Report Template

Activity Based Funding / Management Performance Management Report

Performance Indicator Definitions Manual (Health Service Measures) 2014-2015

Version 1.2 22 October 2014

improving care | managing resources | delivering quality

© Department of Health, State of Western Australia (2014). Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (C’wth Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Resourcing and Performance Division, Western Australian Department of Health. The Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health when reproducing or quoting material from this source.

Important Disclaimer: All information and content in this Material is provided in good faith by the WA Department of Health, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use.

Table of Contents

ACKNOWLEDGMENTS ...... I ACRONYMS ...... II 1. INTRODUCTION ...... 1 2. DATA DEFINITIONS ...... 9 2.1 EFFECTIVENESS ACCESS (EA) PIS ...... 9 EA7: PERCENTAGE OF ED MENTAL HEALTH PATIENTS ADMITTED WITHIN 8 HOURS ...... 10 EA8: THEATRE ACTIVITY ...... 15 EA10: ACCESS BLOCK ...... 21 EA11: ADMISSIONS FROM ED ...... 25 EA12: PERCENTAGE OF SJAA PATIENTS WITH OFF STRETCHER TIME WITHIN 20 MINUTES ...... 28 2.2 EFFECTIVENESS APPROPRIATENESS (EAP) PIS ...... 32 EAP2: ADULT IMMUNISATION: PERCENTAGE OF PEOPLE AGED 65 YEARS AND OVER IMMUNIZED AGAINST INFLUENZA 33 EAP3.A: OBESITY: PERCENTAGE OF POPULATION WHO ARE OVERWEIGHT OF OBESE: A) ADULTS...... 36 EAP3.B: OBESITY: PERCENTAGE OF POPULATION WHO ARE OVERWEIGHT OF OBESE B) CHILDREN ...... 39 EAP4: TOBACCO: PERCENTAGE OF ADULTS WHO ARE CURRENT SMOKERS ...... 42 2.3 EFFECTIVENESS QUALITY (EQ) PIS ...... 45 EQ2: PERCENTAGE OF EMERGENCY DEPARTMENT ATTENDANCES WHICH ARE UNPLANNED RE-ATTENDANCES IN LESS THAN OR EQUAL TO 48 HOURS OF PREVIOUS ATTENDANCE...... 46 EQ4: RATE OF SEVERITY ASSESSMENT CODE (SAC) 1 CLINICAL INCIDENT INVESTIGATION REPORTS RECEIVED BY PATIENT SAFETY SURVEILLANCE UNIT (PSSU) WITHIN 45 WORKING DAYS OF THE EVENT NOTIFICATION DATE ...... 49 EQ6: HOSPITAL ACCREDITATION ...... 52 EQ9.A-G: UNPLANNED HOSPITAL READMISSIONS OF PATIENTS DISCHARGED FOLLOWING MANAGEMENT OF A) KNEE REPLACEMENT, B) HIP REPLACEMENT, C) TONSILLECTOMY & ADENOIDECTOMY, D) HYSTERECTOMY, E) PROSTATECTOMY, F) CATARACT SURGERY, AND G) APPENDICECTOMY ...... 54 EQ12: RATE OF COMMUNITY FOLLOW UP WITHIN FIRST 7 DAYS OF DISCHARGE FROM PSYCHIATRIC ADMISSION ...... 79 EQ13: MEASURES OF PATIENT EXPERIENCE (INCLUDING SATISFACTION) WITH HOSPITAL SERVICES ...... 83 EQ14: HAND HYGIENE COMPLIANCE ...... 87 2.4 EFFICIENCY INPUTS PER OUTPUT UNIT (EI) KPIS ...... 91 EI2: ELECTIVE SURGERY DAY OF SURGERY ADMISSION RATES ...... 92 EI4: YTD DISTANCE OF EXPENDITURE TO BUDGET ...... 96 EI5: YTD DISTANCE OF OWN SOURCED REVENUE TO BUDGET ...... 99 EI7: SCHOOL DENTAL SERVICE RATIO OF EXAMINATIONS TO ENROLMENTS ...... 102 EI9: NUMBER OF SEPARATIONS (UNWEIGHTED): TOTAL ESTIMATED UNWEIGHTED INPATIENT ACTIVITY (EXCLUDING LSMH) ...... 104 EI10: CODED ACUTE MULTIDAY AVERAGE LENGTH OF STAY ...... 112 EI11: YTD DISTANCE OF SALARIES EXPENDITURE TO BUDGET ...... 115 2.5 EQUITY ACCESS (EQA) KPIS ...... 116 EQA2.A&B: STANDARDISED RATE RATIO OF HOSPITALISATIONS OF A) ABORIGINAL PEOPLE COMPARED TO NON- ABORIGINAL PEOPLE B) ABORIGINAL CHILDREN (0-4 YEARS) COMPARED TO NON-ABORIGINAL CHILDREN (0-4 YEARS) 117

EQA3.A&B: CHILDHOOD IMMUNISATION: PERCENTAGE OF CHILDREN FULLY IMMUNISED AT 12-15 MONTHS: A) ABORIGINAL B) TOTAL ...... 120 EQA5: WA HEALTH ABORIGINAL EMPLOYMENT HEADCOUNT ...... 122 2.6 SUSTAINABILITY WORKFORCE (SW) KPIS...... 126 SW1: PROPORTION OF MEDICAL GRADUATES AND OTHER CATEGORIES OF MEDICAL STAFF TO TOTAL MEDICAL STAFF 127 SW2: PROPORTION OF NURSING GRADUATES AND OTHER CATEGORIES OF NURSING STAFF TO TOTAL NURSING STAFF ...... 135 SW4.A: INJURY MANAGEMENT A) LOST TIME INJURY SEVERITY RATE ...... 141 SW4.B: INJURY MANAGEMENT B) PERCENTAGE OF MANAGERS AND SUPERVISORS TRAINED IN OCCUPATIONAL SAFETY AND HEALTH (OSH) AND INJURY MANAGEMENT RESPONSIBILITIES ...... 143 SW5: LEAVE LIABILITY ...... 146 SW6.A: ACTUAL AND BUDGET FTE: AVERAGE MONTHLY TOTAL FULL TIME EQUIVALENTS ...... 150 SW6.B: ACTUAL AND BUDGET FTE: AVERAGE MONTHLY BUDGET FULL TIME EQUIVALENTS ...... 154 2.7 PROCESSES CODING (PC) KPIS ...... 158 PC1: PERCENTAGE OF CASES CODED BY END OF MONTH CLOSING DATE ...... 159 PC3: CLINICAL INFORMATION AUDIT PROGRAM MEASURE OF DRG ACCURACY ...... 163 2.8 PROCESSES FINANCE (PF) KPIS ...... 166 PF1: PATIENT FEE DEBTORS...... 167 PF4: NURSEWEST SHIFTS FILLED ...... 170 PF5: ACCOUNTS PAYABLE – PAYMENT WITHIN TERMS ...... 172

Acknowledgments

The production of the report would not have been possible without the support of the key stakeholders and data providers from the Department of Health. Their advice and provision of information is greatly appreciated.

Acknowledgement is also extended to key staff within the Performance Reporting Branch and Information Development and Management Branch, Resourcing and Performance Division.

Acronyms AAR Age Adjusted Rate ABF Activity Based Funding ABF/M Activity Based Funding/Management ABM Activity Based Management ABS Australian Bureau of Statistics ACEM Australasian College of Emergency Medicine ACHS Australian Council on Health Standards ACIR Australian Childhood Immunisation Register AIHW Australian Institute of Health and Welfare ATSI Aboriginal Torres Strait Islander BMI Body Mass Index CAHS Child and Adolescent Health Service CEO Chief Executive Officer COAG Council of Australian Governments DOH Department of Health DOHA Department of Health and Ageing DOSA Day of Surgery Admission DRG Diagnosis Related Group ED Emergency Department EDDC Emergency Department Data Collection EDIS Emergency Department Information System ESWL Elective Surgery Waiting List eWAU emergency department Weighted Activity Unit FTE Full Time Equivalent GL General Ledger HIN Health Information Network HMDC Hospital Morbidity Data Collections HMDS Hospital Morbidity Data System HR Human Resources HS Health Service HSMR Hospital Standardised Mortality Ratio HWSS Health and Wellbeing Surveillance ICD International Classification of Diseases IDM Information Development and Management Branch iWAU inpatient Weighted Activity Schedule JHC Joondalup Health Campus KPIs Key Performance Indicators MRSA Methicillin Resistant Staphylococcus Aureus NHDD National Health Data Dictionary NMHS North Metropolitan Health Service OP Operational Plan OSH Occupational Safety and Health OSQH Office of Safety and Quality in Health Care OSR Own Sourced Revenue PHC Peel Health Campus PMF Performance Management Framework PRB Performance Reporting Branch SJAA St John Ambulance Australia SA2 Statistical Area 2 SLA Statistical Local Area SMHS South Metropolitan Health Service SMR Standardised Mortality Ratio TOOCS Type of Occurrence Classification System WACHS WA Country Health Service WLDC Wait List Data Collections YTD Year to Date

1. Introduction

The purpose of this manual is to provide consistent and clear definitions for the Performance Indicators (PIs) detailed in the Activity Based Funding and Management Performance Management Framework 2014-15 (PMF) to enable users to report and interpret on the results of the reporting entities. Any changes to the definitions will be in accordance with the “Guidelines for Creating and Changing State-wide Reporting Definitions” document (Information Circular 0087/11).

The PIs cover all domains of performance and include Outcome Measures (KPIs) and Health Service Measures. This document contains Health Service Measures only and should be read in conjunction with the Performance Indicators Definitions Manual (Outcome Measures) document. The selected PIs are aligned to all 4 pillars noted in the WA Health Strategic Intent 2010-2015. An extract of the PIs schedule from 2014-15 PMF is provided in Table 1.

Table 1: Schedule of KPIs and Reporting Frequency 2014-15

Key: * Proposed PAF indicator developed as the same indicator title or a WA Health equivalent measure ^ National core hospital-level outcome indicators recommended by the ACSQHC developed as the same indicator or a WA Health equivalent measure new! Indicator is new to PMF 2014-15 changed! Indicator title, reporting level and/or reporting frequency changed from PMF 2013-14 to PMF 2014-15 deferred! Indicator deferred until 2015-16

ABF/ABM Framework Domain DOH PERFORMANCE MANAGEMENT MEASURES REPORTING REPORTING Domain Dimension Code LEVEL FREQUENCY OUTCOME MEASURE EA1 * Proportion of emergency department patients seen within Facility Monthly recommended times a) % Triage Category 1 - 2 minutes b) % Triage Category 2 - 10 minutes c) % Triage Category 3 - 30 minutes d) % Triage Category 4 - 60 minutes e) % Triage Category 5 - 2 hours

EA2 * NEAT % of ED Attendances with LOE <=4 hours Facility Monthly EA3 Average overdue wait time of elective surgery cases waiting beyond Facility Monthly the clinically recommended time, by urgency category EFFECTIVENESS Access a) beyond 30 days for urgency category 1 b) beyond 90 days for urgency category 2 c) beyond 365 days for urgency category 3

EA4 * Elective surgery patients treated within boundary times: Facility Monthly a) % Category 1 within 30 days b) % Category 2 within 90 days c) % Category 3 within 365 days

EA5 * Percentage of selected elective cancer surgery cases treated within Facility Quarterly boundary time: a) Bladder Cancer b) Bowel Cancer c) Breast cancer

ABF/ABM Framework Domain DOH PERFORMANCE MANAGEMENT MEASURES REPORTING REPORTING Domain Dimension Code LEVEL FREQUENCY HEALTH SERVICE MEASURE EA7 Percentage of ED Mental Health patients admitted within 8 hrs Facility Monthly EA8 Theatre activity Facility Monthly EA10 Access Block Facility Monthly EA11 Admissions from ED Facility Monthly EA12 Percentage of SJAA patients with Off Stretcher time within 20 minutes Facility Monthly new! OUTCOME MEASURE EAP1 Rate of selected potentially preventable chronic condition Whole of Annually hospitalisations (for specified chronic conditions) population (reported at Health Service level) HEALTH SERVICE MEASURE EAP2 Adult immunisation: percentage of people aged 65 years and over Whole of Annually immunised against Influenza population (reported at Health Service Appropriateness level) EAP3 Obesity: percentage of population who are overweight or obese: Whole of Annually a) Adults population b) Children (reported at Statewide level) EAP4 Tobacco: percentage of adults who are current smokers Whole of Annually population (reported at Statewide level)

ABF/ABM Framework Domain DOH PERFORMANCE MANAGEMENT MEASURES REPORTING REPORTING Domain Dimension Code LEVEL FREQUENCY OUTCOME MEASURE EQ1 Age-adjusted rate (AAR) of avoidable deaths Whole of Annually population (reported at Health Service level) EQ3 *^ Staphylococcus aureus bacteraemia infections per 10,000 patient Facility Annually days EQ5 *^ Hospital standardised mortality ratio Facility Annually

EQ7 *^ Death in low-mortality DRGs Facility Annually

EQ8 *^ In hospital mortality rates (for acute myocardial infarction, stroke, Facility Annually fractured neck of femur & pneumonia)

Quality EQ10 Rate of total hospital readmissions within 28 days to an acute Facility Quarterly designated mental health inpatient unit changed!

HEALTH SERVICE MEASURE EQ2 Percentage of Emergency Department Attendances which are Facility Monthly unplanned re-attendances in less than or equal to 48 hours of previous attendance.

EQ4 Rate of Severity Assessment Code (SAC) 1 clinical incident Health Service Quarterly investigation reports received by Patient Safety Surveillance Unit within 45 working days of the event notification date

EQ6 Hospital accreditation Facility Annually EQ9 *^ Unplanned hospital readmissions of patients discharged following Facility Quarterly management of (knee replacement, hip replacement, tonsillectomy & adenoidectomy, hysterectomy, prostatectomy, cataract surgery and appendicectomy)

ABF/ABM Framework Domain DOH PERFORMANCE MANAGEMENT MEASURES REPORTING REPORTING Domain Dimension Code LEVEL FREQUENCY EQ12 * Rate of community follow up within first 7 days of discharge from Facility Quarterly psychiatric admission

EQ13 * Measures of patient experience (including satisfaction) with hospital Facility Annually services

EQ14 Hand Hygiene Compliance Facility Tri-annually

OUTCOME MEASURE EI1 Volume of weighted activity year-to-date: Facility Monthly a) Inpatients (variance from target) b) ED attendances (variance from target) c) Outpatients (variance from target) EI3 Average cost per test panel for PathWest Statewide Monthly EI6 * YTD distance of net cost of service to budget Health Service Monthly EI8 * Ratio of actual cost of specified public hospital services compared Health Service Annual with the ‘state efficient price’ deferred! HEALTH SERVICE MEASURE Inputs per output EFFICIENCY EI2 * Elective surgery day of surgery admission rates Facility Monthly unit EI4 YTD Distance of Expenditure to Budget Health Service Monthly EI5 YTD Distance of Own Sourced Revenue to Budget Health Service Monthly EI7 School Dental Service ratio of examinations to enrolments Whole of Annually population (reported at Health Service level) EI9 Number of separations (unweighted) Facility Monthly EI10 * Coded acute multiday average length of stay Facility Quarterly EI11 YTD Distance of Salaries Expenditure to Budget deferred! Health Service Monthly

ABF/ABM Framework Domain DOH PERFORMANCE MANAGEMENT MEASURES REPORTING REPORTING Domain Dimension Code LEVEL FREQUENCY OUTCOME MEASURE EQA1 Standardised Mortality Ratio (SMR) of deaths among Aboriginal Whole of Annually children (0-4 years) and non-Aboriginal children (0-4 years) population (reported at Health Service level)

EQA4 Proportion of eligible population receiving dental services from Whole of Quarterly subsidised dental programs by group: population a) Aged 16 years and over (reported at b) Aged 65 years and over Health Service c) Total Aboriginal population level)

HEALTH SERVICE MEASURE EQUITY Access EQA2 Standardised Rate Ratio of Hospitalisations of : Whole of Annually a) Aboriginal People compared to non-Aboriginal People. population b) Aboriginal children (0-4 years) compared to non-Aboriginal (reported at children (0-4 years) Health Service level)

EQA3 Childhood immunisation: percentage of children fully immunised at 12- Whole of Quarterly 15 months: population a) Aboriginal (reported at b) Total Health Service level)

EQA5 WA Health Aboriginal employment headcount Health Monthly Service

OUTCOME MEASURE SW3 Staff turnover Facility Monthly SUSTAINABILITY Workforce

ABF/ABM Framework Domain DOH PERFORMANCE MANAGEMENT MEASURES REPORTING REPORTING Domain Dimension Code LEVEL FREQUENCY HEALTH SERVICE MEASURE SW1 Proportion of medical graduates (and other categories of medical Facility Quarterly staff) to total medical staff a) Interns (graduate) b) Resident Medical Officers c) Registrars d) Consultants e) Other

SW2 Proportion of nursing graduates (and other categories of nursing staff) Facility Quarterly to total nursing staff changed! a) Graduate b) Junior c) Experienced d) Senior e) SRN and above f) Other

SW4 Injury management: Health Service Bi-annually a) Lost time injury severity rate b) Percentage of managers and supervisors trained in occupational safety and health (OSH) and injury management responsibilities

SW5 Leave Liability Facility Monthly SW6 Actual and Budget FTE Health Service Monthly

Facilities &

Equipment

OUTCOME MEASURE changed! PROCESSES Coding PC2 Percentage of cases coded and available for reporting within: Facility Monthly a) 2 weeks b) 4 weeks

ABF/ABM Framework Domain DOH PERFORMANCE MANAGEMENT MEASURES REPORTING REPORTING Domain Dimension Code LEVEL FREQUENCY HEALTH SERVICE MEASURE PC1 Percentage of cases coded by end of month closing date Facility Monthly

PC3 Clinical Information Audit Program measure of DRG accuracy new! Facility Quarterly

OUTCOME MEASURE PF2 Manually corrected payroll errors (underpayments) HCN Service Monthly

PF3 Availability of Information Communication Technology (ICT) services: HIN Service Monthly percentage of Service calls resolved at first point of contact

Finance HEALTH SERVICE MEASURE PF1 Patient fee debtors Health Service Monthly PF4 NurseWest shifts filled Statewide Monthly PF5 Accounts payable – payment within terms HCN Service Monthly

2. Data Definitions 2.1 Effectiveness Access (EA) PIs

There are 10 EA PIs proposed in the 2014-15 PMF, including 5 Health Service measures.

EA7: Percentage of ED Mental Health patients admitted within 8 hours Reported Data Description Items

Identifier MDG-04-076

Name Percentage of Emergency Department Admitted Mental Health Patients With A Length Of Episode Less Than Or Equal To 8 Hours

Aliases Length of Episode (LOE) Admitted, ED Length of Episode (Admitted)

Definition The percentage of Mental Health patients who were admitted from the Emergency Department within 8 hours.

Related Metadata . MDG-04-008 Total Admissions From The Emergency Department . MDG-04-054 Emergency Department Length Of Episode For Admitted Mental Health Patients

Guide for Use Admitted patients are determined from event records in the Emergency Department Data Collection (EDDC) using the [Presentation Date], [Presentation

Time], [Discharge Date], [Discharge Time], [Triage Category], [Visit Type], [Admission Date], [Admission Time], [Episode End Status], [Diagnosis], [Presenting Problem], [Major Diagnostic Category] and [Admitting Consultant] fields.

A patient is admitted when they undergo the formal admission process, whereby the hospital accepts responsibility for the patient's care and/or treatment by completion of the administrative process. The administrative process is completed when a hospital records the commencement of treatment and/or care and/or accommodation of a patient.

A Mental Health attendance is recorded when a patient is given a Mental Health code of a [Diagnosis] or a [Presenting Problem] as follows :–

EDIS sites (i.e. Mental Health Codes include a diagnosis of one of the following ICD-10-AM public codes: any F codes or T39.1, T40.0, T40.1, T40.2, T40.3, T40.4, T40.5, T40.6, metropolitan T40.7, T40.8, T40.9, T42.4, T43.9, T50.9, T51.9, T52.0, T52.9, T56.2, Z00.4, hospitals, Z03.2, Z04.6, Z09.3, Z13.3, Z50.4, Z54.3, Z65.8, Z65.9, Z81.8, Z86.5, Z91.4, Bunbury Hospital Z91.5, or one of the following presenting problem codes: T0000, TC000, TW000, and Joondalup TD000, TE000, TF000, TG000, TGA00, TGB00, TH000, TJ000, TS000, TK000, Health Campus) TM000, TN000, TNA00, TP000.

HCARe sites (i.e. Mental Health attendance at the ED is recorded when a patient is given a [Major WACHS Diagnostic Category] code of 19 (Mental diseases and disorders) or 20 hospitals, (Substance use and substance induced organic mental disorders). excluding Bunbury Hospital) {Length of Episode} for admitted Mental Health patients is determined by [Discharge Date] and [Discharge Time] minus [Presentation Date] and [Presentation Time] with the following exception for those patients admitted to the ED.

{Length of Episode} for Mental Health patients admitted to an Emergency Department observation ward by an ED clinician is determined by [Admission Date] and [Admission Time] minus [Presentation Date] and [Presentation Time]. These patients are identified using the [Admitting Consultant] or [Episode End Status] fields.

The above exception is based on advice from the Health Services that a patient admitted to the Emergency Department by an ED clinician for observation is receiving appropriate care. All other admitted patients in the ED are deemed to be waiting for an inpatient bed.

Limitations Peel Health Campus does not provide [Diagnosis], [Presenting Problem] or [Major Diagnostic Category] codes so it is excluded from Mental Health reporting. Peel Health Campus does not have the capacity to record the fields that identify patients who were admitted for ED observation, so {Length Of Episode} cannot be calculated for Admissions to ED (by ED clinician). It is not always possible to correctly identify Mental Health admissions to observation wards due to varying admitting practices. Until there is standardised work practice this report will be interpreted with an understanding that there will possibly be an over count of Mental Health admissions to observation when they are in fact admitted to the hospital. Due to continuous quality improvement processes historical figures may be subject to change.

Reported Data Validation Items

Format Numeric

NNNNNN

Data Values

Inclusions [Presentation Date] and [Presentation Time] are present.

[Discharge Date] and [Discharge Time] are present.

[Admission Date] and [Admission Time] are present.

[Triage Category] = . Resuscitation (1) . Emergency (2) . Urgent (3) . Semi Urgent (4) . Non-urgent (5).

[Diagnosis] or [Presenting Problem] are in the Mental Health Code list or [Major Diagnostic Category] is equal to 19 or 20.

Exclusions [Presentation Date] and [Presentation Time] are not present.

[Discharge Date] and [Discharge Time] are not present.

[Admission Date] and [Admission Time] are not present.

[Episode End Status] . Dead on Arrival (7).

[Visit Type] = . Dead on Arrival (10) . Direct Admission (6, 7, 8, 16).

[Diagnosis] or [Presenting Problem] are not in the Mental Health Code list or [Major Diagnostic Category] is not equal to 19 or 20.

Scope . Includes Public Metropolitan and WACHS Hospitals with an emergency department/service and Joondalup Health Campus (publicly funded activity). . Excludes Peel Health Campus. . Excludes nursing posts and other non-hospital establishments.

Snapshot reports use 23:59 as the reference period.

Formula Determination of A Mental Health patient is deemed to be admitted to ED by an ED clinician if Admitted to ED by [Admitting Consultant] is TRUE that is: an ED clinician

For EDIS sites:

if the [ADMIT_DR_CODE] = (one of supplied list of codes and prior to 1 April 2008) Or [ADMIT_DR_TYPE] = EDADM.

For HCARe sites:

If [Episode End Status] = 10.

Length of Episode {Length of Episode} (in minutes) for each record is the [Admission Date] and – For patients [Admission Time] minus [Presentation Date] and [Presentation Time]. Admitted to ED by an ED clinician

{Length of Episode} (in minutes) for each record is the [Discharge Date] and Length of Episode [Discharge Time] minus [Presentation Date] and [Presentation Time]. – For all other admitted patients Calculation For records where [Presentation Date] and [Presentation Time] are within the reference period and [Diagnosis] or [Presenting Problem] are in the Mental Health Code list or [Major Diagnostic Category] is equal to 19 or 20 and [Admission Date] and [Admission Time] are present and [Discharge Date] and [Discharge Time] are present and [Triage Category] = 1,2,3,4 or 5, minus [Visit Type] of 6, 7, 8, 10 or 16, minus [Episode End Status] = 7; calculate the {Length of Episode} (in minutes).

Numerator: The count of {Mental Health Admissions} calculated as above where [Presentation Date] and [Presentation Time] are within the reference period, and that have a {Length of Episode} less than or equal to 480 minutes. Denominator: The count of {Mental Health Admissions} calculated as above where [Presentation Date] and [Presentation Time] are within the reference period. Calculation: Numerator divided by denominator, expressed as a percentage.

Verification Rules Value is >/= zero

Data Collection Identification Items

Source Emergency Department Data Collection (EDDC) extract provided by Performance, Activity and Quality is updated every day at 2 am for EDIS and every Tuesday for HCARe and Peel, and on the 3rd working day of the month for TOPAS and JHC Meditech.

Governance Items

Purpose of the To monitor the length of episode for admitted Mental Health patients in the ED. data

Source of the Data Integrity Directorate, Mental Health Commission and Health Services definition

Version number V2.0

Approval date 20101012

EA8: Theatre activity

Reported Data Description Items Identifier MDG-14-001 Name Percentage of used theatre hours to allocated hours in theatre. Aliases Definition The proportion of used theatre hours to total allocated theatre hours, expressed as percentage.

Related None Metadata Guide for Use Theatre activity data is extracted from two separate data files in the Theatre Management System (TMS). For each hospitalthe ‘T_Operation’ file is extracted to determine theatre time used, and the ‘T_Thr_Schedule’ file is extracted to determine allocated theatre time. These two files are linked by schedule ID. schedule ID is a unique value for each scheduled (allocated) session that allows used theatre time of operation(s) to be matched with the scheduled session in which the operation(s) was performed. Used Theatre Time Used theatre time is the time accumulated in each allocated session where at least one operation was performed. Accumulated time in theatre used to perform an operation in an allocated session is the time from when a patient arrived in the operating theatre OR the time from when anaesthesia started with a view to continue with induction (what ever time is recorded earlier), to the time when the patient left the operating theatre. The time a patient arrived in the operating theatre is identified by the date/time value in the [Ope_Arrive_Theatre] field of records in the ‘T_operation’ file in TMS at each hospital. The time anaesthesia started (with a view to continue with induction) is identified by the date/time value in the [Ope_Anae_Strt] field of records in the ‘T_operation’ file in TMS at each hospital. The time the patient left the operating theatre is identified by the date/time value in the [Ope_Theatre_End] field of records in the ‘T_operation’ file in TMS at each hospital. Used theatre time is measured in minutes and converted into hours before the calculation of its proportion to total allocated theatre hours. Operations that are included in the calculation of used theatre time in an allocated session are identified using the [Ope_Status] field in the ‘T_operation’ file. Operation records with one of the following codes in the [Ope_Status] field are included: ‘CM’ (Details Committed), ‘CO’ (Recovery Complete), ‘LT’ (Left Theatre), ‘RE’ (Arrived in Recovery) or ‘RP’ (Awaiting Recovery Pickup). Note: Some operations may have a start time earlier than the scheduled session’s start time (early start) and/or a finish time (patient left operating theatre) later than the scheduled session’s finish time (late finish). The time used to perform an operation that is outside the scheduled session’s start time and scheduled session’s finish time is included in the calculation of used theatre

time. Allocated Theatre Time Allocated theatre time is the time (in hours and minutes) allocated to a session holder. It is defined from the scheduled session’s start time to the scheduled session’s finish time. Allocated theatre time accommodates all theatre activity components, e.g. Arrive theatre time, Anaesthetic start time, Patient ready, Procedure start time, surgical start time, Procedure finish time, Patient leave theatre time, and turnaround time (see note below). Where operations start earlier than the scheduled session’s start time and/or finish later than the scheduled session’s finish time, the used time outside the scheduled session’s start time and scheduled session’s finish time is not included as part of the allocated theatre time. The scheduled session’s start time is identified by the date/time value in the [SCH_STRT_TIMESTAMP] field in records in the ‘T_Thr_Schedule’ file in TMS. The scheduled session’s finish time is identified by the date/time value in the [SCH_END_TIMESTAMP] field in records in the ‘T_Thr_Schedule’ file in TMS. Scheduled sessions that are included in the calculation of allocated theatre time are identified using the [Sch_Sess_Use_Flag] field in the ‘T_Thr_Schedule’ file. Scheduled session records with one of the following codes in the [Sch_Sess_Use_Flag] field are included: ‘CONS’ (Consultants) or ‘REG’ (Registrar). Note: Turnaround time is the time incorporated in the scheduled session when an Operating Theatre is between patients. Turnaround time should be included as part of allocated theatre time for a session if another patient is to follow i.e. the next patient arrives in the operating theatre following the previous patient leaving the operating theatre inclusive of cleaning, change of equipment and setting up for a case. Turnaround time in excess of 45 minutes is not considered part of theatre utilisation. Session allocated time can vary between sites, e.g. ‘AD’ (all day) session at RPH is 0815 -1715 hrs while it is 0830-1730HRS at SCGH. Total used theatre time and total allocated theatre time for a reporting period The calculation for percentage of used theatre time to allocated time is attributed to the reporting period (i.e., calendar month) according to the scheduled session’s start time. To identify the reporting period of the operations performed in each allocated session, records in the ‘T_Thr_Schedule’ file are linked to records in the ‘T_Operation’ file, using the scheduled session’s ID value, a common identifier between the two files. This is the [OPE_SCH_ID] field in the ‘T_Operation’ file and the [SCH_ID] field in the ‘T_Thr_Schedule’ file. The allocated session in the ‘T_Thr_Schedule’ file can correspond to multiple operations in the ‘T_Operation’ file; therefore, this will result in one allocated session record linking with multiple operation records. Used theatre time is determined from all linked records but allocated theatre time is determined from unique allocated session records, i.e., from each unique scheduled session ID. Total used theatre time for a reporting (calendar) month is the sum of

accumulated hours and minutes from all operations in each allocated session where the scheduled session’s start time falls between the start date and end date of the reporting month. Total allocated theatre time for a reporting (calendar) month is the sum of hours and minutes from each unique scheduled session where the scheduled session’s start time falls between the start date and end date of the reporting month. Theatre inclusion Only operations with an operation status code in [Ope_Status] field of ‘CM’, ‘CO’, LT’, ‘RE’ or ‘RP’ that were performed in main theatres of each hospital are included for determining used theatre time. Operations performed outside ‘Main theatre’ areas such as ‘Outlying areas’, minor theatres and special units (e.g. endoscopy, radiology, coronary care, day surgery) are excluded. Note: Theatre Activity that occurs at: - Kaleeya is captured as part of Fremantle Hospital (FH).Kaleeya is indicated by the location code ‘FKAL’ or location description ‘Kaleeya’ and sub-location codes ‘TH1’, ‘TH2’, ‘TH3’, ‘TH4’, ‘TH5’. - Shenton Park Campus is captured as part of Royal Perth Hospital (RP). Shenton Park is identified by the location code ‘THEAS’ or location description ‘Theatre SPC’ and sub-location codes ‘SPC1’, ‘SPC2’, ‘SPC3’. Although Kaleeya and Shenton Park are captured as part of Fremantle Hospital and Royal Perth Hospital (respectively), each site is reported separately. Port Hedland Hospital (PH) is the former name and site of Hedland Health Campus (HH). Port Hedland Hospital closed on 17 November 2010. Theatre sub-location codes for both sites are ‘TH01’, ‘TH02’. Limitations As there is a possibility that inclusion for a scheduled session’s allocated time varies between sites, comparison of this indicator among sites must be taken

with caution.

Reported Data Validation Items Format Numeric 8 NNNNNNNN Data Values Inclusions Numerator (Used theatre time): TMS records in the ‘T_Operation’ file where the code in [Ope_Status] equals one of the following. Code Description ‘CM’ Details Committed ‘CO’ Recovery Completed ‘LT’ Left Theatre ‘RE’ Arrived in Recovery ‘RP’ Awaiting Recovery Pickup

Denominator (Allocated theatre time): TMS records in the ‘T_Thr_Schedule’ file where the code in

[Sch_Sess_Use_Flag] field equals one of the following. Code Description ‘CONS’ Consultant ‘REG’ Registrar Exclusions Numerator (Used theatre time): TMS records in the ‘T_Operation’ file where the code in [Ope_Status] equals one of the following. Code Description ‘AN’ Anaesthesia Started

‘BO’ Booked/Confirmed ‘CA’ Cancelled ‘CH’ On Hold - Cancelled ‘ES’ Emergency Surgery Started ‘HC’ On Hold – Confirmed ‘HR’ On Hold – Requested ‘PA’ Arrived in Suite ‘RQ’ Booking Requested ‘SU’ Surgery Started

Denominator (Allocated theatre time): TMS records in the ‘T_Thr_Schedule’ file where the code in [Sch_Sess_Use_Flag] equals one of the following. Code Description ‘CLOS’ Closed ‘MNT’ Maintenance Scope WA public hospitals that have theatre activity recorded in TMS. Only operations performed in allocated sessions in main theatres of each hospital are included. Main theatres of each hospital are identified by sub-location code or sub-location description. Sub-location codes for main theatres of each hospital in TMS records are identified using the [Ope_Subloc_Code] field in the ‘T_Operation’ file as follows.

Hospital Code Sub-location code

AK (Armadale/Kelmscott) ‘OR1’, ‘OR2’, ‘OR3’, ‘OR4’, ‘OR5’, ‘OR6’, ‘OR7’

AL (Albany Hospital) ‘TH1’, ‘TH2’

BL (Bentley Hospital) ‘RTH1’, ‘RTH2’, ‘TH1’, ‘TH2’

BN (Busselton Hospital) ‘TH1’, ‘TH2’

BR (Broome Hospital) ‘TH1’, ‘TH2’

BY (Bunbury Hospital) ‘THA’, ‘THB’, ‘THC’

CA (Carnarvon) ‘TH-A’, ‘TH-B’

DY (Derby Hospital) ‘TH1’, ‘TH2’

ES (Esperance Hospital) ‘TH01’

FH (Fremantle Hospital) ‘TH01’, ‘TH02’, ‘TH03’, ‘TH04’, ‘TH05’, ‘TH06’, ‘TH07’, ‘TH08’, ‘TH09’, ’TH1’, ‘TH2’, ‘TH3’, ‘TH4’, ‘TH5’

GH (Geraldton Hospital) ‘TH1, ‘TH2’

HH (Hedland Health Campus) ‘TH01’, ‘TH02’

KE (King Edward Memorial Hospital) ‘TH1’, ‘TH2’, ‘TH3’, ‘TH4’, ‘TH5’

KG (Kalgoorlie Hospital) ‘TH1’, ‘TH2’

KM (Kalamunda Hospital) ‘TH1’, ‘TH2’

KN (Kununurra Hospital) ‘TH01’

NG (Narrogin Hospital) ‘TH1’

OS (Osborne Park Hospital) ‘TH1’, ‘TH2’, ‘TH3’

PH (Port Hedland Hospital) ‘TH01’, ‘TH02’

PM (Princess Margaret Hospital for Children) ‘PROOM’, ‘TH1’, ‘TH2’, ‘TH3’, ‘TH4’, ‘TH5’, ‘TH5A’, ‘TH6’

QE (Sir Charles Gairdner Hospital) ‘DPRM’, ‘OR01’, ‘OR02’, ‘OR03’, ‘OR04’, ‘OR05’, ‘OR06’, ‘OR07’, ‘OR08’, ‘OR09’, ‘OR10’, ‘OR11’, ‘OR12’

RK (Rockingham General Hospital) ‘TH1’, ‘TH2’, ‘TH3’, ‘TH4’

RP (Royal Perth Hospital) ‘SPC1’, ‘SPC2’, ‘SPC3’, ‘TH01’, ‘TH02’, ‘TH03’,‘TH04’, ‘TH05’, ‘TH06’,‘TH07’, ‘TH08’, ‘TH09’, ‘TH10’, ‘TH11’, ‘TH12’, ‘TH14’, ‘TH15’, ‘TH16’

SW (Swan District Hospital) ‘TH1’, ‘TH2’, ‘TH3’, ‘TH4’,

WM (Nickol Bay Hospital) ‘TH01’, ‘TH02’

Formula Using the linked records from ‘T_Operation’ file and ‘T_Thr_Schedule’ file in TMS at each hospital, the denominator (Total allocated time) and the numerator (Total used theatre time) are calculated as follows. Denominator Total allocated hours for each reporting (calendar) month are the sum of started date/time) from each unique scheduled session ID ([SCH_ID] field), where the code in [Sch_Sess_Use_Flag] equals ‘CONS’ or ‘REG’ and the scheduled session’s start time falls between the start date and end date of the reporting (calendar) month.

Numerator Total used theatre hours for each reporting (calendar) month are the sum of used theatre time (patient left theatre date/time minus patient arrived theatre date/time or anaesthetic started date/time, which ever occurs earlier) from each linked operation record where the code in [Ope_Status] equals ‘CM’, ‘CO’, ‘LT’, ‘RE’ or ‘RP’.

Calculation Percentage of used theatre hours to total allocated hours for a reporting (calendar) month is the total used theatre time (hours) for a reporting (calendar)

month divided by total allocated time (hours) for the same reporting (calendar) month, expressed as percentage.

Used theatre hours (%) = Σ[Patient left theatre – (Patient arrived theatre or Anaes. started)] X 100 Σ(Scheduled finishes – Scheduled starts)

Total used theatre time and total allocated (scheduled) time in minutes are converted into hours before the percentage of used theatre hours is calculated. Verification Rules

Data Collection Identification Items Source Theatre Management System (TMS) at each hospital Governance Items Purpose of To report on efficiency in theatre usage in WA public hospitals. the data

Source of the - TMS Business Unit Group definition - Performance Activity & Quality Division Version 0.3 number Approval Date 20140423 (Noted by PRGC)

EA10: Access Block

Reported Data Description Items

Identifier MDG-04-009

Name Access Block

Alias Patients waiting for 8 hours or more for admission.

Definition The percentage of admitted patients who waited in the Emergency Department (ED) for greater than or equal to 8 hours for admission.

Related Metadata . MDG-04-001 WA ED Attendances. . MDG-04-008 WA ED Admissions.

Guide for Use Access Block is counted from event records in the Emergency Department Data Collection (EDDC) using the [Presentation Date] [Presentation Time], [Discharge Date], [Discharge Time], [Triage Category], [Visit Type], [Admission Date], [Admission Time], [Episode End Status] and [Admitting Consultant] fields. A patient is admitted when they undergo the formal admission process, whereby the hospital accepts responsibility for the patient's care and/or treatment by completion of the administrative process. The administrative process is completed when a hospital records the commencement of treatment and/or care and/or accommodation of a patient. Only admitted patients are included in the count. Admitted patients are determined using the [Admission Date/Time] fields. {Length of Episode} is used to determine patients waiting  8 hours for admission. {Length of Episode} for admitted patients is determined by [Discharge Date/Time] minus [Presentation Date/Time] with the following exception for those patients admitted to the Emergency Department by an ED clinician for observation. {Length of Episode} for patients admitted to an Emergency Department observation ward by an ED clinician is determined by [Admission Date/Time] minus [Presentation Date/Time]. These patients are identified using the [Admitting Consultant] or [Episode End Status] fields. The above exception is based on advice from the Health Services that a patient admitted to the Emergency Department by an ED clinician for observation is receiving appropriate care. All other admitted patients in the ED are deemed to be waiting for an inpatient bed. Patients who are Dead on Arrival or Direct Admissions are excluded from the count.

Limitations Peel Health Campus does not have the capacity to record the fields that identify patients who were admitted for ED observation, so {Length Of Episode} cannot be calculated for Admissions to ED (by ED clinician). Due to continuous quality improvement processes historical figures may be subject to change.

Reported Data Validation Items

Format Numeric

NNN.N

Data Values

Inclusions [Presentation Date] and [Presentation Time] are not missing.

[Discharge Date] and [Discharge Time] are not missing.

[Admission Date] and [Admission Time] are not missing.

[Triage Category] = . Resuscitation (1) . Emergency (2) . Urgent (3) . Semi Urgent (4) . Non-Urgent (5).

Exclusions [Presentation Date] and [Presentation Time] are missing or null.

[Discharge Date] and [Discharge Time] are missing or null.

[Admission Date] and [Admission Time] are missing or null.

[Triage Category] = . Dead on Arrival (6) . Direct Admission (7) . Current Inpatient (8) . Unknown (9).

[Episode end status] = . Dead on Arrival (7).

[Visit Type] = . Dead on Arrival (10)

. Direct Admission (6, 7, 8, 16).

Scope  Public Hospitals with an Emergency Department and publicly funded activity at Joondalup and Peel Health Campuses.  Excludes nursing posts and other non-hospital establishments.

Formula Determination of A patient is deemed to be admitted to ED by an ED clinician if Admitted to ED (by [Admitting Consultant] is TRUE that is: ED clinician

For EDIS sites:

if the [ADMIT_DR_CODE] = (one of supplied list of codes), for records prior to 1 April 2008 Or [ADMIT_DR_TYPE] = EDADM

For HCARe sites: If [Episode End Status] = 10.

Length of Episode – {Length of Episode} (minutes) for each record is the [Admission For patients Admitted Date] and [Admission Time] minus [Presentation Date] and to ED by an ED [Presentation Time]. clinician

Length of Episode – {Length of Episode} (minutes) for each record is the [Discharge For All other admitted Date] and [Discharge Time] minus [Presentation Date] and patients [Presentation Time].

Calculation Numerator Count of those records that have a value within the boundaries of the reference period AND with an [Admission Date] [Admission Time] AND a {Length of Episode} equal to or greater than 480 minutes minus those records with a [Triage Category] of 6, 7, 8 or 9 minus those records with a [Visit Type] of 6, 7, 8, 10 or 16 minus those records with an [Episode end status] of 7.

Denominator Count of those records that have a value within the boundaries of the reference period AND with an [Admission Date] [Admission Time] minus those records with a [Triage Category] of 6, 7, 8 or 9 minus those records with a [Visit Type] of 6, 7, 8, 10 or 16 minus those records with an [Episode End Status] of 7.

Calculation Numerator divided by Denominator, expressed as a percentage.

Verification Rules Value is >/= to zero

Data Collection Identification Items

Source Emergency Department Data Collection (EDDC) extract provided by Performance, Activity and Quality is updated every day at 2 am for EDIS, every Tuesday for HCARe and Peel, and on every 3rd working day of the month for TOPAS and JHC Meditech.

Governance Items

Purpose of the data To establish and monitor the proportion of patients who wait greater than or equal to 8 hours for admission.

Source of the Health Services and Data Integrity Directorate definition

Version number V2.0

Approval date 20101012

EA11: Admissions from ED

Reported Data Description Items

Identifier MDG-04-008

Name Total Admissions from the Emergency Department (ED).

Aliases ED Admits. ED Admissions. Definition A count of all ED attendances that have an admission recorded.

Related Metadata . MDG-04-001 TOTAL ED ATTENDANCES. . MDG-04-026 TOTAL MENTAL HEALTH ADMISSIONS FROM THE EMERGENCY DEPARTMENT

Guide for Use A patient is admitted when they undergo the formal admission process, whereby the hospital accepts responsibility for the

patient's care and/or treatment by completion of the administrative process. The administrative process is completed when a hospital records the commencement of treatment and/or care and/or accommodation of a patient.

Patients admitted to an inpatient ward or the Emergency Department are included in the count. Admitted patients that are Triage Category 1 to 5 are included.

- For all hospitals ED Admissions are counted from event records in the Emergency except PHC Department Data Collection (EDDC) using [Presentation Date] [Presentation Time], [Triage category], [Visit Type], [Episode end status], [Admission Date] and [Admission Time].

Admitted patients are defined as Emergency Department attendances with an [Admission Date] and [Admission Time], (excluding Dead on Arrival and Direct Admit patients).

- For PHC For PHC, ED admitted patients are counted from event records in the EDDC using the [Presentation Date], [Presentation Time], [Triage Category], [Visit Type], and [Episode end status]. Admitted ED patients are defined as ED attendances with an [Episode end status] of Admitted (excluding Dead on Arrival and Direct Admit patients).

Limitations Due to continuous quality improvement processes historical figures may be subject to change.

Reported Data Validation Items Format Numeric 5 NNN.N Data Values Inclusions [Presentation Date] and [Presentation Time] are present - For all hospitals [Admission Date] and [Admission Time] are present except PHC [Triage Category] =

. Resuscitation (1) . Emergency (2) . Urgent (3) . Semi Urgent (4) . Non-Urgent (5)

- For PHC [Presentation Date] and [Presentation Time] are present [Triage Category] = . Resuscitation (1) . Emergency (2) . Urgent (3) . Semi Urgent (4) . Non-urgent (5)

[Episode end status] = . Admitted to ward/other admitted patient unit (1) . Admitted to ED Ward (10) Admitted to HITH/RITH (11) Exclusions [Presentation Date] and [Presentation Time] values are not present - For all hospitals [Admission Date] and [Admission Time] values are not present except PHC

[Episode end status] = . Dead on Arrival (7)

- For PHC [Visit Type] = . Dead on Arrival (10) . Direct Admission (6, 7, 8, 16).

[Presentation Date] and [Presentation Time] are not present

[Episode end status] = . Dead on Arrival (7)

[Visit Type] = . Dead on Arrival (10) Direct Admission (6, 7, 8, 16).

Scope . Public Hospitals (Metropolitan and WACHS) with an Emergency Department and publicly funded activity at Joondalup and Peel Health Campuses . Excludes nursing posts and other non-hospital establishments. Formula Count of records where [Presentation Date] and [Presentation Time] are within the reference period and [Admission Date] and - For all hospitals [Admission Time] are present and [Triage Category] of 1,2,3,4 or 5 except PHC minus [Visit Type] of 6, 7, 8, 10 or 16 minus [Episode end status] of 7. - For PHC Count of records where [Presentation Date] and [Presentation Time] are within the reference period and {Episode end status] of 1, 10 or 11, and [Triage Category] of 1,2,3,4 or 5, minus [Visit Type] of 6, 7, 8, 10 or 16, minus [Episode end status] of 7.

Verification Rules Value is >/= to zero.

Data Collection Identification Items

Source Emergency Department Data Collection (EDDC) extract provided by IMR is updated every day at 2 am, for EDIS and 3rd working day of the month for HCARe, TOPAS and Peel The HCARe extract includes records from the previous month and the 3 months prior to capture delayed data entry

Governance Items

Purpose of the data To count the number of ED attendances that result in an admission to hospital, in order to gauge the inpatient demand level resulting from the hospitals’ ED activity. Source of the Health Services, Information Management and Reporting definition Version number Version 2.4 Approval date 20080616

EA12: Percentage of SJAA patients with Off Stretcher time within 20 minutes

Reported Data Description Items Identifier MDG-04-106

Name Percentage of SJAA patients with Off Stretcher time within 20 minutes

Aliases Off Stretcher; Transfer of Care

Definition Off Stretcher time is the duration from the arrival of the ambulance at the receiving hospital’s Emergency Department (ED) to the transfer of the patient from the care of St John Ambulance Australia (SJAA) crew to the care of the ED staff.

Related Metadata MDG-04-010 HOURS OF AMBULANCE DIVERSION MDG-04-011 AMBULANCE RAMPING MDG-040-107 PERCENTAGE OF SJAA PATIENTS WITH OFF STRETCHER TIME WITHIN 30 MINUTES MDG-040-108 SJAA PATIENTS MEDIAN OFF STRETCHER TIME MDG-040-109 SJAA PATIENTS 90TH PERCENTILE OFF STRETCHER TIME

Guide for Use: Off Stretcher time is monitored because paramedics are required to provide care to the patient until the hospital is ready to accept him/her.

SJAA provides a daily data file containing the following data elements to DOHWA. . [Time dest] being the date and time the SJAA crew arrives at the destination hospital . [Time clear] being the date and time the SJAA crew departs/is ready to depart the hospital . [Ramp time (seconds)] being the number of seconds the SJAA crew was at the hospital beyond 20 minutes . [Dest code] being the SJAA code for the destination hospital . [Crew] – the SJAA designation for the crew . [Ramp flag] – indicates if the ambulance was ramped or not . [DTW flag] – indicates if the ambulance by passed the ED or not . [Time handover] being the date and time the SJAA crew completes the handover of the patient to the hospital . [To location] being the suburb entered onto the SJAA call card for the destination location – in the event of a hospital, this is typically left the same as the [Dest code]

Special [To location] events: ** STOOD DOWN (78)** means that the ambulance has been dispatched but before it arrives at the scene the crew is told they are not required. This can occur when a crew that is closer to the scene becomes available and the job becomes reassigned to a different crew. On occasions this can occur two or three times to a single job particularly during busy periods, though it is rare. It is to ensure that the best equipped available vehicle arrives at the scene.

*** A.N.R.(62) *** (ambulance not required) means that the crew has arrived on scene but is no longer required, so the job is cancelled at that point.

Each daily file from SJAA includes data for the previous seven days. Therefore, at any point in time the data used for reporting will be the most recent and accurate data that has been received for that reference day.

DOHWA’s calculation for {Off Stretcher} time commences when the ambulance arrives at the hospital indicated by value in [Time dest] field, and concludes when the patient is transferred from the care of St John Ambulance Australia (SJAA) crew to the care of the ED staff indicated by value in [Time handover] field which is recorded by the SJAA officer in the electronic Patient Care Records system (ePCR) and confirmed by the ED staff member.

{Off Stretcher} time (in seconds) = [Time handover] minus [Time dest]

{Off Stretcher} time is calculated in seconds is converted into minutes for reporting.

Limitations There may be an issue of inaccuracy if {Off Stretcher} time is reported in hours rather than minutes. This is due to rounding errors.

Data are provided by an external source and therefore data collection and quality control are not under the control of DOHWA.

Data are available only for SJAA ambulances; all other ambulance services are excluded

Reported Data Validation Items

Format Numeric 8 NNNN.NNN

Data Values Seconds

Inclusions SJAA ambulance’s records where: [Time dest] is not missing and is valid. [Time clear] is not missing and is valid.

At least one of the fields [Dest code] or [To location] is not missing and is valid and in scope. If [Dest code] is missing or invalid, [To location] is used instead.

Valid SJAA [Dest code] and [To location] codes:- . AH Armadale/Kelmscott District Memorial Hospital . FH Fremantle Hospital . JHC Joondalup Health Campus . KE King Edward Memorial Hospital For Women . PMH Princess Margaret Hospital For Children . QE2 Sir Charles Gairdner Hospital . RPH Royal Perth Hospital . RH Rockingham General Hospital . SDH Swan District Hospital . PHC Peel Health Campus

[Crew] is not missing and is valid. [Time handover] is not missing and is valid.

Exclusions SJAA ambulance’s records where: [Time dest] is missing or invalid. [Time clear] is missing or invalid.

If [Dest code] and [To location] are both missing or both are invalid, and both are not in scope.

[Crew] is missing or invalid.

[Time handover] is missing or invalid. Note: [Time handover] is invalid if: [Time handover] < [Time dest] or [Time handover] > [Time clear]

[To location] = ** STOOD DOWN (78)** or *** A.N.R.(62) ***

Duplicate records: Note: It is possible (although infrequent) for more than one patient to be transported in the same ambulance in which case all fields would be identical except for [Time handover]. Therefore records are considered duplicates if all fields are identical including [Time handover] and in this instance one record will be excluded and one recorded included.

Formula: Where [Time dest] is within the reference period and [Time dest], [Time clear], [Time_handover] and [Crew] are not missing and are valid; and where either [Dest code] or [To location] is not missing and is valid and is not equal to “** STOOD DOWN (78)**” or “*** A.N.R.(62) ***”, calculate the {Off Stretcher} time in seconds, and convert to minutes in decimal format, as shown in the calculation below.

Calculation: {Off Stretcher} (in minutes in decimal format) = [Time handover] minus [Time dest]/(60)

Numerator The number of patients with Off Stretcher time within 20 minutes is a count of valid SJAA ambulance’s records where Off Stretcher time is . 20.0 minutes (i.e. from 0.0 to 19.9 recurring minutes)

Denominator Total number of Off Stretcher patients is a count of all SJAA ambulance’s records with a valid Off Stretcher time

Calculation Numerator divided by Denominator expressed as a percentage with all exclusions applied to both Numerator and Denominator.

Verification Rules Value is between zero and one hundred (100) percent inclusive.

This Performance Indicator is to be used for WA Department of Health local reporting, as advised by SJAA. This reporting includes NEAT reporting and the publically available ED Activity website.

Scope Scope as at November 2013 includes the following metropolitan hospitals: . Royal Perth Hospital . Sir Charles Gairdner Hospital . Fremantle Hospital . Princess Margaret Hospital . King Edward Memorial Hospital . Armadale-Kelmscott Memorial Hospital . Swan District Hospital . Rockingham General Hospital . Joondalup Health Campus . Peel Health Campus

The reference period is the period of time where this definition is being applied and encompasses from 00:00 at the start of the reference period to 23:59 at the end of the reference period for daily, weekly, monthly and annual reporting. Snapshot reports use 23:59 as the reference period. For cases that begin on one day and end on another, the case is counted on the day the case arrived at

the hospital i.e. [Time dest].

Data Collection Identification Items Source Source: St John Ambulance Australia Provider: St John Ambulance Australia

Governance Items

Purpose of the data To monitor the length of time it takes for a patient to be transferred from the care of St John Ambulance Australia (SJAA) crew to the care of a given hospital(s) Emergency Department(s) (ED) staff, at public metropolitan Emergency Departments.

Source of the definition Area Health Services, Health System Improvement Unit, Performance, Activity and Quality Division and SJAA

Version number 1.0

Approval date 20140121

2.2 Effectiveness Appropriateness (EAP) PIs

There are 4 EAP PIs proposed in the 2014-15 PMF, including 3 Health Service measures.

EAP2: Adult immunisation: percentage of people aged 65 years and over immunized against Influenza

Reported Data Description Items Identifier ABF/M-KPI-EAP2

Name Adult immunizations in persons aged 65 years and over, immunized against seasonal influenza.

Aliases The prevalence of adult immunizations in persons aged 65 years and over, immunized against seasonal influenza. The percentage of adults aged 65 years and over, immunized against seasonal influenza. The proportion of adults aged 65 years and over, immunized against seasonal influenza.

Definition The percentage of persons aged 65 years and over who reported having a seasonal influenza vaccination since March 1st (refers to most recent year).

The indicator is a population based measure of seasonal flu vaccine uptake in over 65 year olds in the Western Australian population as a whole as each individual that is surveyed has their response weighted to the population and adjusted to the age and sex distribution.

The percentage will be presented with a 95% confidence interval.

Related Metadata Prevalence estimates are also reported in the Operational Plan (OP) Performance indicators.

Guide for Use This indicator is a population based measure of preventative health care and takes into account differences in age and sex distribution within Western Australia.

Limitations Due to changes in the wording for the flu question in 2010, no historical data is available for this indicator.

The surveillance system is population based and designed to measure and monitor estimates at the population level. Therefore, while estimates will be representative of the Western Australian population as a whole it is unlikely to be reliably representative of small minority groups within the population such as Aboriginal people.

Data is collected on a monthly basis but is best reported annually. The recommended reporting period is from August – February. 2011 data will not be available until April/May 2012.

Sample sizes are generally consistent between years but if they should vary substantially, this may disproportionately affect the

precision of estimates for those years, reflected in the confidence interval widths. Such instances will be noted if and when they occur.

Reported Data Validation Items Format Numeric

NN.N Data Values

Inclusions All persons aged 65 years and over who received the seasonal flu vaccine.

The survey attracts a response rate of 85% and therefore can be said to be representative of the WA population as a whole.

Population figures: All WA residents assigned to a Health Service (North Metro, South Metro and WACHS) according to SLA based on boundaries outlined by the Epidemiology Branch, Public Health and Clinical Services Division.

Exclusions The data is collected as a Computer Assisted Telephone Interview (CATI) and therefore anyone without access to a phone will be excluded as well as anyone too ill to participate.

Scope Prior to 2014, WA residents who were randomly selected from a transcribed copy of the 2008/09 White Pages. From January 2014 onwards, WA residents who were randomly selected from a transcribed copy of the 2013/14 White Pages.

Formula Prevalence estimates will be calculated using the Complex Samples method. 95% confidence intervals will be calculated using the exact method for Poisson distribution.

Numerator: Persons aged 65 years and over who reported having the seasonal flu vaccine since March 2010. The numerator is weighted to account for the sampling methodology and adjusted to the age and sex distribution of the Western Australia population of the previous year.

Denominator: Total persons aged 65 years and over in Western Australia from the previous year’s Estimated Residential Population.

Verification Rules > 0

Data Collection Identification Items Source Immunisation data: WA Health and Wellbeing Surveillance System (HWSS), Epidemiology Branch. Population data: Australian Bureau of Statistics, Department of

Planning and Infrastructure, Epidemiology Branch.

Governance Items Purpose of the data For ABF/M KPI reporting.

Source of the definition Epidemiology Branch, Public Health and Clinical Services Division

Version number 1.2

Approval date 20140423 (Noted by PRGC)

EAP3.a: Obesity: percentage of population who are overweight of obese: a) adults

Reported Data Description Items Identifier ABF/M-KPI-EAP3a

Name Percentage of the WA adult (16 years and over) population, who are overweight or obese.

Aliases The proportion of the WA adult (16 years and over) population, who are overweight or obese. The prevalence of overweight or obesity among the WA adult (16 years and over) population.

Definition Overweight and obesity are defined using the Body Mass Index (BMI), which requires the input of the respondents height (metres) and weight (kilograms) measurements.

In persons aged 18 years of age and over, overweight is defined as a BMI of greater than 25 and less than 30. Obese is defined as a BMI of greater than or equal to 30. Classifications of overweight and obese for adults are based on the World Health Organisation guidelines.

In persons aged 5 to 17 years of age, BMI is calculated using BMI-for-age charts developed by the United States Centre for Disease Control and Prevention. Classifications of overweight and obese for children aged 5 to 15 years were developed by Cole et al (2000) and are internationally recognized.

The indicator is a population based measure of overweight and obesity in adults 16 years and over in the Western Australian population as a whole as each individual that is surveyed has their response weighted to the population and adjusted to the age and sex distribution.

The percentage will be presented with a 95% confidence interval.

Related Metadata Prevalence estimates are also reported in the Annual Health and Wellbeing Surveillance System adult report.

Guide for Use This indicator is a population based measure of the prevalence of overweight and obesity and takes into account differences in age and sex distribution within Western Australia.

Limitations The surveillance system is population based and designed to measure and monitor estimates at the population level. Therefore, while estimates will be representative of the Western Australian population as a whole it is unlikely to be reliably representative of small minority groups within the population such as Aboriginal people.

Data is collected on a monthly basis but is best reported annually. The data for a calendar year is available within 8 weeks of the next calendar year. E.g. 2011 data will not be available until February/March 2012.

Sample sizes are generally consistent between years but if they should vary substantially, this may disproportionately affect the precision of estimates for those years, reflected in the confidence interval widths. Such instances will be noted if and when they occur.

Reported Data Validation Items Format Numeric

NN.N

Data Values

Inclusions All adults 16 years and over.

The survey attracts a response rate of 85% and therefore can be said to be representative of the WA population as a whole.

Population figures: All WA residents assigned to a Health Service (NMHS, SMHS, WACHS) according to SLA based on boundaries outlined by the Epidemiology Branch, Public Health and Clinical Services Division.

Exclusions The data is collected as a Computer Assisted Telephone Interview (CATI) and therefore anyone without access to a phone will be excluded as well as anyone too ill to participate.

Outliers and biologically implausible results for height and weight are not included in the analysis of BMI.

Formula A correction measure is used on all height and weight measurements that are provided by HWSS respondents aged 20 years and over because the literature states that people tend to under-estimate their weight and over-estimate their height.

Prevalence estimates will be calculated using the Complex Samples method.

95% confidence intervals will be calculated using the exact method for Poisson distribution.

Numerator: Persons aged 16 years and over who have BMI scores that categorise them as overweight or obese. The numerator is

weighted to account for the sampling methodology and adjusted to the age and sex distribution of the Western Australia population of the previous year.

Denominator: Total persons aged 16 years and over in Western Australia from the previous year’s Estimated Residential Population.

Verification Rules > 0

Data Collection Identification Items Source BMI data: WA Health and Wellbeing Surveillance System (HWSS), Epidemiology Branch. Population data: Australian Bureau of Statistics, Department of Planning and Infrastructure, Epidemiology Branch.

Governance Items Purpose of the data For ABF/M KPI reporting.

Source of the definition Epidemiology Branch, Public Health and Clinical Services Division

Version number 1.2

Approval date 20140423 (Noted by PRGC)

EAP3.b: Obesity: percentage of population who are overweight of obese b) children

Reported Data Description Items Identifier ABF/M-KPI-EAP3b

Name Percentage of WA children (5 to 15 years), who are overweight or obese.

Aliases The proportion of WA children (5 to 15 years) who are overweight or obese. The prevalence of overweight or obesity among WA children (5 to 15 years).

Definition Overweight and obesity are defined using the Body Mass Index (BMI), which requires the input of the respondents height (metres) and weight (kilograms) measurements.

The indicator is a population based measure of overweight and obesity in children aged 5 to 15 years in the Western Australian population as a whole as each individual that is surveyed has their response weighted to the population and adjusted to the age and sex distribution.

The percentage will be presented with a 95% confidence interval.

Related Metadata Prevalence estimates are also reported in the Annual Health and Wellbeing Surveillance System child report.

Guide for Use This indicator is a population based measure of the prevalence of overweight and obesity among children aged 5 to 15 years and takes into account differences in age and sex distribution within Western Australia.

Sample sizes are generally consistent between years but if they

should vary substantially, this may disproportionately affect the precision of estimates for those years, reflected in the confidence interval widths. Such instances will be noted if and when they occur.

Reported Data Validation Items Format Numeric

NN.NN

Data Values

Inclusions All children aged 5 to 15 years.

The survey attracts a response rate of 85% and therefore can be said to be representative of the WA population.

Population figures: All WA residents assigned to aHealth Service (NMHS, SMHS, WACHS) according to SLA based on boundaries outlined by the Epidemiology Branch, Public Health and Clinical Services Division.

Exclusions The data is collected as a Computer Assisted Telephone Interview and therefore anyone without access to a phone will be excluded as well as anyone too ill to participate.

Outliers and biologically implausible results for height and weight are not included in the analysis of BMI.

Children aged less than 5 are not included.

Formula Prevalence estimates will be calculated using the Complex Samples Method. 95% confidence intervals will be calculated using the exact method for Poisson distribution.

Numerator: Persons aged 5 to 15 years who have BMI scores that categorise them as overweight or obese.

The numerator is weighted to account for the sampling methodology and adjusted to the age and sex distribution of the Western Australia population for the previous year.

Denominator: Total persons aged 5 to 15 years in Western Australia from the previous year’s Estimated Residential Population.

Verification Rules > 0

Data Collection Identification Items Source BMI data: WA Health and Wellbeing Surveillance System, Epidemiology Branch. Population: Australian Bureau of Statistics, Department of Planning and Infrastructure, Epidemiology Branch.

Governance Items Purpose of the data For ABF/M KPI reporting.

Source of the definition Epidemiology Branch, Public Health and Clinical Services Division

Version number 1.2 Approval date 20140423 (Noted by PRGC)

EAP4: Tobacco: percentage of adults who are current smokers

Reported Data Description Items Identifier ABF/M-KPI-EAP4

Name Percentage of WA adults (18 years and over), who are current daily smokers.

Aliases The prevalence of current daily smoking in WA adults (18 years and over). The proportion of WA adults (18 years and over) who are current daily smokers.

Definition The percentage of people aged 18 years and over who describe their smoking status as smoking daily.

The indicator is a population based measure of current daily smoking in persons 18 years and over in the Western Australian population as a whole as each individual that is surveyed has their response weighted to the population and adjusted to the age and sex distribution.

The prevalence of different areas can be compared using the 95% confidence intervals presented.

Related Metadata Prevalence estimates are reported in the Annual Health and Wellbeing Surveillance System adult report.

Guide for Use This is a population based measure of the smoking prevalence in Western Australia and takes into account differences in age and sex distribution in different areas of the State.

Baseline and targets are set using national data, in line with performance measures for the National Partnership Agreement on Preventive Health (NPAPH). However, State data is used to assess annual performance as national data is only collected on a 3-year basis.

occur.

Reported Data Validation Items Format Numeric

NN.N

Data Values

Inclusions All adults aged 18 years and over, who have a smoking status of daily.

The survey attracts a response rate of 85% and therefore can be said to be representative of the WA population.

Exclusions The data is collected as a Computer Assisted Telephone Interview (CATI) and therefore anyone without access to a phone will be excluded as well as anyone too ill to participate.

Formula Prevalence estimates will be calculated using the Complex Samples Method. 95% confidence intervals will be calculated using the exact method for Poisson distribution.

Numerator: Persons aged 18 years and over who reported smoking daily. The numerator is weighted to account for the sampling methodology and adjusted to the age and sex distribution of the Western Australia population for the previous year.

Denominator: Total persons aged 18 years and over in Western Australia from the previous year’s Estimated Residential Population.

Verification Rules > 0

Data Collection Identification Items Source Smoking data: WA Health and Wellbeing Surveillance System, Epidemiology Branch. Population: Australian Bureau of Statistics, Department of Planning and Infrastructure, Epidemiology Branch.

Governance Items Purpose of the data For ABF/M KPI reporting.

Source of the definition Epidemiology Branch, Public Health and Clinical Services Division

Version number 1.2

Approval date 20140423 (Noted by PRGC)

2.3 Effectiveness Quality (EQ) PIs

There are 13 EQ PIs proposed in the 2014-15 PMF, including 7 Health Service measures.

EQ2: Percentage of Emergency Department Attendances which are unplanned re-attendances in less than or equal to 48 hours of previous attendance

Reported Data Description Items Identifier MDG-04-102 Name National Emergency Access Target (NEAT) Percentage of Emergency Department (ED) Attendances which are an unplanned re-attendance in less than or equal to 48 Hours of previous attendance. Aliases . Percentage of ED with an unplanned re-attendance at any hospital within 48 hours. Definition The percentage of NEAT ED attendances where the patient re-attended any ED in less than or equal to 48 hours. Related . MDG-04-089 NEAT Total Emergency Department Attendances Metadata which are unplanned re-attendance. . MDG-04-101 NEAT Total ED Departures

Guide for Use All NEAT Performance Indicators (PIs) have the following General inclusions/exclusions: Records must have a valid [Presentation Date] and [Presentation Time] Records must have a valid [Discharge Date] and [Discharge Time] Records must have a [Presentation Date] and [Presentation Time] within the Reference Period i.e. for Date fields to be considered valid, the day, month and year components must be accurate, as per Meteor Data Element 294429 Date—accuracy indicator, code AAA. {NEAT Unplanned re-attendances} are counted from event records in the Emergency Department Data Collection (EDDC) using [Presentation Date] and [Presentation Time], [Discharge Date] and [Discharge Time], [Visit Type] and [Data Linkage PID]. The timing of the re-attendance is determined using [Presentation Date] and [Presentation Time] of the current visit and [Discharge Date] and [Discharge Time] of the previous visit, regardless of the site of either visit: Determine 48 Hours: Previous visit [Discharge Date] and [Discharge Time] minus current visit [Presentation Date] and [Presentation Time]. Where the time between visits is less than or equal to 48 hours the record is included in the formula and the count of {NEAT Unplanned re- attendances} is recorded against the hospital (if it is in scope) which recorded the previous attendance. The record will be counted regardless if the hospital is in-scope or not, and the count will be attributed to the hospital where the previous attendance occurred regardless if the hospital is in-scope or not but will only be reported for in-scope hospitals.

Limitations As [Visit Type] of unplanned re-attendance is not available from Peel Health Campus nor any HCARe site, they are excluded from reporting. Due to continuous quality improvement processes, historical figures may

be subject to change.

Reported Data Validation Items Format Numeric

NNN.N% Data Values Inclusions Numerator: {NEAT Unplanned re-attendances} [Presentation Date] and [Presentation Time] are not missing and are valid. [Discharge Date] and [Discharge Time] are not missing and are valid.

[Visit Type] = . Unplanned return (3) [Data Linkage PID] is present

Denominator: {NEAT attendances} [Presentation Date] and [Presentation Time] are not missing and are valid. [Discharge Date] and [Discharge Time] are not missing and are valid.

Exclusions Numerator: {NEAT Unplanned re-attendances} [Presentation Date] or [Presentation Time] are missing or invalid. [Discharge Date] or [Discharge Time] are missing or invalid. [Data Linkage PID] is not present

Denominator: {NEAT attendances} [Presentation Date] or [Presentation Time] are missing or invalid. [Discharge Date] or [Discharge Time] are missing or invalid.

Formulae Numerator: {NEAT Unplanned re-attendances} at all hospitals are determined where [Presentation Date] and [Presentation Time] are not missing and are valid and are within the reference period and [Discharge Date] and [Discharge Time] are not missing and are valid and [Visit Type] = 3 and [Data Linkage PID] is present; and where the same [Data Linkage PID] had a [Discharge Date] and [Discharge Time] that was within 48 hours prior to the [Presentation Date] and [Presentation Time] of the current attendance.

The count of {NEAT Unplanned re-attendances} is given to the site of the previous attendance.

Denominator: The count of {NEAT Attendances} records at the in-scope hospitals (see Scope below) where [Presentation Date] and [Presentation Time] are not missing and are valid and are within the reference period and [Discharge Date] and [Discharge Time] are not missing and are valid. This is the count of total attendances at the site of the previous attendance.

Calculation: Numerator divided by denominator, expressed as a percentage for Scope hospitals.

Verification Rules Value is >/= zero

Reported Data Structure Items Scope Metro Public Hospitals with an Emergency Department, publicly funded activity at Joondalup and Peel Health Campuses; and the following rural hospitals:  Albany Regional Hospital  Bunbury Hospital  Broome District Hospital  Geraldton Regional Hospital  Kalgoorlie Regional Hospital  Nickol Bay Hospital  Hedland Health Campus

Data Collection Identification Items Source Emergency Department Data Collection (EDDC). Provider Performance, Activity and Quality Division

Governance Items Purpose of the data To monitor ED Attendances with unplanned re-attendance to an ED in less than or equal to 48 hours. Source of the National Partnership Agreement, Health System Improvement Unit, definition Performance Activity and Quality Division, Health Services.

Version number V1.1

Approval date 26/09/2012

EQ4: Rate of Severity Assessment Code (SAC) 1 clinical incident investigation reports received by Patient Safety Surveillance Unit (PSSU) within 45 working days of the event notification date

Reported Data Description Items Identifier

Name All SAC 1 clinical incident investigation reports received by PSSU within 45 working days of the event notification

Aliases SAC 1 clinical incident investigation report

Definition SAC 1 clinical incident investigation reports received by PSSU within 45 working days of the notification date, calculated as a percentage of those due to be received.

Related Metadata SAC 1 report

Guide for Use Data is extracted by notification date.

The notification date is when the SAC 1 clinical incident is reported to PSSU.

The Numerator is the number of SAC 1 clinical incident investigation reports received by PSSU within 45 working days of the notification date, per Health Service per month. This is calculated by extracting all SAC 1 clinical incidents by notification date, including the fields: date report due, health service and date report received. The resulting SAC 1 clinical incidents are filtered to those where the date the report was received is equal to or less than the date the report was due, and then by health service and the quarter the report was due.

The Denominator is the number of SAC 1 clinical incident investigation reports due to be received by PSSU within 45 working days of the notification date per Health Service per month. This is calculated by extracting all SAC 1 clinical incidents by notification date, including the fields: date report due, health service and date report received. The resulting SAC 1 clinical incidents are filtered by health service and the quarter the report was due.

For 2013-14 ABF reporting: Reporting frequency: quarterly Reporting level: Health Service (PMR) Facility (Governing Councils Report) Limitations

Reported Data Validation Items Format Percentage

NN.NN%

Data Values >= 0% and <= 100%

Inclusions All SAC 1 notifications received from all Health Services.

SAC 1 clinical incidents are clinical incidents/near misses where serious harm or death is/could be specifically caused by health care rather than the patient’s underlying condition or illness. SAC 1 clinical incidents include the eight nationally endorsed sentinel event categories (below):

1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function. 2. Suicide of an inpatient (including patients on leave). Retained instruments or other material after surgery requiring re-operation or further surgical procedure. 3. Intravascular gas embolism resulting in death or neurological damage. 4. Haemolytic blood transfusion reaction resulting from ABO incompatibility. 5. Medication error resulting in death of a patient. 6. Maternal death or serious morbidity associated with labour or delivery. 7. Infant discharged to the wrong family or infant abduction.

Sentinel event refers to unexpected occurrences involving death or serious physical or psychological injury/harm or risk thereof.

Exclusions  Private health services including Joondalup Health Campus and Peel Health Campus.

Scope Western Australian Health services, except Next Step Drug and Alcohol services, East Perth

Formula Divide the Numerator by the Denominator and multiply by 100 to calculate the percentage of SAC 1 investigation reports received by PSSU within 45 working days (63 calendar days) of the notification date.

Verification Rules >= 0% and <= 100%

Data Collection Identification Items Source Patient Safety Surveillance Unit Severity Assessment Code 1 Database (Access)

Governance Items Purpose of the data A measure of percentage of SAC 1 clinical incident investigation reports received by PSSU within 45 working days of the notification date.

Source of the definition  Clinical Incident Management Policy (2012)  Operational Directive OD 0421/13.

Version number 4.1

Approval date 20130605

EQ6: Hospital accreditation

Reported Data Description Items Identifier Name Hospital Accreditation Aliases Accreditation Definition Accreditation status of public hospitals at a point in time. Related Metadata Guide for Use Accreditation is defined as a status that is conferred on an organisation that has been assessed as having met particular

standards. From 1 January 2013 all public hospitals in Western Australia are required to be accredited to the National Safety and Quality Health Service (NSQHS) Standards using the Australian Health Service Safety and Quality Accreditation Scheme. (Refer to Department of Health, Operational Directive 0410/12 dated 18 December 2012) Public hospitals are required to engage an accrediting agency that is registered with the Australian Commission on Safety and Quality in Health Care, to undertake their accreditation assessment against the NSQHS Standards. Reporting of a hospital’s accreditation is ‘as at a point in time.’ This definition reflects the new accreditation model implemented from 1 January 2013. Limitations

Reported Data Validation Items Format Text Data Values N/A Inclusions All hospitals which treat public patients in WA. Includes private hospitals which are contracted to provide public services. Exclusions Solely private hospitals (i.e., private hospitals which are not contracted to provide public services). Scope Public Hospitals (metropolitan and rural), except Next Step Drug and Alcohol services, East Perth. Private hospitals which are contracted to provide public services, e.g., Joondalup Health Campus, Peel Health Campus. Please refer to a report’s scoping to determine which sites are included/excluded in that particular report. Formula Status of in scope hospitals, presented as the accreditation status as at a point in time.

Verification Rules Permissible accreditation status values:  Accredited  Not Accredited Data Collection Identification Items Source Licensing and Accreditation Regulatory Unit (LARU) Governance Items Purpose of the data Current measure of hospital accreditation status across WA Health sites Source of the definition Licensing and Accreditation Regulatory Unit (LARU) Version number 3.1 Approval date 20130719

EQ9.a-g: Unplanned hospital readmissions of patients discharged following management of a) knee replacement, b) hip replacement, c) tonsillectomy & adenoidectomy, d) hysterectomy, e) prostatectomy, f) cataract surgery, and g) appendicectomy

Reported Data Description Items Identifier (Office use only) Name Unplanned hospital readmissions following selected surgical episodes of care

Aliases Unplanned hospital readmissions Unexpected hospital readmissions

Definition Unplanned hospital readmissions following surgical episodes of care within a set period of time for: (1) knee replacement, (2) hip replacement, (3) tonsillectomy and adenoidectomy, (4) hysterectomy, (5) prostatectomy, (6) cataract surgery and (7) appendicectomy.

Unplanned readmissions are those readmissions where the principal diagnosis (PDx) and readmission interval indicate that the readmission may be related to the care provided by the hospital in an index surgical episode of care.

Related Metadata Unplanned hospital readmissions following selected medical episodes of care (in development).

Guide for Use This reported definition is based on the proposed MyHospitals definition (as at 17 April 2012) and considers unplanned hospital readmissions following select surgical procedures within a set time period to any public hospital.

An index episode of care is an episode of care during which one of the selected surgical procedures occurred during the relevant reference period.

For a separation to be considered a readmission, the separation must follow an index episode of care for the same individual that occurred during the relevant denominator reference period.

Only the first readmission occurring within the specified readmission interval is counted. If more than one surgical procedure occurs at an index episode of care, then the readmissions is counted for each surgical procedure.

This definition is dependent on coded inpatient data (via the Hospital Morbidity Data System [HMDS]) for the numerator and denominator. Therefore this definition is to be reported on a quarterly basis, with a one quarter data lag. This lag is required so a greater volume of data is available for reporting.

The identification of patients and the readmission at any hospital uses the Root LP (Linkage Project) Number available within the HMDS. The Root LP Number is generated by the Data Linkage Branch (Public Health Division) and uses probabilistic matching to match cases. When Root LP Number is not available, a concatenation of Hospital Number and UMRN (Unit Medical Record Number) is used instead.

Only facilities with greater than 50 denominator separations per annum will be considered for reporting for this indicator. A minimum number of procedures are required during the reporting period so the figures are not skewed by small sample sizes and to protect the confidentiality of patients.

Specific rules are applied for the treatment of contiguous hospital separations for the numerator and denominator. The specific rules are outlined in Appendix A.

Limitations This reporting definition is dependent on coded information. To overcome this, a lag is included in the reporting of data. Figures reported for recent months may not be complete due to delays in data coding, data linkage and quality checking.

The Root LP Number used to identify readmissions is generated using probabilistic matching. This is a ‘best estimate’ used to match cases based on a series of patient identifying information, however false matches are possible.

When Root LP Number is not available a concatenation of Hospital Number and UMRN is used instead. In such instances (<1% of cases) readmission to the same hospital can only be reported.

A UMRN for each patient may not be available statewide due to different patient identifiers used between each instance of HCARe CMS and also between TOPAS/webPAS and other systems.

This reporting definition is derived from a national reporting definition and is subject to change.

Reported Data Validation Items Format Percentage 4 NNN.N% Data Values Inclusions The separation is a readmission to any public hospital following an episode of care in which one of the following procedures was performed: knee replacement, hip replacement, tonsillectomy and adenoidectomy, hysterectomy, prostatectomy, cataract surgery or appendicectomy (see procedure lists below).

Knee replacement Number of episodes of care in which one of the following surgical procedures (ACHI(7th Ed) procedure codes) was undertaken.

Procedure Description Code 49518-00 Total arthroplasty of knee, unilaterial 49521-00 Total arthroplasty of knee with bone graft to femur, unilateral 49521-02 Total arthroplasty of knee with bone graft to tibia, unilaterial 49524-00 Total arthroplasty of knee with bone graft to femur and tibia, unilateral

Hip replacement Number of episodes of care in which one of the following surgical procedures (ACHI(7th Ed) procedure codes) was undertaken.

Procedure Code Description

49318-00 Total arthroplasty of hip, unilaterial

49319-00 Total arthroplasty of hip, bilateral

Tonsillectomy and adenoidectomy Number of episodes of care in which one of the following surgical procedures (ACHI(7th Ed) procedure codes) was undertaken. The patient must be aged 14 years or less during the reference period.

Procedure Code Description 41789-00 Tonsillectomy without adenoidectomy 41789-01 Tonsillectomy with adenoidectomy 41801-00 Adenoidectomy without tonsillectomy

Hysterectomy Number of episodes of care in which one of the following surgical procedures (ACHI(7th Ed) procedure codes) was undertaken.

Procedure Description Code

35653-00 Subtotal abdominal hysterectomy 35653-01 Total abdominal hysterectomy 35653-04 Total abdominal hysterectomy with removal of adnexa 35661-00 Abdominal hysterectomy with extensive retroperitoneal dissection 35670-00 Abdominal hysterectomy with radical excision of pelvic lymph nodes 35750-00 Laparoscopically assisted vaginal hysterectomy 35753-02 Laparoscopically assisted vaginal hysterectomy with removal of adnexa 35756-00 Laparoscopically assisted vaginal hysterectomy proceeding to abdominal hysterectomy 35756-03 Laparoscopically assisted vaginal hysterectomy proceeding to abdominal hysterectomy with removal of adnexa. 90448-01 Total laparoscopic abdominal hysterectomy 90448-02 Total laparoscopic abdominal hysterectomy with removal of adnexa 35657-00 Vaginal hysterectomy 35673-02 Vaginal hysterectomy with removal of adnexa 35667-00 Radical abdominal hysterectomy 35664-00 Radical abdominal hysterectomy with radical excision of pelvic lymph nodes 35664-01 Radical vaginal hysterectomy with radical excision of pelvic lymph nodes 35667-01 Radical vaginal hysterectomy 90443-00 Other excision of uterus

Prostatectomy Number of episodes of care in which one of the following surgical procedures (ACHI(7th Ed) procedure codes) was undertaken.

Procedure Code Description 37207-00 Endoscopic laser ablation of prostate (includes TULIP) 37201-00 Transurethral needle ablation of prostate 37203-00 Transurethral resection of prostate 37203-02 Transurethral electrical vaporization of prostate 37203-04 Microwave thermotherapy of prostate 37203-05 High intensity focused ultrasound (transrectal) of prostate 37207-01 Endoscopic laser excision of prostate 37200-03 Suprapubic prostatectomy 37200-04 Retropubic prostatectomy 37224-00 Endoscopic destruction of prostatic lesion

37224-01 Endoscopic resection of prostatic lesion 90407-00 Excision of other lesion of prostate 37203-03 Cryoablation of prostate

Cataract surgery Number of episodes of care in which one of the following surgical procedures (ACHI(7th Ed) procedure codes) was undertaken. The patient must be aged 30 years or over during the reference period.

Procedure Description Code 42698-00 Intracapsular extraction of crystalline lens 42702-00 Intracapsular extraction of crystalline lens with insertion of foldable artificial lens 42702-01 Intracapsular extraction of crystalline lens with insertion of other artificial lens 42698-01 Extracapsular extraction of crystalline lens by simple aspiration (and irrigation) technique 42702-02 Extracapsular extraction of crystalline lens by simple aspiration (and irrigation) technique with insertion of foldable artificial lens 42702-03 Extracapsular extraction of crystalline lens by simple aspiration (and irrigation) technique with insertion of other artificial lens 42698-02 Extracapsular extraction of crystalline lens by phacoemulsification and aspiration of cataract 42702-04 Extracapsular extraction of crystalline lens by phacoemulsification and aspiration of cataract with insertion of foldable artificial lens 42702-05 Extracapsular extraction of crystalline lens by phacoemulsification and aspiration of cataract with insertion of other artificial lens 42698-03 Extracapsular crystalline lens extraction by mechanical phacofragmentation and aspiration of cataract 42702-06 Extracapsular crystalline lens extraction by mechanical phacofragmentation and aspiration of cataract with insertion of foldable artificial lens 42702-07 Extracapsular crystalline lens extraction by mechanical phacofragmentation and aspiration of cataract with insertion of other artificial lens 42698-04 Other extracapsular extraction of crystalline lens 42702-08 Other extracapsular extraction of crystalline lens with insertion of foldable artificial lens 42702-09 Other extracapsular extraction of crystalline lens with insertion of other artificial lens 42731-01 Extraction of crystalline lens by posterior chamber sclerotomy with removal of vitreous 42698-05 Other extraction of crystalline lens 42702-10 Other extraction of crystalline lens with insertion of foldable artificial lens 42702-11 Other extraction of crystalline lens with insertion of other artificial lens

Appendicectomy Number of episodes of care in which one of the following surgical procedures (ACHI(7th Ed) procedure codes) was undertaken.

Procedure Code Description 30571-00 Appendicectomy 30572-00 Laparoscopic appendicectomy

Specific inclusions for the numerator: The principal diagnosis (PDx) code for the episode of care is one of the ICD-10-AM (7th edition) diagnosis codes listed in appendix B. The readmission occurs within a specified number of days from the previous separation date of admission, as specified below:

Procedure Readmission Interval Knee replacement 60 days Hip replacement 60 days Tonsillectomy and adenoidectomy 15 days Hysterectomy 30 days Prostatectomy 30 days Cataract surgery 45 days Appendicectomy 30 days

Where the readmission interval for specified PDx codes is less than the readmission interval for the selected procedure, the readmission interval is noted in appendix B.

Please see appendix A for further details on the treatment of contiguous separations in the numerator and denominator. Exclusions Excludes separations where the patient died in hospital.

Hysterectomy excludes episodes of care with an ICD-10-AM (7th Ed) additional diagnosis code Z37 - Outcome of delivery.

Only the first readmission within the specified readmission interval is counted. Subsequent readmissions for the index separation are excluded.

The following client statuses are excluded from the numerator and denominator: • 0 (Funding Hospital) • 2 (Unqualified Newborn) • 3 (Boarder) • 7 (Organ Procurement) • 8 (Resident) Scope The 36 in-scope Activity Based Funding facilities and where the minimum number of separations for the procedure has been met.

Reported by facility by surgical procedure on a quarterly basis.

Formula Knee Replacement:

Numerator: Count of readmission separations where: the previous procedure code is equal to the procedure list for knee replacement (listed in inclusions above); and client status is not equal to 0,2,3,7 and 8; and a readmission separation has occurred with a principal diagnosis of ‘Y’ for knee replacement in the principal diagnosis codes for numerator list (appendix B); and separation date minus admission date is ‘listed’ for recommended readmission interval for knee replacement in principal diagnosis codes for numerator list (appendix B); else readmission interval is less than or equal to 60 days; and Root LP Number is equal to the previous separation and readmission separation; or if Root LP Number is blank, a concatenation of Hospital Number and UMRN is equal to the previous separation and readmission separation.

Denominator: Count of separations where: the procedure code is equal to the procedure list for knee replacement (listed in inclusions above) for a single separation; and client status is not equal to 0,2,3,7 and 8. If two or more continuous separations occur, the previous separations are counted if: the previous separation must have a mode of separation of 1 or 3; and the subsequent separation must have a source of referral-location of 4 or 5, and a source of referral-professional is not 7; and must be care type acute. Acute separation then surgical procedure performed date of admission [acute separation] is equal to the date of previous separation [surgical procedure separation]; Surgical procedure performed then acute separation: separation date [surgical procedure separation] is equal to the date of admission [acute admission].

Calculation: Numerator divided by the denominator expressed as a percentage.

Hip replacement

Numerator: Count of readmission separations where: the previous procedure code is equal to the procedure list for hip replacement (listed in inclusions above); and client status is not equal to 0,2,3,7 and 8; and a readmission separation has occurred with a principal diagnosis of ‘Y’ for hip replacement in the principal diagnosis codes for numerator list (appendix B); and separation date minus admission date is ‘listed’ for recommended readmission interval for hip replacement in principal diagnosis codes for numerator list (appendix B); else readmission interval is less than or equal to 60 days; and Root LP Number is equal to the previous separation and readmission separation; or if Root LP Number is blank, a concatenation of Hospital Number and UMRN is equal to the previous separation and readmission separation.

Denominator: Count of separations where: the procedure code is equal to the procedure list for hip replacement (listed in inclusions above) for a single separation; and client status is not equal to 0,2,3,7 and 8. If two or more continuous separations occur, the previous separations are counted if: the previous separation must have a mode of separation of 1 or 3; and the subsequent separation must have a source of referral-location of 4 or 5, and a source of referral-professional is not 7; and must be care type acute. Acute separation then surgical procedure performed: date of admission [acute separation] is equal to the date of previous separation [surgical procedure separation]; Surgical procedure performed then acute separation: separation date [surgical procedure separation] is equal to the date of admission [acute admission].

Calculation: Numerator divided by the denominator expressed as a percentage.

Tonsillectomy and adenoidectomy

Numerator: Count of readmission separations where: the previous procedure code is equal to the procedure list for tonsillectomy and adenoidectomy (listed in inclusions above); and client status is not equal to 0,2,3,7 and 8; and patient is aged 14 years or less during the reference period; and a readmission separation has occurred with a principal diagnosis of ‘Y’ for tonsillectomy and adenoidectomy in the principal diagnosis codes for numerator list (appendix B); and separation date minus admission date is ‘listed’ for recommended readmission interval for tonsillectomy and adenoidectomy in principal diagnosis codes for numerator list (appendix B); else readmission interval is less than or equal to 15 days; and Root LP Number is equal to the previous separation and readmission separation; or if Root LP Number is blank, a concatenation of Hospital Number and UMRN is equal to the previous separation and readmission separation.

Denominator: Count of separations where: the procedure code is equal to the procedure list for tonsillectomy and adenoidectomy (listed in inclusions above) for a single separation; and client status is not equal to 0,2,3,7 and 8; and patient is aged 14 years or less during the reference period. If two or more continuous separations occur, the previous separations are counted if: the previous separation must have a mode of separation of 1 or 3; and the subsequent separation must have a source of referral-location of 4 or 5, and a source of referral-professional is not 7; and must be care type acute. Acute separation then surgical procedure performed: date of admission [acute separation] is equal to the date of previous separation [surgical procedure separation]; Surgical procedure performed then acute separation: Separation date [surgical procedure separation] is equal to the date of admission [acute admission].

Calculation: Numerator divided by the denominator expressed as a percentage.

Hysterectomy

Numerator: Count of readmission separations where: the previous procedure code is equal to the procedure list for hysterectomy (listed in inclusions above); and client status is not equal to 0,2,3,7 and 8; and excluding episodes of care with an ICD-10-AM (7th Ed) additional diagnosis code Z37 – Outcome of delivery; and a readmission separation has occurred with a principal diagnosis of ‘Y’ for hysterectomy in the principal diagnosis codes for numerator list (appendix B); and separation date minus admission date is ‘listed’ for recommended readmission interval for hysterectomy in principal diagnosis codes for numerator list (appendix B); else readmission interval is less than or equal to 30 days; and Root LP Number is equal to the previous separation and readmission separation;

or if Root LP Number is blank, a concatenation of Hospital Number and UMRN is equal to the previous separation and readmission separation.

Denominator: Count of separations where: the procedure code is equal to the procedure list for hysterectomy (listed in inclusions above) for a single separation; and client status is not equal to 0,2,3,7 and 8; and excluding episodes of care with an ICD-10-AM (7th Ed) additional diagnosis code Z37 – Outcome of delivery. If two or more continuous separations occur, the previous separations are counted if: the previous separation must have a mode of separation of 1 or 3; and the subsequent separation must have a source of referral-location of 4 or 5, and a source of referral-professional is not 7; and must be care type acute. Acute separation then surgical procedure performed: date of admission [acute separation] is equal to the date of previous separation [surgical procedure separation]; Surgical procedure performed then acute separation: separation date [surgical procedure separation] is equal to the date of admission [acute admission].

Calculation: Numerator divided by the denominator expressed as a percentage.

Prostatectomy

Numerator: Count of readmission separations where: the previous procedure code is equal to the procedure list for prostatectomy (listed in inclusions above); and client status is not equal to 0,2,3,7 and 8; and a readmission separation has occurred with a principal diagnosis of ‘Y’ for prostatectomy in the principal diagnosis codes for numerator list (appendix B); and separation date minus admission date is ‘listed’ for recommended readmission interval for prostatectomy in principal diagnosis codes for numerator list (appendix B); else readmission interval is less than or equal to 30 days; and Root LP Number is equal to the previous separation and readmission separation; or if Root LP Number is blank, a concatenation of Hospital Number and UMRN is equal to the previous separation and readmission separation.

Denominator: Count of separations where: the procedure code is equal to the procedure list for prostatectomy (listed in inclusions above) for a single separation; and client status is not equal to 0,2,3,7 and 8. If two or more continuous separations occur, the previous separations are counted if: the previous separation must have a mode of separation of 1 or 3; and the subsequent separation must have a source of referral-location of 4 or 5, and a source of referral-professional is not 7; and must be care type acute. Acute separation then surgical procedure performed: date of admission [acute separation] is equal to the date of previous separation [surgical procedure separation]; Surgical procedure performed then acute separation: separation date [surgical procedure separation] is equal to the date of admission

[acute admission].

Calculation: Numerator divided by the denominator expressed as a percentage.

Cataract surgery

Numerator: Count of readmission separations where: the previous procedure code is equal to the procedure list for cataract surgery (listed in inclusions above); and client status is not equal to 0,2,3,7 and 8; and patient is aged 30 years or over during the reference period; and a readmission separation has occurred with a principal diagnosis of ‘Y’ for cataract surgery in the principal diagnosis codes for numerator list (appendix B); and separation date minus admission date is ‘listed’ for recommended readmission interval for cataract surgery in principal diagnosis codes for numerator list (appendix B); else readmission interval is less than or equal to 45 days; and Root LP Number is equal to the previous separation and readmission separation; or if Root LP Number is blank, a concatenation of Hospital Number and UMRN is equal to the previous separation and readmission separation;

Denominator: Count of separations where: the procedure code is equal to the procedure list for cataract surgery (listed in inclusions above) for a single separation; and client status is not equal to 0,2,3,7 and 8; and patient is aged 30 years or over during the reference period. If two or more continuous separations occur, the previous separations are counted if: the previous separation must have a mode of separation of 1 or 3; and the subsequent separation must have a source of referral-location of 4 or 5, and a source of referral-professional is not 7; and must be care type acute. Acute separation then surgical procedure performed: date of admission [acute separation] is equal to the date of previous separation [surgical procedure separation]; Surgical procedure performed then acute separation: separation date [surgical procedure separation] is equal to the date of admission [acute admission].

Calculation: Numerator divided by the denominator expressed as a percentage.

Appendicectomy

Numerator: Count of readmission separations where: the previous procedure code is equal to the procedure list for appendicectomy (listed in inclusions above); and client status is not equal to 0,2,3,7 and 8; and a readmission separation has occurred with a principal diagnosis of ‘Y’ for appendicectomy in the principal diagnosis codes for numerator list (appendix B); and separation date minus admission date is ‘listed’ for recommended readmission interval for appendicectomy in principal diagnosis codes for numerator list (appendix B); else readmission interval is less than or equal to 30 days; and Root LP Number is equal to the previous separation and readmission

separation; or if Root LP Number is blank, a concatenation of Hospital Number and UMRN is equal to the previous separation and readmission separation;

Denominator: Count of separations where: the procedure code is equal to the procedure list for appendicectomy (listed in inclusions above) for a single separation; and client status is not equal to 0,2,3,7 and 8. If two or more continuous separations occur, the previous separations are counted if: the previous separation must have a mode of separation of 1 or 3; and the subsequent separation must have a source of referral-location of 4 or 5, and a source of referral-professional is not 7; and must be care type acute. Acute separation then surgical procedure performed: date of admission [acute separation] is equal to the date of previous separation [surgical procedure separation]; Surgical procedure performed then acute separation: separation date [surgical procedure separation] is equal to the date of admission [acute admission].

Calculation: Numerator divided by the denominator expressed as a percentage. Reference Period:

The readmission interval is measured from the separation date of the index episode of care.

To determine if a subsequent episode of care is a readmission, the readmission interval is applied from the date of separation for the index separation to the date of admission for the subsequent episode of care.

For reporting purposes, the readmission is counted against the quarter in which the initial separation occurred. Verification Rules 0-100% Data Collection Identification Items Source Hospital Morbidity Data System, Inpatient Data Collections, Data Integrity, PAQ Governance Items Purpose of the data This information is used for Activity Based Funding and Management reporting, other internal performance reporting and for internal validation of proposed national reporting definition. Source of the Unplanned/ unexpected readmissions following selected surgical episodes of care (any public hospital, same state/ territory) - MyHospitals definition (17/4/2012 draft definition definition). Further revisions made by the Performance Directorate and Data Integrity Directorate in the Performance Activity and Quality Division.

Version number v1.0 Approval date 20130805

Appendix A: Treatment of contiguous hospital separations for denominator and numerator (specific rules used in the draft MyHospitals definition)

Note: DOA - date of admission DOS - date of separation PDx – principal diagnosis

Scenario 1 Separation A Separation B Separation C Procedure Care type: Acute Care type: Non-acute performed DOS Separation A = DOA Separation B AND DOS Separation B = DOA Separation C

Denominator – Index episode of Numerator – Readmission care

 Include Separation A in the  Include Separation B in the denominator numerator as a readmission for Separation A if:  Include Separation B in the index episode of care if:  Source of Referral-Location for Separation B is not 4 or 5 or  DOS Separation A = DOA Source of Referral- Separation B AND Professional is not 7 AND  Source of Referral-Location for  PDx is a readmission PDx as Separation B is 4 (acute per Table 1 hospital) or 5 (psychiatric hospital) and Source of  Include Separation C in the Referral-Professional is not 7 numerator as a readmission for (statistical admission/type Separation B if: change)  Separation B is in denominator AND  Source of Referral-Location for Separation C is not 4 or 5 or Source of Referral- Professional is not 7 AND  PDx is a readmission PDx as per Table 1 Readmission Interval The readmission interval applies from the DOS for Separation A to the DOA for a readmission.

If Separation B is included in the index episode of care, the readmission interval for both Separations A and B applies from the DOS for Separation B to the DOA for a readmission.

Scenario 2 Separation A Separation B Separation C Procedure Care type: Non-acute Care type: Acute performed DOS Separation A = DOA Separation B AND DOS Separation B = DOA Separation C Denominator – Index episode of Numerator – Readmission care

 Include Separation A in the  Include Separation B in the denominator numerator as a readmission for Separation A if:  Separations B and C are not included in the denominator  Source of Referral-Location for Separation B is not 4 or 5 or

Source of Referral- Professional is not 7 AND  PDx is a readmission PDx as per Table 1  Include Separation C in the numerator as a readmission for Separation A if:  Separation B is not in numerator AND  PDx is a readmission PDx as per Table 1 Readmission Interval The readmission interval is measured from the DOS for Separation A.

Appendix B: ICD10-AM (7th Ed) principal diagnosis codes for the numerator (specific rules used in the MyHospitals definition) Note: If the readmission interval shown in this appendix is longer than the procedure’s specified readmission interval (e.g. readmission interval for tonsillectomy and adenoidectomy is 15 days), then the default readmission interval should be the procedure’s specific readmission interval. Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) A04.7 - Enterocolitis due to Clostridium difficile Y Y Y Y Y Y 0-30 days A40 - Streptococcal sepsis Y Y Y Y Y Y Y 0-7 days A41 - Other sepsis Y Y Y Y Y Y Y 0-7 days A49 - Bacterial infection of unspecified site Y Y Y Y Y Y 0-7 days D50.0 - Iron deficiency anaemia secondary to blood loss (chronic) Y Y Y 0-7 days D50.8 - Other iron deficiency anaemias Y Y Y 0-7 days D50.9 - Iron deficiency anaemia, unspecified Y Y Y 0-7 days D62 - Acute posthaemorrhagic anaemia Y Y Y Y Y Y 0-15 days D64.9 - Anaemia, unspecified Y Y Y Y 0-7 days D68.3 - Haemorrhagic disorder due to circulating anticoagulants Y Y Y Y Y Y 0-7 days D68.4 - Acquired coagulation factor deficiency Y Y Y Y Y Y 0-7 days D68.5 - Primary thrombophilia Y Y Y Y Y Y 0-7 days D68.6 - Other thrombophilia Y Y Y Y Y Y 0-7 days D68.8 - Other specified coagulation defects Y Y Y Y Y Y 0-7 days D68.9 - Coagulation defect, unspecified Y Y Y Y Y Y 0-7 days D69.5 - Secondary thrombocytopenia Y Y Y Y Y Y 0-7 days D69.6 - Thrombocytopenia, unspecified Y Y Y Y Y Y 0-7 days D69.8 - Other specified haemorrhagic conditions Y Y Y Y Y Y 0-7 days D69.9 - Haemorrhagic condition, unspecified Y Y Y Y Y Y 0-7 days E10.0 - Type 1 diabetes mellitus with hyperosmolarity Y Y Y Y Y Y 0-7 days E10.1 - Type 1 diabetes mellitus with acidosis Y Y Y Y Y Y 0-7 days E10.64 - Type 1 diabetes mellitus with hypoglycaemia Y Y Y Y Y Y 0-7 days E10.65 - Type 1 diabetes mellitus with poor control Y Y Y Y Y Y 0-7 days E11.0 - Type 2 diabetes mellitus with hyperosmolarity Y Y Y Y Y Y 0-7 days E11.1 - Type 2 diabetes mellitus with acidosis Y Y Y Y Y Y 0-7 days E11.64 - Type 2 diabetes mellitus with hypoglycaemia Y Y Y Y Y Y 0-7 days E11.65 - Type 2 diabetes mellitus with poor control Y Y Y Y Y Y 0-7 days

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) E13.0 - Other specified diabetes mellitus with hyperosmolarity Y Y Y Y Y Y 0-7 days E13.1 - Other specified diabetes mellitus with acidosis Y Y Y Y Y Y 0-7 days E13.64 - Other specified diabetes mellitus with hypoglycaemia Y Y Y Y Y Y 0-7 days E13.65 - Other specified diabetes mellitus with poor control Y Y Y Y Y Y 0-7 days E14.0 - Unspecified diabetes mellitus with hyperosmolarity Y Y Y Y Y Y 0-7 days E14.1 - Unspecified diabetes mellitus with acidosis Y Y Y Y Y Y 0-7 days E14.64 - Unspecified diabetes mellitus with hypoglycaemia Y Y Y Y Y Y 0-7 days E14.65 - Unspecified diabetes mellitus with poor control Y Y Y Y Y Y 0-7 days E27.2 - Addisonian crisis Y Y Y Y Y Y 0-7 days E86 - Volume depletion Y Y Y Y Y Y 0-7 days E87 - Other disorders of fluid, electrolyte and acid- base balance Y Y Y Y Y Y 0-7 days F05.9 - Delirium, unspecified Y Y Y Y Y 0-7 days F10.2 - Mental and behavioural disorders due to use of alcohol, dependence syndrome Y Y Y Y Y 0-7 days F10.5 - Mental and behavioural disorders due to use of alcohol, psychotic disorder Y Y Y Y Y 0-7 days F11.2 - Mental and behavioural disorders due to use of opioids, dependence syndrome Y Y Y Y Y 0-7 days F11.5 - Mental and behavioural disorders due to use of opioids, psychotic disorder Y Y Y Y Y 0-7 days G45 - Transient cerebral ischaemic attacks and related syndromes Y Y Y Y Y 0-7 days G54.0 - Brachial plexus disorders Y Y Y Y Y 0-7 days G54.1 - Lumbosacral plexus disorders Y Y Y Y 0-7 days G56 - Mononeuropathies of upper limb Y Y Y Y Y Y 0-7 days G57 - Mononeuropathies of lower limb Y Y Y Y 0-7 days G97.0 - Cerebrospinal fluid leak from spinal puncture Y Y Y Y 0-7 days G97.1 - Other reaction to spinal and lumbar puncture Y Y Y Y 0-7 days G97.8 - Other postprocedural disorders of nervous system Y Y Y Y Y Y Y 0-7 days

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) G97.9 - Postprocedural disorder of nervous system, unspecified Y Y Y Y Y Y Y 0-7 days H02.4 - Ptosis of eyelid Y H15.0 - Scleritis Y H16.0 - Corneal ulcer Y H16.1 - Other superficial keratitis without conjunctivitis Y H16.2 - Keratoconjunctivitis Y H16.3 - Interstitial and deep keratitis Y H16.8 - Other keratitis Y H16.9 - Keratitis, unspecified Y H20.0 - Acute and subacute iridocyclitis Y H20.2 - Lens-induced iridocyclitis Y H20.8 - Other iridocyclitis Y H20.9 - Iridocyclitis, unspecified Y H21.0 - Hyphaema Y H21.5 - Other adhesions and disruptions of iris and ciliary body Y H21.8 - Other specified disorders of iris and ciliary body Y H26.4 - After-cataract Y H27 - Other disorders of lens Y H31.3 - Choroidal haemorrhage and rupture Y H31.4 - Choroidal detachment Y H33.0 - Retinal detachment with retinal break Y H33.2 - Serous retinal detachment Y H33.3 - Retinal breaks without detachment Y H33.4 - Traction detachment of retina Y H33.5 - Other retinal detachments Y H40.0 - Glaucoma suspect Y H40.2 - Primary angle- closure glaucoma Y H40.4 - Glaucoma secondary to eye inflammation Y H40.8 - Other glaucoma Y H40.9 - Glaucoma, unspecified Y H43.0 - Vitreous prolapse Y H43.1 - Vitreous haemorrhage Y H43.3 - Other vitreous opacities Y H43.8 - Other disorders of vitreous body Y H43.9 - Disorder of vitreous body, unspecified Y

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) H44.0 - Purulent endophthalmitis Y H44.1 - Other endophthalmitis Y H44.4 - Hypotony of eye Y H44.6 - Retained (old) intraocular foreign body, magnetic Y H44.7 - Retained (old) intraocular foreign body, nonmagnetic Y H53 - Visual disturbances Y 0-7 days H57.1 - Ocular pain Y H59 - Postprocedural disorders of eye and adnexa, not elsewhere classified Y I20 - Angina pectoris Y Y Y Y Y 0-7 days I21 - Acute myocardial infarction Y Y Y Y Y 0-7 days I24 - Other acute ischaemic heart diseases Y Y Y Y Y 0-7 days I26 - Pulmonary embolism Y Y Y Y Y Y I33 - Acute and subacute endocarditis Y Y Y Y Y Y 0-15 days I38 - Endocarditis, valve unspecified Y Y Y Y Y Y 0-15 days I39 - Endocarditis and heart valve disorders in diseases classified elsewhere Y Y Y Y Y Y 0-15 days I45 - Other conduction disorders Y Y Y Y Y 0-7 days I46 - Cardiac arrest Y Y Y Y Y Y 0-7 days I47 - Paroxysmal tachycardia Y Y Y Y Y 0-7 days I48 - Atrial fibrillation and flutter Y Y Y Y Y 0-7 days I49 - Other cardiac arrhythmias Y Y Y Y Y 0-7 days I50 - Heart failure Y Y Y Y Y 0-7 days I51 - Complications and ill-defined descriptions of heart disease Y Y Y Y Y 0-7 days I60 - Subarachnoid haemorrhage Y Y Y Y Y 0-7 days I61 - Intracerebral haemorrhage Y Y Y Y Y 0-7 days I62 - Other nontraumatic intracranial haemorrhage Y Y Y Y Y 0-7 days I63 - Cerebral infarction Y Y Y Y Y 0-7 days I64 - Stroke, not specified as haemorrhage or infarction Y Y Y Y Y 0-7 days I65 - Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction Y Y Y Y Y 0-7 days I66 - Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction Y Y Y Y Y 0-7 days I74 - Arterial embolism and thrombosis Y Y Y Y 0-7 days I80 - Phlebitis and thrombophlebitis Y Y Y Y Y Y Y I81 - Portal vein thrombosis Y Y Y Y Y Y

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) I82.2 - Embolism and thrombosis of vena cava Y Y Y Y I82.8 - Embolism and thrombosis of other specified veins Y Y Y Y Y Y Y I95 - Hypotension Y Y Y Y Y Y 0-7 days I97.8 - Other postprocedural disorders of circulatory system, not elsewhere classified Y Y Y Y Y Y 0-15 days I97.9 - Postprocedural disorder of circulatory system, unspecified Y Y Y Y Y Y 0-15 days J02 - Acute pharyngitis Y J03 - Acute tonsillitis Y J06 - Acute upper respiratory infections of multiple and unspecified sites Y 0-7 days J12 - Viral pneumonia, not elsewhere classified Y Y Y Y Y Y 0-7 days J13 - Pneumonia due to Streptococcus pneumoniae Y Y Y Y Y Y 0-7 days J14 - Pneumonia due to Haemophilus influenzae Y Y Y Y Y Y 0-7 days J15 - Bacterial pneumonia, not elsewhere classified Y Y Y Y Y Y 0-7 days J16 - Pneumonia due to other infectious organisms, not elsewhere classified Y Y Y Y Y Y 0-7 days J17 - Pneumonia in diseases classified elsewhere Y Y Y Y Y Y 0-7 days J18 - Pneumonia, organism unspecified Y Y Y Y Y Y 0-7 days J20 - Acute bronchitis Y Y Y Y Y Y 0-7 days J22 - Unspecified acute lower respiratory infection Y Y Y Y Y Y 0-7 days J35 - Chronic diseases of tonsils and adenoids Y J36 - Peritonsillar abscess Y J39 - Other diseases of upper respiratory tract Y 0-7 days J40 - Bronchitis, not specified as acute or chronic Y Y Y Y Y Y 0-7 days J44 - Other chronic obstructive pulmonary disease Y Y Y Y Y 0-7 days J69.0 - Pneumonitis due to food and vomit Y Y Y Y Y Y 0-7 days J81 - Pulmonary oedema Y Y Y Y Y 0-7 days J95.2 - Acute pulmonary insufficiency following nonthoracic surgery Y Y Y Y Y Y 0-7 days J95.4 - Mendelson's syndrome Y Y Y Y Y Y 0-7 days J95.5 - Postprocedural subglottic stenosis Y Y Y Y Y Y 0-7 days J95.8 - Other postprocedural respiratory disorders Y Y Y Y Y Y 0-7 days J95.9 - Postprocedural respiratory disorder, unspecified Y Y Y Y Y Y 0-7 days

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) J96.0 - Acute respiratory failure Y Y Y Y Y Y 0-7 days J96.9 - Respiratory failure, unspecified Y Y Y Y Y Y 0-7 days J98.1 - Pulmonary collapse Y Y Y Y Y Y 0-7 days K12.2 - Cellulitis and abscess of mouth Y K38.3 - Fistula of appendix Y K43 - Ventral hernia Y Y Y K45 - Other abdominal hernia Y Y Y K46 - Unspecified abdominal hernia Y Y Y K56.0 - Paralytic ileus Y Y Y K56.1 - Intussusception Y K56.2 - Volvulus Y Y Y K56.4 - Other impaction of intestine Y Y Y K56.5 - Intestinal adhesions [bands] with obstruction Y Y K56.6 - Other and unspecified intestinal obstruction Y Y Y K56.7 - Ileus, unspecified Y Y Y K57 - Diverticular disease of intestine Y 0-7 days K59.0 - Constipation Y Y Y Y Y 0-7 days K63.0 - Abscess of intestine Y Y K63.1 - Perforation of intestine (nontraumatic) Y Y Y K63.2 - Fistula of intestine Y Y Y K65 - Peritonitis Y Y Y K66.0 - Peritoneal adhesions Y Y K66.1 - Haemoperitoneum Y Y K91.0 - Vomiting following gastrointestinal surgery Y 0-7 days K91.3 - Postprocedural intestinal obstruction Y Y Y Y Y 0-7 days K91.8 - Other postprocedural disorders of digestive system, not elsewhere classified Y Y Y Y 0-7 days K91.9 - Postprocedural disorder of digestive system, unspecified Y Y Y Y 0-7 days K92.0 - Haematemesis Y K92.1 - Melaena Y Y 0-7 days K92.2 - Gastrointestinal haemorrhage, unspecified Y 0-7 days L03.10 - Cellulitis of upper limb Y Y Y Y Y Y 0-7 days L03.11 - Cellulitis of lower limb Y Y 0-7 days L03.2 - Cellulitis of face Y 0-7 days L03.3 - Cellulitis of trunk Y Y Y 0-7 days L23.1 - Allergic contact dermatitis due to adhesives Y Y Y Y Y Y 0-7 days L27.0 - Generalised skin eruption due to drugs and medicaments Y Y Y Y Y Y Y 0-7 days

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) L27.1 - Localised skin eruption due to drugs and medicaments Y Y Y Y Y Y Y 0-7 days L89 - Decubitus ulcer and pressure area Y Y Y Y 0-7 days M00.05 - Staphylococcal arthritis and polyarthritis, pelvic region and thigh Y M00.06 - Staphylococcal arthritis and polyarthritis, lower leg Y M00.25 - Other streptococcal arthritis and polyarthritis, pelvic region and thigh Y M00.26 - Other streptococcal arthritis and polyarthritis, lower leg Y M00.95 - Pyogenic arthritis, unspecified, pelvic region and thigh Y M00.96 - Pyogenic arthritis, unspecified, lower leg Y M21.25 - Flexion deformity, pelvic region and thigh Y M21.26 - Flexion deformity, lower leg Y M21.30 - Wrist or foot drop (acquired), multiple sites Y Y M21.37 - Wrist or foot drop (acquired), ankle and foot Y Y M21.75 - Unequal limb length (acquired), pelvic region and thigh Y M21.76 - Unequal limb length (acquired), lower leg Y Y M24.45 - Recurrent dislocation and subluxation of joint, pelvic region and thigh Y M24.46 - Recurrent dislocation and subluxation of joint, lower leg Y M24.65 - Ankylosis of joint, pelvic region and thigh Y M24.66 - Ankylosis of joint, lower leg Y M25.05 - Haemarthrosis, pelvic region and thigh Y M25.06 - Haemarthrosis, lower leg Y M25.45 - Effusion of joint, pelvic region and thigh Y M25.46 - Effusion of joint, lower leg Y M25.55 - Pain in a joint, pelvic region and thigh Y M25.56 - Pain in a joint, lower leg Y M25.65 - Stiffness of joint, not elsewhere classified, pelvic region and thigh Y

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) M25.66 - Stiffness of joint, not elsewhere classified, lower leg Y M25.85 - Other specified joint disorders, pelvic region and thigh Y M25.86 - Other specified joint disorders, lower leg Y M25.95 - Unspecified joint disorder, pelvic region and thigh Y M25.96 - Unspecified joint disorder, lower leg Y M79.15 - Myalgia, pelvic region and thigh Y Y Y M79.16 - Myalgia, lower leg Y Y Y M79.25 - Neuralgia and neuritis, unspecified, pelvic region and thigh Y Y Y M79.26 - Neuralgia and neuritis, unspecified, lower leg Y Y Y M79.55 - Residual foreign body in soft tissue, pelvic region and thigh Y M79.56 - Residual foreign body in soft tissue, lower leg Y M79.65 - Pain in limb, pelvic region and thigh Y Y Y Y M79.66 - Pain in limb, lower leg Y Y Y Y M84.35 - Stress fracture, not elsewhere classified, pelvic region and thigh Y M84.36 - Stress fracture, not elsewhere classified, lower leg Y M87.05 - Idiopathic aseptic necrosis of bone, pelvic region and thigh Y M87.06 - Idiopathic aseptic necrosis of bone, lower leg Y M87.25 - Osteonecrosis due to previous trauma, pelvic region and thigh Y M87.26 - Osteonecrosis due to previous trauma, lower leg Y M87.85 - Other osteonecrosis, pelvic region and thigh Y M87.86 - Other osteonecrosis, lower leg Y M87.95 - Unspecified osteonecrosis, pelvic region and thigh Y M87.96 - Unspecified osteonecrosis, lower leg Y M96.6 - Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate Y Y M96.8 - Other postprocedural musculoskeletal disorders Y Y Y Y

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) M96.9 - Postprocedural musculoskeletal disorder, unspecified Y Y Y Y N02.8 - Recurrent and persistent haematuria, other Y Y N02.9 - Recurrent and persistent haematuria, unspecified Y Y N13.0 - Hydronephrosis with ureteropelvic junction obstruction Y Y N13.1 - Hydronephrosis with ureteral stricture, not elsewhere classified Y Y N13.3 - Other and unspecified hydronephrosis Y Y N13.4 - Hydroureter Y Y N13.5 - Kinking and stricture of ureter without hydronephrosis Y Y N13.6 - Pyonephrosis Y Y N13.7 - Vesicoureteral- reflux-associated uropathy Y Y N13.8 - Other obstructive and reflux uropathy Y Y N13.9 - Obstructive and reflux uropathy, unspecified Y Y N17 - Acute kidney failure Y Y Y Y Y Y 0-7 days N30.0 - Acute cystitis Y Y Y Y Y N30.3 - Trigonitis Y Y Y Y Y N30.8 - Other cystitis Y Y Y Y Y N30.9 - Cystitis, unspecified Y Y Y Y Y N31.2 - Flaccid neuropathic bladder, not elsewhere classified Y Y Y Y Y N31.8 - Other neuromuscular dysfunction of bladder Y Y Y Y Y N31.9 - Neuromuscular dysfunction of bladder, unspecified Y Y Y Y Y N32.0 - Bladder neck obstruction Y Y N32.1 - Vesicointestinal fistula Y Y N32.2 - Vesical fistula, not elsewhere classified Y Y N35 - Urethral stricture Y Y N39.0 - Urinary tract infection, site not specified Y Y Y Y Y N39.3 - Stress incontinence Y Y Y Y N39.4 - Other specified urinary incontinence Y Y Y Y N41 - Inflammatory diseases of prostate Y N42.1 - Congestion and haemorrhage of prostate Y N45 - Orchitis and epididymitis Y N47 - Redundant prepuce, phimosis and paraphimosis Y N48.1 - Balanoposthitis Y

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) N70 - Salpingitis and oophoritis Y Y N73 - Other female pelvic inflammatory diseases Y Y N76 - Other inflammation of vagina and vulva Y N81 - Female genital prolapse Y N82 - Fistulae involving female genital tract Y N89.5 - Stricture and atresia of vagina Y N93 - Other abnormal uterine and vaginal bleeding Y N94.1 - Dyspareunia Y Y N99.0 - Postprocedural kidney failure Y Y Y Y Y Y 0-7 days N99.1 - Postprocedural urethral stricture Y Y Y Y Y N99.3 - Prolapse of vaginal vault after hysterectomy Y N99.8 - Other postprocedural disorders of genitourinary system Y Y N99.9 - Postprocedural disorder of genitourinary system, unspecified Y Y Q43.0 - Meckel's diverticulum Y R00 - Abnormalities of heart beat Y Y Y Y Y 0-7 days R04.1 - Haemorrhage from throat Y R04.2 - Haemoptysis Y R06.0 - Dyspnoea Y Y Y Y Y Y 0-7 days R06.1 - Stridor Y R07.0 - Pain in throat Y R10.0 - Acute abdomen Y Y Y R10.2 - Pelvic and perineal pain Y Y Y R10.3 - Pain localised to other parts of lower abdomen Y Y Y R11 - Nausea and vomiting Y Y Y Y Y Y Y 0-7 days R13 - Dysphagia Y R15 - Faecal incontinence Y Y R19.0 - Intra-abdominal and pelvic swelling, mass and lump Y Y Y R26.2 - Difficulty in walking, not elsewhere classified Y Y R26.8 - Other and unspecified abnormalities of gait and mobility Y Y R30.1 - Vesical tenesmus Y Y Y Y Y 0-7 days R30.9 - Painful micturition, unspecified Y Y Y Y Y 0-7 days R31 - Unspecified haematuria Y Y Y Y Y 0-7 days R32 - Unspecified urinary incontinence Y Y Y Y Y 0-7 days R33 - Retention of urine Y Y Y Y Y 0-7 days R34 - Anuria and oliguria Y Y Y Y Y 0-7 days

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) R39.0 - Extravasation of urine Y Y R39.1 - Other difficulties with micturition Y Y Y Y Y R39.8 - Other and unspecified symptoms and signs involving the urinary system Y Y Y Y Y R41.0 - Disorientation, unspecified Y Y Y Y Y 0-7 days R42 - Dizziness and giddiness Y Y Y Y Y 0-7 days R49.0 - Dysphonia Y R50 - Fever of other and unknown origin Y Y Y Y Y Y 0-7 days R53 - Malaise and fatigue Y Y Y Y Y Y 0-7 days R58 - Haemorrhage, not elsewhere classified Y Y Y Y Y Y R63.0 - Anorexia Y 0-7 days R63.3 - Feeding difficulties and mismanagement Y 0-7 days R63.8 - Other symptoms and signs concerning food and fluid intake Y Y 0-7 days R79 - Other abnormal findings of blood chemistry Y Y Y Y Y Y 0-7 days S06.1 - Traumatic Y Y 0-7 days cerebral oedema S06.3 - Focal brain injury Y Y 0-7 days S06.4 - Epidural haemorrhage Y Y 0-7 days S06.5 - Traumatic subdural haemorrhage Y Y 0-7 days S06.6 - Traumatic subarachnoid haemorrhage Y Y 0-7 days S06.8 - Other intracranial injuries Y Y 0-7 days S30.2 - Contusion of external genital organs Y Y Y 0-7 days S37.1 - Injury of ureter Y Y Y 0-7 days S37.20 - Injury of bladder, unspecified Y Y 0-7 days S37.21 - Contusion of bladder Y Y 0-7 days S37.22 - Rupture of bladder Y Y S37.28 - Other injury of bladder Y Y 0-7 days S37.30 - Injury of urethra, part unspecified Y Y Y Y Y 0-7 days S37.31 - Injury of membranous urethra Y Y Y Y 0-7 days S37.32 - Injury of penile urethra Y Y Y Y 0-7 days S37.33 - Injury of prostatic urethra Y Y Y Y 0-7 days S37.38 - Injury of other part of urethra Y Y Y Y Y 0-7 days S37.4 - Injury of ovary Y Y 0-7 days S37.5 - Injury of fallopian tube Y Y 0-7 days S37.7 - Injury of multiple pelvic organs Y Y Y 0-7 days S37.81 - Injury of adrenal gland Y Y 0-7 days

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) S37.82 - Injury of prostate Y 0-7 days S37.83 - Injury of seminal vesicle Y 0-7 days S37.84 - Injury of vas deferens Y 0-7 days S37.88 - Injury of other pelvic organ Y Y Y 0-7 days S37.9 - Injury of unspecified pelvic organ Y Y Y 0-7 days S72.0 - Fracture of neck of femur Y Y 0-7 days S73 - Dislocation, sprain and strain of joint and ligaments of hip Y 0-7 days S74 - Injury of nerves at hip and thigh level Y Y Y Y 0-7 days T40.2 - Other opioids Y Y Y Y Y Y 0-7 days T40.4 - Other synthetic narcotics Y Y Y Y Y Y 0-7 days T40.6 - Other and unspecified narcotics y Y Y Y Y Y 0-7 days T45.5 - Anticoagulants Y Y Y Y Y 0-7 days T80.1 - Vascular complications following infusion, transfusion and therapeutic injection Y Y Y Y Y Y Y 0-7 days T80.2 - Infections following infusion, transfusion and therapeutic injection Y Y Y Y Y Y Y 0-7 days T81 - Complications of procedures, not elsewhere classified Excluding T81.1 - Shock during or resulting from a procedure, not elsewhere classified Y Y Y Y Y Y Y T83.0 - Mechanical complication of urinary (indwelling) catheter Y Y Y Y Y 0-7 days T84 - Complications of internal orthopaedic prosthetic devices, implants and grafts Y Y T85.2 - Mechanical complication of intraocular lens Y T85.78 - Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts Y Y Y Y T85.88 - Other complications of internal prosthetic device, implant and graft, NEC Y Y Y Y T85.9 - Unspecified complication of internal prosthetic device, implant and graft Y Y Y Y Y Y T88.5 - Other complications of anaesthesia Y Y Y Y Y Y Y 0-7 days T88.7 - Unspecified adverse effect of drug or medicament Y Y Y Y Y Y Y 0-7 days

Principal Diagnosis Knee Hip Hyster. Prostat. Tonsill. Appendic. Cat.Surg. Recommended Rep. Rep. & readmission Adenoid. interval (if not entire readmission interval) T88.8 - Other specified complications of surgical and medical care, not elsewhere classified Y Y Y Y Y Y Y T88.9 - Complication of surgical and medical care, unspecified Y Y Y Y Y Y Y Z46.6 - Fitting and adjustment of urinary device Y Y Y Y Y Z74.0 - Need for assistance due to reduced mobility Y Y Y Y Y Y 0-7 days

EQ12: Rate of community follow up within first 7 days of discharge from psychiatric admission

Reported Data Description Items Identifier (office use only)

Name Rate of community follow-up within first 7 days of discharge from psychiatric admission Aliases Proportion of public patient contacts with community-based public mental health non-admitted services within seven days post discharge from designated acute psychiatric inpatient units. Definition Proportion of separations from the mental health service organisation’s acute psychiatric inpatient unit(s) for which a community ambulatory service contact, in which the consumer participated, was recorded in the seven days immediately following that separation. An acute psychiatric inpatient unit is defined as services that provide voluntary and involuntary short-term inpatient management and treatment during an acute phase of mental illness, until the person has recovered enough to be treated effectively and safely in the community. An ambulatory service contact is the provision of a clinically significant service by a specialised MH service provider(s) for patients/clients, other than those patients/clients admitted to psychiatric hospitals or designated psychiatric units in acute care hospitals, and those resident in 24 hour staffed specialised residential mental health services, where the nature of the service would normally warrant a dated entry in the clinical record of the patient/client in question. In May 2011 a target of 75% achievement was endorsed by the AHMAC Mental Health Standing Committee. This target will be subject to periodic review and will be further informed by analysis of the data. Related Rate of hospital readmissions within 28 days to an acute designated Metadata mental health inpatient unit. Guide for Use: Continuity of care and support following discharge from an acute mental inpatient service is important as:  A responsive community support system for persons who have experienced an acute psychiatric episode requiring hospitalisation is essential to maintain clinical and functional stability and to minimise the need for hospital readmission. o Patients leaving hospital after a psychiatric admission with a formal discharge plan, involving linkages with community services and supports, are less likely to need early readmission. o Research indicates that patients have increased vulnerability immediately following discharge, including higher risk for suicide. This indicator is reported at the facility at which the patient was discharged from. This indicator is reported at a facility level and is based on the location of

the acute psychiatric inpatient unit (e.g., as Boronia Lodge is located at Swan Districts hospital, any post discharge contacts for separations from Boronia Lodge will be reported under Swan Districts hospital). Limitations Some public patients discharged from designated mental health inpatient units will not be followed up by a public community team. These patients may leave the State or be treated by a private mental health practitioner or a GP. These patients are counted as not being seen when they should be excluded altogether from the denominator. This reporting definition relies on coded data from HMDS. By its nature, this indicator also requires at least 7 days to elapse from the date of separation prior to being able to report. To overcome these limitations, a lag is included in the reporting of data. Figures reported for recent months may not be complete due to delays in data coding and quality checking. It is recommended that this indicator is reported on a quarterly basis with a 6 month lag in the reference period for the data. Reported Data Validation Items Format Percentage 4 NN.N% Data Values Inclusions All public patient separations from designated acute mental health inpatient units within WA. For the numerator – the patient must be present at the service event following discharge. Exclusions For the numerator - Community service contacts on day of separation are not included. The following separations are excluded:  Same day separations.  Statistical and change of care type separations.  Separations that end by transfer to another acute or psychiatric hospital.  Separations that end by death, left against medical advice/discharge at own risk. Scope All WA acute designated psychiatric mental health facilities (as listed below). Acute mental health units Excludes the following non- at the following facilities: acute/rehabilitation units Albany Hospital Armadale Hospital Karri Ward

Bentley Hospital John Milne Centre Broome Hospital Bunbury Hospital Fremantle Hospital Graylands Hospital Ellis, Plaistowe, Casson, Red Wing, Murchison and Plaistowe Forensic Hutchison excluded from 9 January 2014 Joondalup Health Campus Kalgoorlie hospital King Edward Memorial Hospital

Osborne Park Hospital Princess Margaret Hospital Rockingham Hospital Royal Perth Hospital Sir Charles Gairdner Hospital Swan Districts Hospital

For a particular report, please refer to that report’s scoping to determine which sites are included. Formula Numerator: Number of in scope overnight public separations from designated acute mental health inpatient units within the reference period for which a community ambulatory service contact, in which the consumer participated, was recorded in the seven days immediately following that separation. Denominator: Number of in-scope overnight public separations for designated acute mental health inpatient units occurring within the reference period. Calculation (Numerator ÷ Denominator) × 100, expressed as a percentage Verification Rules Value =< 100%

Data Collection Identification Items Source HMDS (Inpatient separations) and MHIS (Ambulatory mental health service contacts)

Governance Items Purpose of the To monitor continuity of care and support following discharge from an data acutemental health inpatient unit.

Source of the Manager, Mental Health Information System. definition AHMAC, National Mental Health Performance subcommittee.

Version number 1.2

Approval date 20140423 (Noted by PRGC)

EQ13: Measures of patient experience (including satisfaction) with hospital services

Reported Data Description Items Identifier (office use only) Name Overall Indicator of Patient Satisfaction Aliases Overall Satisfaction, wghtcomp Definition Overall patient satisfaction for adults admitted 0-34 nights to public hospitals (and to private hospitals contracted to provide public hospital services). Related Metadata Guide for Use The Overall Indicator of Patient Satisfaction is just one component of the Patient Evaluation of Health Services (PEHS) Patient Satisfaction survey, but gives a good indication of overall patient satisfaction as measured by seven domains and is also weighted by overall rankings of importance.

The PEHS survey is conducted annually by Edith Cowan University’s Survey Research Centre using Computer Assisted Telephone Interview. The survey is administered to a randomly selected sample of patients admitted to a WA hospital as a public patient. The survey uses a valid and reliable instrument containing questions that cover seven domains of health care. These domains were identified by Principal Component Analysis and validated by the University of Western Australia.

The seven domains are:  Time and attention paid to your care  Getting into hospital  Information and communication between you and the people caring for you  Meeting your personal as well as clinical needs  Your right to be involved in your care and treatment  The coordination and consistency of your care  The residential aspects of the hospital

Patients are also asked to rank each domain from least important to most important.

Each scale score is calculated as follows. Firstly, the responses to each question in the domains (scales) are weighted from 0 to 1, where 0 is the least acceptable or least favorable response and 1 is the most acceptable or most favorable response. All values in between reflect a range of perceptions between these two extremes. ‘No opinion’ and ‘Doesn’t apply’ are not included in the analysis.

Secondly, the average score out of 100 for each of the seven scales (and their sub-scales if applicable) is

calculated. The scores are then weighted by the rankings of importance. The average of these seven scales is calculated, this is the overall indicator of patient satisfaction.

If the overall score is less than 70, there is cause for concern. An investigation of each scale and individual questions will assist in identifying those areas of patient satisfaction that require attention. Limitations The sampling timeframes have changed over time. In 2010-11 and 2009-10 the surveys were conducted over each full financial year. In 2009 the survey was conducted from 1 February to 30 June 2009.

The number of patients selected from each hospital will vary based on budgetary constraints and the size of the hospital.

The sample is only representative of Western Australian adults admitted to hospitals as a public patient.

Reported Data Validation Items Format Numeric 4 NNN.N Data Values Inclusions Care Type = 21 = Acute Care Funding = 21 = Australian HealthCare Agreements Funding Client Type = 6 = Admitted Client Mode Separation = 9 = Home Length of Stay 0-34 nights (sep - adm=<34) Aged 16-74 years at separation Western Australian Resident (6000<=postcode<=6999) At least one phone number

Exclusions Psychiatric Care Days > 0 Interpreter Required = 1 = Yes Silent Numbers Prisoners Deceased since discharge

Scope Public Hospitals (metropolitan and rural) Joondalup Health Campus, publicly funded activity Peel Health Campus, publicly funded activity

Formula: Weight individual responses to questions from 0 to 1,

If 4 point variable:

wardwait2 =.; if wardwait = 1 then wardwait2 = 0; if wardwait = 2 then wardwait2 = .33; if wardwait = 3 then wardwait2 = .67; if wardwait = 4 then wardwait2 = 1;

drop wardwait; rename wardwait2 wardwait;

If 5 point variable then weight as follows: 1 = 0; 2 = .25; 3 = .5; 4 = .75; 5 = 1;

Then Calculate mean scale scores for each subscale,

E.g. getohosp = MEAN(of wardwait hos_wait adm_feel)*100; …(repeat for all other subscales)

Then Calculate mean scale scores for each scale, as defined by subscales

E.g. access = MEAN(of wardwait hos_wait adm_feel signpost parking rate_ass priv_ask culture dietask adm_proc adm_plan timecons toldward ask_medi ohcpchk )*100; …(and repeat for 6 other scales)

Then Weight each scale score by corresponding patient rankings from least important to most important, avail_mean = mean (of avail); needs_mean = mean (of needs); waittime_mean = mean (of waittime); inform_mean = mean (of inform); involve_mean = mean (of involv); environ_mean = mean (of environ); cocare_mean = mean (of cocare); min = min(of avail_mean needs_mean waittime_mean inform_mean involve_mean environ_mean cocare_mean); sc1 = access*(waittime_mean/min); sc2 = availabl*(avail_mean/min); sc3 = environs*(environ_mean/min); sc4 = specneed*(needs_mean/min); sc5 = continue*(cocare_mean/min); sc6 = informed*(inform_mean/min); sc7 = involved*(involve_mean/min); sumscs = sum(of sc1 sc2 sc3 sc4 sc5 sc6 sc7); if (sc1>=0)then d1=(waittime_mean/min); if (sc2>=0)then d2=(avail_mean/min); if (sc3>=0)then d3=(environ_mean/min); if (sc4>=0)then d4=(needs_mean/min); if (sc5>=0)then d5=(cocare_mean/min); if (sc6>=0)then d6=(inform_mean/min);

if (sc7>=0)then d7=(involve_mean/min);

sumds = sum(of d1 d2 d3 d4 d5 d6 d7);

Then Calculate the mean weighted score.

wghtcomp = (sumscs/sumds); Verification Rules >=0 and <=100

Data Collection Identification Items Source Patient Evaluation of Health Services Survey (PEHS) Patient Satisfaction survey

Governance Items Purpose of the data A measure of overall patient satisfaction of adults admitted 0-34 nights to public hospitals for ABF/ABM Performance Management Reports.

Source of the definition Epidemiology Branch, System Policy & Planning

Version number 1.0

Approval date 20120813

EQ14: Hand Hygiene Compliance

Reported Data Description Items Identifier (office use only)

Name Hospital Hand Hygiene Compliance Rate

Aliases Hand Hygiene Compliance

Definition The hand hygiene compliance rate (expressed as a percentage) of a participating WA Public Hospital.

Related Metadata Guide for Use: Improving hand hygiene (HH) among healthcare workers (HCW) is currently the single most effective intervention to reduce the risk of healthcare associated infections in Australian hospitals. Poor hand hygiene practice among HCWs is strongly associated with healthcare associated infection transmission and is a major factor in the spread of antibiotic-resistant pathogens within hospitals.1

There is convincing evidence that improved hand hygiene can reduce infection rates. More than 20 hospital based studies (including systematic reviews) of the impact of hand hygiene on the risk of healthcare associated infection have been published between 1977 and 2008. Despite study limitations almost all showed an association between improved hand hygiene practices and reduced infection and cross transmission rates.1

The Australian Commission on Safety and Quality in Health Care (ACSQHC) engaged Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI).

The NHHI aims to improve knowledge about infection control among HCWs, including the importance of appropriate HH in reducing the risk of healthcare associated infections.

The NHHI is multi-faceted and includes education regarding HH and alcohol based hand rub (ABHR), measuring infection rates, and tri–annual monitoring and feedback of HH compliance.1

Direct observation by trained observers is the gold standard to monitor compliance with optimal hand hygiene practice. The volume of data collected by hospitals is determined by their acute inpatient bed number. This ensures that audit intensity is consistent with a hospital’s likely infection control risk.2

The audit process to determine hand hygiene compliance is based on the World Health Organization “5 Moments for Hand Hygiene” framework, which defines the five key “Moments” when hand-cleaning is required during patient care, i.e., 1: before touching a patient;

2: before a procedure; 3: after a procedure or body fluid exposure risk; 4: after touching a patient; and 5: after touching a patient’s surroundings.1

Collected data is used to calculate the hand hygiene compliance rate of a hospital (expressed as a percentage). The rate reflects the total number of appropriately performed HH Moments observed in a given period divided by the total number of moments observed in the same period.

WA Health has identified a state-wide benchmark of 70% compliance.3

Published literature notes that a “power band” of disease reduction appears to occur when HH compliance rates improve to 55%–70% using the 5 Moments tool.4

References: 1 HHA 5 moments for hand hygiene manual. Retrieved from http://www.hha.org.au/UserFiles/file/Manual/HHAManual_201 0-11-23.pdf 1/3/2012

2 Outcomes from the first two years of the Australian National Hand Hygiene Initiative (supplemental material), retrieved from http://www.hha.org.au/UserFiles/file/MJA_Supplement/MJA- 2011-10747R1-GRAYSON-SupplementarydataB.pdf 1/3/12

3 retrieved from http://www.health.wa.gov.au/press/view_press.cfm?id=1096 1/3/2012.

4 Grayson LM, Russo PL, Cruickshank M, Bear JL , Gee CA, et al. Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative Medical Journal of Australia 2011; 195 (10): 615-619.

Limitations WA Hospital participation in hand hygiene compliance data collection is identified in Operational Directive 0197/09. From February 2010 data collection is mandatory for all public metropolitan hospitals, WACHS regional resource centres and integrated district health services, and Joondalup and Peel Health Campuses. WACHS small hospital participation is at the discretion of WACHS.

Not all WACHS small hospitals participate in data collection each audit period. In addition a number of mandatory hospitals have not submitted data in each audit period from February 2010.

If data is used for comparison, it is important to note that generally a higher number of moments audited will generate a more reliable compliance rate. HHA recommends using 95% confidence intervals when reporting compliance rates.

Audit periods have changed slightly since the commencement of the NHHI; however, audit periods remain tri-annual. In 2012, The audit periods are;  February 1 – March 30  May 1 – June 30  September 1 – October 31.

Reported Data Validation Items Format Numeric 3 NN.N

Data Values Inclusions Numerator: The total number of appropriately performed HH moments observed at a hospital in a given audit period.

Denominator: the total number of HH Moments observed at a hospital in a given audit period.

The moments are; 1: before touching a patient; 2: before a procedure; 3: after a procedure or body fluid exposure risk; 4: after touching a patient; 5: after touching a patient’s surroundings.

Exclusions Nil

Scope Public metropolitan, WACHS regional resource centres and integrated district health services.

Participating WACHS small hospitals.

Joondalup and Peel Health Campuses.

For a particular report, please refer to that report’s scoping to determine which sites are included.

Formula: Numerator: X=Total number of appropriately performed HH Moments observed at a hospital in a given audit period.

Denominator: Y=Total number of HH Moments observed at a hospital in a given audit period.

Calculation: X/Y *100 = % rate of overall hand hygiene compliance

Utilise numerator / denominator to calculate the exact binomial 95% Confidence Interval

Verification Rules % rate of overall hand hygiene compliance >=0 and <=100%

Data Collection Identification Items Source Office of Safety and Quality in Healthcare.

Governance Items Purpose of the data To report the hand hygiene compliance rate of Western Australian public hospitals for ABF/ABM Performance Management Reports

Source of the definition Quality Improvement Directorate

Version number 1.0

Approval date 20120813

2.4 Efficiency Inputs per output unit (EI) KPIs

There are 11 EI PIs proposed in the 2014-15 PMF, including 7 Health Service measures.

EI2: Elective surgery day of surgery admission rates

Reported Data Description Items Identifier MDG-01-015 Name Day of Surgery (elective) Admission rate Aliases . DOSA Definition The proportion of multi-day elective surgical separations where a procedure was performed on the day of admission. Related metadata Guide for Use Day of Surgery (Elective) Admission (DOSA) rates are counted from records in the Hospital Morbidity Data System (HMDS) using the [Diagnosis Related Groups], [Care Type / Episode of Care Type], [Admit Type], [Client Status / Patient Type], [Procedure Date], [Admission Date] and [Payment Classification] fields. DOSA rates are the proportion of acute multi-day elective surgical separations, where a procedure was undertaken on the same day as admission. DRGs are applied to the discharge records and are only available at the conclusion of clinical coding. Therefore DOSA rates cannot be calculated until the conclusion of clinical coding and thus the HMDS is the accurate source of determining DOSA rates. Only records with Care Type of Acute or Patient Type of Qualified Newborn are included in the count for acute separations. Organ procurement, hospital boarders, unqualified newborns, Aged Care Residents, Flexible Care and Ambulatory Surgical Initiative patients are excluded from the count. Contracted activity is counted at the hospital where the activity is performed (i.e. the contracted hospital). Rates are counted from HMDC based on the DRG applied to the discharge record. Procedure dates are entered during clinical coding of procedures performed. As this information is only available at the conclusion of clinical coding, the source used is HMDS given the improved accuracy of using a DRG to determine true surgical separations. Historical data is updated in each extract, to take account of edit/quality assurance processes.

Limitations Delays in clinical coding may result in a potential lag in data completeness.

Reported Data Validation Items Format Percentage 7 NNN.NN% Data Values Inclusions HMDS TOPAS HCARe Field names and values Care Type / Episode of Care 21 1.0 A  Acute

OR Client Status / Patient Type  Qualified newborns 1 5.0 PG

Admit Type / Status  Elective – Waitlist 3 1 ELW  Elective – Not Waitlist 4 2 ELWN

Surgical DRGs  Surgical 2nd digit of DRG Code is 0, 1, 2 or 3

Funding Source Public patients in private hospitals only and these are defined by:  Australian Health 21 Care Agreements

 Correctional Facility 29  Reciprocal Health 30 Care Agreement

Exclusions HMDS TOPA HCAR Field and value names S e Care Type / Episode of Care = 22 2.0 R . Rehabilitation . Palliative 23 3.0 P . Psychogeriatric 24 5.0 PG . Geriatric Evaluation and 29 4.0 G Management . Maintenance 25 6.0 N . Organ Procurement 27 9.0 OP . Boarders 28 10.0 O . Aged Care Resident 30 AG . Flexible Care 31 F H C

Client Status / Patient Type . Contracting Service/Funding Hospital 0 0 F ((zero) (zero)

Funding Source . Ambulatory Surgical Initiative 646 PR ASI Procedure Date is null

Duplicates excluded as detailed in MDG-01-20 Removal of Duplicates. Scope . Public Hospitals (metropolitan and rural), except Next Step Drug and Alcohol services, East Perth . Joondalup Health Campus, publicly funded activity . Peel Health Campus, publicly funded activity

Formula Numerator HMDS Count of the number of records where [Separation Date] has a value that is within/equal to the start and end date of the reference period for

records where [Care Type / Episode of Care] of 21 or [Client Status / Patient Type] of 1 and [Admission Status] of 3 or 4 and [DRG] = surgical and [Separation Date] > [Admission Date] and [Procedure Date] is not null and [Procedure date] = [Admission Date]. Minus [Client Status / Patient Type] of 0. Minus records where [Payment Classification] = 33. Duplicates excluded as detailed in MDG-01-20 Removal of Duplicates.

Denominator HMDS Count of the number of records where [Separation Date] has a value that is within/equal to the start and end date of the reference period for records where [Care Type / Episode of Care] of 21 or [Client Status / Patient Type] of 1 and [Admission Status] of 3 or 4 and [DRG] = surgical and [Separation Date] > [Admission Date] and [Procedure Date] is not null. Minus [Client Status / Patient Type] of 0. Minus records where [Payment Classification] of 33. Duplicates excluded as detailed in MDG-01-20 Removal of Duplicates.

Calculation Numerator divided by denominator expressed a percentage.

Verification Rules  Value is 0 per cent - 100 per cent inclusive

Data Collection Identification Items Source Hospital Morbidity Data System Updated weekly every Wednesday.

Governance Items Purpose of the data To monitor the proportion of acute elective surgical separations, where patients were admitted on the same day they had their procedure. Source of the  Data Integrity Directorate, Performance Activity and Quality definition Division  Hospital Morbidity Data System Reference Manual  Data Definition: DG-01-020 Removal of Duplicates Version number V2.0

Approval date 20120315

Version 2.0 includes approved changes to align acute / subacute definitions to national definitions which classifies psychogeriatric care type as subacute and qualified newborns as acute care.

EI4: YTD Distance of Expenditure to Budget

Reported Data Description Items Identifier (office use only)

Name YTD Distance of Expenditure to Budget

Aliases n/a

Definition The distance of year to date (YTD) actual total expenditure to the YTD budget.

Related Metadata n/a

Guide for Use YTD actual total expenditure is operating/recurrent expenditure, excluding asset investment program (capital works) expenditure.

It is extracted from the Year to Date Actual measure, of the Discoverer Report HCN_FIN.FR(SUM) – Income Statement – Budget Holder, generated from the General Ledger.

YTD budget is extracted from the YTD Budget measure of the Discoverer report.

The distance of YTD actual expenditure to YTD budget is to be expressed as a percentage.

Discoverer Report Period Name = relevant period (month) of report Parameter Values: Budget Name = Budget 2012 (representing the 2011-12 financial

year). Budget Holders(s) = NMH0000 – NORTH METROPOLITAN HEALTH SERVICE SMH0000 – SOUTH METROPOLITAN HEALTH SERVICE* WCH0000 – CHILD & ADOLESCENT HEALTH SERVICE WACHS00 – WA COUNTRY HEALTH SERVICE *: Includes Peel Health Service

Limitations Internal transactions (purchase of services and recoups, and shared services transactions) are not eliminated at individual entity or health services level, but on consolidation for whole of Health.

Budget figures for a particular month are subject to updates in subsequent months.

Reported Data Validation Items Format Percentage

NNN.NN%

Data Values Leave blank.

Inclusions Include Operating/Recurrent Entities from Oracle Financials 11i:

Entity Posting + Name = 040 (NMHS) Entity Posting + Name = 020 (SMHS) Entity Posting + Name = 075 (Peel HS) Entity Posting + Name = 030 (CAHS) Entity Posting + Name = 080 (WACHS)

Exclusions Exclude Capital Entities from Oracle Financials 11i: Entity Posting + Name = 140 (NMHS) Entity Posting + Name = 120 and 121 (SMHS) Entity Posting + Name = 175 (Peel HS) Entity Posting + Name = 130 (CAHS) Entity Posting + Name = 180 (WACHS)

Scope The four major WA area health services.

Formula Run the report to display only the Operating/Recurrent Entities, as indicated in the above inclusions and exclusions.

Budget = YTD Budget total expenditure

Actual = YTD Actual total expenditure

Calculation = (Budget - Actual) / Budget x 100, expressed as a percentage.

If the denominator is zero, the calculated result should be reported / displayed as "N/A".

Verification Rules Value is likely to be between -100% and 100%, however, it is mathematically possible to be >100%.

Data Collection Identification Items Source Oracle Financials 11i – General Ledger.

Note: The GL is generally closed and ready for reporting on the

4th working day each month, with June being the exception when the GL will remain open for a longer period due to the processing of end of year adjustments.

Governance Items Purpose of the data YTD expenditure to budget is used for monitoring and accountability of budget management.

Source of the definition Health Finance.

Version number 1.0

Approval date 20120813

EI5: YTD Distance of Own Sourced Revenue to Budget

Reported Data Description Items Identifier (office use only)

Name YTD Distance of Own Sourced Revenue to Budget

Aliases n/a

Definition The distance of year to date (YTD) actual total own sourced revenue (OSR) to the YTD budget.

Related Metadata n/a

Guide for Use YTD actual total OSR is operating/recurrent OSR, excluding asset investment program (capital works) OSR.

It is extracted from the Year to Date Actual measure, of the Discoverer Report HCN_FIN.FR(SUM) – Income Statement – Budget Holder, generated from the General Ledger.

YTD budget is extracted from the YTD Budget measure of the Discoverer report.

The distance of YTD actual OSR to YTD budget is to be expressed as a percentage.

Discoverer Report Period Name = relevant period (month) of report Parameter Values: Budget Name = Budget 2012 (representing the 2011-12 financial

year). Budget Holders(s) = NMH0000 – NORTH METROPOLITAN HEALTH SERVICE SMH0000 – SOUTH METROPOLITAN HEALTH SERVICE * WCH0000 – CHILD & ADOLESCENT HEALTH SERVICE WACHSCHS00 – WA COUNTRY HEALTH SERVICE *: Includes Peel Health Service

Budget figures for a particular month are subject to updates in subsequent months.

Reported Data Validation Items Format Percentage

NNN.NN%

Data Values

Inclusions Include Operating/Recurrent Entities from Oracle Financials 11i:

Entity Posting + Name = 040 (NMHS) Entity Posting + Name = 020 (SMHS) Entity Posting + Name = 075 (Peel HS) Entity Posting + Name = 030 (CAHS) Entity Posting + Name = 080 (WACHS)

Scope The four major WA area health services.

Formula Run the report to display only the Operating/Recurrent Entities, as indicated in the above inclusions and exclusions.

NOTE: Based on accounting convention, revenue (OSR) (actual and budget) is presented in Oracle Financials and Discoverer as negative values. For ABF/ABM performance reporting, revenue indicators should be presented as positive values. Multiply revenue values from Oracle Financials or Discoverer by -1 to convert them to positive values.

Budget = YTD Budget total OSR x -1

Actual = YTD Actual total OSR x -1

Calculation = (Actual - Budget) / Budget x 100, expressed as a percentage.

If the denominator is zero, the calculated result should be reported

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/ displayed as "N/A".

Verification Rules Value is likely to be between -100% and 100%, however, it is mathematically possible to be >100%.

Data Collection Identification Items Source Oracle Financials 11i – General Ledger.

Note: The GL is generally closed and ready for reporting on the 4th working day each month, with June being the exception when the GL will remain open for a longer period due to the processing of end of year adjustments.

Governance Items Purpose of the data YTD own source revenue to budget is used for monitoring and accountability of budget management.

Source of the definition Health Finance.

Version number 1.0

Approval date 20120813

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EI7: School Dental Service ratio of examinations to enrolments

Reported Data Description Items Identifier ABF/M-KPI-EI7

Name Ratio of total examinations to total enrolments in the School Dental Service per calendar year

Aliases Any related terms as applicable.

Definition The Numerator is the number of examinations reported per calendar year by the School Dental Service, grouped to North Metropolitan Health Service, South Metropolitan Health Service, West Australian Northern and Remote Country, and Southern Country Health Service, as indicated by the address of the clinic.

The Denominator is the number of children enrolled with each School Dental Service clinic as reported per calendar year by the School Dental Service, grouped to North Metropolitan Health Service, South Metropolitan Health Service, West Australian Country Health Service, as indicated by the address of the clinic.

Related Metadata

Guide for Use

Limitations Mobile Dental Clinics will service child groups in wide areas and may cross from one area health service to another. The proportion of such children/events is expected to be small.

Since individual children are not tracked by this measure, multiple examinations of a single child contribute to the value. Therefore, this measure should be seen as indicating the level of service delivery, rather than the proportion of children examined.

There is no scope for linking the variations in school children population with available Dental Health Services (DHS) FTE providing the delivery of services to these children. That is, there is no guarantee that DHS FTE will be increased to match the increase in school children attending school or enrolled in the school dental service. Examinations are only one aspect of dental health interventions performed by the School Dental Service. Children may attend for a variety of other treatment which will not count towards this indicator.

Reported Data Validation Items Format Ratio

NNNNNNN

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Data Values Positive number

Inclusions All examinations by School Dental Service

Exclusions None

Scope School Dental Service

Formula Calculation = Numerator / Denominator

Verification Rules

Data Collection Identification Items Source School Dental Service

Governance Items Purpose of the data

Source of the definition

Version number 1.2

Approval date 20140423 (Noted by PRGC)

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EI9: Number of separations (unweighted): Total Estimated Unweighted Inpatient Activity (excluding LSMH) Reported Data Element Definition Reported Data Description Items Identifier Name Total Estimated Unweighted Inpatient Activity (including LSMH) Aliases Volume of inpatient activity Unweighted separations Definition Total estimated unweighted inpatient activity is the count of inpatient records available in HMDS, plus records from TOPAS and HCARe where a HMDS record is not available. That is, the counts include records which have been coded and entered into the Hospital Morbidity Data System (HMDS) and uncoded records when the coded record is not available. The count excludes separations classed as non-admitted by national and local definitions. The count also excludes activity at Graylands Selby- Lemnos, referred to as Long Stay Admitted Mental Health (LSMH) activity. Related Percentage Variance from Target – Total Estimated Weighted Inpatient Metadata Activity Percentage Variance from Target – Weighted Emergency Department Attendances Percentage Variance from Target – Weighted Outpatient Occasions of Service Unweighted Long Stay Admitted Mental Health Beddays Guide for Use Total estimated unweighted inpatient activity is counted from HMDS extracts (coded data) and TOPAS, HCARe, Joondalup Health Campus (JHC) and Peel Health Campus (PHC) discharge extracts (uncoded data) using the [Client Status] or [Patient Type], [Separation Date], [Account Number], and [Establishment Code] fields. The total estimated unweighted inpatient activity count is derived from coded (HMDS) and uncoded (discharge extract) information. The coded information takes precedence for inclusion in the count, and uncoded information is used to complete the count due to the delay in available coded data. This method of counting unweighted separations allows for a timely estimate of unweighted activity. This methodology also excludes TOPAS, HCARe records, JHC and PHC discharge records where the record has been deleted, replaced or removed from the Hospital Morbidity Data System, to avoid over counting. The counts include publicly funded activity at JHC and PHC. Contracted dialysis is included in the model (e.g., dialysis activity contracted by the hospitals to non-government organisations, Sir Charles Gairdner contract to Joondalup Health Campus). Under current local and national definitions for admitted patients, the following patient types are considered non-admitted patients – Ambulatory Surgery Initiative (ASI), Organ Procurement, Boarders, Cancelled Elective Surgery, Aged Care & and Flexible Care Residents.

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Apart from ASI patient types, the other above listed patient types are excluded from the WA ABF model in 2012/13. Note that Cancelled Elective Surgery is identified using the [Principal Diagnosis] field, and therefore can only be identified in coded data. Unqualified newborns are also excluded from the local ABF model as the costs are attributed to the mother’s episode of care. Although the exclusions are excluded from reporting, they are first identified in the data set and labelled within the {Ctyp12} field. The {Ctyp12} field contains values that identify the episode of care type or ‘sub-group’ defined for ABF inpatient activity in 2012/13. {Ctyp12} contains the following subgroups (asterisked groups are excluded from reporting): Boarders*, Unqualified Newborns*, Organ Procurement*, Flexible Care Residents*, Cancelled Elective Surgery*, Aged Care* Area Mental Health Service (AMHS), Sub Acute (Rehab, Palliative, Geriatric Evaluation and Management, Psychogeriatric cases not captured in the AMHS grouping), Non Acute (Maintenance), Acute Inpatients. Total Estimated Unweighted Inpatient Activity therefore includes the remaining subgroups, and is reported in total. The subgroups are defined in this document for reference. Activity is counted at the funding hospital; therefore, activity conducted by a hospital that has been funded by another is not counted (i.e., contracted hospital separations are excluded). Activity being funded by Statewide Contracting Services is not included (e.g., renal and palliative care at Bunbury and Broome). This indicator can be calculated for all WA public hospitals and public activity from Peel and Joondalup Health Campuses, except Graylands Selby-Lemnos and Next Step Drug and Alcohol Service. However, please note that the scope of different WA Health reports varies; refer to the details of each report to determine the relevant site inclusions and exclusions. Historical data are updated in each extract. Note: Difference from National Operating Model This definition reflects the West Australian Department of Health (DoH) methodology used in the Service Level Agreements (SLAs) between the DoH and the health services. This methodology incorporates the national methodology where available; however, the scope of included activity which is subject to ABF is wider in the WA SLAs than what is currently required at the national level. Specifically, the WA inpatient indicator includes sub-acute care, long stay mental health (Graylands Selby- Lemnos), and non-acute care, which are not subject to ABF nationally. The national model also restricts which separations are included based on funding source, specifically only including public and private patients with a funding source of Australian Health Care Agreements, Private Health Insurance, Self Funded and Reciprocal Health Care Agreements. The WA model does not have this restriction. The national model only reports on coded activity; the WA model uses an estimation methodology to account for the delays in coding (see following section).

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As at publication, WA is awaiting detailed documentation of the final national model (currently in draft) from the Independent Hospitals Pricing Authority (IHPA); should any national rules change, this definition may be updated accordingly.

Limitations Total Estimated Unweighted Inpatient activity (separation based data) Figures reported for recent months have a higher proportion of uncoded information than earlier months, due to the delays in data coding and edit. Whilst an analysis across prior year information has been undertaken to understand any variability between the actual weights and the estimated weights across all patient episodes, the order of coding could potentially skew early results; simpler cases are likely to be coded before more complex cases, which may cause variability in estimates for weighted activity for recent months. The impact of order of coding diminishes as time goes on and more cases are coded. For final counts, complete HMDS data should be used.

Reported Data Validation Items Format Numeric 6 NNNN.N% Data Values Inclusions For JHC and PHC records only Include only public patients HMDS [Payment Classification] = Australian Health Care Agreements 21 Correctional Facility 29 Reciprocal Health Care Agreement 30

Exclusions The following records are excluded from the HMDS extract: Cases with a record status: D (Deleted), E (Data Entry), I (In Progress), M (Modify), N (New), P (Pending), R (Replaced), V (Removed) or X (Error). The following records are excluded from the HCARe discharge extract: . [Flag] = C (these are reversed or cancelled cases). Exclude duplicate records from within each TOPAS, HCARe and HMDS extract: Duplicate records = [Establishment Code] and [Account Number] are identical within the HMDS, TOPAS and HCARe data sets.

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For TOPAS and HCARe records: Exclude uncoded (TOPAS/HCARe) record where coded (HMDS) record has the same values for the following fields: . [Establishment Code] . [Account Number] Exclude uncoded (TOPAS/HCARe) record where the coded record in the HMDS Deleted, Replaced or Removed (DRV) extract* has the same values for the following fields: . [Establishment Code] . [Account Number] *The HMDS DRV extract is an extract of coded records with a [Record Status] of D (Deleted), R (Replaced) or V (Removed), where a matching record with a [Record Status] of C (Clean) does not exist in HMDS (records are matched using [Establishment Code] and [Account Number]).

For HMDS, TOPAS and HCARe records: Exclude contracted services TOPAS HCARe HMDS [Client Status] or [Patient type] = Contracted Service 5 C 5

The following patient subgroup exclusions are identified in the dataset sequentially, using an if-then-else criteria, then excluded based on the values attributed to each exclusion within {Ctyp12}: Source system value Group to {Ctyp12} Sub-group excluded: TOPAS HCARe HMDS as: 1. Boarders - Care Type/Episode of 10.0 O 28 Care = or BR - Client Status/Patient 3 B 3 Type = 2. Unqualified Newborns - Client Status/Patient 2 U 2 UnqNB Type = 3. Organ Procurement - Care Type/Episode of 9.0 OP 27 OP Care = 4. Flexible Care Residents

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- Care Type/Episode of N/A F 31 Care = H FCR C 5. Aged Care N/A AG 30 ACR 6. Cancelled Elective Surgery - first three characters of N/A N/A Z53 CES [Principal Diagnosis] =

Scope This indicator can be calculated for all public hospitals (metropolitan and rural) and public activity at Joondalup and Peel Health Campuses, excluding: . Graylands Selby-Lemnos (including Frankland Centre) . Country Small Hospitals . Next Step Drug and Alcohol services, East Perth . Nursing posts and other non-hospital establishments For a particular report, please refer to that report’s scoping to determine which sites are included. Formula

{Total Estimated Weighted Inpatient Activity} HMDS records Sum of (Count of the number of records where [Separation Date] has a value that is within/equal to the reference period (i.e., calendar month). Minus cases with a record status of D, E, I, M, N, P, R, V, X. Minus cases where [Establishment Code] and [Account Number] are identical

within the data set. Minus [Client Status] = 5. Minus {Ctyp12} = BR, UnqNB, OP, FCR, ACR or CES). And for JHC and PHC only: And where [Payment Classification] = (21, 29, or 30).

TOPAS, Sum of (Count of the number of records where [Separation Date] has a HCARe, JHC & value that is within/equal to the reference period (i.e., calendar month). PHC discharge Minus HCARe records where [Flag] = C.. Minus TOPAS & HCARe records records where [Establishment Code] and [Account Number] = records in HMDS or HMDS DRV extract. Minus records where [Establishment Code] and [Account Number] are identical within the data sets. Minus [Client Status] = 5. Minus {Ctyp12} = BR, UnqNB, OP, ACR, or FCR). And for JHC and PHC only: And where [Payment Classification] = (21, 29, or 30).

Calculation Sum of formula results for HMDS records and TOPAS & HCARe records. Verification Value is >/= to zero Rules

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Additional information – How to calculate included inpatient subgroups for {Ctyp12} – separation based data Records need to be flagged as Area Mental Health Service within the created field {AMHS} as follows:

Hospital Establishment Number Wards {AMHS} & Name flag - 105 (Sir Charles Gairdner) D20, PYWD Y - 244 (Swan District) MHSW, MHLS, MHLW, Y MHWW, SVCO, SVCS - 239 (Osborne Park) OL Y - 104 (King Edward Memorial) MBU Y - 156 (Boronia Inpatient Unit) All wards Y - 255 (Bentley) W8, W7, W6, W5, JMC, 10A, 10B, 10C, FWP, CRU, W10A, W10B, Y W10C, 1309, ECTD, W6W7 - 102 (Fremantle) W41, W42, W51, W43, W4SW, MOSS, D5W, Y ECT - 203 (Armadale-Kelmscott LOPEN, LHDU, KARRI, Y District Memorial) BANKS, BANKSIA - 2239 (Armadale Mental Health BANKS, KARRI Y for Older People Authorised) - 101 (Royal Perth) 2K, PSYD, EDPP Y - 103 (Princess Margaret) 4H, STUBB Y - 277 (Rockingham General) MHAC, MHAO, MHEC, Y MHEO - 201 (Albany) MENTAL HEALTH Y UNIT, MHU - 208 (Bunbury) MEN, MENTAL Y HEALTH, PICU - 226 (Kalgoorlie) PSYCHIATRIC UNIT Y - 206 (Broome) ACUTE PSYCHIATRIC Y UNIT - All other records N

With records flagged as {AMHS}, the following patient subgroups are identified in the dataset sequentially using an if-then-else criteria, with the values attributed to {Ctyp12} as follows: Field Values Group to

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{Ctyp12} Sub-group: as: 1. Area Mental Health Service - {AMHS} flag = Y AMHS

2. Sub Acute TOPAS HCARe HMDS - Care Type/Episode of Care = Rehabilitation 2.0 R 22 Palliation 3.0 P 23 SubAC Psychogeriatric† 5.0 PG 24 Geriatric Evaluation and 4.0 G 29 Management

3. Non-Acute TOPAS HCARe HMDS - Care Type/Episode of Care = NA Maintenance Care 6.0 N 25 4. Acute Inpatients - All other records that are not yet AC_IP grouped

†Note: Most psychogeriatric cases occur in designated mental health wards and will be grouped to the AMHS sub-group. Any cases that do not occur in a designated mental health ward will be grouped to sub-acute.

Data Collection Identification Items Source

HMDS Weekly HMDS extracts HMDS Updated weekly, maintained by the Hospital Morbidity Data Collection Deleted, Branch Removed or The monthly file provided to Business & Financial Modelling, PAQ Replaced captures all activity to 2359 on last day of the calendar month extract Weekly file extracted at 0600 hours each Monday for data up to Sunday TOPAS 2359 hours (TOPAS Discharge Extract)

The monthly file provided to Business & Financial Modelling, PAQ captures all activity to 2359 on last day of the calendar month

HCARe Extracted every Monday for data up to Sunday 2359 hours (HCARe Discharge Extract) The monthly file provided to Business & Financial Modelling, PAQ captures all activity to 2359 on last day of the calendar month JHC Weekly discharge extract, provided by JHC (contains 7 days of data) The monthly file provided to Business & Financial Modelling, PAQ captures all activity to 2359 on last day of the calendar month PHC Weekly discharge extract, provided by PHC (contains 7 days of data) The monthly file provided to Business & Financial Modelling, PAQ

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captures all activity to 2359 on last day of the calendar month

PAQ WA 2012/13 ABF/M Operating Model documentation Governance Items Purpose of the Total Estimated Unweighted Inpatient Activity is the count used as the data basis for calculating Total Estimated Weighted Inpatient Activity. Total Estimated Weighted Inpatient Activity is used to report volume of activity for WA public hospitals in the Activity Based Funding Performance Management Report, and enables timely reporting against the Service Level Agreements. The Total Estimated Unweighted Inpatient Activity count is an estimated count of final coded separations. For final activity counts, use complete data from the HMDS. Percentage Coded Cases provides an indication of completeness at a given point in time. Source of the Business and Financial Modelling Directorate, Performance Activity and definition/ Quality Division, DoH WA additional Performance Directorate, Performance Activity and Quality Division, DoH information WA Local and National ABF/M Operating Model documentation, available on http://activity Hospital Morbidity Data System Reference Manual, July 2011 – Section 8: Operational Directives and Program Bulletins Version 1.0 number Approval date 20120813

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EI10: Coded acute multiday average length of stay Reported Data Description Items Identifier MDG-02-003b Name Acute Multiday Average Length of Stay (ALOS) Aliases . Acute Multiday ALOS Definition The average length of an acute multiday inpatient episode, measured in days. Related Metadata . Total length of stay . Acute separations . Acute average length of stay . MDG-01-020 Removal of Duplicates . MDG-02-003a (Preliminary Activity Definition) Guide for Use Acute multiday ALOS is calculated from the Hospital Morbidity Data System (HMDS) morbidity data using the [Admission Date], [Separation Date], [Care Type], [Client Status], [Length of Stay], [Qualified Days] and [Hospital Code] fields. Acute multiday ALOS is calculated by dividing the total length of stay of acute multiday separations by the total number of acute multiday separations during the reporting period. Length of stay for inpatient episodes excludes leave days. A case is defined as multiday when the separation date is not equal to the admission date. All days of stay for an episode of care are attributed to the month in which the episode of care was separated (for the length of stay calculation). All non-acute / sub-acute separations are excluded from the count. Activity at public and private hospitals is included. Ambulatory Surgery Initiative cases are included in the count as these patients have undergone a formal admission. Contracted activity is counted at the hospital where the activity is performed (i.e., the contracted hospital). Both numerator and denominator exclude unqualified newborns, posthumous organ procurements, hospital boarders and aged care residents from the count as per the standard reporting. Cases from non-Western Australian hospitals and Residential Aged Care Facilities are excluded. Duplicates excluded as detailed in MDG-01-20 Removal of Duplicates. Historical data are updated in each extract, to take account of edit/quality assurance processes.

Delays in clinical coding may result in a potential lag in data Limitations completeness. For preliminary activity counts refer to MDG-02-003a which sources uncoded discharge extract data. Measuring the ALOS of episodes of care separated during the

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reporting period is not a measure of ALOS of patients receiving care in the reporting period. Long stay patients discharged during the reporting period can affect ALOS for a particular reporting period.

Reported Data Validation Items Format Numeric 6 NNN.NN Data Values Inclusions Field and value names HMDS Care Type =  Acute 21

Client Status =  Qualified newborn 1

Exclusions Field and value names HMDS Client Status = . Contracting Service 0 (zero) /Funding Hospital . Unqualified newborn 2 . Boarder 3 . Organ Procurement 7 . Resident 8

Hospital Code = . Non-WA Hospitals 646 . Aged Care >= 700 not including 935 (Graylands)

Duplicates excluded as detailed in MDG-01-20 Removal of Duplicates.

Scope . All WA public hospitals (metropolitan and rural) . All WA private hospitals (metropolitan and rural)

Formula Numerator If [Client Status] = 1 and [Qualified Days] is greater than 0 and [Qualified Days] is less than [Length of Stay], then [Length of Stay] = [Qualified Days].

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If [Length of Stay] is less than 1, then [Length of Stay] is 1. Sum of [Length of Stay] where the [Separation Date] has a value that is within/equal to start and end date of the reference period and [Separation Date] does not equal [Admission Date]. Include those records with a [Care Type] of 21 or [Client Status] of 1. Minus those records with a [Client Status] of 0, 2, 3, 7 or 8. Minus those records with [Hospital Code] of 646 or >= 700, except 935 (Graylands Hospital).

HMDS Denominator Count of records where [Separation Date] has a value that is within/equal to start and end date of the reference period and [Separation Date] does not equal [Admission Date]. Include those records with a [Care Type] of 21 or [Client Status] of 1. Minus those records with a [Client Status] of 0, 2, 3, 7 or 8. Minus those records with [Hospital Code] of 646 or >= 700, except 935 (Graylands Hospital). HMDS Count of records where [Separation Date] has a value that is within/equal to start and end date of the reference period and [Separation Date] does not equal [Admission Date]. Include those records with a [Care Type] of 21 or [Client Status] of 1. Minus those records with a [Client Status] of 0, 2, 3, 7 or 8. Minus those records with [Hospital Code] of 646 or >= 700, except 935 (Graylands Hospital).

Calculation Numerator divided by denominator Verification Rules

Data Collection Identification Items Source Updated weekly every Wednesday. HMDS Updated weekly every Wednesday.

Governance Items Purpose of the . Data Integrity, Performance Activity and Quality Division data . Hospital Morbidity Data System Reference Manual MDG-01-020 Removal of Duplicates Source of the . V1.0 definition Version Number 20111108 Approval Date

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EI11: YTD Distance of Salaries Expenditure to Budget

This indicator is currently under development.

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2.5 Equity Access (EQA) KPIs

There are 5 EQA PIs proposed in the 2014-15 PMF, including 3 Health Service measures.

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EQA2.a&b: Standardised Rate Ratio of Hospitalisations of a) Aboriginal People compared to Non-Aboriginal People b) Aboriginal children (0-4 years) compared to non-Aboriginal children (0-4 years)

Reported Data Description Items Identifier ABF/M-KPI-EQA2

Name Standardised Rate Ratio of Hospitalisation of Aboriginal People compared to Non-Aboriginal People

Aliases Any related terms as applicable.

Definition Rate ratios are used to compare the rate of an event in different subgroups within a population.

The Aboriginal hospitalisation rate compares the rate of hospitalisations in the Aboriginal population to the rate in the non- Aboriginal population. The rate ratio shows the difference between the two populations, and is presented with a 95% confidence interval.

The rate ratio is shown separately for all ages and for children aged 0-4.

Related Metadata

Guide for Use Hospitalisations among residents of each Health Service (HS) in WA are counted from hospital inpatient separation records extracted from the Hospital Morbidity Data System (HMDS).

The allocation of separation data to HS is based on the location of usual residence of the patient, and not where the hospitalisation occurred. Patient residential details are collected upon admission to hospital and each record is subsequently assigned the relevant Statistical Area 2 (SA2) by the Data Linkage Branch. The Epidemiology Branch then assigns records to the correct HS based on their SA2 of usual residence. Records with missing SA2 information are assigned to a HS by the Epidemiology Branch using the record’s locality or postcode information.

Limitations Due to the availability of complete coded separation data the indicator usually presents data from 9 months previous.

The identification of Aboriginal status will be improved through measures the Epidemiology Branch uses routinely with data linkage. However, the identification of Aboriginal status will be a limitation of the indicator.

Reported Data Validation Items Format Numeric

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NN.N

Data Values Inclusions Hospitalisation separation records where patients are identified as WA residents.

Exclusions Hospital records of non-WA residents (overseas and other Australian states and territories), as well as WA residents with no postcode or locality information recorded. Healthy newborns, boarders, posthumous organ procurements, aged care residents, and funding hospital (duplicate) cases. Non-inpatient, Christmas Island, HITH-only private establishments and residential aged care facilities Hospital records with unknown Aboriginal status or age at admission.

Scope All public and private hospital records for Western Australian residents with a postcode or locality recorded.

Formula All ages and 0-4 years calculated separately.

Age-standardised rate ratios (SRRs) are calculated using the indirect method.

SRRs are calculated annually by financial year.

Numerator: Total hospitalisations Aboriginal population: the numerator is the observed number of hospitalisations in the Aboriginal population. Total hospitalisations Aboriginal population (0 to 4 year olds): the numerator is the observed number of hospitalisations in the Aboriginal population for 0-4 year olds.

Denominator: Total hospitalisations Aboriginal and non-Aboriginal populations: the denominator is the expected number of hospitalisations in the Aboriginal population based on the rate of hospitalisations in the non-Aboriginal population. Total hospitalisations Aboriginal and non-Aboriginal populations (0 to 4 year olds): the denominator is the expected number of hospitalisations in the Aboriginal population for 0-4 year olds based on the rate of hospitalisations in the non-Aboriginal population for 0-4 year olds. To enable the comparison of the indicator over time, the rate of hospitalisations in the non-Aboriginal population will be based on the rate in 2009/10.

Verification Rules > 0 and < 100

For statistical validity the SRR will not be reported if the number of hospitalisations is less than 5.

When data are extracted for the calculation of the rate ratios for

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the new year, data from the same extract are also used for the re- calculation of all previously reported years to ensure that those rate ratios are based on the most up-to-date available data.

Data Collection Identification Items Source Hospitalisations: Hospital Morbidity Data System (HMDS). Population: Australian Bureau of Statistics, Department of Planning Governance Items Purpose of the data For ABF/M KPI reporting.

Source of the definition Epidemiology Branch, Public Health and Clinical Services Division

Version number 1.2

Approval date 20140423 (Noted by PRGC)

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EQA3.a&b: Childhood immunisation: percentage of children fully immunised at 12-15 months: a) Aboriginal b) Total

Reported Data Description Items Identifier ABF/M-KPI-EQA3

Name Percentage of children fully immunized in the 12-15 month age- cohort, as registered on the Australian Childhood Immunisation Register (ACIR).

Aliases The proportion children fully immunized in the 12-15 month age- cohort as registered on the Australian Childhood Immunisation Register (ACIR).

Definition A child is assessed as fully immunised at 12 months of age (12-15 months) if they have received age appropriate immunisations against diphtheria, tetanus, pertussis, polio, pneumococcal, haemophilus influenza B and hepatitis B.

The data is presented as the percentage of children fully immunised for the 12-15 month age-cohort by Indigenous status as well as total.

Related Metadata Information is also reported in the Department of Health Annual Report and Country Health Service Annual Report for the December quarter of the year.

Guide for Use This indicator is a population based measure used to assess the immunisation coverage among children of a particular age cohort. One age cohort is chosen to represent overall coverage among children.

Limitations As it is recommended that this indicator is reported quarterly, the baseline may need to reflect a seasonal variation (if present)

Reported Data Validation Items Format Numeric

NN.N

Data Values Inclusions Only those immunisation services a child has received up to 12 months of age are included.

Population figures: All WA residents assigned to a Health Service (North Metro, South Metro and WACHS [Northern and Remote Country and Southern Country]) according to SLA based on boundaries outlined by the Epidemiology Branch, Public Health

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and Clinical Services Division.

Exclusions Non-WA residents are excluded.

Scope All children in WA aged 12 to 15 months.

Formula Numerator is divided by the denominator and multiplied by 100 to derive the percentage.

Numerator: The number of children fully immunised in the 12-15 month age- cohort as defined in the ACIR.

Denominator: Total number of children in the 12-15 month age-cohort as registered in the ACIR.

Verification Rules > 0

Data Collection Identification Items Source Australian Childhood Immunisation Register (ACIR). Prepared by: Communicable Disease Control Directorate

Governance Items Purpose of the data For ABF/M KPI reporting.

Source of the definition Epidemiology Branch and Communicable Disease Control Directorate, Public Health Division Version number 1.1

Approval date 20140423 (Noted by PRGC)

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EQA5: WA Health Aboriginal employment headcount

Reported Data Description Items Identifier Name Headcount of WA Health Aboriginal employees Aliases Aboriginal and Torres Strait Islander (ATSI) employees Definition A headcount of WA Health employed Aboriginal staff who are in a 50D position or have self-identified as Aboriginal, Torres Strait Islander or both. Related metadata N/A Guide for use The methodology used to determine the number of ATSI staff employed within WA Health is based on:  Employees currently employed under Section 50(d) of the Equal Opportunity Act 1984, and  Current employees that identified as Aboriginal Torres Strait Islander via the: o Equity and Diversity Questionnaire and/or o WA Health N2 New Starters form (since February 2011). The figures reported may differ to information held on local databases across WA Health. This is a monthly report which provides snapshot data of active WA Health employees with a current contract for the end of the reporting month. A range of datasets are extracted from the WA Health Human Resources Data Warehouse (HRDW), such as Employee Details, EEO Survey Results, Position Requirements, and manipulated in an MS Access database to obtain relevant information. Business rules are applied to the data to eliminate non-conforming records. The indicator includes all active WA Health staff including permanent, fixed term, casual and sessional employees. Limitations Due to the implementation of a revised methodology for the extraction of ATSI employees, historic information cannot be provided prior to June 2012. Information is extracted from the WA Health HRDW establishment data. The Employee Details table contains current employee information and will refer to ‘as at the time of extraction’ only. Previous months’ data is ‘frozen’ with the new month’s data appended on. Historical information will not be updated. As the completion of the EEO Survey is voluntary, the indicator may represent an undercount of the total WA Health ATSI employee

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workforce, due to the fact that a part of the data analysis relies on self-nomination of ATSI origin by employees. Where an employee holds more than one contract with the Department (e.g. more than one part time position, casual employment contract), the employee is counted only once in the overall (statewide) count of ATSI employees for WA Health, but more than once in counts at the health service level, if they occupy multiple positions located across different health services. Where an employee is acting in a position at the point of data extraction, it is assumed that position is where they are working at the time and their substantive position has been excluded from analysis.

Reported Data Validation Items Format Numeric 3 NNN Data Values Inclusions All active WA Health employees with a current permanent, fixed-term, casual or sessional contract meeting the following requirements: 1) All occupied positions with a position requirement of: Required Code – 50(d) OR Required Level – S50-D

and/or

2) Employees which have an EEO Employee Table Code of; A – Aboriginal AT – Aboriginal Torres Strait Islander B – Both T – Torres Strait Islander.

Exclusions Non WA Health locations including the Office of Health Review, Peel Health Campus, Joondalup Health Campus, Drug and Alcohol Office, and Mental Health Commission WA. Agency staff Employees falling into the following categories:

Descriptor Code Description Job Type SECON SECONDMENT OUT NOT PAID Job Type OFFV OFFICIAL VISITOR Job Type NOPAY NO PAY Job Type HSGC HEALTH SERVICE GOVERNING COUNCILS Job Type AGNC AGENCY

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Placement Reason WCPAY WORKERS COMPENSATION PAYMENT ONLY Placement Reason M26 TEMP DEP NOT PD Placement Reason M24 SECONDMT NOT PD Placement Reason H07 UNPAID PERIOD Placement Reason EMSNP SECONDMENT EXTERNAL NOT PAID

Non-occupied positions and inactive employees at the time of the snapshot. Employees with permanent and fixed term contracts where employee has no contracted hours recorded. Scope This indicator is reported at the health service level:

Child And Adolescent Health Service Dental Services Department Of Health Director General Health Development Division Health Finance Health Finance Division Health Reform Innovation And Health Reform Office Of The Chief Medical Officer Office Of The Director General Performance Activity And Quality Public Health Division Royal Street Divisions Health Corporate Network Health Information Network North Metro Health Service Pathwest South Metro Health Service WA Country Health Service

‘Department of Health’ Budget holders are not reported individually, but are presented as a rolled-up figure. Formula: Calculation Headcount of all active WA Health employees who have a position requirement code of 50(d) or a position required level of S50-D and/ or have self-identified as being from an Aboriginal and/or Torres Strait Islander origin via the EEO Employee Table Code of A, AT, B or T. A unique identifier created for each employee, consisting of Surname, Firstname, Middlename Initial and Birth Date, is utilised to establish headcounts. Verification rules >0

Data Collection Identification Items Source WA Health Human Resource Data Warehouse

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 Employee Details  Employee Position Details  Position Details  EEO Survey Results  Position Requirements

Governance Items Purpose of the This performance indicator is used to monitor the headcount of WA data Health employees with an Aboriginal and/or Torres Strait Islander origin. Source of the Workforce Modelling and Data, Resource Strategy Directorate, and definition the Aboriginal Health Division, WA Health Version number 1.3 Approval date 20130517

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2.6 Sustainability Workforce (SW) KPIs

There are 6 SW PIs proposed in the 2014-15 PMF, including 5 Health Service measures.

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SW1: Proportion of medical graduates and other categories of medical staff to total medical staff

Reported Data Description Items Identifier ABF/M-KPI-SW1

Name Proportion of medical graduates (interns) to supervising medical staff and to total medical staff

Aliases Medical grouping breakdown

Definition This indicator is used to show the proportion of a medical grouping (e.g. graduates) against the full medical workforce to ensure the correct levels to sustain training and safe patient care are maintained within the WA Health system.

Related Metadata Proportion of new Nursing Graduates to other Nursing Staff and to Total Nursing Staff Guide for Use Reporting of new medical graduates needs to be considered with the other medical groupings to ensure the correct level of supervision and training occurs to ensure satisfactory training and safe patient care.

The medical groupings presented are:

(a) Interns: a doctor in the first postgraduate year of training under conditional registration. (b) Resident Medical Officers: junior doctors from Postgraduate year 2 onwards who have completed an internship and are generally registered as medical practitioners but have not formally commenced vocational training. (c) Registrars: (or specialist in training) a registered doctor who has completed prevocational training and may be in basic vocational training, working towards higher qualification in a medical specialty. (d) Consultants: (or specialist) a doctor who has completed vocational training. (e) ‘Other’ Medical: other doctors including international medical graduates and career medical officers.

These groupings are determined by using the ‘rate ID’ and ‘rate description’ field in the HR data warehouse. These fields relate to actual payment amounts and are the most accurate reflection of the role and activity of the employee. All groupings were determined by the Postgraduate Medical Council of Western Australia in December 2010. These will be reviewed on a regular basis (please see the inclusions listed below to show the actual rate IDs used to determine the groupings).

This indicator excludes ‘null’ or ‘missing’ rate IDs (which are generally associated with agency staff, recoups or data quality issues) as these cannot be appropriately allocated to a medical grouping. For this reason the total medical staff Full Time Equivalent (FTE) may be different from the actual medical FTE indicated in other reports. Due to this, only the percentage is to be reported for this indicator (i.e. the

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number of FTEs is not to be reported).

This is a quarterly indicator- due to variations of medical graduate numbers (with the major intake in January/ February each year) this needs to be considered when reporting.

Limitations This indicator can be reported at the major location level. Consideration must be given to the accuracy of the location data, particularly if a number of physical locations are rolled into one major location or spread across numerous major locations as this may skew the data.

Payment recoups (i.e. interns and RMOs on rotation) can have impacts on the grouping percentages at some sites. This can slightly overestimate or underestimate groupings at some sites, depending upon how the recoup is processed.

This indicator uses rate ID to group into the specific medical groupings. Monitoring of new rate IDs or changes to rate IDs need to occur to ensure the definition remains current.

Reported Data Validation Items Format Percentage 4 NNN.N%

Data Values Medical WFM account codes including: Inclusions Account Account code description Code 0181 Salaried Medical Officers 0182 Salaried Medical Pract s 0183 Salaried Radiology (Medical Imaging) 0184 Salaried Radiotherapy 0185 Salaried Pathology 0186 Salaried Dental Officers 0189 Salaried Other 0191 Sessional Clinical 0192 Sessional Radiology (Medical Imaging) 0193 Sessional Radiotherapy 0194 Sessional Pathology 0195 Sessional Other 0217 Agency Medical Salaried 0218 Agency Medical Sessional

Consultants: Rate ID Rate Description Rate ID Rate Description DUPOS Plastic & Ortho Surg Ses CLA014 Clinical Academic Level 14 9 YR 9 CLA015 Clinical Academic Level 15 DZAN16 Anaesthetist Level 16 CLA016 Clinical Academic Level 16 DZAN17 Anaesthetist Level 17 CLA017 Clinical Academic Level 17 DZAN18 Anaesthetist Level 18 CLA018 Clinical Academic Level 18 DZAN19 Anaesthetist Level 19 CLA019 Clinical Academic Level 19 DZAN20 Anaesthetist Level 20 CLA020 Clinical Academic Level 20 DZAN21 Anaesthetist Level 21 CLA021 Clinical Academic Level 21 DZAN22 Anaesthetist Level 22 CLA022 Clinical Academic Level 22 DZAN23 Anaesthetist Level 23 CLA023 Clinical Academic Level 23 DZAN24 Anaesthetist Level 24

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CLA024 Clinical Academic Level 24 DZPA16 Pathologist Level 16 Clinical Academic Level CLA14.1 14.1 DZPA17 Pathologist Level 17 Clinical Academic Level CLA15.1 15.1 DZPA18 Pathologist Level 18 Clinical Academic Level CLA16.1 16.1 DZPA19 Pathologist Level 19 Clinical Academic Level CLA17.1 17.1 DZPA20 Pathologist Level 20 Clinical Academic Level CLA18.1 18.1 DZPA21 Pathologist Level 21 Clinical Academic Level CLA19.1 19.1 DZPA22 Pathologist Level 22 Clinical Academic Level CLA20.1 20.1 DZPA23 Pathologist Level 23 Clinical Academic Level CLA21.1 21.1 DZPA24 Pathologist Level 24 Clinical Academic Level CLA22.1 22.1 MA16.1 Consultant Ft YR 1 Clinical Academic Level CLA23.1 23.1 MA17.1 Consultant Ft YR 2 Clinical Academic Level CLA24.1 24.1 MA18.1 Consultant Ft YR 3 CLB014 Clinical Academic Level 14 MA19.1 Consultant Ft YR 4 CLB015 Clinical Academic Level 15 MA20.1 Consultant Ft YR 5 CLB016 Clinical Academic Level 16 MA21.1 Consultant Ft YR 6 CLB017 Clinical Academic Level 17 MA22.1 Consultant Ft YR 7 CLB018 Clinical Academic Level 18 MA23.1 Consultant Ft YR 8 CLB019 Clinical Academic Level 19 MA24.1 Consultant Ft YR 9 MHS01. Health Serv Med Pract YR CLB020 Clinical Academic Level 20 1 1 MHS02. Health Serv Med Pract YR CLB021 Clinical Academic Level 21 1 2 MHS03. Health Serv Med Pract YR CLB022 Clinical Academic Level 22 1 3 MMP01. CLB023 Clinical Academic Level 23 1 Senior Medical Pract YR 1 MMP02. CLB024 Clinical Academic Level 24 1 Senior Medical Pract YR 2 MMP03. DJC001 Consultant Yr1 1 Senior Medical Pract YR 3 MVR01. Voc Regist General Pract DJC002 Consultant Yr2 1 YR 1 MVR02. Voc Regist General Pract DJC003 Consultant Yr3 1 YR 2 MVR03. Voc Regist General Pract DJC004 Consultant Yr4 1 YR 3 MVR04. Voc Regist General Pract DJC005 Consultant Yr5 1 YR 4 MVR05. Voc Regist General Pract DJC006 Consultant Yr6 1 YR 5 DJC007 Consultant Yr7 PFT16.1 Pathologist Level 16.1 DJC008 Consultant Yr8 PFT17.1 Pathologist Level 17.1 DJC009 Consultant Yr9 PFT18.1 Pathologist Level 18.1 DKMP0 Health Serv Medical Pract 1 YR 1 PFT19.1 Pathologist Level 19.1 DKMP0 Health Serv Medical Pract 2 YR 2 PFT20.1 Pathologist Level 20.1 DKMP0 Health Serv Medical Pract 3 YR 3 PFT21.1 Pathologist Level 21.1 DMSP0 1 Senior Medical Pract YR 1 PFT22.1 Pathologist Level 22.1 DMSP0 2 Senior Medical Pract YR 2 PFT23.1 Pathologist Level 23.1 DMSP0 Senior Medical Pract YR 3 PFT24.1 Pathologist Level 24.1

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3 DPGP0 Voc Regist General Pract PMS16. Pathologists Med-Sess Lvl 1 YR 1 1 16.1 DPGP0 Voc Regist General Pract PMS17. Pathologists Med-Sess Lvl 2 YR 2 1 17.1 DPGP0 Voc Regist General Pract PMS18. Pathologists Med-Sess Lvl 3 YR 3 1 18.1 DPGP0 Voic Regist General Pract PMS19. Pathologists Med-Sess Lvl 4 YR 4 1 19.1 DPGP0 Voic Regist General Pract PMS20. Pathologists Med-Sess Lvl 5 YR 5 1 20.1 PMS21. Pathologists Med-Sess Lvl DQSF01 General Surgeon FT YR 1 1 21.1 PMS22. Pathologists Med-Sess Lvl DQSF02 General Surgeon FT YR 2 1 22.1 PMS23. Pathologists Med-Sess Lvl DQSF03 General Surgeon FT YR 3 1 23.1 PMS24. Pathologists Med-Sess Lvl DQSF04 General Surgeon FT YR 4 1 24.1 SFA16. DQSF05 General Surgeon FT YR 5 1 Surgeon FT A YR 1.1 SFA17. DQSF06 General Surgeon FT YR 6 1 Surgeon FT A YR 2.1 SFA18. DQSF07 General Surgeon FT YR 7 1 Surgeon FT A YR 3.1 SFA19. DQSF08 General Surgeon FT YR 8 1 Surgeon FT A YR 4.1 SFA20. DQSF09 General Surgeon FT YR 9 1 Surgeon FT A YR 5.1 DQSS0 General Surgeon <5Sess SFA21. 1 YR 1 1 Surgeon FT A YR 6.1 DQSS0 General Surgeon <5Sess SFA22. 2 YR 2 1 Surgeon FT A YR 7.1 DQSS0 General Surgeon <5Sess SFA23. 3 YR 3 1 Surgeon FT A YR 8.1 DQSS0 General Surgeon <5Sess SFA24. 4 YR 4 1 Surgeon FT A YR 9.1 DQSS0 General Surgeon <5Sess SHS01. Health Serv Med Pract YR 5 YR 5 1 1 DQSS0 General Surgeon <5Sess SHS02. Health Serv Med Pract YR 6 YR 6 1 2 DQSS0 General Surgeon <5Sess SHS03. Health Serv Med Pract YR 7 YR 7 1 3 DQSS0 General Surgeon <5Sess SMP01. 8 YR 8 1 Senior Med Pract YR 1 DQSS0 General Surgeon <5Sess SMP02. 9 YR 9 1 Senior Med Pract YR 2 General Surgeon 12Sess SMP03. DRSS01 YR 1 1 Senior Med Pract YR 3 General Surgeon 12Sess DRSS02 YR 2 SP16.1 Consultant Sess YR 1.1 General Surgeon 12Sess DRSS03 YR 3 SP17.1 Consultant Sess YR 2.1 General Surgeon 12Sess DRSS04 YR 4 SP18.1 Consultant Sess YR 3.1 General Surgeon 12Sess DRSS05 YR 5 SP19.1 Consultant Sess YR 4.1 General Surgeon 12Sess DRSS06 YR 6 SP20.1 Consultant Sess YR 5.1 General Surgeon 12Sess DRSS07 YR 7 SP21.1 Consultant Sess YR 6.1 General Surgeon 12Sess DRSS08 YR 8 SP22.1 Consultant Sess YR 7.1 General Surgeon 12Sess DRSS09 YR 9 SP23.1 Consultant Sess YR 8.1

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General Surgeon 14Sess DSSS01 YR 1 SP24.1 Consultant Sess YR 9.1 General Surgeon 14Sess DSSS02 YR 2 SS16.1 Surgeon Sess YR 1.1 General Surgeon 14Sess DSSS03 YR 3 SS17.1 Surgeon Sess YR 2.1 General Surgeon 14Sess DSSS04 YR 4 SS18.1 Surgeon Sess YR 3.1 General Surgeon 14Sess DSSS05 YR 5 SS19.1 Surgeon Sess YR 4.1 General Surgeon 14Sess DSSS06 YR 6 SS20.1 Surgeon Sess YR 5.1 General Surgeon 14Sess DSSS07 YR 7 SS21.1 Surgeon Sess YR 6.1 General Surgeon 14Sess DSSS08 YR 8 SS22.1 Surgeon Sess YR 7.1 General Surgeon 14Sess DSSS09 YR 9 SS23.1 Surgeon Sess YR 8.1 General Surgeon 16Sess DTSS01 YR 1 SS24.1 Surgeon Sess YR 9.1 General Surgeon 16Sess SVR01. Voc Regist General Pract DTSS02 YR 2 1 YR 1 General Surgeon 16Sess SVR02. Voc Regist General Pract DTSS03 YR 3 1 YR 2 General Surgeon 16Sess SVR03. Voc Regist General Pract DTSS04 YR 4 1 YR 3 General Surgeon 16Sess SVR04. Voc Regist General Pract DTSS05 YR 5 1 YR 4 General Surgeon 16Sess SVR05. Voc Regist General Pract DTSS06 YR 6 1 YR 5 General Surgeon 16Sess VDMP0 NW26 Health Serv Med DTSS07 YR 7 1 Pract YR 1 General Surgeon 16Sess VDMP0 NW26 Health Serv Med DTSS08 YR 8 2 Pract YR 2 General Surgeon 16Sess VDMP0 NW26 Health Serv Med DTSS09 YR 9 3 Pract YR 3 DUPOF VDMP0 NW26 Health Serv Med 1 Plastic & Ortho Surg A YR 1 4 Pract YR 4 DUPOF VDMP0 NW26 Health Serv Med 2 Plastic & Ortho Surg A YR 2 5 Pract YR 5 DUPOF VDMP0 NW26 Health Serv Med 3 Plastic & Ortho Surg A YR 3 6 Pract YR 6 DUPOF NW26 DMO (Non 4 Plastic & Ortho Surg A YR 4 VENP01 Procedural) DUPOF NW26 DMO (Non 5 Plastic & Ortho Surg A YR 5 VENP02 Procedural) DUPOF NW26 DMO (Non 6 Plastic & Ortho Surg A YR 6 VENP03 Procedural) DUPOF NW26 DMO (Non 7 Plastic & Ortho Surg A YR 7 VENP04 Procedural) DUPOF NW26 DMO (Non 8 Plastic & Ortho Surg A YR 8 VENP05 Procedural) DUPOF NW26 DMO (Non 9 Plastic & Ortho Surg A YR 9 VENP06 Procedural) DUPOG 1 Plastic & Ortho Surg B YR 1 VFPR01 NW26 DMO (Procedural) DUPOG 2 Plastic & Ortho Surg B YR 2 VFPR02 NW26 DMO (Procedural) DUPOG 3 Plastic & Ortho Surg B YR 3 VFPR03 NW26 DMO (Procedural) DUPOG VGSM0 NW26 Senior Med Officer 4 Plastic & Ortho Surg B YR 4 1 YR1 DUPOG VGSM0 NW26 Senior Med Officer 5 Plastic & Ortho Surg B YR 5 2 YR2 DUPOG Plastic & Ortho Surg B YR 6 VGSM0 NW26 Senior Med Officer

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6 3 YR3 DUPOG VGSM0 NW26 Senior Med Officer 7 Plastic & Ortho Surg B YR 7 4 YR4 DUPOG 8 Plastic & Ortho Surg B YR 8 VHC001 Nw26 Consultant YR 1 DUPOG 9 Plastic & Ortho Surg B YR 9 VHC002 Nw26 Consultant YR 2 DUPOS Plastic & Ortho Surg Ses 1 YR 1 VHC003 Nw26 Consultant YR 3 DUPOS Plastic & Ortho Surg Ses 2 YR 2 VHC004 Nw26 Consultant YR 4 DUPOS Plastic & Ortho Surg Ses 3 YR 3 VHC005 Nw26 Consultant YR 5 DUPOS Plastic & Ortho Surg Ses 4 YR 4 VHC006 Nw26 Consultant YR 6 DUPOS Plastic & Ortho Surg Ses 5 YR 5 VHC007 Nw26 Consultant YR 7 DUPOS Plastic & Ortho Surg Ses 6 YR 6 VHC008 Nw26 Consultant YR 8 DUPOS Plastic & Ortho Surg Ses 7 YR 7 VHC009 Nw26 Consultant YR 9 DUPOS Plastic & Ortho Surg Ses 8 YR 8

Registrars: Rate Rate Description Rate Rate Description ID ID DCRG DHTH0 Trainee Public Health 01 Registrar Yr 1 2 Physician Yr 2 DCRG DHTH0 Trainee Public Health 02 Registrar Yr 2 3 Physician Yr 3 DCRG DHTH0 Trainee Public Health 03 Registrar Yr 3 4 Physician Yr 4 DCRG DHTH0 Trainee Public Health 04 Registrar Yr 4 5 Physician Yr 5 DCRG DHTH0 Trainee Public Health 05 Registrar Yr 5 6 Physician Yr 6 DCRG DHTH0 Trainee Public Health 06 Registrar Yr 6 7 Physician Yr 7 DCRG ME05. 07 Registrar Yr 7 1 Registrar Year 1.1 DDSR ME06. 01 Senior Registrar Yr 1 1 Registrar Year 2.1 DDSR ME07. 02 Senior Registrar Yr 2 1 Registrar Year 3.1 DESM ME08. 01 Supervised Med Off Yr 1 1 Registrar Year 4.1 DESM ME09. 02 Supervised Med Off Yr 2 1 Registrar Year 5.1 DESM ME10. 03 Supervised Med Off Yr 3 1 Registrar Year 6.1 DESM ME11. 04 Supervised Med Off Yr 4 1 Registrar Year 7.1 DESM ME12. 05 Supervised Med Off Yr 5 1 Senior Registrar Year 1.1 DESM ME13. 06 Supervised Med Off Yr 6 1 Senior Registrar Year 2.1 DESM MEO1 07 Supervised Med Off Yr 7 0.1 Registrar Year 6.1 DESM MEO1 08 Supervised Med Off Yr 8 1.1 Registrar Year 7.1 DESM MEO5. 09 Supervised Med Off Yr 9 1 Registrar Year 1.1 DFTM Trainee Medical MEO6. 01 Administrator Yr 1 1 Registrar Year 2.1

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DFTM Trainee Medical MEO7. 02 Administrator Yr 2 1 Registrar Year 3.1 DFTM Trainee Medical MEO8. 03 Administrator Yr 3 1 Registrar Year 4.1 DFTM Trainee Medical MEO9. 04 Administrator Yr 4 1 Registrar Year 5.1 DFTM Trainee Medical MTP01 05 Administrator Yr 5 .1 Trainee Psychiatrist Year 1.1 DFTM Trainee Medical MTP02 06 Administrator Yr 6 .1 Trainee Psychiatrist Year 2.1 DFTM Trainee Medical MTP03 07 Administrator Yr 7 .1 Trainee Psychiatrist Year 3.1 DGTP MTP04 01 Trainee Psychiatrist Yr 1 .1 Trainee Psychiatrist Year 4.1 DGTP MTP05 02 Trainee Psychiatrist Yr 2 .1 Trainee Psychiatrist Year 5.1 DGTP MTP06 03 Trainee Psychiatrist Yr 3 .1 Trainee Psychiatrist Year 6.1 DGTP MTP07 04 Trainee Psychiatrist Yr 4 .1 Trainee Psychiatrist Year 7.1 DGTP VCRG 05 Trainee Psychiatrist Yr 5 01 Nw26 Registrar Yr 1 DGTP VCRG 06 Trainee Psychiatrist Yr 6 02 Nw26 Registrar Yr 2 DGTP VCRG 07 Trainee Psychiatrist Yr 7 03 Nw26 Registrar Yr 3 DHTH Trainee Public Health 01 Physician Yr 1

Resident Medical Officers: Rate ID Rate Description Rate ID Rate Description DBRM0 Resident Medical Off Yr VBRM0 Nw26 Resident Medical Officer 1 1 1 Yr1 DBRM0 Resident Medical Off Yr VBRM0 Nw26 Resident Medical Officer 2 2 2 Yr2 DBRM0 Resident Medical Off Yr VBRM0 Nw26 Resident Medical Officer 3 3 3 Yr3

Interns: Rate ID Rate Description DAI001 Intern

Other Medical: ‘Other Medical’ includes all other Rate Ids that do not fit in the above Intern, Resident Medical Officer, Registrar and Consultant categories. This includes, for example, Medical Administrators, Dental Officers, Specified Calling positions, and positions with negotiated pay rates.

Exclusions Null or missing rate IDs Non WA Health locations including the Office of Health Review, Peel Health Campus, Joondalup Health Campus, Drug and Alcohol Office, and Mental Health Commission WA

Scope ABF/M sites with interns and/or RMOs in 2012/13..

Formula Numerator Medical grouping (either the consultant, registrar, resident medical officer, intern or other medical grouping FTEs).

Denominator Sum of consultants, registrars resident medical officers, interns and

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other medical FTEs.

Calculation Numerator divided Denominator expressed as a percentage for the grouping.

Example % consultants are calculated by dividing the total number of consultants (numerator) by the sum of consultants, registrars, resident medical officers, interns and other medical (denominator) to determine the % consultants in the workforce.

Verification Rules Between 0% and 100%.

Data Collection Identification Items Source HR data warehouse

Governance Items Purpose of the This indicator is used to show the proportion of a medical grouping data (i.e. graduates) against the full medical workforce to ensure the correct levels to sustain training and safe patient care are maintained within the WA Health system.

Source of the Workforce Directorate, WA Health. definition

Version number 1.2

Approval date 20130605

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SW2: Proportion of nursing graduates and other categories of nursing staff to total nursing staff

Reported Data Description Items Identifier ABF/M-KPI- SW2

Name Proportion of nursing graduates and other nursing staff to total nursing staff

Aliases Nursing grouping breakdown

Definition This indicator is used to show the proportion of a nursing grouping (e.g., nursing graduates) against the full nursing workforce to ensure the correct levels to sustain training and safe patient care are maintained within the WA Health system.

Related Proportion of new Medical Graduates to other Medical Staff and to Total Metadata Medical Staff

Guide for Use The reporting of nursing graduates needs to consider the employment context into which they are potentially employed. Frequently, the capacity to employ graduate nurses will vary with the aggregated level of staff experience in the place of employment. Greater numbers of graduate nurses can be employed into areas where there are sufficient numbers of experienced staff to both support and supervise their work, while the opposite is true for areas where there are few experienced nurses.

The nursing groupings presented are:

(a) Graduate: usually the first occasion of employment following qualification and Board registration as either a RN (registered nurse) or an EN (enrolled nurse); most often this period includes a formal graduate development program to support entry into the workforce.

(b) Junior: the period of employment during which an RN or an EN continues to consolidate both their formal education and initial employment experience as a graduate. Since the RN has greater responsibilities and role complexity than is the case for ENs, RNs in their second and third years following graduation are considered relatively junior to more experienced RN colleagues, and ENs in their second year following graduation are considered relatively junior to more experienced EN colleagues.

(c) Experienced: RNs with three or more years post-graduation experience (or more than two years in the case of an EN), will generally possess a broad range of competencies and clinical expertise.

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(d) Senior: RNs with six or more years post-graduation experience (or ENs who have qualified as an ASEN – advanced skills enrolled nurse), possess highly developed competencies and problem solving abilities. This grouping of nurses includes individuals who have specialist clinical, education, and resource management skills. For example, this group is inclusive of ANF level 2 promotional positions for RNs who collectively take responsibility for the quality of patient care delivery and the standard of practice in an assigned ward or unit (CN), or who implement and evaluate staff development and education programs for new and existing staff at ward or unit level (SDN).

(e) SRN and above: this category includes nurses and midwives in very senior roles ranging from front-line manager/leader, clinical consultation roles, through to executive-level strategic service director positions.

(f) ‘Other’ Nursing: non-specific, miscellaneous; often will include individuals attributed as nurses in the payroll system but being paid non- nursing award wages.

These groupings are determined by using the ‘rate ID’ and ‘rate description’ field in the HR data warehouse. These fields relate to actual payment amounts and are the most accurate reflection of employee experience and seniority available for these reporting purposes. All groupings were determined by the Nursing and Midwifery Office of WA Health in December 2010. These will be reviewed on a regular basis (please see the inclusions listed below to show the actual rate IDs used to determine the groupings).

This indicator excludes ‘null’ or ‘missing’ rate IDs (which are generally associated with agency staff, recoups or data quality issues) as these cannot be appropriately allocated to a nursing grouping. For this reason the total nursing staff Full Time Equivalent (FTE) may be different from the actual FTE reported in other reports. Due to this, only the percentage is to be reported for this indicator (i.e. the number of FTEs is not to be reported).

This is a quarterly indicator – be aware some variation in nursing graduate numbers will be associated with bi-annual graduate intakes in January/ February and July/ August of each year.

Payment recoups can have impacts on the grouping percentages at some sites. This can slightly overestimate or underestimate groupings at some

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sites; however, for nursing groupings the impact is believed to be very small.

This indicator uses rate ID to group into the specific nursing groupings. Monitoring of new rate IDs or changes to rate IDs need to occur to ensure the definition remains current.

Reported Data Validation Items Format Percentage 4 NNN.N% Data Values Inclusions Nursing WFM account codes including:

Account Code Account code description 0111 Nursing Services 0113 Casual Nurses 0116 Enrolled Nurses 0117 Enrolled Mental Health Nurses 0211 Agency nurses

Graduate Nurses: Rate ID Rate Description ENE001 ENROLLED NURSE EBA LEV 1 ENE011 NSG ASSIST EBA LEV 1 ENE1.1 ENROLLED NURSE EBA LEVEL 1.1 MST1.1 MIDWIFE STUDENT - REGISTERED NURSE L1.2.1 NEA001 REGISTER M/CRAFT YR1 4WK NEA011 REG GEN NURSE L1-1 4WK REMEB1 ENROLLED MHN EB YR1 4WK RGN1.1 REGISTERED GENERAL NURSE LEVEL 1.1

Junior Nurses: Rate ID Rate Description ENE002 ENROLLED NURSE EBA LEV 2 ENE012 NSG ASSIST EBA LEV 2 ENE1.2 ENROLLED NURSE EBA LEVEL 1.2 NEA012 REG GEN NURSE L1-2 4WK NEA013 REG GEN NURSE L1-3 4WK RGN1.2 REGISTERED GENERAL NURSE LEVEL 1.2 RGN1.3 REGISTERED GENERAL NURSE LEVEL 1.3

Experienced Nurses: Rate ID Rate Description ALL.1 ALL CLASSIFICATIONS.1 EME.3 ENROLLED MENTAL HEALTH NURSE EBA.3 EME.4 ENROLLED MENTAL HEALTH NURSE EBA.4 EME.5 ENROLLED MENTAL HEALTH NURSE EBA.5 EME.6 ENROLLED MENTAL HEALTH NURSE EBA.6 ENE003 ENROLLED NURSE EBA LEV 3 ENE004 ENROLLED NURSE EBA LEV 4 ENE005 ENROLLED NURSE EBA LEV 5 ENE013 NSG ASSIST EBA LEV 3 ENE031 EN SCHOOL NURSE EBA L2 ENE1.3 ENROLLED NURSE EBA LEVEL 1.3 ENE1.4 ENROLLED NURSE EBA LEVEL 1.4 ENE2.1 ENROLLED NURSE EBA LEVEL 2.1

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ENE3.1 ENROLLED NURSE EBA LEVEL 3.1 ENE4.1 ENROLLED NURSE EBA LEVEL 4.1 NEA014 REG GEN NURSE L1-4 4WK NEA015 REG GEN NURSE L1-5 4WK NEA016 REG GEN NURSE L1-6 4WK REMEB2 ENROLLED MHN EB YR2 4WK REMEB3 ENROLLED MHN EB YR3 4WK RGN1.4 REGISTERED GENERAL NURSE LEVEL 1.4 RGN1.5 REGISTERED GENERAL NURSE LEVEL 1.5

Senior Nurses: Rate ID Rate Description ASEE1.1 ADVANCED SKILL EN EBA L 1.1 ASEE1.2 ADVANCED SKILL EN EBA L 1.2 ASEE2.1 ADVANCED SKILL EN EBA L 2.1 ENAS01 ADVANCED SKILL EN EBA L 1 ENAS02 ADVANCED SKILL EN EBA L 2 ENSAS1 ADV SKILL SCHOOL EN L1 ENSAS2 ADV SKILL SCHOOL EN L2 FRM2.1 FBC REGISTERED MIDWIFE L2.1 FRM2.2 FBC REGISTERED MIDWIFE L2.2 FRM2.3 FBC REGISTERED MIDWIFE L2.3 FRM2.4 FBC REGISTERED MIDWIFE L2.4 NEA005 REGISTER M/CRAFT YR5 4WK NEA006 FBC REG M/WIFE L2-1 4WK NEA007 FBC REG M/WIFE L2-2 4WK NEA008 FBC REG M/WIFE L2-3 4WK NEA009 FBC REG M/WIFE L2-4 4WK NEA017 REG GEN NURSE L1-7 4WK NEA018 REG GEN NURSE L1-8 4WK NEA019 REG GEN NURSE L1-9 4WK NEA021 S-DEV/CLIN/A-MAN L2-1 4WK NEA022 S-DEV/CLIN/A-MAN L2-2 4WK NEA023 S-DEV/CLIN/A-MAN L2-3 4WK NEA024 S-DEV/CLIN/A-MAN L2-4 4WK NEA026 SCHOOL NURSE L2-1 4WK NEA027 SCHOOL NURSE L2-2 4WK NEA028 SCHOOL NURSE L2-3 4WK NEA029 SCHOOL NURSE L2-4 4WK NEC021 COMMUNITY M/WIFE L2-1 4WK NEC022 COMMUNITY M/WIFE L2-2 4WK NEC023 COMMUNITY M/WIFE L2-3 4WK NEC024 COMMUNITY M/WIFE L2-4 4WK REMEB4 ENROLLED MHN EB YR4 4WK REMEB5 ENROLLED MHN EB YR5 4WK REMEB6 ENROLLED MHN EB YR6 4WK RGN1.6 REGISTERED GENERAL NURSE LEVEL 1.6 RGN1.7 REGISTERED GENERAL NURSE LEVEL 1.7 RGN1.8 REGISTERED GENERAL NURSE LEVEL 1.8 RGN1.9 REGISTERED GENERAL NURSE LEVEL 1.9 SCA2.1 CLINICAL NURSE LEVEL 2.1 SCA2.2 CLINICAL NURSE LEVEL 2.2 SCA2.3 CLINICAL NURSE LEVEL 2.3 SCA2.4 CLINICAL NURSE LEVEL 2.4

SRN’s and Above Rate ID Rate Description NEAS01 SENIOR REG NSE L 1 4WK NEAS02 SENIOR REG NSE L 2 4WK NEAS03 SENIOR REG NSE L 3 4WK NEAS04 SENIOR REG NSE L 4 4WK NEAS05 SENIOR REG NSE L 5 4WK

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NEAS06 SENIOR REG NSE L 6 4WK NEAS07 SENIOR REG NSE L 7 4WK NEAS08 SENIOR REG NSE L 8 4WK NEAS09 SENIOR REG NSE L 9 4WK NEAS10 SENIOR REG NSE L 10 4WK SRN1.1 SENIOR REG NURSE LEVEL 1.1 SRN2.1 SENIOR REG NURSE LEVEL 2.1 SRN3.1 SENIOR REG NURSE LEVEL 3.1 SRN4.1 SENIOR REG NURSE LEVEL 4.1 SRN5.1 SENIOR REG NURSE LEVEL 5.1 SRN6.1 SENIOR REG NURSE LEVEL 6.1 SRN7.1 SENIOR REG NURSE LEVEL 7.1 SRN8.1 SENIOR REG NURSE LEVEL 8.1 SRN9.1 SENIOR REG NURSE LEVEL 9.1 SR10.1 SENIOR REG NURSE LEVEL 10.1 All “AG4” HSU GEN DIV rate IDs All ‘AP2 HSU PROF DIV and AP4’ rate IDs All ‘AS4’ HSU SNR OFF DIV rate IDs

‘Other’ Nurses (not to be reported as a numerator): Rate ID Rate Description All HW rate IDs HOSP WRKERS All ‘ZZ’ rate IDs NEG RATE All GOS rate IDs GOSAC Please note: ‘other’ nursing also includes various other rate IDs that do not fit in the above graduate, junior, experienced, senior and SRN and above categories. Please see guide for use.

Scope ABF/M sites with graduate and/or junior nurses in 2012/13.

Formula Numerator Nurse grouping (either the graduate, junior, experienced, senior, SRN and above or other grouping)

Denominator Sum of graduate, junior, experienced, senior, SRN and other nursing.

Calculation Numerator divided Denominator expressed as a percentage for the grouping.

Example % senior nurses are calculated by dividing the total number of senior nurses (numerator) by the sum of graduate, junior, experienced, senior, SRN and ‘other’ nursing (denominator) to determine the % senior nurses in the workforce.

Verification Between 0% and 100%. Rules

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Data Collection Identification Items Source HR data warehouse

Governance Items Purpose of the This indicator is used to show the proportion of a nursing grouping (e.g.. data graduates) against the full nursing workforce to ensure the correct levels to sustain training and safe patient care are maintained within the WA Health system.

Source of the Workforce Directorate and the Nursing and Midwifery Office, WA Health definition

Version number 1.2

Approval date 20140423 (Noted by PRGC)

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SW4.a: Injury management a) Lost time injury severity rate

Reported Data Description Items Identifier ABF/M-KPI-SW4a Name Injury severity rate Aliases Lost time injury severity rate Definition The lost time injury severity rate is the number of severe injuries (estimated 60 days /shifts or more lost from work) divided by the number of lost time injuries, presented as a rate per 100 lost time injuries. An injury resulting in death is considered to have accounted for more than 60 days lost. Related Metadata Guide for Use This is a measure of incident/accident prevention and the effectiveness of injury management. Reporting frequency: six-monthly Reporting level: Health Service Note: the data are extracted for the two reporting periods: January- June and July-December at each calendar year. Limitations The medical certificates and medical notes are used in the process of determining if a claim will be included as an estimate. Further information on complying with this reporting requirement, including the calculation and reporting of the performance measures, can be found at http://www.publicsectorsafety.wa.gov.au

Reported Data Validation Items Format Number (rate per 100 lost time injuries) 4 NN.NN Data Values >= 0 and <=100 Inclusions The severity rate is the number of severe injuries (estimated 60 days /shifts or more lost from work) divided by the number of lost time injuries multiplied by 100. Note: the calculation of days lost during the reporting period is to be estimated. An injury resulting in death is included as a severe injury coded as more than 60 days of work hours lost (equivalent to a work days/shifts). Compensated claims = The number of workers’ compensation claims by employees lodged and accepted by RiskCover in the public WA Health System. The count of claims is based on an lodgement date falling within the specified collection time period.

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LTI/D = The number of total compensation claims, where one day/shift or more was lost, in this financial year as a proportion of the total number of workers. The one day/shift is equal to a ≥ 1 (estimated) work day (where a day equates to a work day that may or may not be continuous). Claims are coded according to the Type of Occurrence Classification System (TOOCS) coding system (2nd addition). Exclusions Data exclude reporting entities such as HCN, HIN, Drug and Alcohol Office, and DoH at Royal Street. Includes: Scope  North Metropolitan Health Service o Dental Health o PathWest  South Metropolitan Health Service  Child and Adolescent Health Service  WA Country Health Service

Excludes:  Joondalup Health Campus  Peel Health Campus Formula Numerator: Number of severe injuries (X 100). Denominator: Number of lost time injuries. Verification Rules >=0 or <=100

Data Collection Identification Items Source RiskCover & Health Services RiskCover provides the data for the calculation. The data and result are reviewed and approved by each reporting entity. RiskCover supplies the data to the Performance Reporting Branch (PRB), then PRB send the data to the individual reporting entities for approval. Governance Items Purpose of the data WA State Performance Indicator Definition Source of the Operational Plan 2010-11 report definition for PI 4.9. definition Version number 3.0 Approval date 20130605

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SW4.b: Injury management b) Percentage of managers and supervisors trained in occupational safety and health (OSH) and injury management responsibilities

Reported Data Description Items Identifier ABF/M-KPI-SW4b Name Percentage of managers and supervisors trained in occupational safety, health (OSH) and injury management responsibilities Aliases Percentage of managers trained in occupational safety and health (OSH) and injury management responsibilities Definition The percentage of managers and supervisors trained in occupational safety and health (OSH) and injury management

responsibilities is the number of WA health managers and supervisors who have received training in OSH practices within the last three years, divided by the total number of managers in WA Health, expressed as percentage. The data are based on a snapshot as at a point in time.

Related Metadata Guide for Use This is a measure of incident/accident prevention and the effectiveness of injury management.

This measure is reported in accordance with the Public Sector Commissioner’s Circular 2012-05. The circular states that “The frequency of refresher training is at the discretion of the agency, however it should occur at least every three years or sooner if significant changes to the risk profile of the agency/ work areas or legislative changes occur.” It measures the percentage of current WA health managers and supervisors who have received training in occupational safety, health (OSH) and injury management responsibilities within the last three years, as at a point in time – e.g., snapshot as at the end of the report period. The number of managers is based on headcount, not FTE.

Limitations Defining a manager or supervisor in Health is difficult due to the range of disciplines and management structures. The agreed list

of employees approved by health services below is used to define “Manager”  Directors;  Nurse managers and Clinical Nurse Specialists;  Staff Development nurses;  Tier 6 staff level (specific to PathWest);  Allocated Leader (specific to Allied Health Professionals).

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This list is not exhaustive and other employees classified as managers or supervisors should be included.

Reported Data Validation Items Format Percentage 4 NN.NN% Data Values >= 0% and <=100% Inclusions Numerator and Denominator: Managers include: directors, nurse managers and clinical nurse specialists, staff development nurses, tier 6 staff level (specific to PathWest), and allocated leader (specific to Allied Health Professionals). This list is not exhaustive and other employees classified as managers should be included.

Numerator: Current managers who have received OSH and injury management training within the last three years. This includes refresher training. Exclusions Scope Includes:  North Metropolitan Health Service o Dental Health o PathWest  South Metropolitan Health Service  Child and Adolescent Health Service  WA Country Health Service  Health Corporate Network  Health Information Network  Department of Health For a particular report, please refer to that report’s scoping to determine which sites are included.

Excludes:  Joondalup Health Campus  Peel Health Campus

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 Drug and Alcohol Office. Formula Numerator: Number (headcount) of WA health managers and supervisors who have received training in OSH practices within the prior three years, as at the last day of the reporting period. Denominator: Total number (headcount) of managers employed in WA Health, as at the last day of the reporting period. Numerator divided by Denominator, expressed as a percentage. Verification Rules >=0 or <=100%

Data Collection Identification Items Source Health Services and other WA Health entities. Note: Health Services and entities supply the data to the Performance Reporting Branch (PRB).

Governance Items Purpose of the data To report on the the percentage of current managers (anyone who supervises staff), who have received training in their responsibilities for occupational safety, health and injury management, in line with the Public Sector Commissioner’s Circular. Source of the definition Public Sector Commissioner’s Circular 2012-05 http://publicsectorsafety.wa.gov.au/media/2012- 05_code_of_prac.pdf Version number 2.1 Approval date 20130719

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SW5: Leave Liability

Reported Data Description Items Identifier MDG-06-007

Name Leave Liability Aliases N/A

Definition A count of hours of accrued annual leave and currently available long service leave.

Related Metadata None Guide for Use Leave liability is the sum of the accrued annual leave and currently available long service leave. It does not take into account the liability of pro rata long service leave of those aged 55 years and over. Includes all permanent and non permanent employees. Leave liability data will change for each Budget Holder/location due to staff transfers. Therefore comparisons with previous recorded values may not be directly comparable for a particular location. Limitations

Reported Data Validation Items Format Numeric (to 2 decimals)

NNNNNNN.NN

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132 Radiotherapy 133 Pathology 134 Dietitians 135 Podiatry 136 Chapliancy 137 Health Promotions 138 Rehabilitation Assistance 139 Other Medical Support Services 140 Dental Technician 141 Dental Therapists 142 Occupational Therapy 143 Pharmacy 144 Physiotherapy 145 Social Work 146 Technical 147 Speech Pathology 148 Psychologists 149 Other Ancillary Services 172 Aboriginal Health Worker 4. Admin & Clerical 121 General Admin & Clerical 122 Clinical Admin Support 5. Hotel Services 151 Catering 152 Cleaning Services 153 Orderlies & Transport 154 Patient Support Assistants 155 Laundry & Linen 156 Stores & Supply 157 Home Ancillary Worker 6. Site Services 161 Engineering Maintenance Services 162 Grounds & Gardens 168 Security Services 171 Other Categories

Exclusions Account Group for Agency Staff (0210) Office of Health Review Peel Health Campus Joondalup Health Campus Mental Health Commission WA Drug and Alcohol Office

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Scope Leave Liability will be reported for the following WA State Public Health system locations: . North Metropolitan Health Service . South Metropolitan Health Service . Child and Adolescent Health Service . WA Country Health Service . Others

 Dental Admin

 Dental Central

 Dental North

 Dental South

 Pathology Centre

 Health System Support

 Health Corporate Network

 Dental Health Service

 Director General’s Office

 Health Policy & Clinical Reform

 Health Finance

 Path West

Covers state government hospital employees working on rotation in private hospitals. Leave liability can also be reported by WA Health major locations. For a particular report, please refer to that report’s scoping to determine which major locations are included. Formula Count of hours of accrued annual leave and currently available long service leave. Verification Rules Value is >/= to zero

Data Collection Identification Items Source . Human Resource Data Warehouse. . Data is extracted following advice from HCN that the general ledger is closed and available for reporting. . Department of Health WA Chart of Accounts (http://intranet.health.wa.gov.au/divs/corpfin/coa/). Governance Items Purpose of the The intention is to capture the employer liability in hours. This data information can be used to monitor and report on annual leave and long service leave entitlements.

Source of the Workforce Division and Health Corporate Network, Department of definition Health.

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Version number V1.4 Approval date 20130605

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SW6.a: Actual and Budget FTE: Average Monthly Total Full Time Equivalents

Reported Data Description Items Identifier PMR-12-070a Name Average Monthly Total Full Time Equivalents – Financial View Aliases . Month to Date (MTD) Total FTE . Average Monthly Total FTE . Actual FTE Definition The average number of full time equivalent Total Employees, allocated by cost centre. Related Metadata . MDG-06-001 Average Monthly Total FTE (Major Location View) . PMR-12-070b Average Monthly Budgeted FTE (Financial View) Guide for Use Average Monthly FTE are counts of Nursing Services, Nursing Agency, Admin & Clerical, Medical Support Services, Hotel Services, Site Services, Medical Agency, Medical-Salaried and Medical- Sessional FTEs. The monthly Average FTE is the average hours worked during a period of time divided by the relevant Award Full Time Hours for the same period. This definition is referred to as a ‘Financial view’ because FTEs are allocated according to the cost centre paying for the FTE, irrespective of where the FTE is physically located. Cost centres provide groupings of financial information according to various parameters that may include the description of services delivered, functions performed, projects etc. Cost centre groupings in WA Health range from various levels including Level 5 - Health Service/Entity; Level 4 - Division; Level 3/2 - Directorate; and Posting Level. Cost Centre Level 5 is the highest level. There is an expectation that at the lower the cost centre level, more precise detail is provided as to the grouping or cost centre purpose. Limitations

Reported Data Validation Items Format Numeric 9 NNNNN.#

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184 Salaried Radiotherapy 185 Salaried Pathology 186 Salaried Dental Officers 189 Salaried Other 191 Sessional Clinical 192 Sessional Radiology (Medical Imaging) 193 Sessional Radiotherapy 194 Sessional Pathology 195 Sessional Other 3. Medical Support 114 Registered Dental Nurse 115 Dental Clinic Assistant 131 Radiology (Medical Imaging) 132 Radiotherapy 133 Pathology 134 Dietitians 135 Podiatry 136 Chapliancy 137 Health Promotions 138 Rehabilitation Assistance 139 Other Medical Support Services 140 Dental Technician 141 Dental Therapists 142 Occupational Therapy 143 Pharmacy 144 Physiotherapy 145 Social Work 146 Technical 147 Speech Pathology 148 Psychologists 149 Other Ancillary Services 172 Aboriginal Health Worker 4. Admin & Clerical 121 General Admin & Clerical 122 Clinical Admin Support 5. Hotel Services 151 Catering 152 Cleaning Services 153 Orderlies & Transport 154 Patient Support Assistants 155 Laundry & Linen 156 Stores & Supply 157 Home Ancillary Worker 6. Site Services 161 Engineering Maintenance Services 162 Grounds & Gardens 168 Security Services 171 Other Categories

Exclusions Office of Health Review Joondalup Health Campus Peel Health Campus Mental Health Commission WA Drug and Alcohol Office

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Scope Average monthly total FTE – Financial View will be reported for the following WA Health Level 5 Cost Centres: . North Metropolitan Health Service . South Metropolitan Health Service . Child and Adolescent Health Service . WA Country Health Service . Health Corporate Network . Dental Health Service . Health Information Network . PathWest . Department of Health Divisions (the following divisions are Level 4 Cost Centres) . Office of Director General . Resource Strategy . Systems Policy and Planning . Performance Activity and Quality . Public Health and Clinical Services For a particular report, please refer to that report’s scoping to determine which sites are included. Covers state government hospital employees working on rotation in private hospitals. Formula The Workforce MTD Average FTE uses the following calculation method:

SUM of hours for all [EMPLOYEE EARNING CODE] values where

[FTE FLAG] = Y, divided by the sum of [AWARD] full time equivalent hours for the [PAY MONTH].

Verification Rules Values > 0

Governance Items Purpose of the data The count is used to report the profile of the WA Health workforce, and may be used to report against the Budgeted FTE and FTE ceiling. Source of the Workforce Division definition Resource Strategy & Infrastructure Division Performance Activity & Quality Division

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Version number 1.1 Approval date 20130605

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SW6.b: Actual and Budget FTE: Average Monthly Budget Full Time Equivalents

Reported Data Description Items Identifier PMR-12-070b Name Average Monthly Budget Full Time Equivalents – Financial View Aliases . Month to Date (MTD) Total FTE Budget . Average Monthly Total FTE Budget . Budget FTE . Budgeted FTE Definition FTE Budgets are a measure of the number of FTE that a budget holder can purchase within the approved finanical budget. The FTE budgets are allocated by the budget holders, according to Cost Centre. Related Metadata . PMR-12-070a Average Monthly Total FTE (Financial View) Guide for Use The monthly average FTE budgets are calculated by the budget holders, based on available funding for FTE. Budget holders provide their budgeted FTE to the Department of Health to be loaded into the Human Resource Data Warehouse (HRDW) each month. A report is run from the FTE budget system to extract the monthly budget information, for the purposes of monthly reporting. The FTE budget for closed financial periods (i.e., previous months and the current month) cannot be updated – i.e., only future periods (‘open periods’) can be updated. Period 13 is an additional period that budget holders can use to temporarily allocate funding and therefore budgeted FTE. Period 13 is used when there is funding available, but budget holders are unsure of when the funding will be used. The expectation is that the funding will be allocated to the remaining open periods at some point soon after. Note that ‘actual’ FTE are not reported in period 13. Average Monthly budget FTE are available for Nursing Services, Nursing Agency, Admin & Clerical, Medical Support Services, Hotel Services, Site Services, Medical Agency, Medical-Salaried and Medical-Sessional FTEs. This definition is referred to as a ‘Financial view’ because budgeted FTEs are allocated according to the cost centre paying for the FTE, irrespective of where the FTE is physically located. Cost centres provide groupings of financial information according to various parameters that may include the description of service delivered, functions performed, projects etc. Cost centre groupings in WA Health range from various levels including Level 5 - Health Service/Entity; Level 4 - Division; Level 3/2 - Directorate; and Posting Level. Cost Centre Level 5 is the highest level. There is an expectation that at the lower the cost centre level, more precise detail is provided as to the grouping or cost centre purpose. Limitations

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Reported Data Validation Items Format Numeric 9 NNNNN.#

Data Values Grouping Account Code Description Inclusions 1. Nursing and 111 Nursing Services Nursing Support 113 Casual Nurses 116 Enrolled Nurses 117 Enr'lld Mental Hlth Nurse 118 Assistant In Nursing 2. Medical 181 Salaried Medical Officers 182 Salaried Medical Practitioners 183 Salaried Radiology (Medical Imaging) 184 Salaried Radiotherapy 185 Salaried Pathology 186 Salaried Dental Officers 189 Salaried Other 191 Sessional Clinical 192 Sessional Radiology (Medical Imaging) 193 Sessional Radiotherapy 194 Sessional Pathology 195 Sessional Other 3. Medical Support 114 Registered Dental Nurse 115 Dental Clinic Assistant 131 Radiology (Medical Imaging) 132 Radiotherapy 133 Pathology 134 Dietitians 135 Podiatry 136 Chapliancy 137 Health Promotions 138 Rehabilitation Assistance 139 Other Medical Support Services 140 Dental Technician 141 Dental Therapists 142 Occupational Therapy 143 Pharmacy 144 Physiotherapy 145 Social Work 146 Technical 147 Speech Pathology 148 Psychologists 149 Other Ancillary Services 172 Aboriginal Health Worker 4. Admin & Clerical 121 General Admin & Clerical 122 Clinical Admin Support 5. Hotel Services 151 Catering 152 Cleaning Services 153 Orderlies & Transport 154 Patient Support Assistants 155 Laundry & Linen

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156 Stores & Supply 157 Home Ancillary Worker 6. Site Services 161 Engineering Maintenance Services 162 Grounds & Gardens 168 Security Services 171 Other Categories

Exclusions Office of Health Review Peel Health Campus Joondalup Health Campus Mental Health Commission WA Drug and Alcohol Office

Scope Budget FTE will be reported for the following WA Health Level 5 Cost Centres: . North Metropolitan Health Service . South Metropolitan Health Service . Child and Adolescent Health Service . WA Country Health Service . Health Corporate Network . Dental Health Service . Health Information Network . PathWest . Department of Health Divisions (the following divisions are Level 4 Cost Centres) . Office of Director General . Resource Strategy . Systems Policy and Planning . Performance Activity and Quality . Public Health and Clinical Services Covers state government hospital employees working on rotation in private hospitals.

Formula The budget holders calculate their FTE budget based on the available funding for FTEs. Budget holders provide their monthly budgets to the

DoH, which are then loaded into the budgeted FTE system. Budget holders provide the budgets for each month ([Pay Month]), cost centre ([Cost Centre ID]), and account code ([Account Code]). The budgets for prior months and the current reporting month should not be changed – only budgets for future periods can be updated. The Budget FTE are then extracted from the budgeted FTE system by the Workforce Division as follows: A report is run from the budgeted FTE system (Oracle Warehouse) to

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extract the FTE budget information. Fields extracted are: [Year], [Pay Month], [Cost Centre ID], [Account Code], [Budget MTD], [YTD Monthly Average Budget], [Cost centre Level 5], [Cost Centre Level 4], and [Account Group]. [Pay month] is used to allocate budgets to a particular reporting month. [Cost Centre ID] is used to group cost centres to [Cost Centre Level 5] or [Cost Centre Level 4]. [Account Code] is used to group FTE to [Account Group]. [Budget MTD] can be summed across [Account codes] and within cost centre groupings to report budgeted FTE. Verification Rules Values  0

Data Collection Identification Items Source . Budgeted FTE System, Human Resource Data Warehouse. . Data is extracted following the end of the month. . Department of Health WA Chart of Accounts available from Oracle Discoverer 10G.

Governance Items Purpose of the data To report the FTE budget for the WA Health workforce, and enable comparison against the actual FTE.

Source of the Workforce Division definition Resource Strategy and Infrastructure Division Performance Activity & Quality Division Version number 1.1 Approval date 20130605

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2.7 Processes Coding (PC) KPIs

There are 3 PC PIs proposed in the 2014-15 PMF, including 2 Health Service measures.

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PC1: Percentage of cases coded by end of month closing date

Reported Data Description Items Identifier MDG-01-013 Name Coded cases

Aliases Reportable cases Definition The percentage of all inpatient discharge records which have been clinically coded, transmitted to the Hospital Morbidity Data System (HMDS) and cleared from a range of quality edit processes. Related Metadata . Total Separations . Submitted Cases Guide for Use Numerator A count of records from TOPAS, HCARe CMS (HCARe), Peel Health Campus (PHC) and Joondalup Health Campus (JHC) morbidity extracts generated for the Hospital Morbidity Data Collection (HMDC) unit that have been clinically coded and cleared from a range of quality edit processes by HMDC. Denominator A count of records from inpatient discharge extracts. This extract contains details of all inpatient discharges, irrespective of status of clinical coding. Cases are matched between numerator and denominator using Hospital Number (Est Code) and Account Number.

Limitations Replacement cases: A very small number of cases can be replaced or updated after acceptance into the HMDS. This occurrence falsely increases the number of reportable cases. This effect is negligible. Morbidity extracts from TOPAS are received on a daily basis and HCARe on a semi-weekly basis whereas PHC and JHC data are received on a monthly basis. Dependent on the start and end date of the reference period, discrepancies may exist between private and public hospitals in regard to the number of cases received by HMDC. The data from Next Step Inpatient Withdrawal Unit are not included since the discharge extracts are not available and the morbidity extracts are received on a monthly basis. If the report is generated within 28 days of the end date of the reference period, data are incomplete as the recommended boundary period for coding completeness has not elapsed. Cases in the numerator have passed quality control checks and may have required modification by the Health Services prior to acceptance into the HMDS. Based on current process it is possible for these changes to be reflected in the numerator prior to the denominator. Therefore, if alterations are made to separations dates it is possible to have differing

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dates between the numerator and denominator. The date in the numerator is considered corrected and used when available.

Reported Data Validation Items Format Percentage 7 NNN.NN% Data Values Inclusions Records with a Separation Date that is within or equal to the start and end date of the reference period. If available, the separation date from the numerator is used otherwise the denominator is the source of the separations date (see limitations).

Numerator All records from TOPAS, HCARe, PHC* and JHC* morbidity extracts that have been clinically coded and cleared from a range of quality edit processes by HMDC (record status of “C - Complete”). The Extraction Date for the records needs to be less than or equal to the date when the report is generated. The [Extraction Date] refers to the date when the morbidity extract was generated and is obtained from the extract file name.

Denominator All records from TOPAS, HCARe, PHC* and JHC* inpatient discharge extracts.

*Public patients only and these are defined by: Funding Source HMDS Value . Australian Health Care Agreements 21 . Correctional Facility 29 . Reciprocal Health Care Agreement 30

Numerator/Denominator

Exclusions . Non-public patients at PHC and JHC. . Next Step Inpatient Withdrawal Unit cases (Est Code = 0459). Numerator . Cases with a record status of “D – Deleted”, “E – Data Entry“, “I – In Progress”, “M – Modify“, “N – New”, “P – Pending”, “R – Replaced”, “V – Removed” or “X – Error”. . Duplicate records: are cases with identical Est Code and

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Account Number combinations. In the event of cases with identical Est Code and Account Number combinations the case with the latest batch and case number is kept. Denominator . HCARe discharge extract: Exclude all cases where the variable ‘Flag’ = ‘C’, these are reversed or cancelled cases. . Duplicate records: are cases with identical Est Code and Account Number combinations. In the event of cases with identical Est Code and Account Number combinations the case with the latest Separation Date is kept.

Scope . Public hospitals (metropolitan and rural) . Public patients at PHC and JHC

Formula Numerator Count of the number of clinically coded TOPAS, HCARe, PHC and JHC hospital morbidity records that have been cleared

from a range of quality edit processes by HMDC where [Separation Date] has a value that is within/equal to the start and end date of the reference period.

Denominator Count of [Cases from Discharge Extracts] + [Cases found on Morbidity Extracts that are not present on Discharge Extracts]

[Cases from Discharge Extracts] = The number of TOPAS, HCARe, PHC and JHC inpatient discharge records where [Separation Date] has a value that is within/equal to the start and end date of the reference period.

[Cases found on Morbidity Extracts that are not present on Discharge Extracts] = Contract cases (e.g. Renal Dialysis funded by public hospitals) may not have been entered into TOPAS or HCARe when the discharge extracts were generated. These cases are entered by hospitals at a later date and would eventually be submitted to HMDS. Since the discharge extracts are not as frequently updated for the previous financial year, there would be some discrepancies between discharge extract and morbidity extract. In order to accommodate these discrepancies, the denominator is supplemented with the cases in the numerator that are absent from the denominator by linking with Est Code and Account Number.

Calculation Numerator divided by denominator, expressed as a percentage. Verification Rules 0 -100% inclusive.

Data Collection Identification Items

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Source TOPAS Extracted at 0400 hours every Monday (TOPAS Discharge Extract). webPAS Extracted at 0400 hours every Monday (webPAS Discharge Extract).

HCARe Extracted at 0900 hours every Monday (HCARe Patient Discharge Extract).

JHC/PHC Extracted within 4 weeks of the end of the previous month.

Governance Items Purpose of the data This information is used in hospital statistics, resource utilisation, budgetary allocation, clinical auditing and research, and reporting to external organisations. This information is used to measure the performance of clinical coding at public hospitals.

Source of the definition . Health Service, Information Management and Reporting

Version number V2.1

Approval date 20130605

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PC3: Clinical Information Audit Program Measure of DRG Accuracy

Reported Data Description Items Identifier (office use only)

Name Clinical Information Audit Program Measure of DRG Accuracy

Aliases Accuracy of DRGs as determined by clinical and demographic coding accuracy, ARDT Compliance, and Clinical documentation standards.

Definition The percentage of a sample of coded and grouped inpatient episodes, extracted from the Hospital Morbidity Data System (HMDS) which, after independent re-coding and grouping, from hospital medical records on-site, are verified as having the correct Diagnosis Related Group (DRG) assigned.

Related Metadata

Guide for Use: The Clinical Information Audit Program (CIAP) - Hospital Activity Reporting assesses the accuracy of hospital inpatient activity reporting, for in-scope hospitals, using the DRG as an established unit of measure of hospital activity.

Audits are conducted on a randomly selected sample of data extracted from the Hospital Morbidity Data System prepared by Health Service Cost Modelling. Data is lagged by between 3 and 6 months to allow for coding completeness.

A sample of 1% or a minimum of 100 admission records are selected where the separation date is within/equal to the reference period (e.g., financial quarter) for each in-scope hospital. Selection is achieved using a random number generator.

This measure is reported quarterly based on the most recent audit results. Sampling frequency is dependent on the size of facility and the number of separations. Since July 2012, the following sampling scheme has been used:  Metropolitan teaching hospitals - biannual audit  Metropolitan non-teaching hospitals - annual audit  Regional hospitals - biennial audit  District hospitals - ad hoc

Each admission is independently re-coded utilising the original source documents to establish the audit DRG. If the original DRG cannot be verified against audited result, a DRG error is recorded and sub-categorised as follows: :  Coding Error - Misapplication of clinical coding conventions and standards (The International Classification of Diseases-Australian Modification) or data entry errors  ARDT non-compliance - non-compliance with WA Admissions Re- admission, Discharge & Transfer policy (ARDT)  Documentation Issue - The correct DRG is indeterminate due to critical deficiencies within the documentation. Further clinical input is essential.  Miscellaneous - other errors including software system issues

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Limitations DRG-neutral aspects of demographic and clinical coding error are termed ‘incidental coding issues’ and although discussed in audit reports are not assessed by the indicator.

An absence of error on this indicator does not necessarily indicate that coding is 100% accurate for the facility.

Reported Data Validation Items Format Percentage 4 NNN.N%

Data Values Inclusions Randomly selected inpatient episodes sampled from the Hospital Morbidity Data System where the separation date exists within the sampling period.

Exclusions The following cases are excluded prior to the sampling process:

Principal Diagnosis Z763 or Z764 (Hospital boarders)

Client status = 2 (Unqualified newborns)

DRG Code = L61Z (Dialysis)

DRG Code = R63Z (Chemotherapy)

Funding Source = 33 (Ambulatory Surgical Initiative)

Scope Public hospitals and public activity at Peel Health Campus

Excludes Graylands/Selby/Lemnos

Excludes Private Facilities (except Public activity at Peel Health Campus)

Formula: Numerator DRG verification Count of inpatient episodes where DRG is verifiable

Error types Count of episodes where DRG not verified due to Coding errors Count of episodes where DRG not verified due to ARDT Non-compliance Count of episodes where DRG not verified due to Documentation issues Count of episodes where DRG not verified due to Miscellaneous errors

Denominator DRG verification and Error types Number of audited episodes

Calculation (Numerator ÷ Denominator) x 100, expressed as a percentage.

Verification Rules Values >= 0% and <=100%

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Data Collection Identification Items Source Audit data: Clinical Inpatient Audit Program Database

Sampled admissions: HMDS Morbidity extract

Governance Items Purpose of the data A measure of accuracy for inpatient admission records in public hospitals for ABF/ABFM Performance Management Branch

Source of the Health Service Cost Modelling, Performance Activity and Quality. definition Aligned with WA Health Operational Directive OD 0201/09 Clinical Information Audit Program Hospital Activity reporting

Version number 1.0

Approval date 20140801

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2.8 Processes Finance (PF) KPIs

There are 5 PF PIs proposed in the 2014-15 PMF, including 3 Health Service measures.

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PF1: Patient fee debtors

Reported Data Description Items Identifier (office use only) Name Patient Fees Debtor Days Aliases - Definition The average number of days it takes to recover patient fee debtors. Related Metadata n/a Guide for Use YTD Patient Debtors is sourced from Oracle Discoverer report: HCN_FIN.FR (SUM) - Balance Sheet - GL Account Lines

(Balance Sheet – Entity worksheet) MTD Patient Fees Revenue is sourced from Oracle Discoverer report: HCN_FIN.FR (SUM) - Patient Fees Debtor Days is to be expressed as a number representing the number of days. Oracle Discoverer FR (SUM) - Balance Sheet - GL Account Lines Report Parameter Period Name = select current period (month) of report. Values: Budget Name = Budget [YYYY], representing the financial year

where YYYY is the second half of the financial year, e.g.,: Budget Name = Budget 2014 (representing the 2013-14 financial year), Budget Name = Budget 2015 (representing the 2014-15 financial year), etc. Entity Level 3 Name = ALL Click on the “AA0150 Debtors” row name and drill down to Account Posting + Name. The line “921100 – AR – Patient”. The figure in the “Actual YTD” column represents the YTD Patient Debtors. FR (SUM) – Income Statement – Budget Holder Period Name = select current period (month) of report. Budget Name = Budget [YYYY], representing the financial year where YYYY is the second half of the financial year, e.g.,: Budget Name = Budget 2014 (representing the 2013-14 financial year), Budget Name = Budget 2015 (representing the 2014-15 financial year), etc. Budget Holder Name = ALL When the report run has been successfully completed, select relevant “Entity Posting + Name” under Page Items. The total “AA6000 – Patient Fees” in the “Actual MTD” column represents

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the MTD Patient Fees for the selected Entity. Limitations FR (SUM) reports are based on Oracle Financial’s Summary Tables generated after each month-end process for reporting.

Prior month’s data is not retained or presented since the Summary Tables are refreshed with the current month’s data only. If prior month’s data is required, then the HCN_FIN.FR (PAR) equivalent of the above reports should be used. NOTE: Prior month’s data do not normally change, unless there are exceptional circumstances (eg. Significant budget holder restructures or correction of errors).

Reported Data Validation Items Format Number 7 NNNNN.N Data Values Inclusions Include Operating/Recurrent Entities from Oracle Financials 11i: Entity Posting + Name = 040 (NMHS) Entity Posting + Name = 020 (SMHS) Entity Posting + Name = 075 (Peel HS) Entity Posting + Name = 030 (CAHS) Entity Posting + Name = 080 (WACHS) Exclusions Exclude Capital Entities from Oracle Financials 11i: Entity Posting + Name = 140 (NMHS) Entity Posting + Name = 120 and 121 (SMHS) Entity Posting + Name = 175 (Peel HS) Entity Posting + Name = 130 (CAHS) Entity Posting + Name = 180 (WACHS) Scope All Health budget holders (eg. WACHS, CAHS, NMHS, SMHS). Formula Run the report to display only the Operating/Recurrent Entities, as indicated in the above inclusions and exclusions. Debtors = (YTD Actual Patient Debtors + Prior Financial Year Jun YTD Actual Patient Debtors) / 2 NOTE: Based on accounting convention, revenue (actual and budget) is presented in Oracle Financials and Discoverer as negative values. For ABF/ABM performance reporting, revenue indicators should be presented as positive values. Multiply revenue values from Oracle Financials or Discoverer by -1 to

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convert them to positive values. Patient Fees = YTD Actual Patient Fees x -1 Calculation = (Debtors / Patient Fees) x number of days since 30 June of prior financial year, expressed as number of days (rounded to nearest whole number). Verification Rules Value can be between 0 and 365 days.

Data Collection Identification Items Source Oracle Financials 11i – General Ledger.

Note: The GL is generally closed and ready for reporting on the morning of the 4th working day each month, with June being the exception when the GL will remain open for a longer period due to the processing of end of year adjustments. Governance Items Purpose of the data Debtor days is a measure used for monitoring and accountability of revenue collection management. Source of the definition Resource Strategy Division Version number 2.1 Approval date 20130605

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PF4: NurseWest shifts filled

Reported Data Description Items Identifier (office use only)

Name NurseWest Shifts Filled

Aliases Definition: The proportion of public hospital / health services requested nursing shifts filled by NurseWest/other nursing agencies.

Related Metadata Guide for Use: NurseWest was established in July 2003 to provide a state-wide, centrally coordinated service for the recruitment and deployment of temporary nursing staff to all public hospitals and health services within WA Health and to meet Government savings objective through increased efficiencies. When hospitals and health services exhaust their internal casual nurse pools, NurseWest fill their staffing deficits either with its own casual nurses or staff sourced from external nursing agencies from the Common Use Arrangement (CUA) panel contracts.

A shift is any request received by NurseWest and other nursing agencies to fill a temporary nursing shift in any Metropolitan health site/service including all South Metropolitan Health Services, North Metro Health Services, and Child and Adolescent Health Service and Communicable Disease Control Directorate. NurseWest and other agencies do not provide temporary nurses to Joondalup or Peel Health Campuses.

Limitations

Reported Data Validation Items Format Percentage 6 NNN.NN%

Data Values > 0 and <=100

Inclusions Shifts worked by following registration types only: Registered Nurses (RN) Enrolled Nurse (EN) Registered Midwife (RM) Advanced Skill Enrolled Nurses (ASEN) Nurse Practitioners (NP)

Exclusions NurseWest/other nursing agencies do not provide the following staffing types:  Patient Care Assistants  Assistants in Nursing (AIN) Scope Metropolitan Public Hospitals and Murray District Hospital, Child and Adolescent Health Service (including Child and Adolescent Community Health), Communicable Disease Control Directorate,

Excludes Drug and Alcohol Office, Country Health Service, Peel and

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Joondalup Health Campuses

Formula: Numerator: Count the total number of records where Date is within the reporting period and Outcome = ‘Filled’.

Denominator: Count the total number of records where Date is within the reporting period

Calculation: The proportion of public hospital requested nursing shifts filled by NurseWest/other nursing agencies = numerator/denominator x 100 (expressed as a percentage). The percentage of Metropolitan Health Service nursing shifts filled by NurseWest and nursing agencies = numerator/denominator x 100.

Verification Rules

Data Collection Identification Items Source Microsoft EXCEL report generated at NurseWest extracted from NurseWest/other nursing agencies online staffing solution (Cascom). Monthly file extracted within 5 days of end of month.

Governance Items Purpose of the The proportion of public hospital requested nurse shifts filled through data NurseWest/other nursing agencies provides a measure of sustainability in the provision of hospital care.

Source of the Health Corporate Network definition:

Version number 1.2

Approval date 20140423 (Noted by PRGC)

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PF5: Accounts payable – payment within terms

Reported Data Description Items Identifier (office use only)

Name Accounts payable – payment within terms

Aliases Invoice Payment KPI Payment Within Terms HCN (Metroplitan) invoices paid within 30(36) days

Definition The percentage of invoices paid within 36 days of the invoice date by the Metropolitan Pay Group (HCN) within Oracle Accounts Payable.

Related Metadata Guide for Use: Only includes invoices processed by Oracle AP Metro Pay Group (HCN Supply Payment Management and Finance AP)

Does not include invoices processed by the Country Pay Group (WACHS)

Includes all payments in Oracle AP including reimbursements and other transactions processed as invoices

Includes payment via EFT and issuing of Cheques

Includes Credit Note “invoices”

Includes payments on behalf of non-WA Health entities for which HCN operates a bureau service, such as the Mental Health Commission, Drug & Alcohol Office and Health and Disability Services Complaints Office

Section 608 of the Health Accounting Manual specifies Payment Terms for commercial payments are 30 days from the date of invoice. Oracle AP Terms settings will only allow payment to occur exactly on, or after, the due date. Consequently, as WA Health only operates one pay run per week, payment within 36 days is considered to be within terms.

Non-commercial payments for other than supply related invoices (e.g. subsidies, reimbursements of staff expenses) are paid immediately within the next scheduled payment run

Limitations Commercial and non-commercial payments utilizing the Oracle AP system are not distinguished within the report.

Reported Data Validation Items Format Percentage 5 NNN.NN%

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Data Values >=0% or <=100%

Inclusions Invoices processed by Oracle AP Metro Pay Group (HCN Supply Payment Management and Finance AP) Credit Note “invoices” All payments in Oracle AP including reimbursements and other transactions processed as invoices Payment via EFT and issuing of Cheques Payments on behalf of non-WA Health entities for which HCN operates a bureau service, such as the Mental Health Commission, Drug & Alcohol Office and Health and Disability Services Complaints Office

Exclusions Invoices processed by the Country Pay Group (WACHS)

Scope Invoices processed by Oracle AP Metro Pay Group (HCN Supply Payment Management and Finance AP)

Formula: Numerator Count of invoices paid<=36 days

Denominator Count of invoices paid

Verification Rules >=0% or <=100%

Data Collection Identification Items Source Oracle FinancialsOracle Financials 11i – Accounts 11i – Accounts Payable Payable Discoverer Report – AP Supply Invoice Analysis

Governance Items Purpose of the data Payment Within Terms is a measure of compliance with Section 608 of the Health Accounting Manual, which is in turn based on Treasurers Instruction 323 – Timely Payment of Accounts

Source of the Health Corporate Network Supply definition

Version number 1.0

Approval date 20120813

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