2016, the new Health Complaints Commissioner will be responsible for providing information and resources to organisations to assist in the management of complaints. Health service providers will be required under this legislation to comply with the complaints handling standards and a failure to do so will become grounds for complaint to the Health Complaints Commissioner. Public hospital patient representatives are required to report complaint data to the Office of the Health Services Commissioner in an aggregated form. Under the Health Complaints Act the commissioner will have powers to require the provision of information from health service providers regarding complaints received or dealt with. The process for the routine provision of such information is being reviewed and enhanced in 2016–17 to be incorporated as part of the new incident reporting system, a component of the VHIMS2 Improvement Project.

4.5.10 Health service cultural and linguistic diversity requirements The Cultural responsiveness framework: Guidelines for Victorian health services, was evaluated in 2014 as part of the Doing it with us not for us summative evaluation. A new consumer participation in healthcare policy is under development for 2016–17. The new policy will integrate diversity, equity and consumer and carer community participation within a quality and safety framework; aligning co-related concepts of health literacy, person- and family-centred care, shared decision making and cultural responsiveness. The standards specified in the framework require that all health services demonstrate: • a whole-of-organisation approach to planning and review • leadership for planning by senior management • provision of accredited interpreters to patients who require one • inclusive practice in care planning for patients • participation of culturally and linguistically diverse consumers in the planning, improvement and review of programs • provision of professional development opportunities for staff at all levels across the organisation to enhance their cultural responsiveness.

During this period health services should continue to achieve the standards set out in the framework. All funded organisations are required to actively support and promote cultural responsiveness at all levels of healthcare. Reporting on the standards should continue in the annual quality of care report. In achieving the standards and indicators of the policy, health services will be ensuring that they meet the National Safety Quality Health Service Standards. Further information about the standards and reporting requirements of the Cultural responsiveness framework can be found at . The Language services policy guides the provision of language services and outlines critical points for providing interpreters and translated material. All health services are required to ensure completion of two data elements in the VAED, Victorian Emergency Minimum Dataset (VEMD) and VINAH collections relating to preferred language spoken and interpreter required as proxy measures of local demand for language services. Information about the Language services policy is available at .

4.6 Financial requirements

4.6.1 Health service procurement and purchasing requirements Under the Health Services Act, Health Purchasing Victoria has responsibility, among its other functions: • to develop, implement and review policies and practices to promote best value and probity in relation to the supply of goods and services to public hospitals and the management and disposal of goods by public hospitals • to ensure that probity is maintained in purchasing, tendering and contracting activities in public hospitals • to provide advice, staff training and consultancy services in relation to the supply of goods and services to public hospitals • to monitor compliance by public hospitals with purchasing policies and Health Purchasing Victoria directions and to report irregularities to the minister. On 26 June 2014 Health Purchasing Victoria gazetted five new health purchasing policies to establish a new procurement policy framework for health services incorporating the strategic approach of the Victorian Government Purchasing Board (VGPB) supply policies. These policies are mandated for all Schedule 1 and 5 public hospitals and health services (mandated health services), which must comply from June 2016, following a transition period of two years. These policies may be viewed on the Health Purchasing Victoria website at . To meet its responsibilities to monitor compliance by public hospitals with purchasing policies and to report irregularities to the Minister for Health, Health Purchasing Victoria has developed a compliance framework that includes compliance monitoring and support and prevention activities such as education, training, advice and guidance. All mandated health services are required to: 1. Complete an annual compliance self-assessment: The self-assessment will require the health service to state its compliance with Health Purchasing Victoria policies, including any Health Purchasing Victoria agreement applicable to the health service. The health service chief executive officer (CEO) must approve and submit the self- assessment to Health Purchasing Victoria for inclusion in the Health Purchasing Victoria annual report. 2. Complete compliance audits to Health Purchasing Victoria’s purchasing policies: As per the Health Services Act, Health Purchasing Victoria can require the CEO of a mandated health service to audit compliance with purchasing policies and Health Purchasing Victoria directions and provide audit reports to Health Purchasing Victoria on request within 28 days, or longer as specified by Health Purchasing Victoria. Health services will be required to audit their compliance to Health Purchasing Victoria policies once every three years as per the rolling audit program developed by Health Purchasing Victoria. Health services will be required to provide the final audit report to Health Purchasing Victoria. Findings identified as part of the compliance audits will be reported to the Health Purchasing Victoria Board and monitored until the health service has addressed and closed the issues. 3. Provide information and data on procurement activities: Health Purchasing Victoria can require the CEO of a mandated health service to provide Health Purchasing Victoria with information and data relating to the supply of goods and services and the management and disposal of goods, on request within 28 days, or longer as specified by Health Purchasing Victoria.

Health Purchasing Victoria will be requesting health services to submit:  an annual procurement plan to assist in identifying statewide opportunities for procurement and to oversee individual activities conducted by a health service that are of high value or assessed as high probity risk  details of current contracts for the supply of goods and services to the health service.

Openness and probity in purchasing, tendering and contract activities Health services should ensure the following overlapping probity directives are met: • Mandated health services must transition to the new Health Purchasing Victoria policy framework set out in the new health purchasing policies gazetted on 26 June 2014 by 26 June 2016, and notify the Health Purchasing Victoria Board of their completed transition, including the date of the transition. • Health services are required to ensure their probity controls take into consideration the recommendations contained in the Victorian Ombudsman’s report Probity controls in public hospitals for the procurement of non-clinical goods and services and the Victorian Auditor-General’s report Procurement practices in the health sector. All health services are encouraged to complete the probity training that will be provided by Health Purchasing Victoria for health services’ management and staff with procurement responsibilities. Health services are also encouraged to consult with Health Purchasing Victoria regarding any high value or high risk procurement activities.

4.6.2 Compliance with financial requirements

4.6.2.1 Borrowings Section 30(2) of the Health Services Act requires registered funded agencies to obtain approval from both the Minister for Health and the treasurer before seeking financial accommodation. An approved borrower may obtain financial accommodation, whether within or outside Victoria, secured or arranged in a manner and for a period approved by the treasurer. These borrowings are guaranteed by the state. Section 44 of the Ambulance Services Act 1986 requires an ambulance service to obtain approval from the treasurer before seeking financial accommodation. An approved borrower may obtain financial accommodation, within Australia, secured or arranged in a manner and for a period approved by the treasurer. All registered funded agencies and ambulance services must obtain the appropriate approvals prior to seeking to borrow funds from third parties and prior to entering into third-party finance arrangements for any overdrafts, borrowings or finance leases. These funds may be for purposes such as capital works and equipment expenditure, including motor vehicles. In 2015–16 the treasurer approved access by public hospitals and public health services to VicFleet motor vehicle finance leases.

4.6.2.2 Asset acquisition and disposal Registered funded agencies and ambulance services must not enter into any expenditure related to equipment purchases and capital works where the estimated total costs or total end costs of the works exceeds 10 per cent of the annual revenue of the agency or health service or $2 million (whichever is the lesser amount) unless: • the agency or health service has provided a detailed business plan relating to the proposed expenditure to the Secretary to the department • the expenditure has been approved by the Secretary to the department. The Secretary’s approval in relation to any expenditure referred to the above clauses does not imply or in any way obligate the Secretary or the department to provide any financial support for the works.

4.6.2.3 Operating leases While the department does not place restrictions on the particulars of operating leases, operating lease proposals must comply with the Department of Treasury and Finance’s Prudential risk management framework. A financial evaluation must be performed on any operating lease longer than 12 months and for capital value worth more than $1 million. This must be approved by the board of management of the registered funded agency.

4.6.2.4 Investments From 1 July 2016 a new Ministerial Direction will apply: Standing Direction 3.7.2 Treasury and investment risk management, under the authority bestowed by the Financial Management Act 1994. This Standing Direction requires all public sector entities to ensure that all borrowings, investments and financial arrangements are transacted with a financial institution that: is a state-owned entity or has a credit rating, assigned by a reputable rating agency, that is the same as or better than the rating assigned by the same agency to the State of Victoria. The policy centralises the borrowing and investment powers of state entities with the state’s central finance agencies: Treasury Corporation of Victoria and the Victoria Funds Management Corporation. The policy is subject to certain exemptions, which are listed in the Direction, and the Directions (under section 1.5) also include the treasurer’s right (by delegation from the Minister for Finance) to approve additional exemptions. Where additional exemptions are sought by the Accountable Officer, the application for exemption must be in writing, stating the reasons why the exemption is necessary and include specification of proposed alternative action or procedures. The Accountable Officer must ensure that that proposed alternative action is not implemented until after an exemption is provided, must ensure that the agency complies with the conditions of any exemption and maintains a record of the exemption and conditions. The Health Services Amendment Act 2014 was assented to on 1 April 2014, requiring public health agencies under the Health Services Act to comply with Standing Direction 3.7.2 Treasury and investment risk management. All health sector agencies must be fully compliant with the Standing Direction from 1 July 2016, or obtain a specific exemption. Exemptions provided under the previous Standing Direction no longer apply.

4.6.3 Goods and services tax Funded organisations must register for an Australian Business Number and register for goods and services tax (GST) if required. Each funded organisation is responsible for its own tax compliance and liabilities. Funding between one government-related entity and another government-related entity that is sourced from appropriations and for non-commercial activity is outside the scope of GST pursuant to s. 9–17(3) of the Goods and Services Tax Act 1999. Funding from the Department of Health and Human Services to non-government organisations are taxable supplies. Public hospitals and Ambulance Victoria are government-related entities under s. 41 of the Australian Business Number Act 1999.

4.6.4 Strategic procurement Health system procurement reform will focus on enhancing hospital cost containment and improved procurement processes by: • increasing the range of agencies able to procure from Health Purchasing Victoria contracts and tenders • increasing the value of contracts managed by Health Purchasing Victoria and the number of sourcing activities (invitations to supply) • working with the sector to improve procurement processes

• improving contract delivery and bringing process innovation through category management • working towards an agreed future model for the health supply chain that improves efficiency and cost effectiveness. The Health Services Act was amended during 2012–13 to enable community health centres and women’s health centres to access Health Purchasing Victoria contracts. The Act was further amended in 2013–14 to enable access by entities that deliver ambulance services, health services in association with correctional services, disability services and residential care services, and the Victorian Institute of Forensic Mental Health (VIFMH). Health Purchasing Victoria will focus on collective procurement, volume optimisation and further broadening the scope of agencies that access Health Purchasing Victoria’s sourcing activities and contracts. Health Purchasing Victoria is committed to maintaining and expanding the Victorian Product Catalogue System (VPCS). The VPCS is now available to hospitals and health services via the VPCS web access tool, which contains product and pricing information from 33 HPV Health Purchasing Victoria. Including non- Health Purchasing Victoria contracts, the VPCS contains approximately 290,000 items from more than 400 suppliers. The content and functionality of the VPCS web access tool will continue to be enhanced in periodic releases and will serve as an enabler for future supply chain initiatives. In 2016–17 Health Purchasing Victoria will continue to support health services as they transition to the new strategic procurement policy framework established by the Heath Purchasing Policies, mandatory from 30 June 2016.

4.6.4.1 Supply chain reform Health Purchasing Victoria has also scoped measurable, end-to-end supply chain efficiencies, investigating various reform options and taking into account the practices of other jurisdictions and industries in order to recommend a program of reform to improve the efficiency and effectiveness of the health supply chain. A key element of this program is the development and rollout of a common sector-wide purchasing and logistics system, supported by improved procurement and logistics processes and procedures that will provide Victorian health services and Health Purchasing Victoria access to: • a common set of master data for health services’ products, based on the VPCS, inventory, pricing, suppliers and logistics and supply chain KPIs • a platform for optimising the efficiency of purchasing and inventory management processes and procedures, with electronic data interchange and imprest management capabilities • logistics technology such as warehouse and transport management systems, and demand management and forecasting tools to improve supply chain efficiency • enhanced control, efficiency, and visibility of supply chain activity at a local and sector level, including visibility of purchasing activity, inventory, and supply chain performance measures. Stage 1 of the planned rollout of the solution across the state, incorporates the scoping, design, and sourcing of the purchasing and logistics systems, and the design and implementation of improved processes, incorporating the new systems, at Melbourne Health. This is to be delivered in three distinct phases, with the final phase, the go-live of the purchasing and logistics improvements at Melbourne Health, and the preparation of a business case for extending the implementation to other health services in a proposed separate Stage 2 project. Stage 2 will see the rollout (subject to successful Health Purchasing Victoria Board approval and the Department of Health and Human Services business case approval) to the other Victorian public hospitals and health services.

Other elements of the Supply Chain Reform Program are: • The Information Standards and Master Data Project which seeks to remedy a number of sector-wide issues which currently limit purchasing activities and spend analysis across the health sector such as data accuracy, common categorisation framework and common catalogue. • Implementation of a collective procurement governance framework to optimise the benefits of collective procurement of all goods and services for the public health sector.

4.7 Asset and environmental management

Asset management is the process of guiding the planning, acquisition, use and disposal of assets to make the most of their service delivery potential and to manage the related risks and costs over their entire life. Funded organisations are required to manage, maintain and replace assets in accordance with the Standing Directions of the Minister for Finance under the Financial Management Act and the Victorian Government’s Asset Management Accountability Framework (AMAF). The department requires each funded organisation to provide effective and sustainable asset management for assets under its stewardship or control. This responsibility is for all the physical asset classes held and extends across all stages of their lifecycle, including planning, acquisition, operation and maintenance and disposal. The CEO of a funded organisation is required to assign responsibility, accountability and reporting requirements, and to establish and maintain management processes to plan, report, monitor and assess controlled assets. Consistent with Victorian Government policy expressed in the Asset Management Accountability Framework, the department expects asset management governance, planning and practice in funded organisations to be consistent with the scale of their organisation. The health service board should be regularly informed about the status of asset performance and any material risk posed in addition to any planned timing of specific investment or disinvestment. Further information on the government’s asset management policy is available at . Health services procuring public construction works and services must comply with the requirements of the Project Development and Construction Management Act 1994 and written directions from the responsible minister in relation to public construction. For further information refer to or .

4.7.1 Asset management planning Health services should develop and apply asset management practices consistent with Australian Standards and the Department of Treasury and Finance’s Asset Management Accountability Framework. Effective asset management planning relies on strong governance, aligned corporate leadership and the input of key affected and specialist groups across the health service. If also coupled with ongoing strategic oversight and prudent risk assessment, asset allocation, overall planning quality and implementation improves. Asset management planning by health services should consider factors highlighted in the Medical equipment asset management framework, which has application across asset classes. Additionally, project readiness, project delivery risk management and implementation resourcing are required. Asset management planning by health services should consider the effective and efficient use of medical equipment and be guided by strategic and service planning. Planning for high-value medical equipment should consider access and availability, utilisation and value for money. In 2016–17 each health service is required to lodge an updated basic asset management plan for medical equipment and engineering infrastructure. These should be accountable, transparent and underpin quality annual reporting.

4.7.1.1 Basic asset management plans Health services are expected to develop basic asset management plans covering (as a minimum) four- year rolling asset management data for medical equipment and engineering infrastructure from 2016–17. Health services should include all high-cost medical equipment and engineering infrastructure on the plan, regardless of replacement date or ownership status. Participating health services are required to lodge updated basic asset management plans with the department annually at the end of September. Basic asset management plan templates have been provided to participating health services, and further information is available at .

4.7.1.2 Reporting All 2015–16 specific-purpose capital grant expenditure is required to be reported as part of Agency Information Management System (AIMS) reporting by the end of September 2016. The report needs to correlate with the lodged health service basic asset management plans to demonstrate effective asset management planning and prioritised replacement of in-scope assets. Health services must report on assets replaced under these programs as a condition of funding. This annual reporting helps demonstrate financial and asset accountability, including reporting on the investment against basic asset management plans and critical risk mitigation achieved. The department will use this reporting for accountability (including potential audits), policy and practice development purposes, and to inform advice to government on program status and requirements.

4.7.1.3 Planning and implementation Health services should use their basic asset management plans to prioritise asset replacement according to critical risk and to guide investment of specific-purpose capital grants at the health service level. The devolved funding model facilitates responsive and flexible time-critical replacements, enabling a health service to intervene to avert unacceptable clinical service interruptions or failures. Health services may also submit for funds to replace high value engineering infrastructure or medical equipment in excess of $300,000 (exclusive of GST). Consistent with prioritisation and rationing requirements, health services are required to fund the installation and infrastructure associated with the replacement of the high-cost medical equipment, or the scoping of the works/tender documentation for high-cost engineering infrastructure. Health services may choose to use their specific-purpose capital grant for this purpose. The grants can also be used to replace medical equipment and engineering infrastructure greater than $300,000 (exclusive of GST), if it is considered by the health service to be the highest risk of all the outstanding in-scope assets.

4.7.1.4 Accountability Specific-purpose capital grants must be managed and invested in accordance with health service or hospital board fiduciary responsibilities and as set out in the program guidelines. Health services reporting on asset replacement under the initiative are required to demonstrate financial and asset accountability, including investment against basic asset management plans. Grant reporting will be used for both accountability and policy and practice development purposes. The level of grant is conditional upon meeting funding requirements – risk-based prioritisation of investment aligned with health service basic asset management plans. For more information refer to .

4.7.1.5 Procurement of medical equipment Health services must comply with government policies and guidelines in their procurement activities. The department requires health services to engage early and work collaboratively with Health Purchasing Victoria (HPV) to maximise value-for-money procurement of medical equipment and deliver the most efficient purchasing arrangements, including standardisation and bulk purchasing and achievement of economies of scale. For further information, refer to procurement and purchasing requirements and the HPV website at .

4.7.1.6 Disposal of assets Assets replaced must be decommissioned and disposed of in accordance with standards. The asset status should be updated in the basic asset management plan and asset register.

4.7.2 Property portfolio management Property portfolio management supports the delivery of services from real property assets. In this context, real property means both the land and the buildings attached to that land. Health services are required to actively manage their property portfolios to ensure real property assets under their control or ownership are fully utilised and realise full service delivery potential. Health services should • maintain an accurate dataset of all real property assets and annually review landholdings in accordance with the Victorian Government landholding policy • ensure formal tenure agreements are executed on all land which is department owned or controlled (such as Crown land Committee of Management) • ensure all real property transactions undertaken comply with the requirements of all relevant legislation, ministerial directions and Victorian Government policy (such as the Land Transactions Policy and Guidelines). It is desirable that real property assets under health service management are zoned appropriately for current or proposed use and health services consolidate multiple freehold parcels held under separate titles to simplify future property management activities. As funded organisations seek to best match services to patient needs, service agreements with third parties will require legal tenure agreements relating to the occupation of premises that adequately address legislative and service requirements and related risks. Where tenure agreements are proposed for premises located on Crown land, funded organisations must ensure they have the right to enter into such agreements and must comply with legislative requirements and government policy regarding their implementation. Further information on government land policies and processes, including Crown land management, is available at: .

4.7.3 Asset maintenance Maintenance forms part of asset management. It represents the actions necessary to retain an asset as near as is practical to its original condition. It excludes building cleaning, rehabilitation and any capital investment to replace or renew. Funded organisations are responsible for providing effective asset maintenance for assets under their stewardship or control to ensure adequate maintenance is sustained over the life of assets, in order to: • keep them in appropriate condition for the health services they support • prevent service delivery interruptions or service quality risks • minimise risks to patient safety and occupational health and safety • ensure long-term service performance. Funded organisation maintenance management processes and reporting should include: • internal information on the condition, suitability and capacity of assets • reporting on asset-related risks and strategies in place to mitigate them • establishing annual and long-term maintenance plans for all key sites.

4.7.4 Health service environmental management planning and reporting In order to assist health services to manage their environmental impact and increase their operational efficiency, health services are required to develop and implement a whole-of-organisation environmental management plan and report publicly on environmental performance. The environmental management plan is to focus on the organisation’s material environmental impacts, which could include energy, carbon, water, waste, transport and procurement. Health services are encouraged to expand the plan to include all sites under their control. Health services are to report publicly on environmental performance in accordance with the department’s Environmental reporting guidelines. The environmental data management system produces a standard report which meets these reporting guidelines. A template environmental management plan and the environmental reporting guidelines are available at . Health services are to report energy, water, waste and paper data in the environmental data management system. The reporting of transport, medical gases and refrigerant data is encouraged but is not mandated for the 2016–17 reporting year. The environmental data management system can be accessed at .

4.8 Information and communication technology standards

A health sector technology strategy is currently being developed in consultation with the health sector, and is expected to be finalised by August 2016. It will reference and update the current Statewide health ICT strategic framework, the principles of which all funded organisations should continue to follow. Health service providers have prime accountability and responsibility through their boards for deploying ICT to support service delivery within their health service. They are also required to work with the Health Technology Branch within the Department of Health and Human Services to develop and agree on a statewide health technology strategy, and adhere to agreed architecture and interoperability standards to enable the sharing of clinical information across the health sector. Health services are required to seek approval from the Secretary, Department of Health and Human Services prior to issuing tenders to the marketplace for strategic ICT projects, including business projects with a strategic ICT component. Health services are also required to provide regular reports to the Health Technology Branch, Department of Health and Human Services on their local ICT strategies, plans and projects. The Health Technology Branch have an assurance role for the sector to ensure that minimum ICT capability is in place to support clinical care, as well as ensuring that appropriate project governance and planning is in place to support the delivery of successful ICT enabled health service projects. All health service projects with an ICT component greater than $1 million must also be reported to the Department of Premier and Cabinet for inclusion in the ICT project dashboard for reporting to the government on public sector ICT activities. Conformance with and adoption of the prevailing standards is essential in the healthcare system where the continuum of care traverses many organisational boundaries. Existing ICT standards and specifications that support the ICT framework continue to be in force. Details and relevant links are provided on the department’s Health Technology website at: . Funded organisations must adhere to these standards when planning or implementing ICT projects, including: • national individual healthcare identifiers (IHIs) for patients, healthcare provider identifiers for individual clinicians (HPI-Is) and healthcare provider identifiers for organisations (HPI-Os), as well as other requirements under the Healthcare Identifiers Act 2010 (Cwlth) (these identifiers should be incorporated into all new or updated applications as defined in the minimum interoperability requirements) • national terminology for enterprise-wide electronic medical record (EMR) implementations: Australian standard terminology (SNOMED-CT-AU) and the Australian Medicines Terminology (AMT) • the prevailing Australian version of the Health Level 7 (HL7) as referenced on the Health Technology Digital Design website for use in Victoria (currently the recommended Victorian standard is HL7 v2.4) • interaction with the My Health Record system and the requirements of the My Health Record Act 2012 (Cwlth) • the national eReferral, Discharge Summary, Shared Health Summary and Event Summary standards and specifications, as defined by Standards Australia and the Australian Digital Health Agency • the National Product Catalogue and associated standards and specifications as defined by Standards Australia and the Australian Digital Health Agency • adoption of the National Health Services Directory as the primary source for services directory and location information

• adoption of the National Endpoint Proxy Service as the primary source for endpoint location services to support secure messaging • the recommended national telehealth standards as defined by the National Health Information and Performance Principal Committee (NHIPPC) and Standards Australia • alignment with the National ehealth security and access framework maintained by the Australian Digital Health Agency through its national Cybersecurity Centre. The website of the Australian Digital Health Agency is an important source of reference material for ICT planning. The information contained on the site is subject to continual change, both to the standards and their policy settings. Health services should always first review the information on the Health Technology site which references the information from the agency but includes specific Victorian extensions and other local information that take account of the Victorian legislative and policy framework.

4.9 Risk management

4.9.1 Risk management and assurance Risk management and assurance activities are essential components of good corporate governance for all funded organisations. These activities will facilitate better service outcomes and quality care, and minimise claims and losses.

4.9.1.1 Risk management The Health Services Act, Public Administration Act and the Financial Management Act require funded organisations to have effective and accountable risk management systems and strategies in place. Management and the board are responsible for their organisation’s governance, risk management and control processes. Internal auditors assist both management and the audit committee by examining, evaluating, reporting and recommending improvements on the adequacy, efficiencies and effectiveness of these processes. To ensure risks are being managed in a consistent way, some funded organisations are required under the department’s service agreement, Direction 3.7.1 of the Standing Directions of the Minister for Finance and the Victorian Government Risk Management Framework to attest annually that the responsible body is satisfied that: • the organisation has a risk management framework in place consistent with AS/NZS ISO 31000:2009 Risk Management – Principles and Guidelines • the risk management framework is reviewed annually to ensure it remains current and is enhanced, as required; and supports the development of a positive risk culture within the organisation • the risk management processes are effective in managing risks to a satisfactory level • it is clear who is responsible for managing each risk • inter-agency risks are addressed and the organisation contributes to the management of shared risks across government, as appropriate • the organisation contributes to the identification and management of state significant risks, as appropriate • risk management is incorporated in the organisation’s corporate and business planning processes • adequate resources are assigned to risk management • the organisation risk profile has been reviewed within the past 12 months. An organisation’s risk management framework can consist of the following components: • a risk management policy and plan that integrates with corporate planning • risk registers and profiles • an incident management system and/or the VHIMS (refer to Chapter 4, section 1.2.5 ‘Patient and client safety’) • risk management tools, templates and training • business continuity and emergency management plans • compliance and quality systems • a fraud and corruption control plan. These components assist funded organisations in developing an effective risk-aware culture that includes clinical and all other operational activities. For more information on risk management, refer to SA/SNZ HB 436:2013 Risk management guidelines: companion to AS/NZS ISO 31000:2009 and HB 158:2010 Delivering assurance based on ISO 31000:2009: Risk management – principles and guidelines.

4.9.1.2 Assurance activities Assurance activities are designed to provide independent conclusions and a degree of confidence regarding the outcome of the evaluation or measurement of the subject matter against predetermined criteria. The subject matter can take many forms such as: • corporate governance practices • effectiveness and efficiency of operations • systems, processes, people and performance • data reliability, completeness, integrity and availability • accreditation and certifications • patient or client outcomes and satisfaction • compliance with laws, regulations and contracts. Attestations, internal and external audits, accreditations and surveys are some categories of assurance activities that funded organisations may use to provide independent and reasonable assurance to their board, audit committee and management that they are on track to achieve their objectives. An organisation’s assurance framework can consist of the following components: • an assurance strategy and internal audit charter linked to organisational objectives • an assurance map detailing the sources of all assurance activities • a risk-based assurance and audit plan outlining planned activities • registers and reports to track implementation progress of recommendations • key performance indicators of assurance activities. For more information on assurance and audits, refer to the Australian National Audit Office’s Better practice guide: public sector internal audit and the Institute of Internal Auditor’s International professional practices framework, practice advisories and practice guides.

4.9.2 Emergency management

4.9.2.1 Emergency preparedness policy for clients and services The Department of Health and Human Services Emergency preparedness policy for clients and services aims to protect and enhance the health and safety of people accessing services from Victoria’s health and human services sector. The policy assists the department and funded organisations to prepare for and respond to emergencies. It describes the sector’s responsibilities and considerations to prepare for and respond to all types of emergencies. It seeks to achieve a consistent sector-wide approach, taking into consideration the local environment, conditions and resources. The policy applies to all types of services that are:  delivered from department-owned or managed facilities  delivered by departmental staff  provided through departmental funding • regulated by the department (including supported residential services). The policy and other emergency management information are in the Summer preparedness kit for the health and human services sector. The kit is available at .

4.9.2.2 Vulnerable people in emergencies policy The Vulnerable people in emergencies policy improves the safety of vulnerable people in emergencies through supporting emergency planning with and for vulnerable people. The policy responds to Recommendation 3 of the Victorian Bushfires Royal Commission Final Report, and related recommendations. The policy uses existing relationships with funded organisations in supporting clients to improve their safety and resilience through promoting personal emergency planning. Policy requirements apply to organisations funded by the department to provide personal care, support and case management services either in home or community settings, to clients living in the community within the 64 municipal council areas wholly or partly covered by the Country Fire Authority districts. This includes health or community care services such as home and community care, personal care or disability day programs. The Vulnerable people in emergencies policy is available at .

4.9.2.3 State health emergency response plan The State health emergency response plan (SHERP) outlines the arrangements for coordinating the department’s response to emergency incidents that go beyond day-to-day business arrangements. Such emergencies are complex incidents and local resources may not be able to respond effectively to events such as mass casualty incidents, complex trauma events, mass gatherings and other incidents that affect the health of Victorians. The State health emergency response plan is a subplan of the Victorian State emergency response plan. It is an all hazards, scalable plan and includes detailed arrangements for regional and state health responses. The plan also incorporates contemporary directions in emergency management, with a focus on the needs of children in emergencies and on psychological support to prevent long-term health impacts. The basis for the department’s emergency management responsibilities come from its portfolio responsibilities in health and human services, the Emergency Management Act 2013 and the Emergency management manual Victoria. The department’s two key responsibilities are to act as the Control Agency for the protection of health and to manage pre-hospital and hospital responses to emergency incidents. The State health emergency response plan describes the arrangements for this second responsibility. The State health emergency response plan is available at .

4.9.3 Fire risk management Funded organisations are responsible for ensuring they comply with the department’s guidelines on fire safety management relevant to the premises they operate. The guidelines are available at . Any building surveyor, fire safety engineer or auditor must be accredited by the department. A list of accredited practitioners is at . Funded organisations are responsible for ensuring they comply with all laws, regulations and mandatory standards relating to fire protection (from external threats such as bushfire), fire suppression (fire within the organisation) and general safety that apply to any premises from which the funded organisation operates – irrespective of whether the relevant regulatory requirements place the obligation on the owner or occupier of those premises.

Key fire risk management requirements include the following: • Funded organisations must ensure that appropriate operational readiness measures are developed, implemented and reviewed. In doing so, funded organisations should prepare for, respond to and recover from emergencies in accordance with the ‘all hazards’ approach. This includes bushfire, flood, relocation and evacuation and prolonged service interruption. • Funded organisations must also ensure that essential services are maintained. • At the time of client placement in any premises, funded organisations must ensure that the premises comply with all laws relating to fire protection, health and general safety that apply to any premises from which the organisation operates. • Funded organisations must also ensure that the premises are suitable for efficient client evacuation, taking into account the fire systems installed, and the relocation and evacuation capacities of the client. If any relevant change occurs that may affect a client’s ongoing ability to evacuate safely, the suitability of the placement must be reassessed and appropriate action taken. Health services and funded organisations that are required to comply with the department’s guidelines on fire safety management shall complete and return Certificate No. 6 of fire safety compliance for 2016–17 to the department via , or through their respective regional fire risk management unit coordinator by 30 September 2017. More information on fire risk management, and a copy of this certificate template, is available at .

4.10 Legal obligations

4.10.1 Privacy Funding is provided on the condition that the funded organisation: • complies with the provisions of the Privacy and Data Protection Act 2014 and the Health Records Act 2001 and any codes of practice or guidelines made under those Acts in performing funded services • ensures its employees, officers, agents and subcontractors comply with the Acts and the terms of a funding agreement.

4.10.2 Intellectual property The rights and obligations of funded organisations and the State of Victoria regarding ownership and management of intellectual property are set out below. Funding is provided with the following conditions: • All intellectual property developed by a funded organisation with funding provided by the department (Project IP) vests in the funded organisation unless the department advises the funded organisation in writing prior to the delivery of all or part of the funded services that the State of Victoria will own the Project IP. • The funded organisation grants to the State of Victoria a non-exclusive, world-wide, everlasting, irrevocable, royalty free licence to exercise all rights in relation to the Project IP (including background and third party intellectual property incorporated into Project IP) as if the State of Victoria was the owner, including the right to sub-license. For the avoidance of doubt, the rights conferred on the State of Victoria under the licence include, without limitation, the right to use, reproduce, adapt, broadcast, publish, communicate to the public, and otherwise disseminate the Project IP for the benefit of the Victorian public. • The funded organisation will ensure it obtains all necessary consents (including moral rights consents) to enable the State of Victoria to exercise all the rights conferred on the State of Victoria referred to above. • Immediately following a written request, the funded organisation will provide all Project IP to the department. • The funded organisation will properly manage the Project IP in a manner which allows the State of Victoria to enjoy the full benefit of providing the funding to the funded organisation. • The funded organisation must not accept co-funding, or involve any person in the delivery of the services, on terms that would jeopardise or limit any licence to be granted to the State of Victoria without obtaining the department’s prior agreement and consent in writing. Where a funded organisation has a service agreement with the department, the department’s service agreement more fully records the parties’ rights with respect to Project IP and takes precedence over these guidelines.

4.11 Payments and cash flow

4.11.1 Payments to funded organisations In 2016–17 the department will make monthly payments over 13 periods (two payment periods in July) to all health services through the Budget and Payments System (BPS). Cash flow percentages have been tabled at the Industry Finance Committee and details of these grants/payments can be found on Health Collect . The department will monitor hospital cash flows as reported monthly in the financial data (F1) cash flow statement. The department will make monthly payments to community service organisations through the Service Agreement Management System (SAMS2). Cash flow percentages of individual payment schedules of Service Agreements and details of these grants/payments can be found on My Agency . The department will monitor agency performance and financial sustainability via the eBusiness portal. Payments may be adjusted for recall, loans, enterprise bargaining agreements, indexation, awards and prepayments (refer to Chapter 2, section 2.17 ‘Prior-year adjustment: activity-based funding reconciliation’).

4.11.2 Enterprise bargaining

4.11.2.1 Expiring agreements and enterprise bargaining During the 2016–17 financial year a number of enterprise bargaining agreements (EBAs) relating to staff directly employed by hospitals, health services and Ambulance Victoria will be subject to renegotiation having reached their nominal expiry dates during the financial year. These agreements are listed in Table 4.1.

Table 4.1: Enterprise bargaining agreements to be negotiated in 2016–17

Employee group Nominal expiry date Medical scientists, pharmacists and psychologists 31 October 2016 Maintenance workers 30 November 2016 Doctors in training 30 March 2017 Medical specialists 30 March 2017 Specialist dentists and dentists in training 31 May 2017 Victorian Health Promotion Foundation 31 May 2017 Dental therapists, dental hygienists and oral health therapists 31 May 2017 Biomedical engineers 30 June 2017 General dentists 30 June 2017

4.11.2.2 Wages policy The government’s wages policy consists of a Fair Pay Guide whereby increases of 2.5 per cent per annum are assured as a base increase over the life of the agreement. To achieve outcomes above the Fair Pay Guide, a Service Delivery Partnership Plan (SDPP) needs to be developed that identifies service delivery improvements that the entity plans to implement over the life of the agreement and the costs and benefits attributable to those service improvements. Service delivery improvements must be financially sustainable, forward looking, commence during the life of the agreement and be ongoing.

4.11.2.3 Budgeting for new agreements Enterprise bargaining settlements are rarely timed to coincide with the beginning of a financial year. There may therefore be part-year cost effects in any given financial year relating to both expiring and new enterprise bargaining outcomes. In contrast, budget indexation does apply on a full financial year basis. Health services must identify and account for indexation as it relates to supporting increased wage and salary costs. When new enterprise bargaining agreements take effect, or are likely to take effect in a financial year, health services must keep indexation funding available for such increases. This remains true even when enterprise bargaining processes become protracted or complex and remains unresolved at the end of the financial year in which settlement was expected to occur and have cost effect. Health services must also ensure enterprise bargaining agreement costs are properly attributed to other relevant revenue sources where existing employment costs are met from those other sources.

4.11.2.4 Interim payments for long-stay, high-cost patients The department will consider interim payments (both cash flow and recorded WIES revenue) for long- stay patients who have accumulated significant amounts of WIES, or Subacute WIES, and who remain admitted at 30 June 2016. Health services may apply to the department for special consideration for individual admitted patient episodes. Applications for special consideration must indicate the number of WIES or Subacute WIES. For WIES-funded episodes, the interim diagnostic-related group (DRG) must also be indicated. For Subacute WIES-funded episodes, the AN-SNAP V4.0 must also be indicated. Under no circumstances should agreement to fund an interim payment result in a statistical separation. If the department agrees to provide an interim payment, the health service will be asked to designate the episode as a contracted patient using a specific contract/spoke identification code. When the patient is finally separated, the payment will be adjusted accordingly. For example, the interim amount will be deducted from the final payment. The final DRG may differ from the interim DRG, due to the addition of further complications, comorbidities and procedures, in which case the payments will be adjusted to reflect actual activity. Interim payments for long-stay, high-cost patients will be considered on a case-by-case basis. While interim payments are not governed by strict length of stay (LOS) or WIES criteria, a patient might be recognised as a long-stay, high-cost patient if the patient is: • still admitted at 30 June 2016 and their LOS already exceeds a year • still admitted at 30 June 2016, their LOS already exceeds six months and the patient might reasonably be expected to still be in the hospital at 31 December 2016 • still admitted at 30 June 2016, their LOS already exceeds six months and the patient is receiving significant mechanical ventilation.

4.11.3 Use of contract WIES On occasion, where a health service has reduced capacity (for example, due to workforce shortages or capital works) it may contract with another service to undertake activity for a time-limited period. Contract arrangements of this type must be approved in advance by the department’s Manager, Performance and Governance. Applications can be received via the Health Data Standards and Systems helpdesk < [email protected] >. Approval will only be granted where the health service can demonstrate that the capacity reduction is temporary and that the contract is an appropriate use of allocated WIES, taking into account local demand for services. Technical information for recording and reporting contract WIES is available in the VAED manual.

4.11.4 Health service fees and charges Any fees and charges raised by health services must be in accordance with the department’s manual, Fees and charges for acute health services in Victoria: a handbook for public hospitals. The fees are available at . Health services are permitted to raise fees for the following non-admitted patient services: • dental services • spectacles and hearing aids • surgical supplies • prostheses, however, the following categories of prostheses must be provided free of charge – artificial limbs – prostheses that are surgically implanted, either permanently or temporarily, or are directly related to a clinically necessary surgical procedure • external breast prostheses funded by the National External Breast Prostheses Reimbursement Program • other services, as agreed between the commonwealth and Victoria. Upon an admitted patient separation, a health service may raise fees for: • pharmaceuticals at a level consistent with the Pharmaceutical Benefits Scheme statutory co- payments • aids • appliances • home modification.

4.11.5 Private patient accommodation charges Section 72.1(2) of the Private Health Insurance Act 2007 states that an insurance policy covering hospital treatment must provide at least the ‘minimum benefit’ for that treatment. The Commonwealth Minister for Health stipulates the minimum benefits payable by private health insurers for shared ward accommodation in public hospitals through the private health insurance (benefit requirements) rules. The commonwealth does not set a minimum benefit for single room accommodation. Health services are able to make their own determination on accommodation fees to be charged to private patients who receive treatment at their campuses. In coming to this decision, health services should consider: • the benefit that private health insurance funds will assign to the public hospital in their health insurance products • any co-payment a patient may be willing to pay as a private patient • the amount of any co-payment or excess the hospital can viably forego. To assist health services with this decision, the department provides a guide to average costs and nominal cost recovery rates for private patient accommodation in the department’s Fees manual available at . At a minimum, these rates would be reasonable to apply to private patient charges.

Health services should note the Private health insurance (health insurance business) rules 2007 Part 3 s. 8(b), which state that treatment provided to a person at an emergency department is excluded treatment for the purposes of private health insurance. Health services should ensure that private health funds are not billed for accommodation or services provided to admitted private patients at an emergency department.

4.11.6 Redirection of funds If the total revenue for a funded program exceeds the expenses incurred in delivering the full quantity of services specified in the Statement of Priorities (SoP) or service agreement, the surplus may be used by the funded organisation for any purpose connected with its agreed function. This clause does not apply if there is a contrary arrangement regarding unexpended funding provided for a specially identified purpose.

4.11.7 Doctors in training secondment arrangements Many training programs for junior doctors involve a rotation to a site other than their parent hospital. The parent hospital is responsible for managing and paying the annual leave of doctors in training while on rotation, and where annual (or other) leave is planned within the rotation period, both hospitals should approve this leave. Only the parent hospital is to pay out annual leave, as this is included in the overheads paid to the parent hospital (refer to Hospital Circular 2/2013). The parent hospital will make every endeavour to organise suitable relief when a doctor in training takes other leave (either planned or unexpected) for a period longer than one week. The parent hospital should also make every endeavour to ensure the relieving doctor has commensurate experience and skills to ensure the expected level of service in the external hospital can continue to be provided.

4.11.8 Accountability for visiting medical officer payments Health services that have engaged medical practitioners on a fee-for-service basis are required to establish and maintain appropriate accountability procedures over these payments. These financial controls are in addition to the regular review of credentials and clinical privileges. The type of accountability measures to be established will vary according to the size of the organisation and the extent to which fee-for-service arrangements are used. Accountability measures may include: • installing and using purpose-specific software to monitor and audit claims • obtaining specific advice relating to fee-for-service contract negotiation from the health services’ industrial representative or from independent legal advisors • ensuring that fee-for-service contracts – clearly specify performance expectations and the requirement to participate in annual performance reviews – require contractors to comply with the health services’ code of conduct, by-laws, policies and protocols and procedures in force from time-to-time and relevant to the services provided. • conducting a comprehensive regular audit of fee-for-service claims on a routine or random basis (this may include the review of guidelines and procedures governing the administration and payment of fee-for-service costs to ensure that contractual agreements are current for all providers who are remunerated on a fee-for-service basis, and that all such contracts clearly specify applicable rates and conditions of payment reviewing trends in service delivery and outputs for patient care provided on a fee-for-service basis) • the department, from time-to-time, requiring organisations to report on the nature and extent of fee- for-service claims and the accountability measures that have been put in place to monitor claims.

4.11.9 Long service leave The department assumes the liability arising from the net increase in the long service leave provision for public health services. Refer to Hospital Circular 5/2013 for more details on funding, accounting and reporting of long service leave, in effect from 22 April 2013. In 2016–17 the department will continue to assume this liability. As in previous years, the department will fund an amount of 2.8 per cent through the funding model as a contribution to an organisation’s long service leave liability. The difference between this contribution and the health service’s annual provision will be accounted for by services by creating a non-cash long service leave revenue and will be receivable from the department for the same amount. More details are found in Hospital Circular 5/2013.

4.11.10 Medical indemnity insurance The department has developed the medical indemnity risk-rated premium (RRP) model in consultation and on the advice of the Victorian Managed Insurance Authority (VMIA) and its actuaries. The RRP model allocates a share of the statewide medical indemnity insurance premium to individual hospitals and health services.

4.12 Data collection requirements

Data reporting and analysis are core elements of the department’s health monitoring and funding system. In general, health services and other funded organisations are required to comply with standard definitions for reporting financial and statistical data, as set out in the relevant 2016–17 versions of data collection manuals and any other amending documents prepared by the department.

4.12.1 Data integrity Accurate data are critical for funding purposes, performance monitoring, reporting, policy development and planning and for maintaining public confidence in the health system. Health service boards of management are accountable for the accuracy of reported data. Boards are expected to make data integrity the responsibility of their audit committee and ensure that data accuracy is subject to appropriate controls, including regular internal audits. Health services are required to: • maintain board and board audit committee scrutiny of data integrity practices • complete implementation of security improvements for elective surgery and emergency department information technology systems, including implementation of unique user identity and password controls, and routinely reviewing ICT system transaction logs • implement recommendations from audits conducted at their health services • make a data quality attestation in the health service’s annual report • comply with the Minister for Finance Standing Direction 3.4.13 Information collection and management. The department also provides Data Integrity Guidelines for Health Services. Each health service will have its Victorian Admitted Episodes Dataset (VAED), Elective Surgery Information System (ESIS) and Victorian Emergency Minimum Dataset (VEMD) data collection, recording and reporting practices audited by the department’s independent auditors. In addition, selected health services will be subject to audits of their admitted subacute care data reported to VAED, patient costing data reported to the Victorian Cost Data Collection (VCDC) and specialist clinics data reported to the Victorian Integrated Non-Admitted Health (VINAH) dataset. These audits will cover data accuracy and health service compliance with department policies and business rules. The health data integrity audit program may also include other health service data collection and reporting activities.

4.12.1.1 System updates These data collections are reviewed annually to ensure they are relevant for performance monitoring against current operational priorities, as well as to provide up-to-date indicators of ongoing clinical activity trends. The department remains committed to balancing the resources required to collect and report data against the need for quality data for monitoring, planning and fulfilment of the department’s own reporting obligations. These aims are achieved through various consultative committees and reference groups for specific data collections and feedback received through specific departmental program areas. Proposed changes to data collections are released for comment, and final specifications for change are published by 31 December prior to the financial year to which they apply. The HDSS bulletin provides advice on data quality issues to health services that contribute to the VAED, VEMD, ESIS, VINAH and AIMS. The bulletin is the primary method by which amendments to standards and reporting timelines are published during the year.

Health services should ensure that appropriate staff subscribe to the HDSS bulletin to remain up-to-date with any changes. The HDSS bulletin is issued electronically via both web and email and is free. Subscriptions may be arranged through the Health Data Standards and Systems help desk by emailing .

4.12.1.2 Penalties for noncompliance If health services are noncompliant with the timelines specified in these guidelines, penalties may apply. Refer to the relevant dataset for more information.

4.12.2 Key systems The department operates several data collections on different aspects of health service activity. Key systems include: • F1/Common Chart of Accounts • Portfolio Financial Reporting • the VAED for admitted patient activity • the VEMD for designated emergency department activity • the ESIS for monitoring elective surgery waiting lists • the VINAH minimum dataset for non-admitted patient activity • AIMS, used primarily to collect summary-level financial and statistical information • the VCDC for patient-level costs • the Victorian Perinatal Data Collection (VPDC) for births • total parenteral nutrition activity.

4.12.2.1 Financial data F1 financial returns including revised estimates for all health services and other portfolio entities (excluding cemeteries, VicHealth and sports bodies), at the entity level, are required 12 days after the end of the month for which the financial data are provided (for example, the F1 for July is required by 12 August). A timetable for the financial reporting requirements for whole-of-government will be released separately. For reporting to the Department of Treasury and Finance, public hospitals are required to report actual financial information to the department by the submission dates provided by the department. This data must be complete and accurate. If the data submitted to the department is inaccurate or incomplete, hospitals will be required to amend and re-submit this data, this re-submission must occur in a timely manner. Public hospitals are also required to report both an approved budget and a budget estimate to the department. The submitted approved budget should match the agreed Statement of Priorities and only be amended when agreed. The budget estimate is to be in the form of a full balanced budget trial balance and should be reviewed in line with the budget update timelines required for reporting to the Department of Treasury and Finance which are generally as follows: • Initial estimate - 12 August 2016 • Mid-year estimate - December 2016 • Year-end forecast - 12 April 2017 Public hospitals will provide this information in accordance with the department's timelines, except where a variance is sought and approved.

4.12.2.2 Victorian Admitted Episodes Dataset The Victorian Admitted Episodes Dataset (VAED) contains the core set of clinical, demographic, administrative and financial data for every admitted patient episode occurring in Victorian health services. Maintaining the accuracy of the VAED is critical to ensuring accurate and equitable funding outcomes, supporting health services’ planning, policy formulation, program evaluation and epidemiological research. Analyses and consolidated activity data are provided from the VAED to meet the department’s reporting obligations to the commonwealth and to various research institutes. Further information on the VAED is contained in the VAED manual at . Submission of admitted patient data All organisations that receive funding for admitted patient services must submit data to the VAED minimum dataset. Health services (including small rural health services) will code patient episodes reported to the VAED in accordance with the current Australian Coding Standards, along with Victorian additions, and any amending documents issued by the department. Public health services are required to submit admitted patient data to the VAED according to the following timelines: • Admission and separation details (E5, J5) for any month must be submitted by 5.00 pm on the 10th day of the following month. • Diagnosis, procedure, subacute and palliative care details (X5, Y5, S5, P5) in any month must be submitted by 5.00 pm on the 10th day of the second month following separation. • The 2016–17 financial year must be completed by 5.00 pm on the 10 August 2017. Any final corrections must be submitted before 5.00 pm on 24 August 2017. It is the health service’s responsibility to ensure that data files are submitted on or prior to the 10th of each month regardless of the actual day of the week. Penalties for noncompliance Where health services are noncompliant with the timelines specified above, the department may apply the following penalties: • up to $20,000 per month if more than one per cent of admission and separation details (E5, J5) for a given month are submitted after the timeline specified • up to $20,000 per month if more than one per cent of episodes for a given month are submitted without diagnosis, procedure, subacute or palliative care details (X5, Y5, S5, P5) by the deadline specified • up to $2,000 per episode if there is a significant number of episodes that are ‘dummy coded’ or do not meet the VAED business rules. The above requirements apply to all account classes, including Department of Veterans’ Affairs. Exemptions for late submission penalties If difficulties are anticipated in meeting the relevant data transmission timeframes, the health service must contact the department indicating the nature of the difficulties, remedial action being taken and the expected submission schedule. A pro forma to assist this process is provided on the Health Data Standards and Systems website at . If difficulties prevent the reporting of patient-level data to the VAED, the health service must complete the AIMS S1A form by the 10th of the month. The AIMS S1A form is submitted via HealthCollect. Contact the

for assistance with the S1A. Failure to complete the S1A form by the due date will result in late submission penalties. Software upgrades and migrations Health services undertaking software migrations must undertake VAED data submission testing prior to resuming live VAED data submission. Health services will be exempt from late data submission penalties for two months, provided the S1A form is completed on time. Health services undertaking software upgrades may choose to undertake the VAED data submission testing process prior to resuming live VAED data submission. Health services will be exempt from late data submission penalties for one month, provided the S1A form is completed on time. Health services must ensure their 2016–17 VAED submission is completed by 24 August 2017 as no extensions are permitted.

4.12.2.3 Victorian Emergency Minimum Dataset Emergency departments will submit data to the Victorian Emergency Minimum Dataset (VEMD) according to the timelines in Table 4.2. Health services may submit more frequently than the minimum standards specified in the table.

Table 4.2: Victorian Emergency Minimum Dataset timelines

VEMD 2016–17 Timeline All presentations for the first 14 At least one submission must be received by 5.00 pm on the third working day days of the month after the 14th of the reporting month. All presentations for the full month Data for the remainder of the month must be supplied by 5.00 pm on the third working day of the following month. All presentations for the full month Must be complete and correct – that is, zero rejections and notifiable edits by without errors 5.00 pm on the 10th day of the following month, or the prior business day.

The department will endeavour to process submissions within one working day of receipt. Any corrections to 2016–17 data must be submitted before final consolidation of the VEMD on 28 July 2017. Penalties for noncompliance If health services are noncompliant with these timelines, the department may apply the following penalties: • up to $5,000 per month, if a file containing presentations for the first 14 days of the month is not submitted by the timelines specified in Table 4.2 • up to $10,000 per month, if a file containing presentations for the full month is not submitted by the timelines specified in Table 4.2 • up to $10,000 per month, if a file with all presentations for the full month contains errors by the timelines specified in Table 4.2. Data flagged as unfit for reporting and analysis will be regarded as noncompliant and penalties as above will apply. Exemptions from penalties If difficulties are anticipated in meeting the relevant data submission timeframes, the health service must contact the department indicating the nature of the difficulties, remedial action being taken and the expected submission schedule. A pro forma to assist this process is provided on the Health Data Standards and Systems website at .

Requests for an exemption from late penalties will only be considered if received prior to the relevant deadlines, and the manual aggregate data spreadsheet has been completed by the due date. Extensions or exemptions are not issued in advance. Late submissions penalties are assessed after the end-of-year consolidation deadline, taking into account the health service’s compliance performance for the financial year. For any full month period that the health service is unable to supply unit record data, the health service is required to submit aggregate data using the manual aggregate data spreadsheet. The spreadsheet is available from the Health Data Standards and Systems website at . Failure to complete the manual aggregate data spreadsheet by the due date will result in late submission penalties. Data resubmissions for previous months Health services wishing to resubmit data for a previous period must complete a VEMD data resubmission request as soon as the health service is aware of the circumstances requiring resubmission. The request form must be submitted either prior to the resubmissions or accompanying the resubmitted files. Resubmissions received without the request form will not be processed. The pro forma is available on the Health Data Standards and Systems website at . Software upgrades and migrations Health services undertaking software migrations will be exempt from late data submission penalties for two months, provided the manual aggregate data spreadsheet is completed on time. Health services undertaking software upgrades will be exempt from late data submission penalties for one month, provided the manual aggregate data spreadsheet is completed on time. Health services must ensure their 2016–17 VEMD is submitted completely by 28 July 2017 as no extensions are permitted.

4.12.2.4 Elective surgery information system Health services reporting to the Elective Surgery Information System (ESIS) will be required to adhere to the minimum submission timelines in Table 4.3. Health services may submit more frequently than the minimum standards specified below.

Table 4.3: Elective Surgery Information System timelines

ESIS 2016–17 Timeline First 15 days of the month At least one submission must be received by the third working day after the 15th of the reporting month. The remaining days of the month Data for the remainder of the month must be supplied by the third working day (16th and subsequent) of the following month. All activity for the full month Data must be complete: that is, zero rejections, notifiable or correction edits by without errors the 14th day of the following month, or the prior business day.

The department will endeavour to process submissions within one working day of receipt. Any corrections to 2016–17 data must be submitted before final consolidation of the ESIS database on 18 August 2017. Penalties for noncompliance If health services do not comply with these timelines, the department may apply a penalty of:

• up to $5,000 per month if a file containing episodes for the first 15 days is not submitted by the timelines specified in Table 4.3 • up to $10,000 if a file containing episodes for the full month is not submitted by the timelines specified in Table 4.3 • up to $10,000 if a file with all episodes for the full month contains errors by the timelines specified in Table 4.3. Data that is flagged as unfit for reporting and analysis will be regarded as noncompliant and penalties as above will apply. Exemptions from penalties If difficulties are anticipated in meeting the relevant data transmission timeframes, the health service must contact the department indicating the nature of the difficulties, remedial action being taken and the expected transmission schedule. A pro forma to assist this process is provided on the Health Data Standards and Systems website at . Requests for an exemption from late penalties will only be considered if received prior to the relevant deadlines, and the manual aggregate data spreadsheet is completed by the due date. Extensions or exemptions are not issued in advance. Late submission penalties are assessed after the end-of-year consolidation deadline, taking into account the health service’s compliance performance for the financial year. For any full-month period that the health service is unable to supply unit record data, the health service is required to submit aggregate data using the manual aggregate data spreadsheet. The spreadsheet is available from the Health Data Standards and Systems website at . Requests for an exemption from late penalties will only be considered if it is received prior to the relevant deadlines and the manual aggregate data spreadsheet is completed. Failure to complete the manual aggregate data spreadsheet by the due date will result in late submission penalties. Software upgrades and migrations Health services undertaking software migrations will be exempt from late data submission penalties for two months, provided the manual aggregate data spreadsheet is completed on time. Health services undertaking software upgrades will be exempt from late data submission penalties for one month, provided the manual aggregate data spreadsheet is completed on time. Health services must ensure their 2016–17 ESIS is submitted completely by 18 August 2017 as no extensions are permitted.

4.12.2.5 Victorian Integrated Non-Admitted Health minimum dataset The VINAH MDS is a patient-level electronic reporting system built around a generic framework suitable for reporting a wide range of non-admitted patient-level data. Organisations that receive funding under any of the following programs must transmit data to the VINAH MDS: • Specialist clinics (outpatient) • Health Independence Program – subacute ambulatory care services (including paediatric rehabilitation) – Hospital Admission Risk Program (HARP) – post-acute care (PAC) – residential in-reach service

• community-based palliative care • Family Choice Program • Victorian HIV Service • Victorian Respiratory Support Service • medi-hotel (optional) • Transition Care Program (TCP) • hospital-based palliative care consultancy teams. Further information on VINAH is contained in the VINAH manual at . Submission guidelines Health services reporting VINAH will be required to adhere to the minimum submission timelines in Table 4.4. Health services may submit more frequently than the minimum standards specified below.

Table 4.4: Victorian Integrated Non-Admitted Health timelines

VINAH 2016–17 Timeline Submission date for client, Must be submitted before 5.00 pm on the 10th day of the following month. referral, episode and contact details for the month Clean date for client, referral, Must be submitted before the VINAH file consolidation at 5.00 pm on the 14th episode and contact details for the day of the following month, or the preceding working day if the 14th falls on a month weekend or public holiday data must be complete: that is, zero rejections.

Submitting funded organisations are encouraged to transmit VINAH MDS data frequently and may transmit as often as desired. Funded organisations must meet the following minimum requirements: • VINAH data compliance is reckoned on a monthly basis. Data for each calendar month (reference month), as specified in the ‘reported when’ component of each data element in the VINAH manual, must be transmitted as specified below. • Funded organisations must make at least one submission to the HealthCollect portal for the reference month by no later than 5.00 pm on the 10th day of the month following the reference month. • All errors are to be corrected in time for the VINAH MDS file consolidation at 5.00 pm on the 14th day of the month following the reference month. Complete data for the month are expected to be transmitted by the 14th. Data for the financial year must be completed in time for the VINAH MDS file consolidation on 24 August. Any final corrections must be received at the HealthCollect portal before the VINAH MDS database is finalised on 24 August 2017. It is the funded organisation’s responsibility to ensure the department receives the data in time to meet the processing schedule detailed above, regardless of the actual day of the week. Penalties for noncompliance If funded organisations do not comply with these timelines, the department may apply a penalty of: • up to $10,000 if an initial transmission of a reference month’s activity for a program is not submitted within the timelines specified in Table 4.4 • up to $10,000 if a reference month’s complete activity for a program is not submitted in accordance with the timelines specified in Table 4.4. Funded organisations that have VINAH MDS reporting obligations for multiple programs (for example, subacute ambulatory care services, HARP, PAC) should note that the above penalties apply per program. Data that is flagged as unfit for reporting and analysis will be regarded as noncompliant and penalties as above will apply. Exemptions from penalties Organisations seeking exemption from penalties for late data must complete a ‘Late Data Request Form’ (available on the HealthCollect portal) advising of the issues experienced, the organisation’s plan for overcoming the issues and the expected submission date. Exemptions will be granted at the discretion of the department. Organisations must report aggregate data for acute non-admitted activity via the AIMS S10 form and subacute non-admitted activity via the AIMS S11 form. The department has developed a process and criteria for discontinuing reporting via AIMS where patient-level data are being reported to VINAH for selected programs. The process and application details can be found at .

Software upgrades and migrations Health services undertaking software migrations will be exempt from late data submission penalties for three months. Health services undertaking software upgrades will be exempt from late data submission penalties for one month. Health services must ensure their 2016–17 VINAH transmitted completely by 24 August 2017, and should ensure software updates and migrations do not prevent complete VINAH transmissions by this date, as no extensions will be possible.

4.12.2.6 Agency Information Management System Health services will provide AIMS data to the department electronically via the HealthCollect web portal and in accordance with the timelines specified in the AIMS Public hospital user manual 2014–15. The HealthCollect web portal is at . Penalties for noncompliance If health services are noncompliant with these timelines, the department may apply a penalty of up to $5,000 for each return not submitted by the due date specified in the AIMS manual. Organisations seeking exemption from penalties for late data must notify the HDSS helpdesk < [email protected] >, advising of the issues experienced, the organisation’s plan for overcoming the issues and the expected submission date. Further details are available at .

4.12.2.7 Victorian Cost Data Collection All major provider health services are required to operate and maintain patient costing systems that monitor service provision to patients and determine accurate patient-level costs. Victorian health services are required to adhere, where possible, to the Australian Hospital Patient Costing Standards – version 3.1 (or the most recent version in the instance that a successor becomes available) and any other guidance provided by the department in the coming year. Format and scope The cost data submission to the department must comply with the Victorian Cost Data Collection (VCDC) file specifications and the VCDC reporting requirements of the relevant financial year. The specifications and requirements are available at . The cost data submitted should be fit-for-purpose and cover all areas of activity undertaken by the health service including all admitted, non-admitted (specialist clinics) and emergency presentations. Health services are to examine their current cost data for completeness across subacute (admitted and non-admitted), mental health programs and non-admitted (non-specialist outpatients activity generally) services. The National Health Reform Agreement specifies that these areas will be activity-base funded from 1 July 2013 and cost data is required from all of these services to support development of national weights. Submission and timeframes The first draft of cost data episodes for 2015–16 is to be submitted to the department by Friday 28 October 2016. The final submission is due to the department by Thursday 15 December 2016. Reconciliation templates accompanying the cost data are to be submitted no later than five business days after the final submission of cost data.

Penalties for noncompliance Where health services are noncompliant with the format or timelines specified above, the department may apply the following penalties:  up to $20,000 per month if cost data is not submitted after the timeline specified  up to $2,000 per episode if there are a significant number of episodes that are do not meet the VCDC business rules. Exemptions from penalties If difficulties are anticipated in meeting the relevant data transmission timeframes, the health service must contact the department indicating the nature of the difficulties, remedial action being taken and the expected transmission schedule. Software upgrades and migrations Health services undertaking software migrations must undertake VCDC data submission testing prior to resuming live VCDC data transmissions. Health services must ensure their 2015–16 VCDC is transmitted by the due date and should ensure software updates and migrations do not prevent complete VCDC transmissions by this date.

4.12.2.8 Victorian Health Incident Management Health services and other relevant funded organisations (including registered community health services) must provide a de-identified data extract of all clinical incidents to the department on a monthly basis. De-identified data must be sent to the department via an electronic secure data exchange process. This secure pathway allows for data encryption. Funded organisations are required to provide data according to the timelines detailed below. • Incident data for each month must be transmitted in time for the VHIMS file consolidation on the 12th day of the following month. • Corrections or amendments to incident data can be submitted in the following month’s data transmission. • Final cut-off for amendments is 1 September of the new financial year; for example, amendments to 2015–16 data must be completed and transmitted to the department by 1 September 2016. Health services are responsible for ensuring that the incident data submitted to the department meets the VHIMS dataset specification and validation rules. Further information on Victorian Health Incident Management reporting is available at . The department is undertaking a significant work program to upgrade and implement the new incident reporting system (VHIMS2) for clinical and occupational health and safety incidents and patient feedback, throughout 2016–17. Health services and other relevant funded organisations will be supported to transition to the new system. The department will advise transmission requirements and dataset specifications ahead of implementation of the new system. Additional information on the work program can be accessed at .

4.12.2.9 Better Patient Dataset The Better Patient Dataset (BPD) contains a core set of demographic information about every patient who has been treated in Victorian health services. Regular updates of the Better Patient Dataset are essential for optimum health services’ planning, policy formulation, program evaluation and epidemiological research. Health services will provide the Better Patient Dataset to the department electronically via the Secure Data Exchange in accordance with specifications advised directly by the department, by the 10th day of each month, for Patient Master Index data as at the end of the preceding month. Penalties for noncompliance If health services are noncompliant with these timelines, the department may apply a penalty of up to $3,800 for each return not submitted by the due date specified above. Organisations seeking exemption from penalties for late data must write to the Manager, Centre for Victorian Data Linkage advising of the issues experienced, the organisation’s plan for overcoming the issues and the expected submission date.

4.12.2.10 Total parenteral nutrition reporting requirements Health services funded to provide total parenteral nutrition (TPN) services will be required to report activity and cost data to the department in 2016–17. Activity data is to be reported via the AIMS S10 by the 15th day following the end of the reporting month. Further details and examples are contained in the factsheet which is available at . Cost data reported to the department for TPN should take into account the cost of consumables, equipment, maintenance and overheads. It should not include the cost of consultations with a health professional. Health services may be requested to provide ad hoc activity and cost data during 2016–17 to enable further analysis of activity and costs in order to inform future funding approaches.

4.12.2.11 Home enteral nutrition reporting requirements Health services funded to provide home enteral nutrition (HEN) services will be required to report activity and cost data to the department in 2016–17. Activity data is to be reported via the AIMS S10 by the 15th day following the end of the reporting month. Further details and examples are contained in the factsheet which is available at . Counting Self-administered and home delivered HEN activity is counted as Service Event. For HEN activity to count towards the service event target, it needs to meet all but one criterion of the Service Event definition. The one criterion not needing to be met is the ‘interaction between patient and health care provider’ as the treatment is self-administered. The other criteria must be met and include: • non-admitted patient • therapeutic or clinical content • there is a dated entry in the patient’s medical record (for example, a care plan outlining treatment). For the HEN program, all non-admitted patient sessions performed in a single month will be bundled and counted as one, non-admitted service event. For example, if a patient receives HEN every day in their

Volume 2: Health operations 2016–17, Chapter 4 Page 87 Conditions of funding home during the month, this will be counted as one patient service event. Another patient may only receive HEN once in a month. This will also be counted as one service event. Health services should count and report consultations with healthcare providers separately to home delivered, self-administered HEN. For example, if a patient who receives HEN has a consultation with a dietician in an outpatient clinic, this should be counted and reported as a nutrition/dietician consultation, rather than as home delivered HEN. Costing Cost data reported to the department for HEN should take into account the cost of consumables, equipment, maintenance and overheads. It should not include the cost of consultations with a health professional. Health services may be requested to provide ad hoc activity and cost data during 2016–17 to enable further analysis of activity and costs in order to inform future funding approaches

4.12.2.12 Telehealth in emergency departments Telehealth has the potential to facilitate a coordinated, integrated and sustainable service model to support improved service access, provide optimal care to patients and support health service staff to deliver healthcare. Telehealth can be a cost-effective, real-time and convenient alternative to the more traditional face-to- face way of providing healthcare, professional advice and education. It can help remove many of the barriers currently experienced by health consumers and professionals, such as distance, time and cost, which can prevent or delay the delivery of timely and appropriate healthcare services and educational support. To encourage and facilitate the use of telehealth in emergency settings, emergency departments have been able to count the number of telehealth consultations provided to patients in an Urgent Care Centre or in another emergency department since June 2015. From 2016–17, the department will be incorporating telehealth consultations as an activity component of the Non-Admitted Emergency Services Grant (NAESG) and the Group C Accident & Emergency Grant (Group C A&E). Purpose of the data collection Telehealth consultations that are provided by an emergency department (ED) when there is a need to deliver clinical advice remotely will be counted in an annual aggregate ED activity reported to the Department of Health and Human Services. Collection of the data relating to telehealth consultations will enable the activity to be reflected within the rebasing of the NAESG and Group C A&E for 2016–17 which occurred in March 2016. Scope Any Victorian public ED may provide telehealth consultations to a consenting patient located within another Victorian public ED or Victorian public Urgent Care Centre (UCC). Activity that can be counted A nurse or doctor from an ED or UCC can tele-present a patient to a remote doctor or nurse in another ED for assessment, evaluation and treatment using a videoconferencing system. The telehealth activity must be an interactive, real-time clinical consultation provided to a consenting patient. To be counted as an ED telehealth consultation, the activity must meet the following criteria: • The consultation must be of virtual equivalence to a face-to-face consultation. This means both the remote ED clinician and the patient must interact in a mutually responsive manner, utilising a video conferencing system. • A medical record must be kept both at the site where the patient is physically located and at the ED that has provided a remote telehealth consultation.

• The consultation must involve an interaction between at least one clinician in the ED providing the telehealth consultation and the patient. • The patient’s presenting condition/injury must be visible to the remote ED clinician. • The patient’s presentation must be of an unplanned nature. • The patient must be triaged at the physical presentation site before initiating a telehealth consultation. • The patient’s physical location must be within a Victorian Urgent Care Centre or ED. • In situations where a telehealth consultation has ended and the patient is discharged, any subsequent presentations are counted as a new presentation. • If a patient is transferred from the presenting site to the telehealth consultation site, this should be recorded in both the patient’s medical record at the physical location and in the Telehealth in ED Data Collection Form. Note: On arrival to the ED, the patient should be recorded as a new presentation in the VEMD. Activity that is excluded • Outpatients of a health service that receive an ED consultation as part of their outpatient care are not eligible to be counted as an ED telehealth consultation. • Consultations where a patient is not located at a Victorian public health service are not eligible to be counted as an ED telehealth consultation. • Consultations conducted with Adult Retrieval Victoria or the Paediatric Infant Perinatal Emergency Retrieval service for major trauma patients are not eligible to be counted as an ED telehealth consultation. • Administrative phone calls and second opinions where the consultation does not include an audio- visual interaction with the patient is not eligible to be counted as an ED telehealth consultation. Data collection The ED that provides a telehealth consultation must manually enter the details of each consultation in the Telehealth in ED Data Collection 2016–17 form. Data submission Telehealth data should be collected and aggregated in the Telehealth in ED Data Collection 2016–17 form and submitted to the department on an annual basis via email to .

Table 4.5: Telehealth in emergency department timelines

Telehealth in ED 2016–17 Timeline Telehealth consultations in ED Must be submitted before 3 March 2017

For more information If you have any questions regarding telehealth, please phone the Manager Telehealth on 9096 1405 or email .

4.12.3 Acute data reporting requirements

4.12.3.1 Victorian Healthcare Associated Infection Surveillance System The department receives infection surveillance reports from health services via the Victorian Healthcare Associated Infection Surveillance System (VICNISS) coordinating centre. All public health services are required to participate in the VICNISS HAI surveillance program. Mandatory reporting requirements exist for hip and knee arthroplasty, coronary artery bypass graft surgery and caesarean section (restricted to The Royal Women’s Hospital and Mercy Health only), intensive care unit central line-associated blood stream infections, hand hygiene compliance rates, hospital identified Clostridium difficile infections and Staphylococcus aureus bacteraemia. Further infection surveillance activities can be undertaken by health services on a voluntary and needs basis.

Health services with a statistically significant higher rate than the aggregate are notified and requested to provide information on actions that are being taken to reduce this rate. A limited number of HAI performance indicators are reported publicly on the Victorian Health Services Performance website at . Compliance rates for Staphylococcus aureus bacteraemia and hand hygiene are publicly reported on the MyHospitals website at . Staphylococcus aureus bacteraemia is a quality and safety performance benchmark under the National Health Reform Agreement.

4.12.3.2 Healthcare worker immunisation Health services must take all reasonable steps to ensure staff members are protected against vaccine- preventable diseases. High coverage rates for immunisation in healthcare workers are essential to reduce the risk of transmission in healthcare settings. Health services are required to report healthcare workers’ influenza immunisation compliance to the department annually. The benchmark rate requires 75 per cent of health service category A, B and C healthcare workers as outlined in the Health Care Worker Influenza Vaccination Protocol available at who are permanently, temporarily or casually (bank staff) employed by the health service throughout the influenza period, to be immunised.

4.12.3.3 Cleaning standards for Victorian public health services All health services are required to report on cleaning standards three times a year. The auditing process, which has been standardised, is to be undertaken by people who are qualified or suitably experienced to conduct audits against the Victorian cleaning standards. A minimum acceptable quality level (AQL) of cleaning is to be achieved by all health services; those health services that fail to achieve the AQL are required to rectify the issues and reaudit within a predetermined timeframe. The external audit results reported to the department in August 2016 will be included in patient management framework Q1 reporting.

4.12.3.4 Victorian State Trauma System All public health services, including the three designated major trauma services, are required to participate in the Victorian State Trauma Registry. The department contracts the Victorian State Trauma Registry to collect data on major trauma patients from health services. The performance and effectiveness of the Victorian State Trauma System is monitored via the registry. State aggregate data is reported every year in the Victorian State Trauma Registry summary report. Annual reports are available at .

4.12.3.5 Victorian Audit of Surgical Mortality The Victorian Audit of Surgical Mortality (VASM) is a systematic peer-review audit of deaths associated with surgical care that is undertaken through the Royal Australasian College of Surgeons (RACS) Victorian Office. Surgeon participation in the VASM is a requirement of the RACS continuing professional development program. The VASM contributes to the Australian and New Zealand Audit of Surgical Mortality. The objective of the audit is to identify system-wide issues from a peer review of all surgical deaths, including all deaths that occur in a hospital following a surgical procedure and deaths that occur in a hospital while under the care of a surgeon (irrespective of whether a surgical procedure was performed).

The Royal Australasian College of Surgeons provides health services with an annual report containing information on the key outcomes of audited cases from their service along with comparable data for similar state and national hospitals. The department also receives a copy of these reports and will follow up with health services with outlying results regarding their performance improvement strategies. All health services and surgeons must participate in this audit. More details are available at: .

4.12.3.6 Consultative councils reporting requirements Consultative councils are ministerial advisory committees that report on specialised areas within healthcare to reduce mortality and morbidity. Consultative councils operate under the provisions of the Public Health and Wellbeing Act 2008 and related Regulations. Victorian Consultative Council on Anaesthetic Mortality and Morbidity The Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) monitors, analyses and reports on potentially preventable anaesthetic mortality and morbidity and provides strategic advice and recommendations to improve the clinical and system-wide performance of anaesthetic services in Victoria. The Victorian Consultative Council on Anaesthetic Mortality and Morbidity reviews voluntarily reported cases of mortality and morbidity received from medical practitioners, hospitals and other sources such as the coroner. Health services are expected to support and encourage clinicians to report anaesthesia-related events to allow system-wide learning to be disseminated. A new secure electronic notification form will be implemented during 2016, which will standardise and simplify case notification to the council and improve the council’s reporting functions and timeliness. Further information about VCCAMM is available at: . Consultative Council on Obstetric and Paediatric Mortality and Morbidity The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) provides advice to the Minister for Health on issues relating to perinatal, maternal and paediatric mortality and morbidity. The council collects information on births and reviews all maternal, perinatal and paediatric (from 29 days of age up to 17 completed years) deaths in Victoria to consider preventable or contributing factors in each case, develop de-identified recommendations and for annual reporting of health and mortality indicators. Section 48 of the Public Health and Wellbeing Act requires that all births are reported to CCOPMM within a prescribed period after the birth for inclusion in the VPDC (see Chapter 1, section 1.9.2.7 ‘Victorian Perinatal Data Collection’). The legislation pertaining to the VPDC has been amended to specify that birth data must be submitted within 30 days from the date of a birth (instead of 90 days). The department will be monitoring health service compliance with this change. The VPDC is a population-based surveillance system to collect and analyse information on the health of mothers and babies. It contains comprehensive information on obstetric conditions, procedures and outcomes, neonatal morbidity and congenital anomalies relating to every birth in Victoria. The VPDC manual, including data definitions, business rules and submission guidelines are available at . Health services and clinicians are also required to provide information on all maternal and perinatal deaths (stillbirths and neonates) and child deaths (up to the age of 18) pursuant to ss. 39–40 and 47 of the Public Health and Wellbeing Act and within the timeframe specified by the council. The confidentiality of information provided to CCOPMM is heavily protected under legislation.

All health services providing maternity services will have an arrangement to regularly review all perinatal deaths and provide their findings to CCOPMM. This process will conform to the Perinatal Society of Australia and New Zealand Clinical Practice Guideline for Perinatal Mortality, 2nd edition, version 2.2 (April 2009). Smaller maternity services will combine the functions of the Perinatal Mortality Review Committee with another hospital committee or regional mortality review committee (section 2.2.2 (i)). Templates and guidance for reporting maternal, perinatal child and adolescent deaths are available at . Victorian Surgical Consultative Council The Victorian Surgical Consultative Council (VSCC) considers the outcomes and recommendations of the Victorian Audit of Surgical Mortality and provides strategic advice and recommendations to the Minister for Health, the department and health services to improve the safety and quality of surgical services in Victoria. The VSCC work closely with the VASM (see Chapter 4, section 12.3.5 ‘Victorian Audit of Surgical Mortality’) to disseminate shared learnings from the audit across the peri-operative service sectors. The VSCC has access to information from the VAED and other sources to explore areas of serious surgical morbidity. Health services are expected to ensure that accurate surgical data is submitted to the VAED and to the VASM to allow system-wide lessons relating to surgery to be disseminated. Further information about the VSCC is available at .

4.12.3.7 Adult paediatric and neonatal critical care reporting Adult and paediatric Health services that operate an adult or paediatric critical care unit must submit data to the Adult Patient Database and the Australian and New Zealand Paediatric Intensive Care Registry administered by the Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE). To facilitate statewide access to critical care beds, all health services providing adult and paediatric critical care services are required to update bed occupancy data on the Retrieval and Critical Health Information System (REACH) website four times a day, at approximately 8.00 am, 12.00 pm, 4.00 pm and 8.00 pm. Metropolitan and larger regional health services are expected to operate a minimum number of intensive care unit (ICU) equivalent beds each day, where one ICU equivalent bed equals one ICU bed occupied by a patient being nursed at a one nurse to one patient ratio. A patient being nursed at a ratio of one nurse to two patients is considered high dependency unit level, and equal to 0.5 of an ICU equivalent bed (this also applies to coronary care unit patients in units that operate as a combined ICU and coronary care unit). Health services may operate below their expected minimum number of ICU equivalent beds, with the expectation that an empty bed is declared on the REACH website when this occurs. The expected minimum number of ICU equivalent beds for relevant health services are outlined in Table 4.6. Comparison of health service ICU bed occupancy and expected ICU equivalent beds will be undertaken periodically.

Table 4.6: Expected minimum number of ICU equivalent beds for relevant health services

Health service Expected minimum number of ICU equivalent beds Albury Wodonga Health 5 Alfred Health 37 Austin Health 22 Ballarat Health Services 7 Barwon Health 17 Bendigo Health Care Group 6 Eastern Health 17 Goulburn Valley Health 4 Latrobe Regional Hospital 7 Melbourne Health 26^ Monash Health 32* Northern Health 9* Peninsula Health 10 The Royal Children's Hospital 19 St Vincent's Health Melbourne 15 Western Health 17 * Once critical care capital works are complete. ^ Increase from 24 to 26 once VCCC operational.

Neonatal Health services providing neonatal care services are required to update the Victorian Perinatal Information Centre website; twice daily for the four health services with a neonatal intensive care unit and daily for all other health services with special care nurseries. In 2016–17, the department will consult on the transition of statewide system level information on capacity and occupancy in Victoria's neonatal intensive care units and special care nurseries being migrated to the Retrieval and Critical Health Information System (REACH) which hosts intensive care, coronary care and mental health bed status information. The statewide Paediatric Infant Perinatal Emergency Retrieval (PIPER) service, under the governance of The Royal Children’s Hospital, will continue to provide health services with a quarterly report on maternity and neonatal retrievals and transfers. This is intended to enable health services to review and monitor trends and opportunities to improve care and safety.

4.12.3.8 Maternity services reporting Health services providing maternity and neonatal care must submit specified data to the Victorian Perinatal Data Collection and the Victorian Admitted Episode Dataset for inclusion in the annual Victorian perinatal services performance indicators report. The perinatal services performance indicators are reported at a statewide (public and private) and individual (identified) public hospital level to drive improvement in outcomes for Victorian women and babies. Health services providing a Koori Maternity Service Program must submit program data bi-annually to the department’s Maternity and Newborn Program. This data provides evidence of the work being undertaken to provide culturally competent maternity care and improve the health and wellbeing of Aboriginal women and babies.

4.12.3.9 Cardiac surgery registry Since 2001 the department has contracted the Australian and New Zealand Society of Cardiac and Thoracic Surgeons to provide a system that collects data to monitor clinical performance in cardiac surgery. The Cardiac Surgery Database Project is coordinated by the Monash University School of Public Health and Preventative Medicine, and the department expects all health services that perform cardiac surgery to participate. The Cardiac Surgery Database Project includes maintenance of a comprehensive clinical registry, statistical analysis and report generation. These components enable a structured peer-review process that can identify variation in performance at the practitioner and health service level. The department publishes a public version of the Cardiac Surgery Database Project annual reports on its website and more detailed reports are provided to participating health services. Further information about the cardiac surgery registry is available at .

4.12.3.10 Victorian Cardiac Outcomes Registry The department has supported the development and implementation of a cooperative cardiac registry that aims to help improve the safety and quality of healthcare provided to cardiovascular patients in Victoria. All public and the majority of private health services that perform percutaneous coronary interventions now provide this data to the Victorian Cardiac Outcomes Registry, and a module is being piloted for acute management of early ST elevation myocardial infarction (STEMI) in regional and rural settings. Additional modules planned relate to implantable cardiac devices (such as pacemakers and defibrillators) and a dataset for patients presenting to hospital with heart failure. This registry is coordinated by the Monash University School of Public Health and Preventive Medicine and has the support of the Cardiac Society of Australia and New Zealand. The Victorian Cardiac Clinical Network supports and promotes the implementation of the registry.

4.12.3.11 Australian Stroke Clinical Registry The Australian Stroke Clinical Registry is a collaborative national effort to monitor, promote and improve the quality of acute stroke care. It is a prospective, multicentre, observational outcomes database designed to collect data on the demographics, presentation, diagnosis, treatment and outcomes of hospitalised patients with stroke. The Department of Health and Human Services is funding the registry $1 million over four years to support its implementation across the Victorian system. The Victorian Stroke Clinical Network promotes the implementation of the registry at all metropolitan and regional stroke units, and is supporting the development of automated data extraction platforms to reduce the burden of data entry for clinicians.

4.12.3.12 Radiotherapy services reporting Radiotherapy providers are required to report: • monthly to the Victorian Radiotherapy Minimum Dataset (VRMDS) • monthly to AIMS form S8 (until exempted, see Chapter 2, section 2.2.4 ‘Radiotherapy’) • monthly to the AIMS form S10.

The department continues to contribute data from the VRMDS to the Australian Institute of Health and Welfare (AIHW), along with other jurisdictions. The data is included in the AIHW draft report Radiotherapy in Australia, released annually. The report presents waiting times at public radiotherapy providers by state or territory. Waiting times for private providers will be amalgamated into a national figure.

4.12.3.13 Renal dialysis reporting All health services that provide facility dialysis must report public and private admitted activity at a unit record level to the VAED. This includes activity in all facilities. Aggregate data for all non-admitted patients, including both clinic activity and home dialysis service events, is reported through AIMS S10 Non-Admitted Clinical Activity. This includes reporting on dialysis performed by the patient in their home without the presence of a healthcare provider. The department maintains a dialysis register comprising patient-level data provided by specialist services and coordinated by Melbourne Health. The register excludes private patients dialysing in private hospitals.

4.12.3.14 Registry of kidney disease The department has funded the establishment of a clinical outcomes registry for chronic kidney disease that aims to support quality improvement in renal services. The registry data will be used to drive clinical improvement initiatives through the early identification of chronic kidney disease and intervention to prevent or slow the progression of renal disease, and developing complications. The registry initially incorporates data from six major metropolitan renal units but will expand to include all units over time. It will eventually be linked to the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) to provide a robust evidence base of chronic kidney disease from diagnosis to disease progression, including dialysis, transplant and death. This registry is coordinated by the Monash University School of Public Health and Preventive Medicine. The Renal Health Clinical Network supports and promotes the implementation of the registry.

4.12.3.15 Victorian Healthcare Experience Survey The Victorian Health Experience Survey (VHES) aims to understand how consumers and, where appropriate, carers feel about their recent experience of care provided by a Victorian public health service. Each month the VHES collects data for adult and child inpatient and emergency department consumers, and maternity clients. In 2016–17 there will also be annual collections for nominated specialist clinics and community health services. For the VHES adult inpatient, adult emergency, maternity, paediatric inpatient and paediatric emergency, health services are required to upload contact details of eligible consumers to the contractor by the 15th of the month following discharge. This upload includes the service received which determines the type of questionnaire sent. For the annual specialist clinics survey, nominated health services are required to upload contact details of eligible consumers for the three months nominated for survey collection. For the annual community health service survey, health services are required to support the census survey process. Data transfers occur in a secure online environment through the Project Control Portal at . The Project Control Portal provides access to the Data Upload manual and the template required for submission. Quarterly reports are available online at . At present these results are only available to health services and departmental staff.

4.12.3.16 HealthLinks: Chronic Care Health services participating in the HealthLinks: Chronic Care (HLCC) trial must comply with all departmental routine data submissions (PRS/2) including due dates. Data compliance is necessary for the department to administer, and the independent evaluator to estimate the impact of the trial. Participating sites will be required to report patient-level data (for example, patient ID, HLCC admission/discharge dates) to the department as patients are recruited to the Health Links: Chronic Care program. This information will be used to inform any adjustments in funding that may be required and also be used by the evaluation team to determine if fidelity to the pool of enrolled patients is being maintained. Participating sites will also be required to commit to the collection and submission of data as specified by the independent evaluator for the department evaluation study.

4.12.4 Subacute data reporting requirements

4.12.4.1 Admitted GEM and rehabilitation All health services providing inpatient rehabilitation and geriatric evaluation and management (GEM) services are required to report a Functional Independence Measure (FIMTM) score on admission and separation for patients with rehabilitation (excluding paediatric rehabilitation) and GEM care types. This is a mandatory VAED reporting requirement. Reports submitted to the department without a FIMTM score will be rejected.

4.12.4.2 Admitted palliative care All health services providing inpatient palliative care services are required to report data elements linked to the phase of care, including specific elements for the final phase. This is a mandatory VAED reporting requirement. Reports submitted to the department without a phase of care identified will be rejected.

4.12.4.3 Admitted maintenance care All health services providing maintenance care are required to report a Resource Utilisation Group – Activity of Daily Living (RUG ADL) score. This is a mandatory VAED reporting requirement. Reports submitted to the department without these measures will be rejected.

4.12.4.4 Nursing home type care The department no longer provides direct funding for public patients reported as nursing home type (NHT) in Victorian hospitals with subacute or non-acute care services. Therefore, it is not expected that health services will report NHT activity. Current arrangements for Department of Veterans’ Affairs, compensable and private patients remain in place regarding the NHT process and funding. A patient co- contribution payment cannot be levied on patients in admitted acute and subacute care types (excluding Transition Care Program).

4.12.4.5 Health Independence Program and Community Palliative Care All health services providing Health Independence Program (HIP) or Community Palliative Care (CPC) services are required to report activity using the program and stream element, as described in the VINAH data collection system: • contacts will be reported through VINAH as per the standard VINAH reporting requirements • the AIMS S11 form will continue to be required to report service events for commonwealth reporting processes. Health services are expected to maintain sustained effort across all Health Independence Program services. Recall will be applied to the total Health Independence Program activity target based on activity reported through VINAH.

Non-admitted subacute care programs and services that reliably submit VINAH data for all subacute program streams will be able to cease providing AIMS data once agreement has been reached with the department. The department will continue to work with Health Independence Program and Community Palliative Care services to better understand data compliance and quality issues for non-admitted services. The department aims to identify models of care that support good practice across the service delivery components in order to reduce unexplained variations across services.

4.12.4.6 Reporting requirements for palliative consultancy programs There are different reporting requirements across the three consultancy programs. Reporting the VINAH dataset Hospital consultancy programs are eligible to report patient-level data using the VINAH dataset in 2016– 17. Individual health services should make an assessment about the resource impacts of reporting their information using the dataset against the benefits. Services that undertake the service but do not report their data will not receive the aggregated feedback reports that provide activity benchmarking across all services. Statewide and regional consultancy programs are not required to report data using the VINAH dataset in 2016–17. AIMS regional and statewide consultancy reporting In 2016–17 statewide and regional consultancy programs are required to use the AIMS S11 form to ensure aggregate activity counts comply with the definition of a service event. Statewide and regional consultancy teams must report: • number of contacts • number of referrals • active episodes • number of episodes opened • number of episodes closed • number of patients. Services are required to report AIMS data by the 15th of each month.

4.12.5 Ambulance Victoria data reporting requirements Stage 1 of the Victorian Ambulance Data Set (VADS) became operational in 2015–16. It will be progressively expanded during 2016–17 to incorporate data for the Referral Service and Adult Retrieval Victoria. In 2016–17 VADS will be used to support and further develop the new funding model for Ambulance Victoria and to fulfil the department’s public accountability requirements, including requirements under the proposed Transparency in Government Bill 2015. The department will continue to work with Ambulance Victoria to validate and extend the VADS collection. Ambulance Victoria will be required to continue existing reporting requirements until both the department and Ambulance Victoria confirm the accuracy of VADS data for the purposes of public reporting and performance monitoring. Ambulance Victoria will supply data to the department according to the timelines specified in Table 4.7.

Table 4.7: Victorian Ambulance Data Set timelines

VADS 2016–17 Timeline Request for service and response Year-to-date submission to be received by the 10th day of the month data following the Case Date. Transport and patient data Year-to-date submission to be received by the 10th day of the second month following the Case Date. Data for the 2016–17 financial year Year-to-date submission must be received before final consolidation of VADS on 10 August 2017.

Ambulance Victoria will also supply the existing datasets including new measures introduced for 2016– 17, until such time as an agreement has been reached between Ambulance Victoria and the department that the VADS collection is an accurate replacement for parts of these collections. Existing datasets (as outlined in Table 4.8) will include all current data elements.

Table 4.8: Existing ambulance data collections

Collection Description and submission timeline Aggregate Ambulance Minimum Dataset The indicators identified in Table 4.16 will be supplied to the department in spreadsheet format by the10th day of the month following the monthly reporting period. New indicators introduced in 2015–16 have been included in the table and are marked with (c) after the indicator name. Daily ambulance patient transfer times A rolling two-week unit-record data submission of all ambulance patient transports to Victorian emergency departments, to be emailed to a nominated departmental contact each day for the two- week period ending two days earlier. Weekly ambulance patient transfer times A weekly unit-record data submission of all ambulance patient transports to Victorian emergency departments to be submitted to the department via the departmental portal within two days following the end of the reporting period. Ambulance membership movements Changes in Ambulance membership in spreadsheet format to be emailed to a nominated departmental contact on the seventh day of each month following the end of the monthly reporting period.

Penalty for noncompliance The penalty for noncompliance is: • up to $10,000 per month if a file containing data for the full reporting period is not submitted by the timelines specified in Table 4.7 and Table 4.8. Penalties for non-compliance will be in place for the VADS collection (Table 4.7) and for the collections outlined in Table 4.8 from 1 July 2016.

4.12.6 Mental health services data reporting requirements Information about clinical mental health services relevant to funding, activity and performance monitoring is collected by the department through a range of channels including: • the CMI/ODS, which includes data on bed status as required by the bed coordination initiative and seclusion and restraint as required by the Mental Health Act • the mental health triage minimum dataset • reportable deaths • quarterly data collection for disability services • quarterly Mental Health Community Support Service activity • annual Mental Health Establishments collection

• the VAED (see Chapter 4, section 12.2.2 ‘Victorian Admitted Episodes Dataset’) • the VEMD (see Chapter 4, section 12.2.3 ‘Victorian Emergency Minimum Dataset’). The collections form an essential underpinning of public accountability for service provision, with the outputs from these collections contributing to a range of national datasets, as well as performance measurement and monitoring for commonwealth, state and departmental purposes.

4.12.6.1 Client Management Interface and Operational Data Store The statewide Operational Data Store (ODS) is simultaneously updated from local Client Management Interface (CMI) systems as data are captured, providing a live 24-hour, seven-day-a-week statewide view of the transactional history of mental health services. Services are expected to use the CMI/ODS for data collection, which includes outcome measurement and client-related activity and complies with the due dates as summarised in Table 4.9.

Table 4.9: CMI/ODS reporting timelines

Data entry Rationale Due date Compulsory order/legal status To ensure timely monitoring of Twice daily, seven days per week compulsory/forensic/security clients Admissions, transfers and Maintain statewide bed register Twice daily, seven days per week separations Contacts Monitoring 10th of the month following the contact Outcome measures Monitoring 10th of the month following the measure collection

Electroconvulsive therapy Statutory reporting As soon as practicably possible procedures Seclusion and restraint Statutory reporting 10th of the month following the event

Departmental circulars detail the business rules for key data requirements and guidelines for data recording practices.

The frequency of data entry for Compulsory Orders has been increased for 2016–17 to twice daily, seven days a week to ensure timely automated transfer of order details to the Mental Health Tribunal. Business rules for data recording can be found under CMI/ODS at . Regular meetings are held with hospital mental health system administrators to discuss system and data issues. Regular system upgrades are performed to improve the functionality and utility of the system and data. Mental health data quality validations Services are required to review and reconcile data quality issues identified by the department and provide return advice on a quarterly basis. All issues from the prior financial year need to be reconciled by the end of November, in time for the annual Mental Health National Minimum Dataset submissions. Electroconvulsive therapy The Chief Psychiatrist requires that all occasions of electroconvulsive therapy (ECT) be reported to the Office of the Chief Psychiatrist. All ECT course details and procedures are to be recorded on the CMI/ODS as soon as practicably possible after each procedure.

4.12.6.2 Mental Health Establishments National Minimum Dataset The Mental Health Establishments National Minimum Dataset replaced the National Survey of Mental Health Services in 2005–06. This annual collection captures all mental health workforce data and all expenditure and is compiled to meet Victoria’s national mental health reporting requirements. The data collection for the previous year (stage 1) begins in September each year, with health services, residential service providers and regions required to submit a return. The 2015–16 mental health establishment collection for health services performance data will be pre- populated using CMI/ODS. This information is subject to health service confirmation or amendment as required. The F1 finance return (where applicable) will be used to pre-populate the organisation-level information page for health services. Further advice will be provided prior to the HealthCollect portal opening for the stage 1 2015–16 data submission. Reporting timelines for the Mental Health Establishments National Minimum Dataset are outlined in Table 4.10.

Table 4.10: Mental Health Establishments National Minimum Dataset reporting timelines

Collection Reporting requirements Due date 2014–15 Stage 2: This process is required to be finalised by 29 29 August 2016 August 2015. Timely resolution of these issues enables the department to submit validated data to the Report on Government Services. 2015–16 Stage 1: Data submission will open through the 14 October 2016 HealthCollect portal on 13 September 2016. Data entry by health services to be finalised by 14 October 2016 when the portal will close. 2015–16 Stage 1: Resolution of services’ validation issues arising 2 May 2017 from the HealthCollect portal. 2015–16 Stage 2: Resolution of issues identified by the 29 September 2017 commonwealth.

4.12.6.3 Mental health triage minimum dataset In 2010–11 the department introduced a triage minimum dataset. Quarterly reports and an annual detailed report are to be drawn from this data in support of the Chief Psychiatrist’s guideline Priority access for out-of-home care (2011). Triage data are required to be provided to the department in the prescribed format on a monthly basis by the 15th of each month. The data file must be sent to the following secure email address: . Documents detailing the format and reporting timelines can be found at .

4.12.6.4 Mental health community support New funding and performance management models were introduced in 2015–16 as part of the reform of the mental health community support services sector. Agencies funded to deliver reformed mental health community support service activity are expected to provide data via the Quarterly Data Collection (QDC), which has been updated to capture new reporting requirements. Those agencies delivering activity not impacted by sector reform are also required to report service activity via the QDC system in addition to reporting key agency deliverable outcomes on a quarterly basis via a supplementary excel spreadsheet. This spreadsheet will be phased out during 2016–17.

Under reform, compliance with these reporting requirements has become a key accountability requirement to be used as part of the ongoing review and monitoring processes. Public reporting of mental health community support services indicators will commence during 2016–17. Quarterly Data Collection data must be submitted by 7th of the month following the end of the quarter. The QDC has a dedicated help desk support team to assist users with the quarterly data collection. The supplementary excel spreadsheet data file must be submitted by the 15th of the month following the end of the quarter. The file must be submitted to .

4.12.6.5 Reportable deaths Under the Mental Health Act, services are required to report the death of a current inpatient, a person being treated as an involuntary patient, and the unnatural, unexpected or violent death of a person receiving treatment in the community. Guidance in relation to reportable deaths is provided in the Chief Psychiatrist’s guideline available at . The Chief Psychiatrist maintains a record of all deaths reported and liaises with the coroner when indicated.

4.12.7 Alcohol and drug services data reporting requirements Information about alcohol and drug treatment services which are relevant to funding, activity and performance monitoring is collected through a range of channels including: • the Alcohol and Drugs Information System (ADIS) • the Alcohol and Other Drug Treatment Services Supplementary spreadsheet collection • the Needle and Syringe Program Information System • the Drugs and Poisons Information System • the Opioid Replacement Therapy Dispenser Census.

4.12.7.1 Alcohol and Drugs Information System The Alcohol and Drugs Information System (ADIS) forms an essential underpinning of public accountability for service provision. Outputs contribute to a range of national datasets, as well as performance measurement and monitoring for commonwealth, state and departmental purposes. The quality of this data is the subject of ongoing review, with the department liaising directly with organisations where data quality issues are identified. The department also maintains help desk support to ensure users are fully aware of data entry requirements, including a help desk facility for system users at . In addition to the ADIS collection Lead Providers funded to deliver reformed alcohol and drug treatment activity are required to submit a supplementary spreadsheet on a quarterly basis to report on intake contacts, completed treatment courses and referral outcomes. The reported completed courses in turn inform on the delivery of drug treatment activity units (DTAUs), which form a basis for funding. Alcohol and Drugs Information System data and the supplementary spreadsheet are to be provided to the department by the 15th of the month following the end of the quarter. The file must be submitted to . Guidelines and supporting information for the ADIS collection can be found at . The current ADIS v4.0 data collection specifications will be replaced with new Alcohol and Drug Treatment Services reporting requirements commencing 2017–18. Work on the development of associated data collection and reporting specifications will commence in 2016–17, guided by a project reference group. The associated data collection and reporting specifications will be made available to providers during 2016–17.

Providers should be aware that the FullADIS application will not be updated to accommodate new data collection requirements from 1 July 2017. Helpdesk support for the FullADIS application will cease on 30 June 2017.

4.12.7.2 Needle and Syringe Program Information System The Victorian and Commonwealth Governments fund services to reduce harms associated with alcohol and drug use. The harm reduction services data collection records the level of activity in these services in terms of contacts, service provision (for example, needles provided and returned, education and referrals), responses to harm reduction questions, as well as information about the free provision of a range of injecting and safe-sex equipment, and the disposal of returned waste. Data is provided by: needle and syringe programs; mobile overdose response services; and mobile drug safety workers. All Primary Needle and Syringe Program providers and recipients of Ice Action Plan funding are required to report monthly via the Needle and Syringe Information System Agency Reporting (NSPIS-AR) application. Organisations using the NSPIS-AR application can generate the extract and email it to . Paper-based surveys should be sent to the department via email at , by fax (03) 9096 8726, or posted to: NSP Data Collection MHD Information Analysis and Reporting System Intelligence and Analytics Branch Strategy and Analytics Division Department of Health and Human Services GPO Box 4541 Melbourne VIC 3001 Secondary Needle and Syringe Program providers currently submitting hard copy forms via fax or the post should transition to email-based submission prior to 1 July 2017. From July 2017 the department will only accept PDF survey forms submitted via email from Secondary Needle and Syringe Program providers and pharmacies. Secondary Needle and Syringe Program providers are also strongly encouraged to use the NSPIS-AR application to improve data quality.

4.12.7.3 Drugs and poisons information system The department operates an electronic information system known as the drugs and poisons information system to support its administration of the Drugs, Poisons and Controlled Substances Act 1981. The drugs and poisons information system is a stand-alone system and provides the department with the ability to record treatment permits issued to doctors prescribing Schedule 8 drugs to patients. This includes methadone and buprenorphine prescriptions for opioid replacement therapy (pharmacotherapy). Through this system, the department can identify possible instances of a patient seeking Schedule 8 drugs from multiple prescribers (‘doctor shopping’) in the event that other prescribers apply for permits to treat the same patient. The system is additionally used to record information collected during prescription-monitoring activities and during investigative processes. Interventions are initiated if unlawful or possibly unsafe prescribing is identified. Non-compliant health practitioners may be subject to further action, ranging from educational counselling to prosecution or other disciplinary action. More serious offending (for example, trafficking) will commonly be the subject of joint investigations involving departmental officers and police. The drugs and poisons information system also records licences and permits issued to organisations or individuals who have a legitimate need to use, possess, manufacture or supply drugs and poisons as part of their course of practice or business (such as for research, industrial or health services).The information system also records the payment of fees relating to such licences and permits associated with the possession of drugs and poisons.

4.12.7.4 Opioid Replacement Therapy Dispenser Census The department conducts the Opioid Replacement Therapy Dispenser Census annually. It surveys all community, correctional, health service and specialist pharmacotherapy service dispensaries dosing opioid replacement therapy clients in Victoria. All dispensers are faxed the survey form, to be returned by fax, recording the number of clients being dosed with respective opioid replacement therapy medications. It also records the numbers of opioid replacement therapy clients on a minimal supervision regimen who are eligible for departmental dispensing support, or with interstate prescriptions. The data provides a count of clients being dosed at a given time. This allows patterns of opioid replacement therapy access to be closely monitored across the state, which in turn informs departmental sector support activities. In 2016 additional questions have been added to the Census to assist in identifying Aboriginal and Torres Strait Island clients involved in the program.

4.12.8 Aged care data reporting requirements Data collection requirements and timelines for ageing, aged and home care services are provided in Table 4.11. This includes information for Home and Community Care (HACC), public sector residential aged care and aged care assessment services (ACAS) through a range of channels including: • the HACC national minimum dataset • the Aged Care Assessment Program national minimum dataset • HACC fees data collection • HACC annual service activity reports • residential services data collection. Since the Home and Community Care Program will be split between the commonwealth and the state on 1 July 2016, reporting requirements for clients aged 65 and over (and Indigenous clients aged 50 and over) will be determined by the Commonwealth Department of Health, which administers the Commonwealth Home Support Programme. For clients aged less than 65 (and Indigenous clients aged less than 50) who remain in the HACC Program managed by Victoria, reporting requirements remain unchanged – that is, via the HACC Minimum Data Set. Organisations should continue to send the data to the department. The Carers Recognition Act sets out obligations for councils and organisations covered by the Act, including the obligation to raise awareness and understanding of the care relationship principles as set out in the Act. Relevant organisations are required to report on their compliance against these obligations in their annual report. Specific requirements can be found in ss. 5, 11 and 12 of the Act.

Table 4.11: Ageing, aged and home care data collection and reporting requirements

Activity no Activity name Measure description

13005 ACAS assessment Six-monthly report on ACAP operations 13005 ACAS assessment Six-monthly report on ACAP staffing

13015 HACC linkages packages HACC national minimum dataset

13023 HACC service development grant Project report

Activity no Activity name Measure description 13024 HACC assessment HACC national minimum dataset 13024 HACC assessment HACC fees data collection 13026 HACC domestic assistance HACC national minimum dataset 13026 HACC domestic assistance HACC fees data collection 13027 HACC respite HACC national minimum dataset 13027 HACC respite HACC fees data collection 13031 Public sector residential aged care Annual returns data collection supplement 13031 Public sector residential aged care Residential aged care services data supplement collection and residential aged persons mental health data collection 13035 Support for carers HACC national minimum dataset 13038 HACC service system resourcing Annual HACC service activity report 13038 HACC service system resourcing HACC fees data collection 13043 HACC flexible service response HACC national minimum dataset 13043 HACC flexible service response Annual HACC service activity report 13043 HACC flexible service response HACC fees data collection 13053 Victorian Eyecare Service Victorian Eyecare Service program data collection (program guidelines updated 2013) 13056 HACC planned activity group – core HACC national minimum dataset 13056 HACC planned activity group – core HACC fees data collection 13057 HACC planned activity group – high HACC national minimum dataset 13057 HACC planned activity group – high HACC fees data collection 13059 Residential aged care complex care Annual returns data collection supplement 13059 Residential aged care complex care Residential aged care services data supplement collection 13063 HACC volunteer coordination HACC national minimum dataset 13063 HACC volunteer coordination HACC fees data collection 13063 HACC volunteer coordination Annual HACC service activity report 13082 Low-cost accommodation support HACC national minimum dataset 13082 Low-cost accommodation support Community connection program annual narrative report 13082 Low-cost accommodation support Housing support for the aged program annual narrative report 13082 Low-cost accommodation support Older persons high-rise support program annual narrative report 13082 Low-cost accommodation support SRS oral health initiative service activity six monthly report 13096 HACC allied health HACC national minimum dataset 13096 HACC allied health HACC fees data collection 13096 HACC allied health Annual HACC service activity report 13097 HACC delivered meals HACC national minimum dataset

Activity no Activity name Measure description 13097 HACC delivered meals HACC fees data collection 13099 HACC property maintenance HACC national minimum dataset 13099 HACC property maintenance HACC fees data collection 13103 Language services VITS data collection 13107 Rural small high-care supplement Annual returns data collection 13107 Rural small high-care supplement Public sector residential aged care services quality activities 13130 HACC volunteer coordination – other Annual HACC service activity 13131 RDNS HACC allied health HACC national minimum dataset 13131 RDNS HACC allied health HACC fees data collection 13155 Dementia services Support for carers of people with dementia data collection 13156 Seniors health promotion Healthy ageing demonstration project report 13211 Aged annual provisions – minor works Annual returns data collection 13223 HACC nursing HACC national minimum dataset 13223 HACC nursing HACC fees data collection 13226 HACC personal care HACC national minimum dataset 13226 HACC personal care HACC fees data collection 13227 ACCO services – aged and home care HACC national minimum dataset 13227 ACCO services – aged and home care HACC fees data collection 13227 ACCO services – aged and home care Annual HACC service activity report 13302 SRS Supporting Accommodation for Annual SAVVI (narrative) reports, which will Vulnerable Victorians Initiative include data regarding SAVVI expenditure 13303 SAVVI Supporting Connections HACC national minimum dataset 13303 SAVVI Supporting Connections SAVVI supporting connections annual narrative report 13352 Victorian Seniors Festival Seniors community programs data collection 13354 Elder abuse prevention and response HACC national minimum dataset (adapted for Senior Rights Victoria) 13354 Elder abuse prevention and response Seniors community programs data collection 13355 Seniors community programs Seniors community programs data collection 13356 Information and lifelong learning HACC national minimum dataset (adapted for Senior Rights Victoria) 13356 Information and lifelong learning Seniors community programs data collection 35010 Small rural – aged support services Seniors Health Promotion Project report 35011 Small rural – residential aged care Annual returns data collection 35011 Small rural – residential aged care Public sector residential aged care services quality performance data collection 35011 Small rural – residential aged care Residential aged care services data collection (AIMS S5_129 form) 35011 Small rural – residential aged care Residential aged care services aged persons mental health data collection (AIMS S5_115 form)

Activity no Activity name Measure description 35030 Small rural – HACC healthcare and support HACC national minimum dataset 35030 Small rural – HACC healthcare and support HACC fees data collection 35036 Small rural – Department of Veterans’ Affairs HACC national minimum dataset HACC 35036 Small rural – Department of Veterans’ Affairs HACC fees data collection HACC

4.12.9 Primary, community and dental health data reporting requirements A summary of reporting requirements is shown in Table 4.12.

4.12.9.1 Community health services All funded organisations receiving community health program funding are required to submit data that outlines service delivery performance against targets. Agencies are responsible for the timely submission of data as per the documented reporting requirements. Over 2016–17, further work will progress to explore options to streamline reporting for community health services. The Community Health Program Data Reporting Guidelines are available from the department’s website at . All health services receiving community health program funding are required to ensure that: • information systems comply with the department’s reporting requirements • client information management systems comply with the current specification for the Service Coordination Tool Templates (SCTTs), and support secure sharing of the SCTTs (e-referral) • service information remains up-to-date on the National Human Services Directory. The Service Coordination Tool Templates are available at . Additional evidence may be required from time-to-time to demonstrate that funding has been used appropriately. Community health services are also required to contribute to the Primary Care Partnerships reporting, as outlined in Chapter 4, section 12.9.2 ‘Primary Care Partnerships’.

4.12.9.2 Primary Care Partnerships Primary Care Partnerships are required to report annually to demonstrate progress in achieving the strategic objectives outlined in the Primary Care Partnership program logic 2013–17. These reporting requirements demonstrate progress in achieving system improvements against the domains: ‘Early intervention and integrated care’, ‘Consumer and community empowerment’ and ‘Prevention’ in the program logic. Primary Care Partnerships are responsible for the timely submission of reports as per the documented reporting requirements. As a key objective of Primary Care Partnership activity is to strengthen collaboration and integration across sectors, Primary Care Partnership reporting should reflect partnership with Primary Health Networks to progress this work.

4.12.9.3 Dental health services The department requires a monthly extract of dental health program dataset items. This extract includes all episodes created during the reporting period and any episodes modified during the reporting period. Agencies with multiple databases should provide one extract per database.

Funded organisations are required to submit data to the department by the third business day of each month. The department is responsible for validating monthly extracts and providing error reports to agencies. Funded organisations must correct errors in their data before the next extract of all health program dataset items is submitted. The department will provide validated data to funded organisations and Dental Health Services Victoria.

Table 4.12: Primary and dental health data collection and reporting requirements

Activity no Activity name Data collection description 27017 Oral health – health promotion Report against agreed deliverables linked to Healthy Together Victoria: Action plan for oral health promotion 2013–17 27019 Royal Dental Hospital Melbourne dental care Dental health program dataset 27023 Community dental care Dental health program dataset 28000 Health Self Help (Band 1) Annual activity report 28015 Family and Reproductive Rights Education Program (FARREP) Community health minimum dataset 28016 FARREP – health promotion Report against health promotion plan 28018 Family planning – health promotion Report against health promotion plan 28021 Innovative Health Services for Homeless Youth (IHSHY) – health promotion Report against health promotion plan 28048 Language services Community health minimum dataset 28050 Women’s health – health promotion Report against health promotion plan 28061 Primary health – Department of Veterans’ Affairs Community health minimum dataset 28062 Telephone counselling Regional report 28063 Family planning – education and training Community health minimum dataset 28064 Family planning – clinical services and training Community health minimum dataset 28066 IHSHY Community health minimum dataset 28067 Women’s health Community health minimum dataset 28068 Family planning Community health minimum dataset 28071 Aboriginal services and support Community health minimum dataset 28072 Integrated chronic disease management Community health minimum dataset 28076 Refugee and asylum seeker health services Community health minimum dataset 28080 Healthy Mothers Healthy Babies Community health minimum dataset 28081 National Diabetes Services Scheme Monthly report 28085 Community health – health promotion Community health minimum dataset 28086 Community health Community health minimum dataset 28087 Primary Care Partnerships Report against PCP planning and reporting guidelines 28088 ACCO services – primary health Round table reporting 35048 Small rural – Primary Health Flexible Services Community health minimum dataset

4.12.9.4 Public health data reporting requirements services

Table 4.13: Public health data collection and reporting requirements

Activity no. Activity name Data collection requirements description 16034 Languages services Cultural and linguistic diversity level of interpreter data collection 16038 Tuberculosis screening – management TB screening data collection 16084 Immunisation services National Australian Childhood Immunisation Register data collection 16102 Infectious disease surveillance Public Health and Wellbeing Regulations 2009 Schedule 4 Notifiable Conditions 16107 Public health research capacity building Project-specific data collection for public health research projects 16108 Health research projects Project-specific data collection for public health research projects 16119 School and adult immunisation services School immunisation data collection report 16203 Regulation of *ART and associated legislation Donor register data collection 16206 Laboratory testing Public Health and Wellbeing Regulations 2009 Schedule 4 – Notifiable conditions 16373 BBV and STI – clinical services Annual agency report (public health) 16377 BBV and STI – surveillance BBV STI surveillance data collection 16450 Diabetes prevention Monthly data reporting, quarterly data and progress reporting and an annual financial acquittal 16462 Prevention system initiatives Percentage of early childhood services, schools and workplaces registered to Health Together Achievement Program 16505 **BBV and ***STI – training and development Annual agency report, including financial acquittal against BBV STI training and development data plan 16506 BBV and STI – research Project-specific data collection for public health research projects 16507 BBV and STI – laboratory services Annual financial acquittal against funding provided; any emerging issues identified must be tabled 16508 BBV and STI – health promotion and Annual agency report, including acquittal prevention against BBV STI health promotion plan 16509 BBV and STI – community-based care and Annual agency report, including financial support acquittal against CBCS plan (public health) 16517 Cancer and screening registers Victorian Cervical Cytology Registry data collection 16517 Cancer and screening registers BreastScreen data collection 16517 Cancer and screening registers Cancer Registry data collection Note: *ART – Assisted reproductive technology **BBV – Blood-borne virus ***STI – Sexually transmitted infections

4.12.9.5 Workforce data reporting requirements Reporting is required against the workforce programs to inform statewide policy, to contribute to the collection and utilisation of a statewide workforce dataset and to ensure the utilisation of funds to support the development of Victoria’s future health workforce.

4.12.9.6 Health Services Payroll and Workforce Minimum Employee Dataset Health services are required to transmit information detailed in the health services payroll and workforce Minimum Dataset (MDS) data dictionary to the department. Data must be transmitted to the department by the 10th day of the following month, or the prior working day if this falls on a weekend or public holiday. Payroll data is required monthly, while workforce information is required biannually, covering the periods ending 31 December and 30 June each year. Where health services undertake their own payroll processing, they are required to transmit the information directly to the department. In cases where health services engage a payroll bureau to process their payroll, health services may authorise the bureau to transmit the data to the department on their behalf. Notwithstanding such an arrangement, health services remain responsible for the accuracy of the data transmitted. Where a health service decides to change payroll providers, it will be necessary to complete an accreditation process, prior to the change, to ensure that continuity of data transmission to the department will not be compromised. Full details regarding the MDS can be found at .

4.12.9.7 Training and development grant reporting requirements Reporting requirements In order to be eligible for training and development grant funding, health services are required to participate in Workforce Networks and to contribute to an efficient and effective clinical training system. In particular, health services are expected to: • complete the annual executive-level endorsement of funded training and development activities to ensure visibility of, and prioritisation to, workforce development • report against the seven externally reportable Best practice clinical learning environment (BPCLE) framework indicators through BPCLE tool. Professional-entry student placements To be eligible for the professional-entry student placement subsidy, health services are required to: • plan and report clinical placement activity through viCPlace biannually (or through an interim reporting tool for medicine and health information management placement providers not yet using viCPlace) • adhere to the Standardised schedule of fees for clinical placement of students in Victorian public health services (‘the schedule’), including recording of fees in viCPlace. Further information regarding the schedule, viCPlace, and the BPCLE framework is available via the following links: • • • .

Transition to practice (graduate) – allied health, medical (PGY1 and PGY2), nursing and midwifery To access transition to practice (graduate) funding, the following criteria must be met: • Transition to practice (graduate) positions are filled through the statewide matching process, or by another process as determined by the department. • Health services will be required to report on the headcount and full-time equivalent of new graduates each year for the previous calendar year. • The health service must allocate adequate training and supervision to each position and must provide advice if a graduate does not commence in, or complete, an allocated position. • The programs should conform to the most recent versions of guidelines (where available), including the guidelines and standards set by the Australian Health Practitioner Regulation Agency, the Medical Board of Australia and the Nursing and Midwifery Board of Australia. For further information relating to eligibility criteria refer to . Postgraduate – medical, nursing and midwifery All health services are required to reconcile actual activity at the completion of the calendar year. All health services receiving funding for the Victorian medical specialist and Victorian Paediatric Training Programs and the basic physician training program are required to provide confirmation of filled training posts through annual program reports. Funded postgraduate nursing and midwifery programs must lead to an award classification at Graduate Certificate, Graduate Diploma or Master level. Where students are enrolled in a Masters program with exit points at Graduate Certificate or Graduate Diploma level, only the Graduate Certificate or Graduate Diploma components are eligible. For further information relating to eligibility criteria refer to . The reporting timetable for training and development grants is shown by Table 4.14.

Table 4.14: Training and development grants – reporting timetable

Program Reporting required by health services Due date All programs Annual executive-level endorsement of funded training July 2016 and development activities to ensure visibility of, and prioritisation to, workforce development. Automated reporting of seven externally reportable Best February 2017 practice clinical learning environment (BPCLE) framework indicators through BPCLE tool. Professional-entry student Automated reporting of clinical placement activity from July 2016 (for activity placements viCPlace bi-annually. An interim reporting tool is January–June 2016) and available for disciplines not yet using viCPlace. February 2017 (for activity July–December 2016). Transition to practice Report on the headcount and full-time equivalent hours February 2017 (graduate) – allied health, of 2016 graduate activity. medical (PGY1 and PGY2), nursing and midwifery Postgraduate – medical Victorian medical specialist training program acquittal of February 2017 specialist training posts and positions in 2016. Victorian Paediatric Training Program acquittal of posts and positions in 2016. Basic physician training program acquittal of posts and positions in 2016. Postgraduate – nursing and Report on the headcount and full-time equivalent hours February 2017 midwifery of 2016 postgraduate activity.

4.12.10 Commonwealth–state reporting requirements Funded organisations may receive payments arising from commonwealth–state agreements. Funding received under such arrangements is subject to each program’s specific conditions of funding. Organisations funded under commonwealth–state programs are required to submit regular statistical and financial reports for the monitoring of activity, payment of grants and acquittal to the commonwealth. The information required, format and timelines for individual programs are detailed in the relevant Intergovernmental Agreements with the commonwealth and the guidelines applicable to the appropriate commonwealth–state programs.

Volume 2: Health operations 2016–17, Chapter 4 Page 111 Conditions of funding Appendix 4.1: Performance targets and monitoring

Table 4.15: Ageing, aged and home care performance targets and monitoring

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 13004 Aged Care Report against agreed objectives Reports Yearly Mandatory Key output measure Assessment Service project 13005 Aged Care *Percentage of priority 1, 2 and 3 clients Percentage Quarterly Mandatory Other standard Assessment Service assessed on time – in community – 80% measure assessment 13005 Aged Care *Percentage of priority1, 2 and 3 clients assessed Percentage Quarterly Mandatory Other standard Assessment Service on time – in hospital – 85% measure assessment 13005 Aged Care Number of assessments Assessments Quarterly Mandatory Key output measure Assessment Service assessment 13019 Personal Alert Security activity report Reports Yearly Mandatory Key output measure Victoria 13015 Home and Number of packages Packages Quarterly Mandatory Key output measure Community Care linkages packages 13023 Home and One electronic project report submitted Reports Yearly Mandatory Key output measure Community Care service development grant 13024 Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care assessment 13026 Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care domestic assistance

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 13027 Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care respite 13031 Public sector Number of occupied bed days Occupied bed days Monthly Mandatory Key output measure residential aged care supplement 13035 Support for carers Number of carers Carers Yearly Non-mandatory Other standard measure 13035 Support for carers Number of hours of service Hours Quarterly Mandatory Key output measure 13038 Home and Service activity report Reports Yearly Mandatory Key output measure Community Care service system resourcing 13043 Home and Service activity report Reports Yearly Mandatory Key output measure Community Care flexible service response 13053 Victorian Eyecare Number of occasions of service (metropolitan) Occasions of service Quarterly Mandatory Key output measure Service 13053 Victorian Eyecare Number of occasions of service (outreach) Occasions of service Yearly Mandatory Other standard Service measure 13053 Victorian Eyecare Number of occasions of service (rural) Occasions of service Yearly Mandatory Other standard Service measure 13056 Home and Number of hours of service (provided to clients) Hours Quarterly Mandatory Key output measure Community Care planned activity group – core 13057 Home and Number of hours of service (provided to clients) Hours Quarterly Mandatory Key output measure Community Care planned activity group – high 13059 Residential aged Number of occupied bed days Occupied bed days Monthly Mandatory Key output measure care complex care supplement

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 13063 Home and Number of hours of coordinator time Hours Yearly Non-mandatory Key output measure Community Care volunteer coordination 13063 Home and Number of hours of service (provided to clients) Hours Quarterly Mandatory Other standard Community Care measure volunteer coordination 13067 Aged community Number of projects Projects Yearly Mandatory Key output measure grants

13082 Low-cost Number of clients assisted Clients Quarterly Mandatory Key output measure accommodation support 13083 Aged training and Number of filled positions (academic) Positions Quarterly Mandatory Key output measure development 13083 Aged training and Number of filled positions (training) Positions Quarterly Non-mandatory Other standard development measure 13096 Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care allied health 13097 Home and Number of meals (funding is a subsidy only) Meals Quarterly Mandatory Key output measure Community Care delivered meals 13099 Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care property maintenance 13100 Aged research and Report against agreed objectives Reports Yearly Mandatory Key output measure evaluation 13103 Language services Number of occasions of service Occasions of service Monthly Mandatory Key output measure 13107 Rural small high-care Number of occupied bed days Occupied bed days Monthly Mandatory Key output measure supplement

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 13109 Aged Care Evaluation unit meets requirements of Rating Yearly Mandatory Key output measure Assessment Service commonwealth conditions of grant evaluation 13131 RDNS Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care allied health 13155 Dementia services Number of contacts Contacts Yearly Mandatory Other standard measure 13155 Dementia services Number of hours of service Hours Yearly Mandatory Key output measure 13155 Dementia services Number of sessions Sessions Yearly Mandatory Other standard measure 13156 Seniors health Report against agreed objectives Reports Yearly Mandatory Key output measure promotion 13210 Aged Care Funds expended on training needs of staff Dollars Yearly Mandatory Key output measure Assessment Service training and development 13223 Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care nursing 13226 Home and Number of hours of service Hours Quarterly Mandatory Key output measure Community Care personal care 13227 ACCO services – Development of service profile Completed service Yearly Mandatory Key output measure aged and home care profile 13229 Home and Hours of client care coordination Hours Quarterly Mandatory Key output measure Community Care access and support 13301 Aged quality Current authorisations for information exchange Signed documents Yearly Mandatory Other standard improvement between the department and: measure Department of Social Services Australian Aged Care Quality Agency

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 13302 SRS Supporting Number of facility cost relief expenditure plans Plans Yearly Mandatory Key output measure Accommodation for developed and implemented Vulnerable Victorians Initiative (SAVVI) 13302 SRS Supporting Number of facility cost relief cluster plans Plans Yearly Mandatory Other standard Accommodation for developed and implemented measure Vulnerable Victorians Initiative (SAVVI) 13302 SRS Supporting Number of proprietors of assisted supported Proprietors Yearly Mandatory Other standard Accommodation for residential services that meet accountability and measure Vulnerable Victorians reporting requirements for facility cost relief Initiative (SAVVI) 13303 SAVVI Supporting Number of clients Clients Yearly Mandatory Key output measure Connections 13352 Victorian Seniors Number of events and participants Events Yearly Non-mandatory Other standard Festival Participants measure 13354 Elder abuse Number of telephone calls Calls Six-monthly Non-mandatory Other standard prevention and measure response 13354 Elder abuse Number of professional educations sessions Events participants Six-monthly Non-mandatory Other standard prevention and attendees measure response 13354 Elder abuse Number of community education sessions Events Six-monthly Non-mandatory Other standard prevention and measure response 13355 Seniors community Number of projects Reports Quarterly Non-mandatory Other standard programs measure 13356 Information and Number of information requests/contacts Contacts Quarterly Non-mandatory Other standard lifelong learning measure 13356 Information and New programs Programs Six-monthly Non-mandatory Other standard lifelong learning New U3As U3As measure

Table 4.16: Ambulance Victoria performance targets and monitoring

Reporting Service plan Activity Measure description Unit of measure frequency Status Quantity – transports Emergency road: all Number of transports provided Number Monthly Mandatory Emergency road: metro Emergency road: rural and regional Non-emergency stretcher: all Non-emergency stretcher: metro Non-emergency stretcher: rural and regional Non-emergency clinic car Fixed-wing emergency Fixed wing non-emergency Rotary wing Quantity – incidents Emergency road: all Number of 000 calls or planned events Number Monthly Mandatory Emergency road: metro to which one or more ambulance resources are dispatched Emergency road: rural and regional Treatment without transport Non-emergency stretcher: all Non-emergency stretcher: metro Non-emergency stretcher: rural and regional Non-emergency clinic car Fixed-wing emergency Patient experience Patient satisfaction Percentage Annual Mandatory Pain reduction Percentage Quarterly Mandatory

Stroke patients transported Percentage of adult patients suspected Percentage Quarterly Mandatory of having a stroke who were transported within 60 minutes to a health service with the capability to deliver intravenous thrombolysis Trauma patients transported Trauma patients transported to the highest level trauma service within 45 minutes

Reporting Service plan Activity Measure description Unit of measure frequency Status Cardiac arrest survived event rate Adult VF/VT patients with vital signs at hospital Adult VF/VT patients surviving to hospital discharge Governance leadership and Safety culture Composite of safety culture score Percentage Annual Mandatory culture based on eight safety culture items in the People Matter survey Safety and quality HCWI – influenza Healthcare worker immunisation – Percentage Annual Mandatory influenza Clinical compliance audits: emergency Audited cases meeting clinical practice Percentage Monthly Mandatory standards Clinical compliance audits: non-emergency Clinical compliance audits: CERT Access Response time statewide Emergency Code 1 incidents Percentage Monthly Mandatory responded to within 15 minutes Response time urban Emergency Code 1 incidents Percentage Monthly Mandatory responded to within 15 minutes in centres with population > 7,500 Response time CERT Community Emergency Response Percentage Quarterly Mandatory Team arrival prior to ambulance where dispatched Average response time Average time to respond to Emergency Minutes Monthly Mandatory Code 1 incidents Clearing time at hospital Average ambulance hospital clearing Minutes Monthly Mandatory time Call referral Events where 000 caller receives Percentage Monthly Mandatory advice or service from another health service provider as an alternative to emergency ambulance response 40-minute transfer Proportion of patients transferred from Percentage Weekly Mandatory paramedic care to hospital emergency care within 40 minutes of ambulance arrival Notes: Additional measures will be developed and included in the data submissions.

Table 4.17: Mental health service performance indicators

Measure or indicator Unit Adult report CAMHS report Older person report Government target 28-day readmission rate per cent Yes No Yes <14 Adult services only Pre-admission contact per cent Yes Yes1 Yes 60 Adult services only Post discharge follow up per cent Yes Yes1 Yes 75 All age ranges Total seclusion rate Episodes per 1,000 bed days Yes Yes Yes <15 All age ranges HoNOS2 compliance – all inpatient, all ages per cent Yes Yes Yes >85 HoNOS2 compliance – ambulatory, all ages per cent Yes Yes Yes >85 Emergency department presentations departing per cent Yes No No 80 to a mental health bed within 8 hrs Basis/SDQ3 compliance per cent Yes Yes Yes >85 Notes: .1 Slight variation in definition as results attributed to client’s home AMHS not the separating AMHS as for adult and older person. .2 HoNOS refers to the Health of the Nation Outcome Scale and is a key mental health consumer outcome measure that has been implemented nationally. .3 Basis and Strengths and Difficulties Questionnaire (SDQ) are used by the consumer’s and/or carer’s (SDQ only) to present their views on behaviour to inform discussions with the AMHS. There are collected as part of the outcome measures suite at predefined points of time.

Table 4.18: Primary and dental health performance targets and monitoring

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 27019 RDHM Dental Care Number of clients Clients Yearly Mandatory Key output measure 27023 Community Dental Care Number of clients Clients Yearly Mandatory Key output measure 28015 FARREP Number of hours of service Hours Quarterly Mandatory Key output measure 28016 FARREP – Health Promotion Report against health promotion plan Reports Yearly Non-mandatory Other standard measure 28018 Family Planning – Health Report against health promotion plan Reports Yearly Non-mandatory Other standard Promotion measure 28021 IHSHY – Health Promotion Report against health promotion plan Reports Yearly Non-mandatory Other standard measure 28048 Language Services Number of occasions of service Occasions of Monthly Mandatory Key output measure service 28050 Women’s Health – Health Report against health promotion plan Reports Yearly Non-mandatory Other standard Promotion measure 28061 Primary Health Department of Number of hours of service Hours Yearly Mandatory Key output measure Veterans’ Affairs 28062 Telephone Counselling Number of calls answered Calls Quarterly Mandatory Key output measure 28062 Telephone Counselling Percentage of calls answered Calls Quarterly Mandatory Other standard measure 28063 Family Planning – Education and Number of hours of service Hours Quarterly Mandatory Key output measure Training 28064 Family Planning – Clinical Number of hours of service Hours Quarterly Mandatory Key output measure Services and Training 28066 IHSHY Number of hours of service Hours Quarterly Mandatory Key output measure 28067 Women’s Health Number of hours of service Hours Quarterly Mandatory Key output measure 28068 Family Planning Number of hours of service Hours Quarterly Mandatory Key output measure 28071 Aboriginal Services and Support Number of hours of service Hours Quarterly Mandatory Other standard measure

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 28071 Aboriginal Services and Support Report against agreed objectives Reports Yearly Mandatory Key output measure 28072 Integrated Chronic Disease Number of hours of service Hours Quarterly Mandatory Key output measure Management 28076 Refugee and Asylum Seeker Number of hours of service Hours Quarterly Mandatory Key output measure Health Services 28080 Healthy Mothers Healthy Babies Numbers of hours of service Hours Quarterly Mandatory Key output measure 28081 National Diabetes Services Number of packs of needles and syringes Needles and Monthly Mandatory Key output measure Scheme syringes 28085 Community Health – Health Report against health promotion plan Reports Yearly Non-mandatory Other standard Promotion measure 28086 Community Health Number of hours of service Hours Quarterly Mandatory Key output measure 28087 Primary Care Partnerships Report against PCP planning and reporting Reports Yearly Mandatory Key output measure guidelines 28088 ACCO Services – Primary Health Development of service profile Completed service Yearly Mandatory Key output measure

Table 4.19: Public health performance targets and monitoring

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 16119 School and adult Number of people immunised People Yearly Mandatory Key output type immunisation services 16163 Food safety education Report against agreed objectives Reports Yearly Mandatory Key output type 16203 Regulation of ART and Report against agreed objectives Reports Yearly Mandatory Key output type associated legislation 16206 Laboratory testing Provision of a public health Services Yearly Mandatory Key output type reference/testing service 16206 Laboratory testing Percentage of notifications within Notifications Yearly Mandatory Other standard specified timelines measure 16206 Laboratory testing Provision of required testing in Testing Yearly Mandatory Other standard accordance with accredited standards measure

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 16234 Public Health Legislative Report against agreed objectives Reports Yearly Mandatory Key output type Review 16308 Injury prevention Report against agreed objectives Reports Yearly Mandatory Key output type 16348 Children’s obesity Report against agreed objectives Reports Half-yearly Mandatory Key output type 16349 Obesity – community projects Report against agreed objectives Reports Yearly Mandatory Key output type 16373 BBV and STI – clinical Report against agreed objectives Report Annual Mandatory Key output type services 16381 Risk management and Report against agreed objectives Reports Yearly Mandatory Key output type emergency response 16449 Smoking information – advice Research reports Reports Yearly Mandatory Key output type and interventions 16450 Diabetes prevention Report against agreed objectives Reports Quarterly Mandatory Key output type 16452 Aboriginal health Report against agreed objectives Reports Half-yearly Mandatory Key output type advancement 16453 Aboriginal health worker Report against agreed objectives Reports Half-yearly Mandatory Key output type support 16454 Health promotion initiatives Report against agreed objectives Reports Quarterly Mandatory Key output type 16460 Targeted recruitment for Report against agreed deliverables Reports Yearly Mandatory Key output type screening programs 16505 BBV and STI – training and Report against agreed deliverables Reports Yearly Mandatory Key output type development 16507 BBV and STI – laboratory Report against agreed deliverables Reports Reports Mandatory Key output type services 16508 BBV and STI – health Report against health promotion plan Reports Yearly Mandatory Key output type promotion and prevention 16509 BBV and STI – community Report against agreed deliverables Reports Yearly Mandatory Key output type based care and support 16513 Screening and preventative Report against agreed deliverables Reports Yearly Mandatory Key output type messages

Activity no. Activity name Measure description Unit of measure Frequency Status Output type 16514 Screening service Report against agreed deliverables Reports Yearly Mandatory Key output type development 16515 Education and training in Report against agreed deliverables Reports Yearly Mandatory Key output type screening programs 16516 Screening counselling and Number of occasions of service Occasions of service Yearly Mandatory Key output type support 16517 Cancer and screening Statistical report within an agreed timeline Reports Yearly Mandatory Key output type registers and publicly available 16518 Cancer and screening Report against agreed objectives Reports Yearly Mandatory Key output type intelligence 16519 Screening tests and Percentage of target population screened Percentage Yearly Mandatory Other standard assessments over an agreed period measure 16519 Screening tests and Number of clients screened Clients Yearly Mandatory Key output type assessments

Appendix 4.2: Service standards and guidelines

Table 4.20: Small rural health services – service standards and guidelines

Activity no. Activity name Service standards and guidelines description 35010 Small rural – aged The Home and Community Care national standards support services instrument and guidelines, Commonwealth Department of Health and Ageing, 2000 Small Rural Health Services Guide 2003–04 and updates 35011 Small rural – residential Aged Care Act 1997 as amended aged care Guide to Aged Care Law, Department of Social Services Small rural health services guide 2003–04 and updates 35024 Small rural – flexible Small rural health services guide 2003–04 and updates health service delivery 35025 Small rural – *TAC – Small rural health services guide 2003–04 and updates acute health 35026 Small rural – Department Small rural health services guide 2003–04 and updates of Veteran’s Affairs – acute health 35028 Small rural – acute Small rural health services guide 2003–04 and updates health service system development and resourcing 35030 Small rural – HACC Victorian HACC program manual healthcare and support Small rural health services guide 2003–04 and updates 35036 Small rural – Department Victorian HACC program manual of Veteran’s Affairs Small rural health services guide 2003–04 and updates HACC 35042 Small rural – drugs Adult AOD Screening and Assessment Tool services Incident reporting instruction (May 2013) Victorian Alcohol and Other Drug Treatment Principles Victorian AOD Client Charter Severe Substance Dependence Treatment Act 2010 Shaping the future: the Victorian alcohol and other drug quality framework, April 2008 35048 Small rural – primary Small rural health services guide 2003–04 and updates health flexible services 35052 Small rural – specified Small rural health services guide 2003–04 and updates services *TAC = Transport Accident Commission

Volume 2: Health operations 2016–17, Chapter 4 Conditions of funding

Table 4.21: Drug services – service standards and guidelines

Standards and guidelines description Activity name Alcohol and other drug program guidelines 34041, 34045, 34046, 34048, 34049, 34051, 34053, 34056, 34060, 34064, 34074, 34078, 34080, 34084, 34202, 34204, 34205, 34206, 34208, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34057,34060, 34061, 34062, 34066, 34069, 34070, 34078, 34079, 34082, 34084, 34200, 34202, 34203, 34205, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304, 34305 Alcohol and other drug withdrawal practice guidelines 34050, 34056, 34064, 34203, 24204, 34214, 34303 (2009) Alcohol in the workplace: guidelines for developing a 34009 workplace alcohol policy Assessment and intervention tool for youth alcohol and 34041, 34045, 34046, 34048, 34049, 34051, 34053, drug treatment services (prepared by Turning Point 34056, 34060, 34064, 34075, 34078, 34080, 34084, Alcohol and Drug Centre Inc. for the Department of 34202, 34204, 34205, 34206, 34208 Human Services) 2004 Adult AOD screening and assessment tool 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34057, 34060, 34061, 34062, 34066, 34069, 34070, 34078, 34079, 34082, 34084, 34200, 34202, 34203, 34205, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304, 34305 Catchment-based AOD planning function overview 34304 (2015) Catchment-based intake and assessment guide (2015) 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304, 34305 Child Wellbeing and Safety Act 2005 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304, 34305 Children, Youth and Families Act 2005 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304, 34305 Clinical treatment guidelines for alcohol and drug 34003, 34004, 34006, 34009, 34021, 34040, 34041, clinicians: co-occurring acquired brain injury/cognitive 34042, 34044, 34045, 34046, 34047, 34048, 34049, impairment and alcohol and drug use disorders 34050, 34053, 34056, 34057, 34060, 34061, 34062, National comorbidity guidelines 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304, 34305

Standards and guidelines description Activity name Clinical treatment guidelines for methamphetamine 34003, 34004, 34006, 34009, 34021, 34040, 34041, dependence and treatment 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Code of practice for running safer music festivals and 34004 events Cultural diversity guide 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 COATS, Community Correctional Services and Drug 34003, 34004, 34006, 34009, 34021, 34040, 34041, Treatment Services protocol 34042, 34044, 34045, 34046, 34047, 34048, 34049, Drug treatment organisations receiving government 34050, 34053, 34056, 34057, 34060, 34061, 34062, funding are required to accept referrals from COATS in a 34064, 34066, 34069, 34070, 34071, 34078, 34079, timely manner and provide drug treatment services to 34080, 34082, 34084, 34200, 34202, 34203, 34204, forensic clients 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Drugs, Poisons and Controlled Substances Act 1981 34061, 34070 (Victoria), reprint no. 6 Act No 9719 1981 Incident reporting instruction (May 2013) 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Interagency protocol between Victoria Police and 34003, 34004, 34006, 34009, 34021, 34040, 34041, nominated agencies 34042, 34044, 34045, 34046, 34047, 34048, 34049, Drugs Poisons and Controlled Substances (Volatile 34050, 34053, 34056, 34057, 34060, 34061, 34062, Substances) Act 2003 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Management response to inhalant use: guidelines for 34003, 34004, 34006, 34009, 34021, 34040, 34041, the community care and drug and alcohol sector (2005) 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Victorian Alcohol and Other Drug Treatment Principles 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Victorian AOD client charter 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304

Standards and guidelines description Activity name Victorian policy for maintenance pharmacotherapy for 34047, 34057 opioid dependence (2013) National guidelines for medication-assisted treatment of opioid dependence (2014) Third national hepatitis C strategy 2010–2013 34070 National hepatitis B strategy 2010–2013 Sixth national HIV strategy 2010–2013 34070 Second national sexually transmissible infections strategy, 2010–2013 Third National Aboriginal and Torres Strait Islander blood borne viruses and sexually transmissible infections strategy 2010–2013 National needle and syringe programs strategic 34070 framework 2010–2014 National amphetamine-type stimulant (ATS) strategy 34070 2008–2011 Protocol between drug treatment services and Child 34003, 34004, 34006, 34009, 34021, 34040, 34041, Protection for working with parents with alcohol and drug 34042, 34044, 34045, 34046, 34047, 34048, 34049, issues 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Service specification for the delivery of selected non- 34300, 34301, 34302, 34303, 34304 residential alcohol and drug treatment services in Victoria Severe Substance Dependence Treatment Act 2010 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Shaping the future: the Victorian alcohol and other drug 34003, 34004, 34006, 34009, 34021, 34040, 34041, quality framework, April 2008 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 SHPA standards of practice for Australian poisons 34003 information centres Victoria’s alcohol and drug treatment services: the 34003, 34004, 34006, 34009, 34021, 34040, 34041, framework for service delivery, Department of Human 34042, 34044, 34045, 34046, 34047, 34048, 34049, Services, 1997 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304 Victorian needle and syringe programs operating policy 34070 and guidelines, Department of Health (revised Nov 2008)

Standards and guidelines description Activity name Working with Children Act 2005 34003, 34004, 34006, 34009, 34021, 34040, 34041, 34042, 34044, 34045, 34046, 34047, 34048, 34049, 34050, 34053, 34056, 34057, 34060, 34061, 34062, 34064, 34066, 34069, 34070, 34071, 34078, 34079, 34080, 34082, 34084, 34200, 34202, 34203, 34204, 34205, 34206, 34207, 34209, 34211, 34212, 34213, 34214, 34300, 34301, 34302, 34303, 34304

Table 4.22: Ageing, aged and home care service standards and guidelines

Activity no. Activity name Service standards and guidelines description 13004 Aged Care Assessment Aged Care Act 1997, as amended – Projects 13004 Aged Care Assessment Aged Care Client Record user guide, July 2014 – Projects 13004 Aged Care Assessment Aged Care Assessment Programme national training strategy, – Projects January 2012 13004 Aged Care Assessment Aged Care Assessment Programme financial guidelines, – Projects November 2004 (Commonwealth Department of Health and Ageing) 13004 Aged Care Assessment Aged Care Act 1997, as amended – Projects 13005 Aged Care Assessment Aged Care Assessment Programme guidelines, January 2014 13005 Aged Care Assessment Aged Care Act 1997, as amended 13005 Aged Care Assessment Aged Care Assessment Programme financial guidelines, November 2004 (Commonwealth Department of Health and Ageing) 13005 Aged Care Assessment Aged Care Client Record user guide, July 2014 13005 Aged Care Assessment Aged Care Assessment Programme national training strategy, January 2012 13005 Aged Care Assessment Branding and due recognition policy, May 2007 (Commonwealth Department of Health and Ageing) 13005 Aged Care Assessment Guidelines for streamlining pathways between Aged Care Assessment Services and Home and Community Care Assessment Services, 2009 13005 Aged Care Assessment Aged Care Assessment Services protocol: younger people with a disability, 2009 (Department of Human Services, Disability Services) 13005 Aged Care Assessment Protocol Between Aged Care Assessment Services and the Office of the Public Advocate, 2011 13005 Aged Care Assessment Protocol between Victorian Aged Care Assessment services and Aged Persons Mental Health, 2008 (Department of Human Services) 13005 Aged Care Assessment Strengthening access to Aged Care Assessment Services for Aboriginal consumers 13015 HACC Linkages Victorian HACC program manual Packages 13019 Personal Alert Victoria Personal Alert Victoria program and service guidelines Personal Alert Victoria response service guidelines

13023 HACC Service Victorian HACC program manual Development

Activity no. Activity name Service standards and guidelines description 13024 HACC Assessment Victorian HACC program manual 13026 HACC Domestic Victorian HACC program manual Assistance 13027 HACC Respite Victorian HACC program manual 13031 Public Sector Residential Aged Care Act 1997, as amended Aged Care Supplement Guideline to aged care law (see ) 13035 Support for Carers Carers Recognition Act 2012 A Victorian charter supporting people in care relationships and information kit Program guidelines – Support for Carers Program Victorian HACC program manual 13038 HACC Service System Victorian HACC program manual Resourcing SRS Service Coordination and Support Program service activity report, guidelines and pro forma 13043 HACC Flexible Service Community Connection Program quality standards framework Response and data collection guidelines, 2001 Victorian HACC program manual SRS Service Coordination and Support Program service activity report, guidelines and pro forma 13053 Victorian Eye Service Victorian Eye Service program guidelines, 2015 (interim) 13056 HACC Planned Activity Victorian HACC program manual Group – Core 13057 HACC Planned Activity Victorian HACC program manual Group – High 13059 Residential Aged Care Aged Care Act 1997, as amended Complex Care Supplement 13063 HACC Volunteer Victorian HACC program manual Coordination 3082 Low Cost Community Connection Program quality standards framework Accommodation Support and data collection guidelines, 2001 Flexible Care Fund guidelines for the Older Persons High Rise Support Program, August 2002 Older Persons High Rise Support Program submission guidelines, 2001 Housing Support for the Aged Program submission guidelines, 2000 SRS Oral Health initiative service model specifications, 2011 13096 HACC Allied Health Victorian HACC program manual 13097 HACC Delivered Meals Victorian HACC program manual 13099 HACC Property Victorian HACC program manual Maintenance 13107 Rural Small High Care Aged Care Act 1997, as amended Supplement 13109 Aged Care Assessment Aged Care Assessment Programme guidelines, January 2014 Service Evaluation Unit 13109 Aged Care Assessment Aged Care Act 1997, as amended Service Evaluation Unit

Activity no. Activity name Service standards and guidelines description 13109 Aged Care Assessment Aged Care Assessment Programme financial guidelines, Service Evaluation Unit November 2004 (Commonwealth Department of Health and Ageing) 13109 Aged Care Assessment Aged Care Client Record user guide, July 2014 Service Evaluation Unit 13109 Aged Care Assessment National Transaction File Format version 5.1 and 5.2 Service Evaluation Unit 13109 Aged Care Assessment Aged Care Assessment Programme national training strategy, Service Evaluation Unit January 2012 13109 Aged Care Assessment Branding and due recognition policy, May 2007 (Commonwealth Service Evaluation Unit Department of Health and Ageing) 13109 Aged Care Assessment Aged Care Assessment Services protocol: younger people with a Service Evaluation Unit disability, 2009 (Disability Services , Department of Human Services) 13109 Aged Care Assessment Protocol between Aged Care Assessment Services and the Service Evaluation Unit Office of the Public Advocate, 2011 13109 Aged Care Assessment Protocol between Victorian Aged Care Assessment Services and Service Evaluation Unit Aged Persons Mental Health, 2008 (Department of Human Services) 13109 Aged Care Assessment Transition Care training handbook for Aged Care Assessment Service Evaluation Unit Teams, 2006 (Commonwealth Department of Health and Ageing) 13109 Aged Care Assessment Strengthening access to Aged Care Assessment Services for Service Evaluation Unit Aboriginal consumers 13130 HACC Volunteer Victorian HACC program manual Coordination – Other 13131 RDNS HACC Allied Victorian HACC program manual Health 13155 Dementia Services Carers Recognition Act 2012 Program guidelines: Support for carers of people with dementia including younger people with dementia guidelines (updated 2013) Support and Links Service program statement 13156 Seniors Health Victorian HACC program manual Promotion Older Persons High Rise Support Program guidelines 13210 ACAS Training and Aged Care Assessment Programme national training strategy, Development January 2012 13223 HACC Nursing Victorian HACC program manual 13224 Department of Veterans’ Victorian HACC program manual Affairs HACC 13226 HACC Personal Care Aged Care Act 1997 (as amended) 13227 Aboriginal Community- Victorian HACC program manual Controlled Organisations Services – Aged and Home Care 13229 HACC Access and Victorian HACC program manual Support 13301 Aged Quality Aged Care Act 1997, as amended Improvement Guideline to aged care law (see )

Activity no. Activity name Service standards and guidelines description 13302 Supporting SRS supporting accommodation for vulnerable Victorians Accommodation for guidelines, 2012 Vulnerable Victorians Initiative 13303 SAVVI Supporting SRS supporting accommodation for vulnerable Victorians Connections guidelines, 2012 SAVVI Supporting Connections flexible funds guidelines, 2010 SAVVI Supporting Connections services specifications, 2008 13352 Victorian Seniors Victorian Seniors Festival Community Grants Program guidelines Festival 13354 Elder Abuse Prevention Contract guidelines and schedules and Response 13355 Seniors Community Funded program guidelines Programs 13356 Information and Lifelong Funded program guidelines Learning 13303 SAVVI Supporting SRS supporting accommodation for vulnerable Victorians Connections guidelines, 2012 SAVVI Supporting Connections flexible funds guidelines, 2010 SAVVI Supporting Connections services specifications, 2008

Table 4.23: Public health service standards and guidelines

Service standards and guidelines description Activity no. Community Health Integrated Health Promotion Program: Planning Guidelines 16454 2013–17 Community Health and Women’s Health Integrated Health Promotion: Reporting 16454 Guidelines 2013–17 Guide to Municipal Public Health and Wellbeing Planning, 2013 (including the 16454 Environments for Health Framework) Healthy Together Victoria: Standards and Guidelines 16462 BBV/STI Program Guidelines for Funded Agencies (current edition) 16373 16377 16505 16506 16507 16508 16509

Table 4.24: Primary, community and dental health service standards and guidelines

Activity name Activity no. Service standards and guidelines description Dental health 27010 National Safety and Quality Health Service (NSQHS) Standards 27011 (https://www2.health.vic.gov.au/primary-and-community- health/dental-health) 27017 27019 27020 27023 27024 27025 27026 27028 27029 Community health 28033 Community health integrated program guidelines: Direction for 28043 the community health program (www.health.vic.gov.au/pch) 28069 Victorian Aboriginal affairs framework (VAAF) standards ( www.healt h.vic.gov.au/pch/commhealth) 28074 28080 28084 28085 28086 Maternal health 28080 Community health integrated program guidelines: Direction for 28085 the community health program (www.health.vic.gov.au/pch) 28086 Healthy Mothers, Healthy Babies Program (www.health.vic.gov.au/pch/cyf/mothers_babies.htm) Child health 28082 Child health services: Guidelines for the community health 28085 program 28086 Child health teams (www.health.vic.gov.au/pch/cyf/child_health_teams.htm) Young people 28021 Community health integrated program guidelines: Direction for 28066 the community health program (www.health.vic.gov.au/pch) 28085 Child, youth and family health ( www.health.vic.gov.au/pch/cyf ) 28086 Innovative Health Services for Homeless Youth (IHSHY) ( www.health.vic.gov.au/pch/cyf/ihshy .htm) Women’s health 28015 Women’s health (www.health.vic.gov.au/vwhp) 28016 Health promotion (www.health.vic.gov.au/healthpromotion) 28018 28050 28063 28064 28068 28067 28085 28086 Aboriginal health 28071 Community health integrated program guidelines: Direction for 28085 the community health program ( www.health.vic.gov.au/pch ) 28086 Various other publications (www.health.vic.gov.au/aboriginalhealth/publications)

Activity name Activity no. Service standards and guidelines description People with chronic 28072 Community health integrated program guidelines: Direction for disease 28074 the community health program (www.health.vic.gov.au/pch) 28081 Early intervention in chronic disease (www.health.vic.gov.au/pch/icdm/early_intervention) 28085 Integrated chronic disease management 28086 (www.health.vic.gov.au/pch/icdm) Culturally diverse 28048 Community health integrated program guidelines: Direction for groups 28076 the community health program (www.health.vic.gov.au/pch) 28085 Refugee and asylum seeker health services: Guidelines for the community health program 28086 Victorian Aboriginal affairs framework (VAAF) standards Cultural responsiveness framework: guidelines for Victorian health services (2009) (Note: A summative evaluation of Doing it with us not for us and the Cultural responsiveness framework has been completed and a new participation and equity policy will be developed over 2015 and include a program of work to support its implementation). Refugee health ( www.health.vic.gov.au/pch/refugee) Guidelines for the Refugee Health Nurse Program, 2008 Health Translations (www.healthtranslations.vic.gov.au) Partnerships and 28054 Primary Care Partnerships (PCPs) (www.health.vic.gov.au/pcps) system support 28087 PCP 2013–2017 planning and reporting requirements (www.health.vic.gov.au/pcps/about/prr) Service coordination (www.health.vic.gov.au/pcps/coordination) General practice and private providers (www.health.vic.gov.au/pch/gpp) Working with general practice: position statement and resource guide (www.health.vic.gov.au/pch/gpp/working/position_resource) Integrated health promotion (www.health.vic.gov.au/pcps/hp) Notes: .1 Organisations that receive funds associated with activity 28085 and 28086 should note that these funds can be applied flexibly across the broad range of programs and initiatives to meet the needs of the local community.

List of tables

Table 4.1: Enterprise bargaining agreements to be negotiated in 2016–17...... 328 Table 4.2: Victorian Emergency Minimum Dataset timelines...... 336 Table 4.3: Elective Surgery Information System timelines...... 337 Table 4.4: Victorian Integrated Non-Admitted Health timelines...... 340 Table 4.5: Telehealth in emergency department timelines...... 345 Table 4.6: Expected minimum number of ICU equivalent beds for relevant health services...... 349 Table 4.7: Victorian Ambulance Data Set timelines...... 354 Table 4.8: Existing ambulance data collections...... 354 Table 4.9: CMI/ODS reporting timelines...... 355 Table 4.10: Mental Health Establishments National Minimum Dataset reporting timelines...... 356 Table 4.11: Ageing, aged and home care data collection and reporting requirements...... 359 Table 4.12: Primary and dental health data collection and reporting requirements...... 363 Table 4.13: Public health data collection and reporting requirements...... 364 Table 4.14: Training and development grants – reporting timetable...... 366 Table 4.15: Ageing, aged and home care performance targets and monitoring...... 368 Table 4.16: Ambulance Victoria performance targets and monitoring...... 373 Table 4.17: Mental health service performance indicators...... 375 Table 4.18: Primary and dental health performance targets and monitoring...... 376 Table 4.19: Public health performance targets and monitoring...... 377 Table 4.20: Small rural health services – service standards and guidelines...... 380 Table 4.21: Drug services – service standards and guidelines...... 381 Table 4.22: Ageing, aged and home care service standards and guidelines...... 384 Table 4.23: Public health service standards and guidelines...... 387 Table 4.24: Primary, community and dental health service standards and guidelines...... 388

Volume 2: Health operations 2016–17, Chapter 4 List of tables Conditions of funding

Acronyms and abbreviations

A&EP Aids and Equipment Program AAPL Automatically Admitted Procedure List ABF activity-based funding ABN Australian Business Number ACAS aged care assessment service ACHA Assistance with Care and Housing for the Aged ACHI Australian Classification of Health Interventions ACS Australian Coding Standard ACSQHC Australian Commission on Safety and Quality in Health Care ADA Australian Dental Association ADIS Alcohol and Drugs Information System AIDS acquired immune deficiency syndrome AIMS Agency Information Management System ALOS average length of stay AN-SNAP Australian National Subacute and Non-Acute Patient ANZICS Australian and New Zealand Intensive Care Society AOD Alcohol and other drugs AQL acceptable quality level AR-DRG Australian Refined Diagnosis Related Groups ASD atrial septal defect BBV blood borne virus BPCLE Best practice clinical learning environments BPD Better Patient Dataset BPT Basic physician training CCCS Community Care Common Standards CCOPMM Consultative Council on Obstetric and Paediatric Mortality and Morbidity CDBS Child Dental Benefits Schedule CEO chief executive officer CHO chief health officer CKD Chronic kidney pathway CLABSI central line associated blood stream infection CMBS Commonwealth Medicare Benefit Scheme CMI Client Management Interface CMI/ODS Client Management Interface/Operational Data Store CORE Centre for Outcome and Resource Evaluation CPC Community Palliative Care CSO community service organisation CTN clinical training networks DEECD Department of Education and Early Childhood Development DET Department of Education and Training DFI Dr Foster Intelligence

Acronyms and abbreviations Volume 2: Health operations 2016–17, Chapter 4 Conditions of funding

DHHS Department of Health and Human Services DRG diagnosis-related group DTC day therapy centres DuV dental unit of value DTAU drug treatment activity unit EBA enterprise bargaining agreement ECDS Electronic Communications Devices Scheme ECT electroconvulsive therapy EMR electronic medical record ED emergency department eMAP Electronic Management and Assistance for Primary Care ESIS Elective Surgery Information System F1 financial data FARREP Family and Reproductive Rights Education Program FIM Functional Independence Measure FOBT faecal occult blood test FTE full-time equivalent GEM geriatric evaluation and management GST goods and services tax HACC Home and Community Care HAI healthcare-associated infections HARP Hospital Admission Risk Program HDSS Health Data Standards and Systems HEN Home Enteral Nutrition HIP Health Independence Program HIRC Health Innovation and Reform Council HITH Hospital in the Home HIV human immunodeficiency virus HPI-I healthcare provider identifiers individual clinicians HPI-O healthcare provider identifiers for organisations HPV Health Purchasing Victoria HSMR hospital standardised mortality ratios ICS Integrated Cancer Services ICT information and communications technology ICU intensive care unit IHCS Integrated Hepatitis C Service IHI individual healthcare identifiers IHPA Independent Hospital Pricing Authority ISCP Individualised Client Support Packages IHSHY Innovative Health Services for Homeless Youth i-SNAC Interim Subacute and Non-Acute Classification KMS Koori Maternity Services LGBTI Lesbian, Gay, Bisexual, Transgender and Intersex LOP length of phase

Volume 2: Health operations 2016–17, Chapter 4 Acronyms and abbreviations Conditions of funding

LOS length of stay MDS Hospital Minimum Payroll and Workforce Employee Dataset MHCC Mental Health Complaints Commissioner MHCSS mental health community support services MHT Mental Health Tribunal MICA Mobile Intensive Care Ambulance MOU memorandum of understanding MPS multi-purpose service MSS Membership Subscription Scheme MYEFO Mid-Year Economic and Fiscal Outlook NAESG Non-Admitted Emergency Services Grant NAQAL Not Automatically Qualified for Admission List NATA National Association of Testing Authorities NBCSP National Bowel Cancer Screening Program NDIS National Disability Insurance Scheme NDSS National Diabetes Syringe Scheme NEAT National Emergency Access Target NEC national efficient cost NEHTA National E-Health Transition Authority NEP national efficient price NEPT Non-emergency patient transport NETS Newborn Emergency Transfer Service NFC Nationally Funded Centres NGO non-government organisation NHIPPC National Health Information and Performance Principal Committee NHRA National Health Reform Agreement NHS National Health Service (United Kingdom) NHT nursing home type NPA national partnership agreement NRCP National Respite for Carers Program NSAP National Standards for Providing Quality Palliative Care NSPs Needle and syringe program NSQHS National Safety and Quality Health Service ODS Operational Data Store NWAU national weighted activity unit OCIO Office of the Chief Information Officer OCP Optimal Care Pathways OHS occupational health and safety OHSC Office of the Health Services Commissioner PAC post-acute care OIS operational infrastructure support PARC prevention and recovery care PAS performance assessment score PCEHR Personally Controlled Electronic Health Record

Acronyms and abbreviations Volume 2: Health operations 2016–17, Chapter 4 Conditions of funding

PCP Primary Care Partnership PDI The Peter Doherty Institute for Infection and Immunity PDRSS Psychiatric Disability Rehabilitation and Support Services PRISM Program Report for Integrated Service Monitoring PSRACS public sector residential aged care service PTC patient treatment coordinator QDC Quarterly Data Collection RACS Royal Australasian College of Surgeons REACH Retrieval and Critical Health ROSH risk of significant harm RRI Reducing Restrictive Interventions RRP risk-rated premium RUG ADL Resource Utilisation Group – Activity of Daily Living SAMS Service Agreement Management System SAVVI Supporting Accommodation for Vulnerable Victorians Initiative SCTT service coordination tools template SHERP State health emergency response plan SIDS Sudden infant death syndrome SOII Surgical Outcomes Information Initiative SoP Statement of Priorities SRHS small rural health service SRS supported residential service STEMI ST Elevation Myocardial Infarction STI sexually transmissible infections SWEP Statewide Equipment Program T&D training and development TAC Transport Accident Commission TB tuberculosis TCP Transition Care Program TPN total parenteral nutrition VADS Victorian Ambulance Data Set VAED Victorian Admitted Episodes Dataset VAGO Victorian Auditor-General’s Office VALP Victorian Artificial Limb Program VASM Victorian Audit of Surgical Mortality VCCAMM Victorian Consultative Council on Anaesthetic Mortality and Morbidity VCCN Victorian Cardiac Clinical Network VCDC Victorian Cost Data Collection VCOR Victorian Cardiac Outcomes Registry VCTC Victorian Clinical Training Council VEMD Victorian Emergency Minimum Dataset VFPMS Victorian Forensic Paediatric Medical Services VGPB Victorian Government Purchasing Board VHES Victorian Healthcare Experience Survey

Volume 2: Health operations 2016–17, Chapter 4 Acronyms and abbreviations Conditions of funding

VHIA Victorian Hospitals Industrial Association VHIMS Victorian Health Incident Management System VIC-DRG Victorian-modified Diagnosis Related Group VICNISS Victorian Healthcare Associated Infection Surveillance System ViCTOR Victorian Children’s Tool for Observation and Response VIFMH Victorian Institute of Forensic Mental Health VINAH Victorian Integrated Non-Admitted Health VMIA Victorian Managed Insurance Authority VMNCN Victorian Maternity and Newborn Clinical Network VPCN Victorian Paediatric Clinical Network VPCS Victorian Product Catalogue System VPDC Victorian Perinatal Data Collection VPRS Victorian Paediatric Rehabilitation Service VPTP Victorian Paediatric Training Program VRMDS Victorian Radiotherapy Minimum Dataset VRSS Victorian Respiratory Support Service VSCC Victorian Surgical Consultative Council VWA Victorian WorkCover Authority WAU weighted activity unit WBD weighted bed day WIES weighted inlier equivalent separation WOt weighted occupancy target

Acronyms and abbreviations Volume 2: Health operations 2016–17, Chapter 4