4. Quality Programs - Hospital Access

Appropriate access of patients to elective surgery, emergency and critical care services is an essential attribute of a high quality health care system. The provision of funding through the Hospital Access Program (HAP) is an incentive for Networks and individual hospital campuses to improve patient access to these services.

The HAP has been introduced for 1998 - 99 to bring together the former Emergency Services and Elective Surgery Enhancement Programs and recently established indicators focussing on inter-hospital transfers of critical care patients. This approach recognises the interrelated nature of demand management across these three areas and emphasises the need for an integrated approach by Network/hospital management to service delivery, including bed management, in order to attain a balance in meeting demand for elective, emergency and critical care services. Details are provided in Appendix 3.

Incentive funding to hospitals has been modelled on the assumption that targets for Networks and hospitals will be met. Failure to achieve performance targets results in bonus funds being recalled.

Commencing in 1998 - 99, bonus payments will not be paid until the Acute Health Schedule of the Health Service Agreement is signed.

4.1 Emergency Services

Incentive funding to improve the delivery of emergency department services and encourage improved management of hospital beds was introduced in 1994 - 95 under the Emergency Services Enhancement Program (ESEP). Since the Program's introduction, there has been a significant improvement in the access to and timeliness of patient treatment in hospital emergency departments.

Performance criteria will continue to focus on the:

• The time the most urgent patients (categorised as triage 1, 2 or 3), wait to be treated;
• Waiting times of patients requiring admission to a ward; and
• The number of occasions of ambulance bypass.

For 1998 - 99, the major change to the emergency services performance criteria has been to admission block targets. In 1998 - 99:

• Targets are expressed as the proportion of admissions blocked compared with the total number of emergency department admissions to a ward, rather than as actual numbers;
• An annual benchmark for admission block targets has been determined, based on the average performance of the two best performing hospitals with an emergency department level of E1. This benchmark does not apply to all hospitals. However, the expectation is that hospitals will reach or exceed it in 2000 - 2001;
• Actual 1998 - 99 annual targets have been set for individual hospitals by determining their performance expectations in relation to benchmark performance;
• Hospitals will determine quarterly targets to achieve the annual target, in consultation with the Department. This will provide flexibility for changes in services; and
• Seasonal issues, such as the specific timing and extent of influenza outbreaks, have been built into the targets in two ways. Firstly, proportional targets allow for variations in the actual number of admissions blocked, as long as they are in line with fluctuations in the emergency department workload (as reflected by admissions). Secondly, enabling hospitals to determine quarterly targets in consultation with the Department means that higher targets can be chosen for quarters when there is greater demand on hospitals, because of factors such as influenza and related conditions. Should epidemiological data indicate more than one influenza outbreak in the same financial year or a more serious outbreak than usual, the Department will give consideration to reducing bonus recall.

4.2 Elective Surgery

Incentive funding to improve the delivery of elective surgery was introduced in 1994 - 95 under the Elective Surgery Enhancement Program (ELSEP). Since the Program's introduction, the number of patients requiring urgent elective surgery (category 1 patients) waiting longer than the clinically recommended 30 days has reduced to virtually nil. In addition, despite continuing pressure placed on public hospitals due to a growth in the cost and quantum of demand for elective surgery and a decline in private health insurance levels:

• The number of patients requiring semi-urgent surgery (category 2 patients) waiting beyond the clinically recommended 90 days has been more than halved since the Program was introduced; and
• The total number of patients on the waiting list has stabilised.

For 1998 - 99, targets for category 1 patients remain at 1997 - 98 levels, that is all of these patients should be treated within 30 days.

The major change to the elective surgery performance criteria has been to targets for category 2 patients and total waiting list numbers:

• Annual target reductions for category 2 patients have been maintained at 24 per cent;
• Annual target reductions for total waiting list numbers have been maintained at 6 per cent;
• Annual targets for category 2 patients and total waiting list numbers have been based on adjusted 1997 - 98 targets rather than 1997 - 98 performance; and
• Hospitals will determine quarterly target reductions for category 2 patients and total waiting list numbers to achieve the annual target reduction, in consultation with the Department. This enhances the ability of hospitals to manage seasonal fluctuations in emergency and non-elective critical care services, as well as plan for events, for example, capital works programs.

4.3 Critical Care Inter-hospital Transfers (CCIHTs)

The transfer of critically ill patients has been reviewed within the Office of the Co-ordinator of Emergency and Critical Care Services. While some transfers are unavoidable, transfer of such patients generally needs to be kept to the minimum.

A critical care inter-hospital transfer as defined in this Program is a transfer of a patient from one public hospital to another for intensive or coronary care. To reduce the current level of transfers of such patients indicators have been introduced for 1998 - 99.

The indicators compare:

• The number of patients transferred because no intensive care bed is available, with the total number of intensive care patients; and
• The number of patients transferred because no coronary care bed is available, with the total number of coronary care patients.

Current data can provide information on the utilisation of intensive care and coronary care services, but it has not been possible to accurately measure the current number of critical care inter-hospital transfers at the hospital level, or to set performance benchmarks or targets based on comprehensive data. For 1998 - 99, targets for each participating hospital have been negotiated between Networks and the Department, based on the best available hospital and Departmental data on the current level of hospital and statewide transfers.

Future data collected through fields introduced to the 1998 - 99 version of the VIMD will enable the setting of benchmarks and timeframes. It is anticipated that a benchmark approach will be implemented in 2 to 3 years.

4.4 Purchase of Private Hospital Critical Care for Public Patients

In addition to transfers within the public system, public patients may be transferred to private hospital intensive care and coronary care beds, when there are no appropriate critical care beds available in the public system.

These transfers are authorised by the Office of the Coordinator of Emergency and Critical Care Services (OCECCS). To date payment for the treatment of these patients has been met by the Department via a budget allocation to the OCECCS.

In 1998 - 99, the Austin and Repatriation Medical Centre and Networks which provide adult intensive care will take financial responsibility for transfers of public patients to the private sector. The OCECCS role in authorising these transfers will not change. Private sector utilisation will continue to be approved only when no public critical care beds are available.

The funding allocation provided to Networks and the Austin and Repatriation Medical Centre for these transfers is based on non-same day WIES activity for 1996 - 97, and may be used to expand critical care bed capacity to limit the need for transfers to the private sector. Networks and the Austin and Repatriation Medical Centre will be responsible for the cost of purchasing private critical care should they exceed their allocated funding.

OCECCS will continue to receive funding for the purchase of critical care from private hospitals for patients transferred from rural hospitals and the Women's and Children's Health Care Network and public patients presenting to private hospital emergency departments for whom no public beds are available.

4.5 Hospital Access Development Program

The need for ongoing development of Networks and new approaches to access will also be recognised through the implementation of a Hospital Access Development Program during 1998 - 99. This Program will rechannel recalled Hospital Access Program funds to projects which improve access practices.