Appendix 3: Hospital Access Program

The Hospital Access Program (HAP) has been introduced for 1998 - 99 to bring together elements of the former Emergency and Elective Surgery Enhancement Programs and recently established indicators focussing on reducing the number of critical care (intensive and coronary) inter-hospital transfers. The aim of the Hospital Access Program for 1998 - 99 is to improve the access of emergency, elective and critical care patients to acute health services. The eligibility criteria, funding and performance criteria for each of the service delivery components of the HAP are listed below.

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

1. Emergency services

The maximum funding allocated to the emergency services component of the HAP will be $13 million.

To be eligible for HAP funding allocated to emergency services, hospitals must:

• Have a 24 hour emergency department;
• Be a Group A or B hospital;
• Have provided more than 4000 non same day projected emergency WIES5 during 1997 - 98; and
• Be able to provide data via the Victorian Emergency Minimum Dataset (VEMD).

The maximum bonus payment for each hospital eligible for the emergency services component of the Program has been determined according to the projected number of 1997 - 98 non-same day emergency WIES5 (NSDEW). Linking funding levels to NSDEW remains the simplest and most effective way of taking account of both numbers and complexity of emergency department patients.

Bonus allocations for emergency services will be paid in advance. Funds will be recalled at the end of each quarter where targets are not met.

Performance criteria

The emergency services performance criteria will continue to focus on ambulance bypass, waiting time to treatment and waiting time prior to admission to a ward. The ambulance bypass targets and targets for waiting time for triage categories 1 and 2 remain at 1997 - 98 levels.

Ambulance bypass - Target: a maximum of 5 occasions of ambulance bypass per quarter.

Bonus reduction for failing to meet target: a 2% reduction in the maximum quarterly bonus allocation for each occasion of ambulance bypass in excess of the quarterly target. The maximum reduction for failing to meet this target is 100% of the total quarterly bonus.

Waiting time for triage category 1 patients - Target: 100% of patients receive immediate treatment.

Bonus reduction for failing to meet target: a 20% reduction in the maximum quarterly bonus allocation for each patient waiting longer than the target. The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

Waiting time for triage category 2 patients - Target: 80% of category 2 patients receive treatment within 10 minutes.

Bonus reduction for failing to meet target: a 1% reduction in the maximum quarterly bonus allocation for each 1% of patients less than the quarterly target. The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

Waiting time for triage category 3 patients - Target: 75% of category 3 patients receive treatment within 30 minutes.

Bonus reduction for failing to meet target: a 1% reduction in the maximum quarterly bonus allocation for each 1% of patients less than the quarterly target. The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

The waiting time of emergency department patients requiring admission to a ward is an area where improvement is required, particularly from major metropolitan hospitals. If a patient waits in an emergency department for more than 12 hours prior to being admitted to a ward because a bed is unavailable, their admission is defined as blocked. The time the patient waits is measured from the time they arrive at the emergency department to the time of their departure from the emergency department.

For 1998 - 99 admission block targets are expressed in terms of the proportion of admissions blocked compared with the total number of admissions to ward from the emergency department. This enables flexibility in the actual number of admissions blocked, in response to changes in the emergency department workload.

An annual benchmark level of 4.37% of admissions blocked has been determined. For 1998 - 99 this does not apply to all hospitals. However, the expectation is that hospitals will reach or exceed this benchmark in 2000 - 2001.

The benchmark has been calculated by averaging the performance of the two best performing hospitals with an E1 emergency department. The performance of rural hospitals and metropolitan hospitals with an emergency department level other than E1 could not be used as the basis for determining the benchmark, as the best performing hospitals in these categories have achieved zero admission block figures. Data used to determine the benchmark is taken from Quarters 3 and 4 of 1996 - 97 and Quarters 1 and 2 of 1997 - 98. This ensures that the impact of the yearly influenza outbreak is factored in.

Annual targets have been set for individual hospitals by determining their performance expectations in relation to admission block benchmark performance. Negotiation on hospital targets may occur in particular circumstances. Targets differentiate between 3 groups of hospitals as follows:

• Metropolitan hospitals performing better than the benchmark and all rural hospitals - targets aim to maintain their level of performance during Quarters 3 and 4 of 1996 - 97 and Quarters 1 and 2 of 1997 - 98;
• Metropolitan hospitals performing slightly worse than benchmark level - targets are set at benchmark level; and
• Metropolitan hospitals performing significantly worse than benchmark level - targets are based on a 50% improvement in the difference between their performance during Quarters 3 and 4 of 1996 - 97 and Quarters 1 and 2 of 1997 - 98 and the benchmark level. These hospitals are expected to work toward performing at benchmark level in 2000 - 2001.

This approach to target setting aims to maintain or improve the performance level of all hospitals and improve statewide performance.

Hospitals must determine quarterly targets to achieve their annual target in consultation with the Department. Quarterly targets should be finalised prior to the commencement of the 1998 - 99 financial year.

Target: to not exceed the maximum proportion of admissions blocked.

Bonus reduction for failing to meet target: a 4% reduction in the maximum quarterly bonus allocation for each 0.01% of admissions blocked in excess of the quarterly target, to a maximum reduction of 60% of the total quarterly bonus allocation.

2. Elective surgery

Hospitals which perform elective surgery are eligible for funding allocated to this component of the HAP and the maximum funding allocated to the elective surgery component of the HAP will be $13 million.

Non waiting list hospitals (that is, hospitals which do not participate in the targetted elective surgery component of the Program) will be allocated funds on the basis of 50% of their proportion of the statewide projected non-same-day elective surgical WIES5 for 1997 - 98.

Waiting list hospitals

Hospitals which participate in the targetted elective surgery component of the Program will be allocated a proportion of the available bonus funds on the basis of the net number of patients to be removed from the waiting list, weighted according to the hospital's projected non same day elective surgical WIES5 for 1997 - 98.

This method of allocation recognises the size and nature of a hospital's waiting list and the magnitude of the task to reduce it. This formula for allocating bonus funds directs more funding to hospitals with larger waiting lists of more complex patients, which therefore require relatively more resources to reduce numbers. These hospitals provide performance data to the Department via the Elective Surgery Information System (ESIS).

Bonus allocations for elective surgery will be paid in advance. Funds will be recalled from participating hospitals at the end of each quarter where targets are not met.

Performance criteria

The elective surgery performance criteria will continue to focus on category 1 and category 2 patients and total waiting list numbers.

The approach to category 1 patients is unchanged from 1997 - 98, aiming for none of these patients to be delayed for more than 30 days. However, for 1998 - 99 annual targets have been set for category 2 patients and total waiting list numbers. Hospitals must determine quarterly targets for category 2 patients and total waiting list numbers to achieve the required annual targets, in consultation with the Department. Quarterly targets should be finalised prior to the commencement of the 1998 - 99 financial year. This approach will enhance the ability of hospitals to manage seasonal fluctuations in emergency and non-elective critical care services.

Performance will be assessed as at the census date at the end of each quarter.

Category 1 patients - Target: no category 1 patient delayed for more than 30 days.

Bonus reduction for failing to meet target: a 20% reduction for each category 1 patient delayed for more than 30 days. The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

Category 2 patients - Target: a 24% reduction based on the adjusted 1997–98 target for the number of category 2 patients who are delayed for over 90 days.

Bonus reduction for failing to meet target: a 1% reduction for each percentage point by which the number of category 2 patients delayed more than 90 days exceeds the target at each quarter. The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

Total waiting list - Target: a 6% reduction based on the adjusted 1997–98 target for the total number of patients on the waiting list.

Bonus reduction for failing to meet target: a 1% reduction for each percentage point by which the total waiting list exceeds the target at each quarter. The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

3. Critical Care Inter-hospital Transfers (CCIHTs)

Incentive funding linked to the attainment of targets for the maximum number of intensive and coronary care transfers due to a bed not being available at the sending hospital has been introduced for 1998–99. The transfer of patients because the sending hospital does not have the specialty/service available to provide treatment is appropriate and performance measures do not apply to these transfers. The maximum funding allocated to the CCIHT component of the HAP will be $3.5 million.

To be eligible for HAP funding allocated to the reduction of inappropriate CCIHTs, hospitals must:

• Have a level 2 or 3 adult intensive care unit;
• Have a level 2, 3 or 4 adult coronary care unit; and
• Be located within a Melbourne metropolitan Health Care Network/ARMC.

CCIHT incentive payments have been determined based on the projected number of 1997–98 non-same day WIES5. This method acknowledges the relationship of coronary and intensive care provision to both emergency and elective services and makes some allowance for complexity by focussing on non-same day WIES.

Bonus allocations for CCIHTs will be paid in advance. Funds will be recalled at the end of each 6 month period where targets are not met.

Performance criteria

The CCIHT criteria will focus on inappropriate transfers of intensive care and coronary care patients.

The targets are proportional. The percentages are based on:

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

Given the limitations of current data collections in providing intensive care and coronary care information, it has not been possible to ascertain the current number of critical care inter-hospital transfers at the hospital level. As a consequence, the Department and the Networks have negotiated on and agreed to, targets for the maximum number of inappropriate transfers for each hospital participating in this component of the HAP.

Performance against agreed targets will be assessed 6 monthly, enabling hospitals to plan for changes in demand influenced by seasonal factors. Performance from one 6 month period can not be carried over to the next 6 month period.

Targets: to not exceed the maximum proportions of inappropriate intensive care and coronary care transfers.

Bonus reduction for failing to meet targets: a 6% percent reduction in the maximum 6 monthly bonus allocation for each inappropriate transfer in excess of the targets.

The maximum reduction for failing to meet the coronary care target is 70% of the total 6 monthly bonus allocation. The maximum reduction for failing to meet the intensive care target is 70% of the total 6 monthly bonus allocation.

The maximum reduction for failing to meet both targets is 100% of the total 6 monthly bonus allocation.

4. Hospital Access Development Program

The need for ongoing development of Networks’ and hospitals’ approach to access will also be recognised through the implementation of a Hospital Access Development Program during 1998–99. This Program will rechannel recalled HAP funds to projects which further integrated approaches to demand management.

Review and reporting

Any hospital which artificially reduces its transfers, waiting list numbers or waiting times, or otherwise misreports its performance, will have its bonus payments adjusted by the Department.

Hospitals which fail to achieve any bonus payments for any of the three components of the Program for two consecutive quarters may be reviewed by the Department.

During 1998–99, the VEMD and the ESIS will be transferred to the RAPID Data Warehouse. Prior to this transfer, and for a transition period to be determined, hospitals participating in emergency and elective components of the 1998–99 HAP will be required to report their emergency and elective activity in accordance with current processes, by the seventh working day of each month.

CCIHT data will be supplied to the Department via the VIMD, by the hospital receiving the transfer. An additional validation process will be implemented by the Department to audit and reconcile differences between sending hospital and receiving hospital data. Failure to supply accurate and complete data by the due date may result in recall of up to 40% of bonus payments.

The Department will continue to publish quarterly hospital and statewide emergency services and elective surgery performance data including:

• the number of patients treated in emergency departments;
• the number and percentage of patients treated within ideal times in emergency departments;
• the number of patients staying for extended periods in emergency departments; and
• the number of elective patients booked and waiting by category and hospital.
• Data will also be provided to the Department of Human Services’ Executive Management Information System (EMIS).

The 1998–99 Hospital Access Program will be reviewed prior to the next financial year.