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Section A - Policy

16. Specific Programs & Technical Details

Appendix 4-Hospital Access Program

The Hospital Access Program (HAP) was introduced in 1998-99 to provide a stronger focus on access to the key areas of elective surgery, emergency and critical care services. Information on eligibility criteria, performance indicators, targets and funding for the three Program components is provided below.

1. Emergency Services

The maximum total 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 multi-day projected emergency WIES6 during 1998-99; 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 by allocating available funds according to each hospital's proportion of projected 1998-99 multi-day emergency WIES6.

Quarterly bonus payments will be made retrospectively, following submission of relevant performance data. Where targets are not met the quarterly bonus allocation will be reduced in accordance with the formula for the relevant indicator.

Performance indicators and targets

Performance indicators will continue to focus on ambulance bypass, waiting time to treatment and time spent in the emergency department prior to admission to a ward. The ambulance bypass targets and targets for waiting time for triage categories 1, 2 and 3 remain at 1998-99 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 2% reduction in the maximum quarterly bonus allocation for each percent under the quarterly target (ie if the target is 80% and the quarterly performance is 78.5%, the bonus reduction will be 3% of the quarterly allocation). The maximum reduction for failing to meet the target is 100% of the total quarterly bonus. The triage category 2 bonus reduction has been increased from 1% to 2% to better recognise the urgency of this group of patients and to signal the Department's intent to investigate the timeliness of their treatment more closely during 1999-2000.

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 equivalent to the percentage amount under the quarterly target (ie if the target is 75% and the quarterly performance is 73.8%, the bonus reduction will be 1.2% of the quarterly allocation). 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

If a patient spends more than 12 hours in an emergency department prior to being admitted to an inpatient ward, their admission is defined as blocked. The time the patient spends is measured from the time they arrive at the emergency department to the time they depart from the emergency department.

Admission block targets are expressed in terms of the maximum percentage of emergency department admissions to ward which can be blocked. This enables flexibility in the actual number of admissions blocked, in response to changes in the emergency department workload.

Annual targets will be set by the Department. Each hospital will determine quarterly targets to achieve its annual target in consultation with the Department. Higher targets should be set for Quarters 1 and 4 when there is greater demand on hospitals, because of factors such as influenza and related conditions. Quarterly targets should be finalised prior to the commencement of the 1999-2000 financial year.

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

Bonus reduction for failing to meet target: a 3% reduction in the maximum quarterly bonus allocation for each patient in excess of the quarterly target, to a maximum reduction of 60% of the total quarterly bonus allocation.

Data Quality and Timeliness

During 1998-99 the central collection of the Victorian Emergency Minimum Dataset (VEMD) commenced. This involves the electronic transmission of patient level data to the Department in preparation for its inclusion into the RAPID Data Warehouse.

Aggregate paper based reports which contain information derived from the VEMD are also forwarded to the Department. These paper reports will become obsolete when the electronic data system has been fully tested and the aggregate reports can be satisfactorily extracted from the system.

As part of the VEMD quality assurance processes, the Department will be comparing the electronic data with aggregate reports to check consistency. This process will be undertaken on data supplied from October 1998 onwards. If inconsistencies are found hospitals will be informed and requested to respond by resubmitting corrected data and/or providing the Department with a report outlining plausible reasons for the inconsistency.

Improvements to data quality and timeliness of submission to the VEMD will be encouraged in 1999-2000 financial year by linking these requirements to incentive funding paid under the HAP.

Timelines have been established for:

• 1999-2000 electronic data and paper based reports
• electronic patient level data for the period August 1998 - June 1999 inclusive
• hospitals' response to inconsistencies in the comparison of electronic data and paper based aggregate reports.

Timelines are detailed in the table below.

2. Critical Care

The critical care component of the Hospital Access Program is designed to minimise inappropriate transfers of critical care patients between public hospitals. 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. 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/St Vincent's

Hospitals' maximum CCIHT bonus has been allocated according to each participating hospital's projected number of 1998-99 non-same day elective and emergency WIES6. 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. Bonuses will be paid at the end of each six month period where targets have been met.

Performance indicators and targets

The CCIHT component of HAP measures inappropriate transfers of intensive care and coronary care patients, as follows:

• The percentage of intensive care patients transferred because no intensive care bed is available; and
• The percentage of coronary care patients transferred because no coronary care bed is available.

As available data covers only a proportion of a full year, it has not been possible to set benchmarks for critical care transfers for 1999-2000. Targets for this component of HAP will be set at the individual hospital level and will generally require maintenance of or improvement on last years' targets/performance.

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

Bonus reduction for failing to meet targets: there will be a 6% reduction in the six monthly bonus 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 six monthly bonus allocation. The maximum reduction for failing to meet the intensive care target is 70% of the total six monthly bonus allocation. The maximum reduction for failing to meet both targets is 100% of the total six monthly bonus allocation.

Transfers to the private sector

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).

The Austin and Repatriation Medical Centre, Barwon Health, St Vincent's Hospital and Health Care Network hospitals providing adult intensive care have financial responsibility for transfers of public patients to the private sector, and receive a WIES allocation for this purpose. Private sector utilisation will continue to be approved only when no suitable public critical care beds are available.

The relative funding allocation for participating Health Care Networks and hospitals for the purchase of private critical care is based on projected 1998-99 non-same day elective and emergency WIES6. These funds may be used to expand public critical care bed capacity to limit the need for transfers to the private sector. Participating Networks and hospitals 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, the Women's and Children's Health Care Network, Werribee Mercy and the Mercy Hospital for Women as well as public patients presenting to private hospital emergency departments for whom no public beds are available.

3. Elective Surgery

The elective surgery component of the Hospital Access Program has been operating since 1994-95, aiming to encourage continued improvement in the management of health care provision to elective surgery patients and to provide incentive funds to hospitals which achieve targeted reductions in waiting times for elective surgery.

Hospitals with waiting lists who submit waiting list performance data to the Department on a monthly basis are eligible for bonus funding under the Hospital Access Program. The maximum funding allocated under the elective surgery component of the HAP will be $13 million.

Hospitals who do not report waiting lists will be allocated funds on the basis of 50% of their proportion of the statewide elective surgical WIES6 for the period June 1998 to February 1999. Hospitals reporting waiting list performance data via the Elective Surgery Information System (ESIS) will be allocated a proportion of the available bonus funds on the basis of the number of patients on the waiting list, weighted according to the hospital's average elective surgical WIES6 for June 1998 to February 1999. This method of allocation recognises demand and the complexity of the hospital's patient load.

Performance criteria

To achieve their bonuses, each hospital will need to optimally manage its waiting list and achieve reductions in waiting times to elective surgery services as measured by the performance criteria detailed below. The indicators refer to the percentage of patients admitted within clinically desirable times, the number of patients on the waiting list and the waiting times of patients on the waiting list and booking list at the end of the quarter.

Hospital performance will be measured on a quarterly bases and bonus payments will be paid retrospectively. The maximum bonus reduction in any quarter shall be no more than 100% of the maximum possible bonus for the quarter.

All calculations will be based on data submitted by hospitals through the revised Elective Surgery Information System (ESIS) to be operational from 1 July 1999.

Total Waiting Time for each patient will include time on the waiting list and time on the booking list. Total Waiting Time, therefore, is equivalent to the sum of time on the waiting list and time on the booking list for each patient. Waiting Time for each patient will be calculated as the time on the elective surgery waiting list from category reassignment date to admission date or from the registration date to admission if there is no category reassignment date excluding any not ready for care days.

Following the introduction of the new ESIS, targets will be monitored against the new baseline data and revised during the year if required.

Admitted patients

Category 1 Patients

Indicator The percentage of Category 1 patients admitted from the waiting or booking lists during the quarter with a total waiting time prior to admission of 30 days or less.

Target 100% of Category 1 patients to be admitted from the waiting or booking lists within 30 days.

Denominator The total number of Category 1 patients admitted from the waiting or booking lists during the quarter.

Numerator The total number of Category 1 patients admitted from the waiting or booking list during the quarter whose total waiting time prior to admission is 30 days or less.

Bonus Calculation The elective surgery bonus will be reduced by 20% for each patient admitted during the quarter whose total waiting time is more than 30 days.

Category 2 Patients

Indicator The percentage of Category 2 patients admitted from the waiting or booking list during the quarter with a total waiting time of 90 days or less .

Target An increase in the proportion of Category 2 patients admitted from the waiting list or booking list within 90 days by 0.5 percentage points per quarter based on 30 June 1999 targets.

Hospitals which admit 100% of category 2 patients within the required 90 days as at the 30 June 1999 will be expected to maintain that performance.

Denominator The total number of Category 2 patients admitted from the waiting or booking list during the quarter.

Numerator The total number of Category 2 patients admitted from the waiting or booking list during the quarter with a total waiting time prior to admission of 90 days or less.

Bonus Calculation The elective surgery bonus will be reduced by 2% for each percentage point by which the Category 2 patients admitted from the waiting or booking list during the quarter within 90 days is below target.

Patients on the Waiting or Booking List

Average Waiting Time of Category 2 Patients

Indicator The average total waiting time of Category 2 patients on the waiting or booking list at the census date.

Target A quarterly reduction on 30 June 1999 targets in the average total waiting time of Category 2 patients on the waiting or booking list. The size of the quarterly reduction will be specific to each hospital.

Denominator The number of Category 2 patients on the waiting or booking list at the census date.

Numerator The sum of the total waiting time of all Category 2 patients on the waiting or booking list at the census date.

Bonus Calculation A 2% reduction for each percentage point by which the average total waiting time of Category 2 patients on the waiting or booking list at the census date is below target.

Average Waiting Time of Category 3 Patients

Indicator The average total waiting time of Category 3 patients on the waiting or booking list at the census date.

Target A quarterly reduction based on 30 June 1999 targets in the average total waiting time of Category 3 patients on the waiting or booking list. The size of the quarterly reduction will be specific to each hospital.

Denominator The number of Category 3 patients on the waiting or booking list at the census date.

Numerator The sum of the total waiting time of all Category 3 patients on the waiting or booking list at the census date.

Bonus Calculation A 1% reduction for each percentage point by which the average total waiting time of Category 3 patients on the waiting or booking list at the census date is below target.

Total Numbers of Patients on the Waiting List

Target A quarterly reduction in the total number of patients on the waiting list on 30 June 1999 numbers. The size of the quarterly reduction will be specific to each hospital.

Bonus Calculation A 1% reduction for each percentage point by which the total waiting list exceeds the target at the end of each quarter.

Data Quality and Timeliness

Further improvements will be encouraged in the 1999-2000 financial year by linking data quality improvement and timeliness of data submissions to the HAP Program.

Data Quality Improvement

As part of efforts to improve data quality, the revised ESIS has a list of edits, or reasons for a patient record to be rejected or flagged. Edits have been classified into three types:

• Type 1: Fatal error: rejected and must be fixed by the hospital as a priority. Processing of data affected.
• Type 2: Non-fatal error: rejected and must be fixed by the hospital, but does not stop the further processing of data.
• Type 3: Warning: this record may be correct but is unusual and should be brought to the attention of the hospital for confirmation or amendment.

In this financial year only Type 1 errors will be tied to bonus payments.

Timeliness

Hospitals are required to submit ESIS data within 7 working days following the monthly census date. Hospitals will be sent an error report within 5 working days of the Department receiving their initial submission and are required to return the corrected data file (duly verified as final by the CEO or a delegate) within 5 working days of receiving the error report.

4. Hospital Access Program 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 1999-2000, 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, as outlined above.

CCIHT data will be supplied to the Department via the VAED, 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 reduction 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 and percentage of patients staying for extended periods in emergency departments; and
• the number of elective surgery patients waiting and overdue by category and hospital.

Data will also be provided to the Department of Human Services' Executive Management Information System (EMIS).

The 1999-2000 Hospital Access Program will be reviewed prior to the next financial year.

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