Activity Based Funding /
Management
Performance Management Report
Performance Indicator Definitions Manual
(Health Service Measures) 2013-2014
Version 1.2
27 February 2014
improving care | managing resources | delivering quality
© Department of Health, State of Western Australia (2013).
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Important Disclaimer:
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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
EA9: AMBULANCE DIVERSION........................................................................................................................................... 21
EA10: ACCESS BLOCK......................................................................................................................................................... 23
EA11: ADMISSIONS FROM ED ........................................................................................................................................... 27
2.2 EFFECTIVENESS APPROPRIATENESS (EAP) PIS.............................................................................................................. 30
EAP2: ADULT IMMUNISATION: PERCENTAGE OF PEOPLE AGED 65 YEARS AND OVER IMMUNIZED AGAINST INFLUENZA 31
EAP3.A: OBESITY: PERCENTAGE OF POPULATION WHO ARE OVERWEIGHT OF OBESE: A) ADULTS.................................... 34
EAP3.B: OBESITY: PERCENTAGE OF POPULATION WHO ARE OVERWEIGHT OF OBESE B) CHILDREN ................................. 37
EAP4: TOBACCO: PERCENTAGE OF ADULTS WHO ARE CURRENT SMOKERS ...................................................................... 40
2.3 EFFECTIVENESS QUALITY (EQ) PIS................................................................................................................................ 43
EQ2: PERCENTAGE OF EMERGENCY DEPARTMENT ATTENDANCES WHICH ARE UNPLANNED RE-ATTENDANCES IN LESS
THAN OR EQUAL TO 48 HOURS OF PREVIOUS ATTENDANCE............................................................................................. 44
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 ............................. 47
EQ6: HOSPITAL ACCREDITATION ....................................................................................................................................... 50
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 ........................................................................... 52
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 .......................................................................................................... 90
EI2: ELECTIVE SURGERY DAY OF SURGERY ADMISSION RATES .......................................................................................... 91
EI4: YTD DISTANCE OF EXPENDITURE TO BUDGET ............................................................................................................. 95
EI5: YTD DISTANCE OF OWN SOURCED REVENUE TO BUDGET .......................................................................................... 98
EI7: SCHOOL DENTAL SERVICE RATIO OF EXAMINATIONS TO ENROLMENTS ................................................................... 101
EI9: NUMBER OF SEPARATIONS (UNWEIGHTED): TOTAL ESTIMATED UNWEIGHTED INPATIENT ACTIVITY (EXCLUDING
LSMH) ............................................................................................................................................................................. 103
EI10: CODED ACUTE MULTIDAY AVERAGE LENGTH OF STAY ........................................................................................... 111
EI11: YTD DISTANCE OF SALARIES EXPENDITURE TO BUDGET ......................................................................................... 114
2.5 EQUITY ACCESS (EQA) KPIS........................................................................................................................................ 115
EQA2.A&B: STANDARDISED RATE RATIO OF HOSPITALISATIONS OF A) ABORIGINAL PEOPLE COMPARED TO NONABORIGINAL PEOPLE B) ABORIGINAL CHILDREN (0-4 YEARS) COMPARED TO NON-ABORIGINAL CHILDREN (0-4 YEARS) 116
EQA3.A&B: CHILDHOOD IMMUNISATION: PERCENTAGE OF CHILDREN FULLY IMMUNISED AT 12-15 MONTHS: A)
ABORIGINAL B) TOTAL .................................................................................................................................................... 119
EQA5: WA HEALTH ABORIGINAL EMPLOYMENT HEADCOUNT ........................................................................................ 121
2.6 SUSTAINABILITY WORKFORCE (SW) KPIS................................................................................................................... 125
SW1: PROPORTION OF MEDICAL GRADUATES AND OTHER CATEGORIES OF MEDICAL STAFF TO TOTAL MEDICAL STAFF 126
SW2: PROPORTION OF NURSING GRADUATES AND OTHER CATEGORIES OF NURSING STAFF TO TOTAL NURSING STAFF
....................................................................................................................................................................................... 132
SW4.A: INJURY MANAGEMENT A) LOST TIME INJURY SEVERITY RATE ............................................................................ 138
SW4.B: INJURY MANAGEMENT B) PERCENTAGE OF MANAGERS AND SUPERVISORS TRAINED IN OCCUPATIONAL SAFETY
AND HEALTH (OSH) AND INJURY MANAGEMENT RESPONSIBILITIES ............................................................................... 140
SW5: LEAVE LIABILITY ..................................................................................................................................................... 143
SW6.A: ACTUAL AND BUDGET FTE: AVERAGE MONTHLY TOTAL FULL TIME EQUIVALENTS ............................................. 147
SW6.B: ACTUAL AND BUDGET FTE: AVERAGE MONTHLY BUDGET FULL TIME EQUIVALENTS .......................................... 151
2.7 PROCESSES CODING (PC) KPIS ................................................................................................................................... 155
PC1: PERCENTAGE OF CASES CODED BY END OF MONTH CLOSING DATE ........................................................................ 156
2.8 PROCESSES FINANCE (PF) KPIS .................................................................................................................................. 160
PF1: PATIENT FEE DEBTORS............................................................................................................................................. 161
PF4: NURSEWEST SHIFTS FILLED ...................................................................................................................................... 164
PF5: ACCOUNTS PAYABLE – PAYMENT WITHIN TERMS ................................................................................................... 166
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, Performance Activity and Quality
Division.
I
Acronyms
AAR
ABF
ABF/M
ABM
ABS
ACEM
ACHS
ACIR
AIHW
ATSI
BMI
CAHS
CEO
COAG
DOH
DOHA
DOSA
ED
EDDC
EDIS
ESWL
eWAU
FTE
GL
HIN
HMDC
HMDS
HR
HS
HSMR
HWSS
ICD
IDM
iWAU
JHC
KPIs
MRSA
NHDD
NMHS
OP
OSH
OSQH
OSR
PHC
PMF
PRB
SLA
SMHS
SMR
TOOCS
WACHS
WLDC
YTD
Age Adjusted Rate
Activity Based Funding
Activity Based Funding/Management
Activity Based Management
Australian Bureau of Statistics
Australasian College of Emergency Medicine
Australian Council on Health Standards
Australian Childhood Immunisation Register
Australian Institute of Health and Welfare
Aboriginal Torres Strait Islander
Body Mass Index
Child and Adolescent Health Service
Chief Executive Officer
Council of Australian Governments
Department of Health
Department of Health and Ageing
Day of Surgery Admission
Emergency Department
Emergency Department Data Collection
Emergency Department Information System
Elective Surgery Waiting List
emergency department Weighted Activity Unit
Full Time Equivalent
General Ledger
Health Information Network
Hospital Morbidity Data Collections
Hospital Morbidity Data System
Human Resources
Health Service
Hospital Standardised Mortality Ratio
Health and Wellbeing Surveillance
International Classification of Diseases
Information Development and Management Branch
inpatient Weighted Activity Schedule
Joondalup Health Campus
Key Performance Indicators
Methicillin Resistant Staphylococcus Aureus
National Health Data Dictionary
North Metropolitan Health Service
Operational Plan
Occupational Safety and Health
Office of Safety and Quality in Health Care
Own Sourced Revenue
Peel Health Campus
Performance Management Framework
Performance Reporting Branch
Statistical Local Area
South Metropolitan Health Service
Standardised Mortality Ratio
Type of Occurrence Classification System
WA Country Health Service
Wait List Data Collections
Year to Date
II
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 2013-14 (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 2013-14 PMF is provided in
Table 1.
1
Table 1: Schedule of KPIs and Reporting Frequency 2013-14
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 2013-14
changed! Indicator reporting level and/or reporting frequency changed from PMF 2012-13 to PMF 2013-14
deferred! Indicator deferred until 2014-15
ABF/ABM Framework
Domain
DOH PERFORMANCE MANAGEMENT MEASURES
REPORTING
REPORTING
Code
LEVEL
FREQUENCY
Domain
Dimension
EA1
EA2
EA3
EFFECTIVENESS
Access
EA4
EA5
EA7
OUTCOME MEASURE
* Proportion of emergency department patients seen within
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
* NEAT % of ED Attendances with LOE <=4 hours
Average overdue wait time of elective surgery cases waiting beyond
the clinically recommended time, by urgency category
a) beyond 30 days for urgency category 1
b) beyond 90 days for urgency category 2
c) beyond 365 days for urgency category 3
* Elective surgery patients treated within boundary times:
a) % Category 1 within 30 days
b) % Category 2 within 90 days
c) % Category 3 within 365 days
* Percentage of selected elective cancer surgery cases treated within
boundary time:
a) Bladder Cancer
b) Bowel Cancer
c) Breast cancer
HEALTH SERVICE MEASURE
Percentage of ED Mental Health patients admitted within 8 hrs
2
Facility
Monthly
Facility
Facility
Monthly
Monthly
Facility
Monthly
Facility
Quarterly
Facility
Monthly
ABF/ABM Framework
Domain
Dimension
Domain
Code
DOH PERFORMANCE MANAGEMENT MEASURES
EA8
EA9
EA10
EA11
Theatre activity
Ambulance Diversion
Access Block
Admissions from ED
EAP1
OUTCOME MEASURE
Rate of selected potentially preventable chronic condition
hospitalisations (for specified chronic conditions)
EAP2
HEALTH SERVICE MEASURE
Adult immunisation: percentage of people aged 65 years and over
immunised against Influenza
Appropriateness
EAP3
Obesity: percentage of population who are overweight or obese:
a) Adults
b) Children
EAP4
Tobacco: percentage of adults who are current smokers
EQ1
OUTCOME MEASURE
Age-adjusted rate (AAR) of avoidable deaths
Quality
EQ3
*^ Staphylococcus aureus bacteraemia infections per 10,000 patient
days
3
REPORTING
LEVEL
REPORTING
FREQUENCY
Facility
Facility
Facility
Facility
Monthly
Monthly
Monthly
Monthly
Whole of
population
(reported at
Health Service
level)
Annually
Whole of
population
(reported at
Health Service
level)
Whole of
population
(reported at
Statewide level
Annually
Whole of
population
(reported at
Statewide level
Annually
Whole of
population
(reported at
Health Service
level)
Facility
Annually
Annually
Annually
ABF/ABM Framework
Domain
Dimension
Domain
Code
DOH PERFORMANCE MANAGEMENT MEASURES
REPORTING
LEVEL
REPORTING
FREQUENCY
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,
fractured neck of femur & pneumonia)
Facility
Annually
EQ10
Rate of total hospital readmissions within 28 days to a designated
mental health inpatient unit
Facility
Quarterly
Facility
Monthly
Health Service
Quarterly
EQ2
HEALTH SERVICE MEASURE
Percentage of Emergency Department Attendances which are
unplanned re-attendances in less than or equal to 48 hours of
previous attendance.
EQ4
Rate of Severity Assessment Code (SAC) 1 clinical incident
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
management of (knee replacement, hip replacement, tonsillectomy &
adenoidectomy, hysterectomy, prostatectomy, cataract surgery and
appendicectomy) changed!
Facility
Quarterly
EQ12
* Rate of community follow up within first 7 days of discharge from
psychiatric admission
Facility
Quarterly
EQ13
* Measures of patient experience (including satisfaction) with hospital
services
Facility
Annually
4
ABF/ABM Framework
Domain
Dimension
Domain
Code
EQ14
EI2
EI4
EI5
EI7
EI9
Number of separations (unweighted)
EI10
* Coded acute multiday average length of stay
EI11
YTD Distance of Salaries Expenditure to Budget new!
OUTCOME MEASURE
Standardised Mortality Ratio (SMR) of deaths among Aboriginal
children (0-4 years) and non-Aboriginal children (0-4 years)
EI3
EI6
EI8
Inputs per output
unit
EQA1
EQUITY
Hand Hygiene Compliance
OUTCOME MEASURE
Volume of weighted activity year-to-date:
a) Inpatients (variance from target)
b) ED attendances (variance from target)
c) Outpatients (variance from target)
Average cost per test panel for PathWest
* YTD distance of net cost of service to budget
* Ratio of actual cost of specified public hospital services compared
with the ‘state efficient price’ deferred!
HEALTH SERVICE MEASURE
* Elective surgery day of surgery admission rates
YTD Distance of Expenditure to Budget
YTD Distance of Own Sourced Revenue to Budget
School Dental Service ratio of examinations to enrolments
EI1
EFFICIENCY
DOH PERFORMANCE MANAGEMENT MEASURES
Access
EQA4
Proportion of eligible population receiving dental services from
5
REPORTING
LEVEL
REPORTING
FREQUENCY
Facility
Tri-annually
Facility
Monthly
Statewide
Health Service
Health
Service
Monthly
Monthly
Annual
Facility
Health Service
Health Service
Whole of
population
(reported at
Health Service
level)
Facility
Monthly
Monthly
Monthly
Annually
Facility
Quarterly
Health Service
Monthly
Whole of
population
(reported at
Health Service
level)
Whole of
Annually
Monthly
Quarterly
ABF/ABM Framework
Domain
Dimension
Domain
Code
EQA2
EQA3
EQA5
SW3
SW1
SUSTAINABILITY
Workforce
DOH PERFORMANCE MANAGEMENT MEASURES
subsidised dental programs by group: changed!
a) Aged 16 years and over
b) Aged 65 years and over
c) Total Aboriginal population
HEALTH SERVICE MEASURE
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)
REPORTING
LEVEL
population
(reported at
Health Service
level)
Whole of
population
(reported at
Health Service
level)
Childhood immunisation: percentage of children fully immunised at 12Whole of
15 months:
population
a) Aboriginal
(reported at
b) Total
Health Service
level)
WA Health Aboriginal employment headcount
Health
Service changed!
OUTCOME MEASURE
Staff turnover
Facility
HEALTH SERVICE MEASURE
Proportion of medical graduates (and other categories of medical
Facility
staff) to total medical staff
a) Interns (graduate)
b) Resident Medical Officers
c) Registrars
d) Consultants
e) Other
6
REPORTING
FREQUENCY
Annually
Quarterly
Monthly changed!
Monthly
Quarterly
ABF/ABM Framework
Domain
Dimension
Domain
Code
DOH PERFORMANCE MANAGEMENT MEASURES
REPORTING
LEVEL
REPORTING
FREQUENCY
SW2
Proportion of nursing graduates (and other categories of nursing staff)
to total nursing staff
a) Graduate
b) Junior
c) Experienced
d) Senior
e) SRN and above
Facility
Quarterly
SW4
SW5
Injury management:
Health Service
a) Lost time injury severity rate
b) Percentage of managers and supervisors trained in occupational
safety and health (OSH) and injury management
responsibilities changed!
Leave Liability
Facility changed!
SW6
Actual and Budget FTE
Bi-annually
Monthly
Health Service
Monthly
Facility
Monthly
Facility
Monthly
HCN Service
Monthly
HIN Service
Monthly
Health Service
Monthly
Facilities &
Equipment
PC2
Coding
PC1
PROCESSES
PF2
Finance
PF3
OUTCOME MEASURE
Percentage of cases coded within boundary
a) Cases within 2 weeks of discharge
b) Remaining cases within 4 weeks of discharge
HEALTH SERVICE MEASURE
Percentage of cases coded by end of month closing date
OUTCOME MEASURE
Manually corrected payroll errors (underpayments)
Availability of Information Communication Technology (ICT) services:
percentage of Service calls resolved at first point of contact
HEALTH SERVICE MEASURE
PF1
Patient fee debtors
7
ABF/ABM Framework
Domain
Dimension
Domain
Code
PF4
PF5
DOH PERFORMANCE MANAGEMENT MEASURES
NurseWest shifts filled
Accounts payable – payment within terms
8
REPORTING
LEVEL
REPORTING
FREQUENCY
Statewide
HCN Service
Monthly
Monthly
2. Data Definitions
2.1 Effectiveness Access (EA) PIs
There are 10 EA PIs proposed in the 2013-14 PMF, including 5 Health Service measures.
9
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


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.
MDG-04-008 Total Admissions From The Emergency Department
MDG-04-054 Emergency Department Length Of Episode For Admitted Mental
Health Patients
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.
public
metropolitan
hospitals,
Bunbury Hospital
and Joondalup
Health Campus)
Mental Health Codes include a diagnosis of one of the following ICD-10-AM
codes: any F codes or T39.1, T40.0, T40.1, T40.2, T40.3, T40.4, T40.5, T40.6,
T40.7, T40.8, T40.9, T42.4, T43.9, T50.9, T51.9, T52.0, T52.9, T56.2, Z00.4,
Z03.2, Z04.6, Z09.3, Z13.3, Z50.4, Z54.3, Z65.8, Z65.9, Z81.8, Z86.5, Z91.4,
Z91.5, or one of the following presenting problem codes: T0000, TC000, TW000,
TD000, TE000, TF000, TG000, TGA00, TGB00, TH000, TJ000, TS000, TK000,
TM000, TN000, TNA00, TP000.
HCARe sites (i.e.
WACHS
hospitals,
excluding
Bunbury Hospital)
Mental Health attendance at the ED is recorded when a patient is given a [Major
Diagnostic Category] code of 19 (Mental diseases and disorders) or 20
(Substance use and substance induced organic mental disorders).
{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.
10
{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
6
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)
11

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.
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, quarterly and annual
reporting.
Snapshot reports use 23:59 as the reference period.
Formula
Determination of
Admitted to ED by
an ED clinician
A Mental Health patient is deemed to be admitted to ED by an ED clinician if
[Admitting Consultant] is TRUE that is:
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:
12
If [Episode End Status] = 10.
Length of Episode
– For patients
Admitted to ED by
an ED clinician
Length of Episode
– For all other
admitted patients
Calculation
{Length of Episode} (in minutes) for each record is the [Admission Date] and
[Admission Time] minus [Presentation Date] and [Presentation Time].
{Length of Episode} (in minutes) for each record is the [Discharge Date] and
[Discharge Time] minus [Presentation Date] and [Presentation Time].
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
data
To monitor the length of episode for admitted Mental Health patients in the ED.
Source of the
definition
Data Integrity Directorate, Mental Health Commission and Health Services
13
Version number
V2.0
Approval date
20101012
14
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
Metadata
None
Guide for Use
Theatre activity data required for the determination of percentage of used theatre
hours to total allocated hours in theatre are extracted from two separate data
files in the Theatre Management System (TMS) at each hospital, i.e., the
‘T_Operation’ file is extracted for the determination of used theatre time, and the
‘T_Thr_Schedule’ file is extracted for the determination of allocated theatre time.
These two files are linked by schedule ID, which is a unique value for each
scheduled (allocated) session to match used theatre time of operation(s) 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
15
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 and Patient leave theatre time.
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 during a scheduled session when an operating
theatre is not occupied by a patient. Turnaround time is included as part of
allocated theatre time for the session if another patient is to follow on, i.e., the
next patient arrives in the operating theatre following the previous patient leaving
the operating theatre without interruption by other factors such as cleaning or
other maintenance.
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.
16
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:
Kaleeya is recorded as a theatre location at Fremantle Hospital (FH) and is
indicated by location code ‘FKAL’ or location description ‘Kaleeya’ and sublocation codes ‘TH1’, ‘TH2’, ‘TH3’, ‘TH4’, ‘TH5’.
Shenton Park Campus is recorded as a theatre location at Royal Perth Hospital
(RP) and is identified by location code ‘THEAS’ or location description ‘Theatre
SPC’ and sub-location codes ‘SPC1’, ‘SPC2’, ‘SPC3’.
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
‘CM’
‘CO’
‘LT’
‘RE’
‘RP’
Exclusions
Description
Details Committed
Recovery Completed
Left Theatre
Arrived in Recovery
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
Numerator (Used theatre time):
TMS records in the ‘T_Operation’ file where the code in [Ope_Status] equals one
of the following.
17
Scope
Code
‘AN’
Description
Anaesthesia Started
‘BO’
‘CA’
‘CH’
‘ES’
‘HC’
‘HR’
‘PA’
‘RQ’
‘SU’
Booked/Confirmed
Cancelled
On Hold - Cancelled
Emergency Surgery Started
On Hold – Confirmed
On Hold – Requested
Arrived in Suite
Booking Requested
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
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’
18
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’
Formula
QE (Sir Charles Gairdner Hospital)
‘DPRM’, ‘OR01’, ‘OR02’,
‘OR03’, ‘OR04’, ‘OR05’,
‘OR06’, ‘OR07’, ‘OR08’,
‘OR09’, ‘OR10’, ‘OR11’, ‘OR12’
RK (Rockinghamd 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’
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’.
19
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 leaved 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
the data
To report on efficiency in theatre usage in WA public hospitals.
Source of the
definition
TMS Business Unit Group
Version
number
V 0.2
Approval Date
Interim approval – 12 April 2011
Performance Activity & Quality Division
20
EA9: Ambulance Diversion
Reported Data Description Items
Identifier
MDG-04-010
Name
Metropolitan area hours of Ambulance Diversion
Aliases


Definition
The total number of hours when ambulances are diverted from one
metropolitan hospital ED to another metropolitan hospital ED.
Ambulance Diversion
Number of hours Emergency Department (ED) on Ambulance
Diversion
Related metadata
Guide for Use
Provider: St John Ambulance Australia
Limitations
There may be discrepancies, due to rounding, in ambulance
diversion data when data is reported in minutes (e.g. Daily report)
rather than hours.
Reported Data Validation Items
Format
Numeric
7
N, NNN.N
Data Values
Hours
Inclusions
Exclusions
Scope
Formula
•
•
•
•
•
•
•
Sir Charles Gardiner Hospital
Swan District Hospital
Armadale-Kelmscott Hospital
Fremantle Hospital
Rockingham-Kwinana Hospital
Royal Perth Hospital
Joondalup Health Campus
Count of [Ambulance Diversion Finish Time] minus [Ambulance
Diversion Activate time] minus ambulance diversion overlapping
21
time divided by 60 for all records during reporting period.
Overlapping time = the time where one or more diversions occur at
the same time at the same hospital site.
Where an emergency department is on diversion at 1200 midnight
on the last reporting day of the month, only the diversion time prior
to midnight is counted in that reporting period. The diversion time
post midnight will be captured in the subsequent reporting month.
Verification Rules
Value is ≥ to zero
Data Collection Identification Items
Source
Ambulance Diversion Reporting System (ADRS), St John
Ambulance Australia
Governance Items
Purpose of the data
To monitor the total hours of ambulance diversion at metropolitan
Emergency Departments
Source of the definition
Health Services, Information Management and Reporting
Version number
V 1.4
Approval date
20071015
22
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


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.
MDG-04-001 WA ED Attendances.
MDG-04-008 WA ED Admissions.
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.
23
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
5
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] =





Exclusions
Resuscitation (1)
Emergency (2)
Urgent (3)
Semi Urgent (4)
Non-Urgent (5).
[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)
24

Scope
Direct Admission (6, 7, 8, 16).
•
•
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
Admitted to ED (by
ED clinician
A patient is deemed to be admitted to ED by an ED clinician if
[Admitting Consultant] is TRUE that is:
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 –
For patients Admitted
to ED by an ED
clinician
Length of Episode –
For All other admitted
patients
Calculation
{Length of Episode} (minutes) for each record is the [Admission
Date] and [Admission Time] minus [Presentation Date] and
[Presentation Time].
{Length of Episode} (minutes) for each record is the [Discharge
Date] and [Discharge Time] minus [Presentation Date] and
[Presentation Time].
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.
25
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
definition
Health Services and Data Integrity Directorate
Version number
V2.0
Approval date
20101012
26
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


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.
MDG-04-001 TOTAL ED ATTENDANCES.
MDG-04-026 TOTAL MENTAL HEALTH ADMISSIONS FROM
THE EMERGENCY DEPARTMENT
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
except PHC
ED Admissions are counted from event records in the Emergency
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.
27
Reported Data Validation Items
Format
Numeric
5
NNN.N
Data Values
Inclusions
[Presentation Date] and [Presentation Time] are present
- For all hospitals
except PHC
[Admission Date] and [Admission Time] are present
[Triage Category] =





- For PHC
Resuscitation (1)
Emergency (2)
Urgent (3)
Semi Urgent (4)
Non-Urgent (5)
[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
except PHC
[Admission Date] and [Admission Time] values are not present
[Episode end status] =

- For PHC
Dead on Arrival (7)
[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)
28
[Visit Type] =
Scope
Formula
- For all hospitals
except PHC


Dead on Arrival (10)
Direct Admission (6, 7, 8, 16).

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.
Count of records where [Presentation Date] and [Presentation
Time] are within the reference period and [Admission Date] and
[Admission Time] are present 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.
- 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
definition
Health Services, Information Management and Reporting
Version number
Version 2.4
Approval date
20080616
29
2.2 Effectiveness Appropriateness (EAP) PIs
There are 4 EAP PIs proposed in the 2013-14 PMF, including 3 Health Service measures.
30
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 bases 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
31
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
4
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, System
Policy & Planning.
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
WA residents who were randomly selected from a transcribed
10% portion of the 2008/09 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.
32
Governance Items
Purpose of the data
For ABF/M KPI reporting.
Source of the definition
Epidemiology Branch, System Policy & Planning
Version number
1.1
Approval date
20130605
33
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.
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.
Limitations
Data is collected on a monthly basis but is best reported annually.
34
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
4
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 aHealth Service
(NMHS, SMHS, WACHS) according to SLA based on boundaries
outlined by the Epidemiology Branch, System Policy & Planning.
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.
Scope
WA residents who were randomly selected from a transcribed
10% portion of the 2008/09 White Pages.
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
35
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, System Policy & Planning
Version number
1.1
Approval date
20130605
36
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.
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 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.
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.
37
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
4
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, System Policy & Planning.
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.
Scope
WA residents who were randomly selected for a transcribed 10%
portion of the 2008/09 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 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
38
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, System Policy & Planning
Version number
1.1
Approval date
20130605
39
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.
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.
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.
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
40
the confidence interval widths. Such instances will be noted
if and when they occur.
Reported Data Validation Items
Format
Numeric
4
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.
Population figures: All WA residents assigned to a Health Service
(NMHS, SMHS, WACHS) according to SLA based on boundaries
outlined by the Epidemiology Branch, System Policy & Planning.
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
WA residents who were randomly selected from a transcribed
10% portion of the 2008/09 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 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.
41
Source of the definition
Epidemiology Branch, System Policy & Planning
Version number
1.1
Approval date
20130605
42
2.3 Effectiveness Quality (EQ) PIs
There are 13 EQ PIs proposed in the 2013-14 PMF, including 7 Health Service measures.
43
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 which are
Metadata
unplanned re-attendance.
 MDG-04-101 NEAT Total ED Departures
Guide for Use
Limitations
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.
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.
44
Reported Data Validation Items
Format
Numeric
6
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
45
Verification Rules
Scope hospitals.
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, Performance
definition
Activity and Quality Division, Health Services.
Version number
V1.1
Approval date
26/09/2012
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
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
4
47
NN.NN%
Data Values
>= 0% and <= 100%
Inclusions
All SAC 1 notifications received from all Health Services
Metropolitan and WACHS public hospitals and.
SAC 1clinical 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)
48
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
4.0
Approval date
20130605
49
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
50
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
51
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
Guide for Use
Unplanned hospital readmissions following selected medical
episodes of care (in development).
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 is 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
53
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
Code
49518-00
49521-00
49521-02
49524-00
Description
Total arthroplasty of knee, unilaterial
Total arthroplasty of knee with bone graft to
femur, unilateral
Total arthroplasty of knee with bone graft to
tibia, unilaterial
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
41789-00
41789-01
41801-00
Description
Tonsillectomy without adenoidectomy
Tonsillectomy with adenoidectomy
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
Code
Description
35653-00
35653-01
35653-04
Subtotal abdominal hysterectomy
Total abdominal hysterectomy
Total abdominal hysterectomy with removal of
adnexa
Abdominal hysterectomy with extensive
retroperitoneal dissection
Abdominal hysterectomy with radical excision of
pelvic lymph nodes
Laparoscopically assisted vaginal hysterectomy
Laparoscopically assisted vaginal hysterectomy
with removal of adnexa
35661-00
35670-00
35750-00
35753-02
54
35756-00
35756-03
90448-01
90448-02
35657-00
35673-02
35667-00
35664-00
35664-01
35667-01
90443-00
Laparoscopically assisted vaginal hysterectomy
proceeding to abdominal hysterectomy
Laparoscopically assisted vaginal hysterectomy
proceeding to abdominal hysterectomy with
removal of adnexa.
Total laparoscopic abdominal hysterectomy
Total laparoscopic abdominal hysterectomy with
removal of adnexa
Vaginal hysterectomy
Vaginal hysterectomy with removal of adnexa
Radical abdominal hysterectomy
Radical abdominal hysterectomy with radical
excision of pelvic lymph nodes
Radical vaginal hysterectomy with radical
excision of pelvic lymph nodes
Radical vaginal hysterectomy
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
37207-00
37201-00
37203-00
37203-02
37203-04
37203-05
37207-01
37200-03
37200-04
37224-00
37224-01
90407-00
37203-03
Description
Endoscopic laser ablation of prostate
(includes TULIP)
Transurethral needle ablation of prostate
Transurethral resection of prostate
Transurethral electrical vaporization of
prostate
Microwave thermotherapy of prostate
High intensity focused ultrasound (transrectal)
of prostate
Endoscopic laser excision of prostate
Suprapubic prostatectomy
Retropubic prostatectomy
Endoscopic destruction of prostatic lesion
Endoscopic resection of prostatic lesion
Excision of other lesion of prostate
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
Code
42698-00
42702-00
42702-01
Description
Intracapsular extraction of crystalline lens
Intracapsular extraction of crystalline lens with
insertion of foldable artificial lens
Intracapsular extraction of crystalline lens with
insertion of other artificial lens
55
42698-01
42702-02
42702-03
42698-02
42702-04
42702-05
42698-03
42702-06
42702-07
42698-04
42702-08
42702-09
42731-01
42698-05
42702-10
42702-11
Extracapsular extraction of crystalline lens by
simple aspiration (and irrigation) technique
Extracapsular extraction of crystalline lens by
simple aspiration (and irrigation) technique with
insertion of foldable artificial lens
Extracapsular extraction of crystalline lens by
simple aspiration (and irrigation) technique with
insertion of other artificial lens
Extracapsular extraction of crystalline lens by
phacoemulsification and aspiration of cataract
Extracapsular extraction of crystalline lens by
phacoemulsification and aspiration of cataract
with insertion of foldable artificial lens
Extracapsular extraction of crystalline lens by
phacoemulsification and aspiration of cataract
with insertion of other artificial lens
Extracapsular crystalline lens extraction by
mechanical phacofragmentation and aspiration of
cataract
Extracapsular crystalline lens extraction by
mechanical phacofragmentation and aspiration of
cataract with insertion of foldable artificial lens
Extracapsular crystalline lens extraction by
mechanical phacofragmentation and aspiration of
cataract with insertion of other artificial lens
Other extracapsular extraction of crystalline lens
Other extracapsular extraction of crystalline lens
with insertion of foldable artificial lens
Other extracapsular extraction of crystalline lens
with insertion of other artificial lens
Extraction of crystalline lens by posterior
chamber sclerotomy with removal of vitreous
Other extraction of crystalline lens
Other extraction of crystalline lens with insertion
of foldable artificial lens
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:
56
Procedure
Knee replacement
Hip replacement
Tonsillectomy and adenoidectomy
Hysterectomy
Prostatectomy
Cataract surgery
Appendicectomy
Readmission Interval
60 days
60 days
15 days
30 days
30 days
45 days
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.
Exclusions
Please see appendix A for further details on the treatment of
contiguous separations in the numerator and denominator.
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.
Scope
The following client statuses are excluded from the numerator and
denominator:
•
0 (Funding Hospital)
•
2 (Unqualified Newborn)
•
3 (Boarder)
•
7 (Organ Procurement)
•
8 (Resident)
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;
57
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 referrallocation 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 referrallocation of 4 or 5, and a source of referral-professional is not 7;
58
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 referrallocation 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.
59
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 referrallocation 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
60
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 referrallocation 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:
61
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 referrallocation 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 referrallocation 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
62
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.
Verification
For reporting purposes, the readmission is counted against the
quarter in which the initial separation occurred.
0-100%
Rules
Data Collection Identification Items
Source
Hospital Morbidity Data System, Inpatient Data Collections, Data
Integrity, PAQ
Governance Items
Purpose of the
data
Source of the
definition
This information is used for Activity Based Funding and
Management reporting, other internal performance reporting and
for internal validation of proposed national reporting definition.
Unplanned/ unexpected readmissions following selected surgical
episodes of care (any public hospital, same state/ territory) MyHospitals definition (17/4/2012 draft 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
63
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
Procedure
performed
Separation B
Separation C
Care type: Acute
Care type: Non-acute
DOS Separation A = DOA Separation B AND
DOS Separation B = DOA Separation C
Denominator – Index episode of
care
Numerator – Readmission
• Include Separation A in the
• Include Separation B in the
numerator as a readmission for
Separation A if:
− Source of Referral-Location for
Separation B is not 4 or 5 or
Source of ReferralProfessional is not 7 AND
− PDx is a readmission PDx as
per Table 1
denominator
• Include Separation B in the index
episode of care if:
− DOS Separation A = DOA
Separation B AND
− Source of Referral-Location for
Separation B is 4 (acute
hospital) or 5 (psychiatric
hospital) and Source of
Referral-Professional is not 7
(statistical admission/type
change)
• Include Separation C in the
numerator as a readmission for
Separation B if:
− Separation B is in denominator
AND
− Source of Referral-Location for
Separation C is not 4 or 5 or
Source of ReferralProfessional 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.
64
Scenario 2
Separation A
Procedure
performed
Separation B
Separation C
Care type: Non-acute
Care type: Acute
DOS Separation A = DOA Separation B AND
DOS Separation B = DOA Separation C
Denominator – Index episode of
care
Numerator – Readmission
• Include Separation A in the
• Include Separation B in the
numerator as a readmission for
Separation A if:
− Source of Referral-Location for
Separation B is not 4 or 5 or
Source of ReferralProfessional is not 7 AND
− PDx is a readmission PDx as
per Table 1
denominator
• Separations B and C are not
included in the denominator
• 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.
65
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
A04.7 - Enterocolitis due
to Clostridium difficile
A40 - Streptococcal
sepsis
A41 - Other sepsis
A49 - Bacterial infection of
unspecified site
D50.0 - Iron deficiency
anaemia secondary to
blood loss (chronic)
D50.8 - Other iron
deficiency anaemias
D50.9 - Iron deficiency
anaemia, unspecified
D62 - Acute
posthaemorrhagic
anaemia
D64.9 - Anaemia,
unspecified
D68.3 - Haemorrhagic
disorder due to circulating
anticoagulants
D68.4 - Acquired
coagulation factor
deficiency
D68.5 - Primary
thrombophilia
D68.6 - Other
thrombophilia
D68.8 - Other specified
coagulation defects
D68.9 - Coagulation
defect, unspecified
D69.5 - Secondary
thrombocytopenia
D69.6 Thrombocytopenia,
unspecified
D69.8 - Other specified
haemorrhagic conditions
D69.9 - Haemorrhagic
condition, unspecified
E10.0 - Type 1 diabetes
mellitus with
hyperosmolarity
E10.1 - Type 1 diabetes
mellitus with acidosis
E10.64 - Type 1 diabetes
mellitus with
hypoglycaemia
E10.65 - Type 1 diabetes
mellitus with poor control
E11.0 - Type 2 diabetes
mellitus with
hyperosmolarity
E11.1 - Type 2 diabetes
mellitus with acidosis
E11.64 - Type 2 diabetes
mellitus with
hypoglycaemia
E11.65 - Type 2 diabetes
mellitus with poor control
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
0-7 days
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
0-30 days
Y
Y
0-7 days
0-7 days
0-7 days
0-15 days
0-7 days
66
Principal Diagnosis
E13.0 - Other specified
diabetes mellitus with
hyperosmolarity
E13.1 - Other specified
diabetes mellitus with
acidosis
E13.64 - Other specified
diabetes mellitus with
hypoglycaemia
E13.65 - Other specified
diabetes mellitus with
poor control
E14.0 - Unspecified
diabetes mellitus with
hyperosmolarity
E14.1 - Unspecified
diabetes mellitus with
acidosis
E14.64 - Unspecified
diabetes mellitus with
hypoglycaemia
E14.65 - Unspecified
diabetes mellitus with
poor control
E27.2 - Addisonian crisis
E86 - Volume depletion
E87 - Other disorders of
fluid, electrolyte and acidbase balance
F05.9 - Delirium,
unspecified
F10.2 - Mental and
behavioural disorders due
to use of alcohol,
dependence syndrome
F10.5 - Mental and
behavioural disorders due
to use of alcohol,
psychotic disorder
F11.2 - Mental and
behavioural disorders due
to use of opioids,
dependence syndrome
F11.5 - Mental and
behavioural disorders due
to use of opioids,
psychotic disorder
G45 - Transient cerebral
ischaemic attacks and
related syndromes
G54.0 - Brachial plexus
disorders
G54.1 - Lumbosacral
plexus disorders
G56 - Mononeuropathies
of upper limb
G57 - Mononeuropathies
of lower limb
G97.0 - Cerebrospinal
fluid leak from spinal
puncture
G97.1 - Other reaction to
spinal and lumbar
puncture
G97.8 - Other
postprocedural disorders
of nervous system
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
0-7 days
Y
Y
67
Y
Y
0-7 days
Y
0-7 days
Principal Diagnosis
G97.9 - Postprocedural
disorder of nervous
system, unspecified
H02.4 - Ptosis of eyelid
H15.0 - Scleritis
H16.0 - Corneal ulcer
H16.1 - Other superficial
keratitis without
conjunctivitis
H16.2 Keratoconjunctivitis
H16.3 - Interstitial and
deep keratitis
H16.8 - Other keratitis
H16.9 - Keratitis,
unspecified
H20.0 - Acute and
subacute iridocyclitis
H20.2 - Lens-induced
iridocyclitis
H20.8 - Other iridocyclitis
H20.9 - Iridocyclitis,
unspecified
H21.0 - Hyphaema
H21.5 - Other adhesions
and disruptions of iris and
ciliary body
H21.8 - Other specified
disorders of iris and ciliary
body
H26.4 - After-cataract
H27 - Other disorders of
lens
H31.3 - Choroidal
haemorrhage and rupture
H31.4 - Choroidal
detachment
H33.0 - Retinal
detachment with retinal
break
H33.2 - Serous retinal
detachment
H33.3 - Retinal breaks
without detachment
H33.4 - Traction
detachment of retina
H33.5 - Other retinal
detachments
H40.0 - Glaucoma
suspect
H40.2 - Primary angleclosure glaucoma
H40.4 - Glaucoma
secondary to eye
inflammation
H40.8 - Other glaucoma
H40.9 - Glaucoma,
unspecified
H43.0 - Vitreous prolapse
H43.1 - Vitreous
haemorrhage
H43.3 - Other vitreous
opacities
H43.8 - Other disorders of
vitreous body
H43.9 - Disorder of
vitreous body, unspecified
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
68
Recommended
readmission
interval (if not
entire readmission
interval)
0-7 days
Principal Diagnosis
H44.0 - Purulent
endophthalmitis
H44.1 - Other
endophthalmitis
H44.4 - Hypotony of eye
H44.6 - Retained (old)
intraocular foreign body,
magnetic
H44.7 - Retained (old)
intraocular foreign body,
nonmagnetic
H53 - Visual disturbances
H57.1 - Ocular pain
H59 - Postprocedural
disorders of eye and
adnexa, not elsewhere
classified
I20 - Angina pectoris
I21 - Acute myocardial
infarction
I24 - Other acute
ischaemic heart diseases
I26 - Pulmonary embolism
I33 - Acute and subacute
endocarditis
I38 - Endocarditis, valve
unspecified
I39 - Endocarditis and
heart valve disorders in
diseases classified
elsewhere
I45 - Other conduction
disorders
I46 - Cardiac arrest
I47 - Paroxysmal
tachycardia
I48 - Atrial fibrillation and
flutter
I49 - Other cardiac
arrhythmias
I50 - Heart failure
I51 - Complications and
ill-defined descriptions of
heart disease
I60 - Subarachnoid
haemorrhage
I61 - Intracerebral
haemorrhage
I62 - Other nontraumatic
intracranial haemorrhage
I63 - Cerebral infarction
I64 - Stroke, not specified
as haemorrhage or
infarction
I65 - Occlusion and
stenosis of precerebral
arteries, not resulting in
cerebral infarction
I66 - Occlusion and
stenosis of cerebral
arteries, not resulting in
cerebral infarction
I74 - Arterial embolism
and thrombosis
I80 - Phlebitis and
thrombophlebitis
I81 - Portal vein
thrombosis
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
0-15 days
Y
Y
Y
Y
Y
Y
0-15 days
Y
Y
Y
Y
Y
Y
0-15 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
69
Y
Principal Diagnosis
I82.2 - Embolism and
thrombosis of vena cava
I82.8 - Embolism and
thrombosis of other
specified veins
I95 - Hypotension
I97.8 - Other
postprocedural disorders
of circulatory system, not
elsewhere classified
I97.9 - Postprocedural
disorder of circulatory
system, unspecified
J02 - Acute pharyngitis
J03 - Acute tonsillitis
J06 - Acute upper
respiratory infections of
multiple and unspecified
sites
J12 - Viral pneumonia, not
elsewhere classified
J13 - Pneumonia due to
Streptococcus
pneumoniae
J14 - Pneumonia due to
Haemophilus influenzae
J15 - Bacterial
pneumonia, not elsewhere
classified
J16 - Pneumonia due to
other infectious
organisms, not elsewhere
classified
J17 - Pneumonia in
diseases classified
elsewhere
J18 - Pneumonia,
organism unspecified
J20 - Acute bronchitis
J22 - Unspecified acute
lower respiratory infection
J35 - Chronic diseases of
tonsils and adenoids
J36 - Peritonsillar abscess
J39 - Other diseases of
upper respiratory tract
J40 - Bronchitis, not
specified as acute or
chronic
J44 - Other chronic
obstructive pulmonary
disease
J69.0 - Pneumonitis due
to food and vomit
J81 - Pulmonary oedema
J95.2 - Acute pulmonary
insufficiency following
nonthoracic surgery
J95.4 - Mendelson's
syndrome
J95.5 - Postprocedural
subglottic stenosis
J95.8 - Other
postprocedural respiratory
disorders
J95.9 - Postprocedural
respiratory disorder,
unspecified
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-15 days
Y
Y
Y
Y
Y
Y
0-15 days
Y
Recommended
readmission
interval (if not
entire readmission
interval)
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
0-7 days
Y
0-7 days
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
0-7 days
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
70
Principal Diagnosis
J96.0 - Acute respiratory
failure
J96.9 - Respiratory failure,
unspecified
J98.1 - Pulmonary
collapse
K12.2 - Cellulitis and
abscess of mouth
K38.3 - Fistula of
appendix
K43 - Ventral hernia
K45 - Other abdominal
hernia
K46 - Unspecified
abdominal hernia
K56.0 - Paralytic ileus
K56.1 - Intussusception
K56.2 - Volvulus
K56.4 - Other impaction of
intestine
K56.5 - Intestinal
adhesions [bands] with
obstruction
K56.6 - Other and
unspecified intestinal
obstruction
K56.7 - Ileus, unspecified
K57 - Diverticular disease
of intestine
K59.0 - Constipation
K63.0 - Abscess of
intestine
K63.1 - Perforation of
intestine (nontraumatic)
K63.2 - Fistula of intestine
K65 - Peritonitis
K66.0 - Peritoneal
adhesions
K66.1 - Haemoperitoneum
K91.0 - Vomiting following
gastrointestinal surgery
K91.3 - Postprocedural
intestinal obstruction
K91.8 - Other
postprocedural disorders
of digestive system, not
elsewhere classified
K91.9 - Postprocedural
disorder of digestive
system, unspecified
K92.0 - Haematemesis
K92.1 - Melaena
K92.2 - Gastrointestinal
haemorrhage, unspecified
L03.10 - Cellulitis of upper
limb
L03.11 - Cellulitis of lower
limb
L03.2 - Cellulitis of face
L03.3 - Cellulitis of trunk
L23.1 - Allergic contact
dermatitis due to
adhesives
L27.0 - Generalised skin
eruption due to drugs and
medicaments
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
0-7 days
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
0-7 days
Y
0-7 days
Y
0-7 days
Y
0-7 days
0-7 days
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
71
Y
0-7 days
Principal Diagnosis
L27.1 - Localised skin
eruption due to drugs and
medicaments
L89 - Decubitus ulcer and
pressure area
M00.05 - Staphylococcal
arthritis and polyarthritis,
pelvic region and thigh
M00.06 - Staphylococcal
arthritis and polyarthritis,
lower leg
M00.25 - Other
streptococcal arthritis and
polyarthritis, pelvic region
and thigh
M00.26 - Other
streptococcal arthritis and
polyarthritis, lower leg
M00.95 - Pyogenic
arthritis, unspecified,
pelvic region and thigh
M00.96 - Pyogenic
arthritis, unspecified,
lower leg
M21.25 - Flexion
deformity, pelvic region
and thigh
M21.26 - Flexion
deformity, lower leg
M21.30 - Wrist or foot
drop (acquired), multiple
sites
M21.37 - Wrist or foot
drop (acquired), ankle and
foot
M21.75 - Unequal limb
length (acquired), pelvic
region and thigh
M21.76 - Unequal limb
length (acquired), lower
leg
M24.45 - Recurrent
dislocation and
subluxation of joint, pelvic
region and thigh
M24.46 - Recurrent
dislocation and
subluxation of joint, lower
leg
M24.65 - Ankylosis of
joint, pelvic region and
thigh
M24.66 - Ankylosis of
joint, lower leg
M25.05 - Haemarthrosis,
pelvic region and thigh
M25.06 - Haemarthrosis,
lower leg
M25.45 - Effusion of joint,
pelvic region and thigh
M25.46 - Effusion of joint,
lower leg
M25.55 - Pain in a joint,
pelvic region and thigh
M25.56 - Pain in a joint,
lower leg
M25.65 - Stiffness of joint,
not elsewhere classified,
pelvic region and thigh
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Recommended
readmission
interval (if not
entire readmission
interval)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
72
Principal Diagnosis
M25.66 - Stiffness of joint,
not elsewhere classified,
lower leg
M25.85 - Other specified
joint disorders, pelvic
region and thigh
M25.86 - Other specified
joint disorders, lower leg
M25.95 - Unspecified joint
disorder, pelvic region and
thigh
M25.96 - Unspecified joint
disorder, lower leg
M79.15 - Myalgia, pelvic
region and thigh
M79.16 - Myalgia, lower
leg
M79.25 - Neuralgia and
neuritis, unspecified,
pelvic region and thigh
M79.26 - Neuralgia and
neuritis, unspecified,
lower leg
M79.55 - Residual foreign
body in soft tissue, pelvic
region and thigh
M79.56 - Residual foreign
body in soft tissue, lower
leg
M79.65 - Pain in limb,
pelvic region and thigh
M79.66 - Pain in limb,
lower leg
M84.35 - Stress fracture,
not elsewhere classified,
pelvic region and thigh
M84.36 - Stress fracture,
not elsewhere classified,
lower leg
M87.05 - Idiopathic
aseptic necrosis of bone,
pelvic region and thigh
M87.06 - Idiopathic
aseptic necrosis of bone,
lower leg
M87.25 - Osteonecrosis
due to previous trauma,
pelvic region and thigh
M87.26 - Osteonecrosis
due to previous trauma,
lower leg
M87.85 - Other
osteonecrosis, pelvic
region and thigh
M87.86 - Other
osteonecrosis, lower leg
M87.95 - Unspecified
osteonecrosis, pelvic
region and thigh
M87.96 - Unspecified
osteonecrosis, lower leg
M96.6 - Fracture of bone
following insertion of
orthopaedic implant, joint
prosthesis, or bone plate
M96.8 - Other
postprocedural
musculoskeletal disorders
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
73
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
Principal Diagnosis
M96.9 - Postprocedural
musculoskeletal disorder,
unspecified
N02.8 - Recurrent and
persistent haematuria,
other
N02.9 - Recurrent and
persistent haematuria,
unspecified
N13.0 - Hydronephrosis
with ureteropelvic junction
obstruction
N13.1 - Hydronephrosis
with ureteral stricture, not
elsewhere classified
N13.3 - Other and
unspecified
hydronephrosis
N13.4 - Hydroureter
N13.5 - Kinking and
stricture of ureter without
hydronephrosis
N13.6 - Pyonephrosis
N13.7 - Vesicoureteralreflux-associated uropathy
N13.8 - Other obstructive
and reflux uropathy
N13.9 - Obstructive and
reflux uropathy,
unspecified
N17 - Acute kidney failure
N30.0 - Acute cystitis
N30.3 - Trigonitis
N30.8 - Other cystitis
N30.9 - Cystitis,
unspecified
N31.2 - Flaccid
neuropathic bladder, not
elsewhere classified
N31.8 - Other
neuromuscular
dysfunction of bladder
N31.9 - Neuromuscular
dysfunction of bladder,
unspecified
N32.0 - Bladder neck
obstruction
N32.1 - Vesicointestinal
fistula
N32.2 - Vesical fistula, not
elsewhere classified
N35 - Urethral stricture
N39.0 - Urinary tract
infection, site not specified
N39.3 - Stress
incontinence
N39.4 - Other specified
urinary incontinence
N41 - Inflammatory
diseases of prostate
N42.1 - Congestion and
haemorrhage of prostate
N45 - Orchitis and
epididymitis
N47 - Redundant
prepuce, phimosis and
paraphimosis
N48.1 - Balanoposthitis
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Tonsill.
&
Adenoid.
Appendic.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
74
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
0-7 days
Principal Diagnosis
N70 - Salpingitis and
oophoritis
N73 - Other female pelvic
inflammatory diseases
N76 - Other inflammation
of vagina and vulva
N81 - Female genital
prolapse
N82 - Fistulae involving
female genital tract
N89.5 - Stricture and
atresia of vagina
N93 - Other abnormal
uterine and vaginal
bleeding
N94.1 - Dyspareunia
N99.0 - Postprocedural
kidney failure
N99.1 - Postprocedural
urethral stricture
N99.3 - Prolapse of
vaginal vault after
hysterectomy
N99.8 - Other
postprocedural disorders
of genitourinary system
N99.9 - Postprocedural
disorder of genitourinary
system, unspecified
Q43.0 - Meckel's
diverticulum
R00 - Abnormalities of
heart beat
R04.1 - Haemorrhage
from throat
R04.2 - Haemoptysis
R06.0 - Dyspnoea
R06.1 - Stridor
R07.0 - Pain in throat
R10.0 - Acute abdomen
R10.2 - Pelvic and
perineal pain
R10.3 - Pain localised to
other parts of lower
abdomen
R11 - Nausea and
vomiting
R13 - Dysphagia
R15 - Faecal incontinence
R19.0 - Intra-abdominal
and pelvic swelling, mass
and lump
R26.2 - Difficulty in
walking, not elsewhere
classified
R26.8 - Other and
unspecified abnormalities
of gait and mobility
R30.1 - Vesical tenesmus
R30.9 - Painful micturition,
unspecified
R31 - Unspecified
haematuria
R32 - Unspecified urinary
incontinence
R33 - Retention of urine
R34 - Anuria and oliguria
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Y
Y
Y
Y
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
0-7 days
75
Principal Diagnosis
R39.0 - Extravasation of
urine
R39.1 - Other difficulties
with micturition
R39.8 - Other and
unspecified symptoms
and signs involving the
urinary system
R41.0 - Disorientation,
unspecified
R42 - Dizziness and
giddiness
R49.0 - Dysphonia
R50 - Fever of other and
unknown origin
R53 - Malaise and fatigue
R58 - Haemorrhage, not
elsewhere classified
R63.0 - Anorexia
R63.3 - Feeding
difficulties and
mismanagement
R63.8 - Other symptoms
and signs concerning food
and fluid intake
R79 - Other abnormal
findings of blood
chemistry
S06.1 - Traumatic
cerebral oedema
S06.3 - Focal brain injury
S06.4 - Epidural
haemorrhage
S06.5 - Traumatic
subdural haemorrhage
S06.6 - Traumatic
subarachnoid
haemorrhage
S06.8 - Other intracranial
injuries
S30.2 - Contusion of
external genital organs
S37.1 - Injury of ureter
S37.20 - Injury of bladder,
unspecified
S37.21 - Contusion of
bladder
S37.22 - Rupture of
bladder
S37.28 - Other injury of
bladder
S37.30 - Injury of urethra,
part unspecified
S37.31 - Injury of
membranous urethra
S37.32 - Injury of penile
urethra
S37.33 - Injury of prostatic
urethra
S37.38 - Injury of other
part of urethra
S37.4 - Injury of ovary
S37.5 - Injury of fallopian
tube
S37.7 - Injury of multiple
pelvic organs
S37.81 - Injury of adrenal
gland
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Y
Y
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Recommended
readmission
interval (if not
entire readmission
interval)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
0-7 days
Y
Y
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
0-7 days
Y
Y
0-7 days
Y
Y
0-7 days
Y
Y
0-7 days
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
0-7 days
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
0-7 days
Y
0-7 days
Y
0-7 days
Y
Y
Y
Y
Y
Y
76
Principal Diagnosis
S37.82 - Injury of prostate
S37.83 - Injury of seminal
vesicle
S37.84 - Injury of vas
deferens
S37.88 - Injury of other
pelvic organ
S37.9 - Injury of
unspecified pelvic organ
S72.0 - Fracture of neck
of femur
S73 - Dislocation, sprain
and strain of joint and
ligaments of hip
S74 - Injury of nerves at
hip and thigh level
T40.2 - Other opioids
T40.4 - Other synthetic
narcotics
T40.6 - Other and
unspecified narcotics
T45.5 - Anticoagulants
T80.1 - Vascular
complications following
infusion, transfusion and
therapeutic injection
T80.2 - Infections
following infusion,
transfusion and
therapeutic injection
T81 - Complications of
procedures, not
elsewhere classified
Excluding T81.1 - Shock
during or resulting from
a procedure, not
elsewhere classified
T83.0 - Mechanical
complication of urinary
(indwelling) catheter
T84 - Complications of
internal orthopaedic
prosthetic devices,
implants and grafts
T85.2 - Mechanical
complication of intraocular
lens
T85.78 - Infection and
inflammatory reaction due
to other internal prosthetic
devices, implants and
grafts
T85.88 - Other
complications of internal
prosthetic device, implant
and graft, NEC
T85.9 - Unspecified
complication of internal
prosthetic device, implant
and graft
T88.5 - Other
complications of
anaesthesia
T88.7 - Unspecified
adverse effect of drug or
medicament
Knee
Rep.
Y
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Y
Recommended
readmission
interval (if not
entire readmission
interval)
0-7 days
Y
0-7 days
Y
0-7 days
Y
Y
Y
0-7 days
Y
Y
Y
0-7 days
Y
0-7 days
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
0-7 days
y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
0-7 days
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0-7 days
Y
Y
Y
Y
Y
Y
Y
0-7 days
77
Principal Diagnosis
T88.8 - Other specified
complications of surgical
and medical care, not
elsewhere classified
T88.9 - Complication of
surgical and medical care,
unspecified
Z46.6 - Fitting and
adjustment of urinary
device
Z74.0 - Need for
assistance due to reduced
mobility
Knee
Rep.
Hip
Rep.
Hyster.
Prostat.
Tonsill.
&
Adenoid.
Appendic.
Cat.Surg.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
78
Y
Recommended
readmission
interval (if not
entire readmission
interval)
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
Aliases
Definition
Rate of community follow-up within first 7 days of discharge from
psychiatric admission
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.
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
Metadata
Rate of hospital readmissions within 28 days to a designated mental
health inpatient unit.
Guide for Use:
Continuity of care and support following discharge from a 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.
79
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.
•
Separations where length of stay is one night only and procedure
code for ECT is recorded.
Note: the Procedure code for ECT is identified from the ACHI 7th Edition:
Electroconvulsive therapy block 1907.
Scope
All WA designated psychiatric mental health facilities (as listed below).
80
Acute mental health units
at the following facilities:
Excludes the following nonacute/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
Joondalup Health Campus
Kalgoorlie hospital
King Edward Memorial
Hospital
Mercy 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%
81
Data Collection Identification Items
Source
HMDS (Inpatient separations) and MHIS (Ambulatory mental health
service contacts)
Governance Items
Purpose of the
data
To monitor continuity of care and support following discharge from a
mental health inpatient unit.
Source of the
definition
Manager, Mental Health Information System.
Version number
1.1
Approval date
20130605
AHMAC, National Mental Health Performance subcommittee.
82
EQ13: Measures of patient experience (including satisfaction) with
hospital services
Reported Data Description Items
Identifier
Name
Aliases
Definition
Related Metadata
Guide for Use
(office use only)
Overall Indicator of Patient Satisfaction
Overall Satisfaction, wghtcomp
Overall patient satisfaction for adults admitted 0-34 nights
to public hospitals (and to private hospitals contracted to
provide public hospital services).
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
83
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.
Limitations
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.
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
Data Values
Inclusions
Exclusions
Scope
Formula:
Numeric
4
NNN.N
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
Psychiatric Care Days > 0
Interpreter Required = 1 = Yes
Silent Numbers
Prisoners
Deceased since discharge
Public Hospitals (metropolitan and rural)
Joondalup Health Campus, publicly funded activity
Peel Health Campus, publicly funded activity
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;
84
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);
85
sumds = sum(of d1 d2 d3 d4 d5 d6 d7);
Then
Calculate the mean weighted score.
Verification Rules
wghtcomp = (sumscs/sumds);
>=0 and <=100
Data Collection Identification Items
Source
Patient Evaluation of Health Services Survey (PEHS)
Patient Satisfaction survey
Governance Items
Purpose of the data
Source of the definition
Version number
Approval date
A measure of overall patient satisfaction of adults
admitted 0-34 nights to public hospitals for ABF/ABM
Performance Management Reports.
Epidemiology Branch, System Policy & Planning
1.0
20120813
86
EQ14: Hand Hygiene Compliance
Reported Data Description Items
Identifier
Name
Aliases
Definition
Related Metadata
Guide for Use:
(office use only)
Hospital Hand Hygiene Compliance Rate
Hand Hygiene Compliance
The hand hygiene compliance rate (expressed as a
percentage) of a participating WA Public Hospital.
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
87
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/MJA2011-10747R1-GRAYSON-SupplementarydataB.pdf 1/3/12
3 retrieved from
http://www.health.wa.gov.au/press/view_press.cfm?id=1096
1/3/2012.
Limitations
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.
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
88
•
•
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.
Exclusions
Scope
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.
nil
Public metropolitan, WACHS regional resource centres and
integrated district health services.
Participating WACHS small hospitals.
Joondalup and Peel Health Campuses.
Formula:
For a particular report, please refer to that report’s scoping to
determine which sites are included.
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:
compliance
Verification Rules
X/Y *100 = % rate of overall hand hygiene
Utilise numerator / denominator to calculate the exact binomial
95% Confidence Interval
% rate of overall hand hygiene compliance >=0 and <=100%
Data Collection Identification Items
Source
Governance Items
Purpose of the data
Source of the definition
Version number
Approval date
Office of Safety and Quality in Healthcare.
To report the hand hygiene compliance rate of Western
Australian public hospitals for ABF/ABM Performance
Management Reports
Quality Improvement Directorate
1.0
20120813
89
2.4 Efficiency Inputs per output unit (EI) KPIs
There are 11 EI PIs proposed in the 2013-14 PMF, including 7 Health Service measures.
90
EI2: Elective surgery day of surgery admission rates
Reported Data Description Items
Identifier
MDG-01-015
Name
Day of Surgery (elective) Admission rate
Aliases

Definition
The proportion of multi-day elective surgical separations where a
procedure was performed on the day of admission.
DOSA
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.
Limitations
Historical data is updated in each extract, to take account of
edit/quality assurance processes.
Delays in clinical coding may result in a potential lag in data
completeness.
Reported Data Validation Items
Format
Percentage
91
7
NNN.NN%
Data Values
Inclusions
HMDS
Field names and values
Care Type / Episode of Care
• Acute
OR
Client Status / Patient Type
• Qualified newborns
21
1.0
A
1
5.0
PG
3
4
1
2
ELW
ELWN
Admit Type / Status
• Elective – Waitlist
• Elective – Not Waitlist
Surgical DRGs
• Surgical
TOPAS HCARe
2nd digit of DRG Code is 0, 1, 2 or 3
Funding Source
Public patients in private hospitals only and these are defined by:
21
• Australian Health Care
Agreements
29
• Correctional Facility
30
• Reciprocal Health Care
Agreement
Exclusions
Field and value names
Care Type / Episode of Care =
 Rehabilitation
 Palliative
 Psychogeriatric
 Geriatric Evaluation and Management
 Maintenance
 Newborn
 Organ Procurement
 Boarders
 Aged Care Resident

Flexible Care
HMDS TOPAS HCARe
22
23
24
29
25
26
27
28
30
2.0
3.0
5.0
4.0
6.0
7.0
9.0
10.0
31
Client Status / Patient Type
 Contracting Service/Funding Hospital
Funding Source
 Ambulatory Surgical Initiative
Procedure Date is null
92
F
H
C
0 ((zero) 0 (zero)
646
R
P
PG
G
N
U
OP
O
AG
PR
F
ASI
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-0120 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-0120 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
To monitor the proportion of acute elective surgical separations,
data
where patients were admitted on the same day they had their
procedure.
Source of the
•
Data Integrity Directorate, Performance Activity and
93
definition
Quality 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.
94
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
Parameter Values:
Period Name = relevant period (month) of report
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.
95
Reported Data Validation Items
Format
Percentage
7
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%.
96
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
97
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
Parameter Values:
Period Name = relevant period (month) of report
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
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.
98
Reported Data Validation Items
Format
Percentage
7
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)
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.
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.
99
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 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
100
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
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.
Reporting frequency: yearly
Reporting level: Health Service
Related Metadata
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.
Reported Data Validation Items
Format
Ratio
7
NNNNNNN
Data Values
Positive number
Inclusions
All examinations by School Dental Service
101
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
Approval date
1.1
20130605
102
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 SelbyLemnos, referred to as Long Stay Admitted Mental Health (LSMH)
activity.
Related
Metadata
Percentage Variance from Target – Total Estimated Weighted Inpatient
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.
103
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 SelbyLemnos), 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).
104
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] =
Exclusions
Australian Health Care Agreements
21
Correctional Facility
29
Reciprocal Health Care Agreement
30
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.
For TOPAS and HCARe records:
105
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:
TOPAS HCARe
Exclude contracted services
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
Sub-group excluded:
TOPAS
HCARe
HMDS
10.0
O
28
Group to
{Ctyp12}
as:
1. Boarders
-
Care Type/Episode of
Care =
or
-
BR
Client Status/Patient
Type =
3
B
3
2
U
2
UnqNB
9.0
OP
27
OP
N/A
F
31
FCR
2. Unqualified Newborns
-
Client Status/Patient
Type =
3. Organ Procurement
-
Care Type/Episode of
Care =
4. Flexible Care
Residents
-
Care Type/Episode of
106
Care =
H
C
5. Aged Care
N/A
AG
30
ACR
N/A
N/A
Z53
CES
6. Cancelled Elective Surgery
-
Scope
first three characters of
[Principal Diagnosis] =
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,
HCARe, JHC &
PHC discharge
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 HCARe records where [Flag] = C.. Minus TOPAS & HCARe
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
Rules
Value is >/= to zero
Additional information – How to calculate included inpatient subgroups for {Ctyp12}
107
– separation based data
Records need to be flagged as Area Mental Health Service within the
created field {AMHS} as follows:
Hospital Establishment Number
& Name
Wards
{AMHS}
flag
-
105 (Sir Charles Gairdner)
D20, PYWD
Y
-
244 (Swan District)
MHSW, MHLS, MHLW,
MHWW, SVCO, SVCS
Y
-
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,
W10C, 1309, ECTD,
W6W7
Y
W41, W42, W51, W43,
W4SW, MOSS, D5W,
ECT
Y
Y
-
102 (Fremantle)
-
203 (Armadale-Kelmscott
District Memorial)
LOPEN, LHDU, KARRI,
BANKS, BANKSIA
-
2239 (Armadale Mental Health
for Older People Authorised)
BANKS, KARRI
-
101 (Royal Perth)
2K, PSYD, EDPP
Y
-
103 (Princess Margaret)
4H, STUBB
Y
-
277 (Rockingham General)
MHAC, MHAO, MHEC,
MHEO
Y
-
201 (Albany)
MENTAL HEALTH
UNIT, MHU
Y
-
208 (Bunbury)
MEN, MENTAL
HEALTH, PICU
Y
-
226 (Kalgoorlie)
PSYCHIATRIC UNIT
Y
-
206 (Broome)
ACUTE PSYCHIATRIC
UNIT
Y
-
All other records
Y
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
Sub-group:
108
Group to
{Ctyp12}
as:
1. Area Mental Health Service
-
{AMHS} flag =
Y
2. Sub Acute
-
TOPAS
HCARe
HMDS
Rehabilitation
2.0
R
22
Palliation
3.0
P
23
Psychogeriatric†
5.0
PG
24
Geriatric Evaluation and
Management
4.0
G
29
TOPAS
HCARe
HMDS
6.0
N
25
Care Type/Episode of Care =
3. Non-Acute
-
AMHS
SubAC
Care Type/Episode of Care =
Maintenance Care
NA
4. Acute Inpatients
-
All other records that are not yet
grouped
AC_IP
†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
Deleted,
Removed or
Replaced
extract
Updated weekly, maintained by the Hospital Morbidity Data Collection
Branch
TOPAS
The monthly file provided to Business & Financial Modelling, PAQ
captures all activity to 2359 on last day of the calendar month
Weekly file extracted at 0600 hours each Monday for data up to Sunday
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
captures all activity to 2359 on last day of the calendar month
109
PAQ
WA 2012/13 ABF/M Operating Model documentation
Governance Items
Purpose of the
data
Total Estimated Unweighted Inpatient Activity is the count used as the
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
definition/
additional
information
Business and Financial Modelling Directorate, Performance Activity and
Quality Division, DoH WA
Performance Directorate, Performance Activity and Quality Division, DoH
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
number
1.0
Approval date
20120813
110
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

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
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.
111
Limitations
Delays in clinical coding may result in a potential lag in data
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
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 =
•
21
Acute
Client Status =
•
Exclusions
1
Qualified newborn
Field and value names
HMDS
Client Status =

Contracting Service
/Funding Hospital
0 (zero)

Unqualified newborn
2

Boarder
3

Organ Procurement
7

Resident
8
Hospital Code =

Non-WA Hospitals

Aged Care
646
>= 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)
112
Formula
Numerator
HMDS
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].
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).
Denominator
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
HMDS
Updated weekly every Wednesday.
Governance Items
Purpose of the
data
Source of the
definition

Data Integrity, Performance Activity and Quality Division

Hospital Morbidity Data System Reference Manual

MDG-01-020 Removal of Duplicates
Version Number
V1.0
Approval Date
20111108
113
EI11: YTD Distance of Salaries Expenditure to Budget
This indicator is currently under development.
114
2.5 Equity Access (EQA) KPIs
There are 5 EQA PIs proposed in the 2013-14 PMF, including 3 Health Service measures.
115
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 nonAboriginal 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
census collection district (CD) and statistical local area (SLA), by
the Data Linkage Branch. The Epidemiology Branch then assigns
records to the correct HS based on their SLA of usual residence.
Records with missing CD or SLA 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.
116
Reported Data Validation Items
Format
Numeric
4
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.
Duplicated records of contracted services at funding hospitals
(patient type = 0).
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.
117
When data are extracted for the calculation of the rate ratios for
the new year, data from the same extract are also used for the recalculation 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, System Policy & Planning
Version number
1.1
Approval date
20130605
118
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 agecohort, as registered on the Australian Childhood Immunisation
Register (ACIR).
Aliases
The proportion children fully immunized in the 12-15 month agecohort 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 immunizations
against diphtheria, tetanus, pertussis, polio, 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
4
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
119
(North Metro, South Metro and WACHS [Northern and Remote
Country and Southern Country]) according to SLA based on
boundaries outlined by the Epidemiology Branch, System Policy &
Planning.
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 agecohort 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
Version number
Epidemiology Branch and Communicable Disease Control
Directorate, Public Health Division
1.0
Approval date
20120813
120
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.
121
As the completion of the EEO Survey is voluntary, the indicator may
represent an undercount of the total WA Health ATSI employee
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
AT
B
T
Exclusions
–
–
–
–
Aboriginal
Aboriginal Torres Strait Islander
Both
Torres Strait Islander.
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
Job Type
Job Type
Code
SECON
OFFV
122
Description
SECONDMENT OUT NOT PAID
OFFICIAL VISITOR
Job Type
Job Type
Job Type
Placement Reason
NOPAY
HSGC
AGNC
WCPAY
Placement Reason
Placement Reason
Placement Reason
Placement Reason
M26
M24
H07
EMSNP
NO PAY
HEALTH SERVICE GOVERNING COUNCILS
AGENCY
WORKERS COMPENSATION PAYMENT
ONLY
TEMP DEP NOT PD
SECONDMT NOT PD
UNPAID PERIOD
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
123
Source
WA Health Human Resource Data Warehouse
•
•
•
•
•
Employee Details
Employee Position Details
Position Details
EEO Survey Results
Position Requirements
Governance Items
Purpose of the
data
This performance indicator is used to monitor the headcount of WA
Health employees with an Aboriginal and/or Torres Strait Islander
origin.
Source of the
definition
Workforce Modelling and Data, Resource Strategy Directorate, and
the Aboriginal Health Division, WA Health
Version number
1.3
Approval date
20130517
124
2.6 Sustainability Workforce (SW) KPIs
There are 6 SW PIs proposed in the 2013-14 PMF, including 5 Health Service measures.
125
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
Guide for Use
Proportion of new Nursing Graduates to other Nursing Staff and to Total Nursing Staff
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
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
126
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
Inclusions
Medical WFM account codes including:
Account Code
0181
0182
0183
0184
0185
0186
0189
0191
0192
0193
0194
0195
0217
0218
Account code description
Salaried Medical Officers
Salaried Medical Pract s
Salaried Radiology (Medical Imaging)
Salaried Radiotherapy
Salaried Pathology
Salaried Dental Officers
Salaried Other
Sessional Clinical
Sessional Radiology (Medical Imaging)
Sessional Radiotherapy
Sessional Pathology
Sessional Other
Agency Medical Salaried
Agency Medical Sessional
Consultants:
Rate ID
CLA014
CLA015
CLA016
CLA017
CLA018
CLA019
CLA020
CLA021
CLA022
CLA023
CLA024
CLA14.1
CLA15.1
CLA16.1
CLA17.1
CLA18.1
CLA19.1
CLA20.1
CLA21.1
CLA22.1
CLA23.1
CLA24.1
CLB014
Rate Description
Clinical Academic Level 14
Clinical Academic Level 15
Clinical Academic Level 16
Clinical Academic Level 17
Clinical Academic Level 18
Clinical Academic Level 19
Clinical Academic Level 20
Clinical Academic Level 21
Clinical Academic Level 22
Clinical Academic Level 23
Clinical Academic Level 24
Clinical Academic Level 14.1
Clinical Academic Level 15.1
Clinical Academic Level 16.1
Clinical Academic Level 17.1
Clinical Academic Level 18.1
Clinical Academic Level 19.1
Clinical Academic Level 20.1
Clinical Academic Level 21.1
Clinical Academic Level 22.1
Clinical Academic Level 23.1
Clinical Academic Level 24.1
Clinical Academic Level 14
127
Rate ID
DUPOS9
DZAN16
DZAN17
DZAN18
DZAN19
DZAN20
DZAN21
DZAN22
DZAN23
DZAN24
DZPA16
DZPA17
DZPA18
DZPA19
DZPA20
DZPA21
DZPA22
DZPA23
DZPA24
MA16.1
MA17.1
MA18.1
MA19.1
Rate Description
Plastic & Ortho Surg Ses YR 9
Anaesthetist Level 16
Anaesthetist Level 17
Anaesthetist Level 18
Anaesthetist Level 19
Anaesthetist Level 20
Anaesthetist Level 21
Anaesthetist Level 22
Anaesthetist Level 23
Anaesthetist Level 24
Pathologist Level 16
Pathologist Level 17
Pathologist Level 18
Pathologist Level 19
Pathologist Level 20
Pathologist Level 21
Pathologist Level 22
Pathologist Level 23
Pathologist Level 24
Consultant Ft YR 1
Consultant Ft YR 2
Consultant Ft YR 3
Consultant Ft YR 4
CLB015
CLB016
CLB017
CLB018
CLB019
CLB020
CLB021
CLB022
CLB023
CLB024
DJC001
DJC002
DJC003
DJC004
DJC005
DJC006
DJC007
DJC008
DJC009
DKMP01
DKMP02
DKMP03
DMSP01
DMSP02
DMSP03
DPGP01
DPGP02
DPGP03
DPGP04
DPGP05
DQSF01
DQSF02
DQSF03
DQSF04
DQSF05
DQSF06
DQSF07
DQSF08
DQSF09
DQSS01
DQSS02
DQSS03
DQSS04
DQSS05
DQSS06
DQSS07
DQSS08
DQSS09
DRSS01
DRSS02
DRSS03
DRSS04
DRSS05
DRSS06
DRSS07
DRSS08
DRSS09
DSSS01
DSSS02
DSSS03
DSSS04
DSSS05
DSSS06
DSSS07
Clinical Academic Level 15
Clinical Academic Level 16
Clinical Academic Level 17
Clinical Academic Level 18
Clinical Academic Level 19
Clinical Academic Level 20
Clinical Academic Level 21
Clinical Academic Level 22
Clinical Academic Level 23
Clinical Academic Level 24
Consultant Yr1
Consultant Yr2
Consultant Yr3
Consultant Yr4
Consultant Yr5
Consultant Yr6
Consultant Yr7
Consultant Yr8
Consultant Yr9
Health Serv Medical Pract YR 1
Health Serv Medical Pract YR 2
Health Serv Medical Pract YR 3
Senior Medical Pract YR 1
Senior Medical Pract YR 2
Senior Medical Pract YR 3
Voc Regist General Pract YR 1
Voc Regist General Pract YR 2
Voc Regist General Pract YR 3
Voic Regist General Pract YR 4
Voic Regist General Pract YR 5
General Surgeon FT YR 1
General Surgeon FT YR 2
General Surgeon FT YR 3
General Surgeon FT YR 4
General Surgeon FT YR 5
General Surgeon FT YR 6
General Surgeon FT YR 7
General Surgeon FT YR 8
General Surgeon FT YR 9
General Surgeon <5Sess YR 1
General Surgeon <5Sess YR 2
General Surgeon <5Sess YR 3
General Surgeon <5Sess YR 4
General Surgeon <5Sess YR 5
General Surgeon <5Sess YR 6
General Surgeon <5Sess YR 7
General Surgeon <5Sess YR 8
General Surgeon <5Sess YR 9
General Surgeon 12Sess YR 1
General Surgeon 12Sess YR 2
General Surgeon 12Sess YR 3
General Surgeon 12Sess YR 4
General Surgeon 12Sess YR 5
General Surgeon 12Sess YR 6
General Surgeon 12Sess YR 7
General Surgeon 12Sess YR 8
General Surgeon 12Sess YR 9
General Surgeon 14Sess YR 1
General Surgeon 14Sess YR 2
General Surgeon 14Sess YR 3
General Surgeon 14Sess YR 4
General Surgeon 14Sess YR 5
General Surgeon 14Sess YR 6
General Surgeon 14Sess YR 7
128
MA20.1
MA21.1
MA22.1
MA23.1
MA24.1
MHS01.1
MHS02.1
MHS03.1
MMP01.1
MMP02.1
MMP03.1
MVR01.1
MVR02.1
MVR03.1
MVR04.1
MVR05.1
PFT16.1
PFT17.1
PFT18.1
PFT19.1
PFT20.1
PFT21.1
PFT22.1
PFT23.1
PFT24.1
PMS16.1
PMS17.1
PMS18.1
PMS19.1
PMS20.1
PMS21.1
PMS22.1
PMS23.1
PMS24.1
SFA16.1
SFA17.1
SFA18.1
SFA19.1
SFA20.1
SFA21.1
SFA22.1
SFA23.1
SFA24.1
SHS01.1
SHS02.1
SHS03.1
SMP01.1
SMP02.1
SMP03.1
SP16.1
SP17.1
SP18.1
SP19.1
SP20.1
SP21.1
SP22.1
SP23.1
SP24.1
SS16.1
SS17.1
SS18.1
SS19.1
SS20.1
SS21.1
Consultant Ft YR 5
Consultant Ft YR 6
Consultant Ft YR 7
Consultant Ft YR 8
Consultant Ft YR 9
Health Serv Med Pract YR 1
Health Serv Med Pract YR 2
Health Serv Med Pract YR 3
Senior Medical Pract YR 1
Senior Medical Pract YR 2
Senior Medical Pract YR 3
Voc Regist General Pract YR 1
Voc Regist General Pract YR 2
Voc Regist General Pract YR 3
Voc Regist General Pract YR 4
Voc Regist General Pract YR 5
Pathologist Level 16.1
Pathologist Level 17.1
Pathologist Level 18.1
Pathologist Level 19.1
Pathologist Level 20.1
Pathologist Level 21.1
Pathologist Level 22.1
Pathologist Level 23.1
Pathologist Level 24.1
Pathologists Med-Sess Lvl 16.1
Pathologists Med-Sess Lvl 17.1
Pathologists Med-Sess Lvl 18.1
Pathologists Med-Sess Lvl 19.1
Pathologists Med-Sess Lvl 20.1
Pathologists Med-Sess Lvl 21.1
Pathologists Med-Sess Lvl 22.1
Pathologists Med-Sess Lvl 23.1
Pathologists Med-Sess Lvl 24.1
Surgeon FT A YR 1.1
Surgeon FT A YR 2.1
Surgeon FT A YR 3.1
Surgeon FT A YR 4.1
Surgeon FT A YR 5.1
Surgeon FT A YR 6.1
Surgeon FT A YR 7.1
Surgeon FT A YR 8.1
Surgeon FT A YR 9.1
Health Serv Med Pract YR 1
Health Serv Med Pract YR 2
Health Serv Med Pract YR 3
Senior Med Pract YR 1
Senior Med Pract YR 2
Senior Med Pract YR 3
Consultant Sess YR 1.1
Consultant Sess YR 2.1
Consultant Sess YR 3.1
Consultant Sess YR 4.1
Consultant Sess YR 5.1
Consultant Sess YR 6.1
Consultant Sess YR 7.1
Consultant Sess YR 8.1
Consultant Sess YR 9.1
Surgeon Sess YR 1.1
Surgeon Sess YR 2.1
Surgeon Sess YR 3.1
Surgeon Sess YR 4.1
Surgeon Sess YR 5.1
Surgeon Sess YR 6.1
DSSS08
DSSS09
DTSS01
DTSS02
DTSS03
DTSS04
DTSS05
DTSS06
DTSS07
DTSS08
DTSS09
DUPOF1
DUPOF2
DUPOF3
DUPOF4
DUPOF5
DUPOF6
DUPOF7
DUPOF8
DUPOF9
DUPOG1
DUPOG2
DUPOG3
DUPOG4
DUPOG5
DUPOG6
DUPOG7
DUPOG8
DUPOG9
DUPOS1
DUPOS2
DUPOS3
DUPOS4
DUPOS5
DUPOS6
DUPOS7
DUPOS8
General Surgeon 14Sess YR 8
General Surgeon 14Sess YR 9
General Surgeon 16Sess YR 1
General Surgeon 16Sess YR 2
General Surgeon 16Sess YR 3
General Surgeon 16Sess YR 4
General Surgeon 16Sess YR 5
General Surgeon 16Sess YR 6
General Surgeon 16Sess YR 7
General Surgeon 16Sess YR 8
General Surgeon 16Sess YR 9
Plastic & Ortho Surg A YR 1
Plastic & Ortho Surg A YR 2
Plastic & Ortho Surg A YR 3
Plastic & Ortho Surg A YR 4
Plastic & Ortho Surg A YR 5
Plastic & Ortho Surg A YR 6
Plastic & Ortho Surg A YR 7
Plastic & Ortho Surg A YR 8
Plastic & Ortho Surg A YR 9
Plastic & Ortho Surg B YR 1
Plastic & Ortho Surg B YR 2
Plastic & Ortho Surg B YR 3
Plastic & Ortho Surg B YR 4
Plastic & Ortho Surg B YR 5
Plastic & Ortho Surg B YR 6
Plastic & Ortho Surg B YR 7
Plastic & Ortho Surg B YR 8
Plastic & Ortho Surg B YR 9
Plastic & Ortho Surg Ses YR 1
Plastic & Ortho Surg Ses YR 2
Plastic & Ortho Surg Ses YR 3
Plastic & Ortho Surg Ses YR 4
Plastic & Ortho Surg Ses YR 5
Plastic & Ortho Surg Ses YR 6
Plastic & Ortho Surg Ses YR 7
Plastic & Ortho Surg Ses YR 8
SS22.1
SS23.1
SS24.1
SVR01.1
SVR02.1
SVR03.1
SVR04.1
SVR05.1
VDMP01
VDMP02
VDMP03
VDMP04
VDMP05
VDMP06
VENP01
VENP02
VENP03
VENP04
VENP05
VENP06
VFPR01
VFPR02
VFPR03
VGSM01
VGSM02
VGSM03
VGSM04
VHC001
VHC002
VHC003
VHC004
VHC005
VHC006
VHC007
VHC008
VHC009
Surgeon Sess YR 7.1
Surgeon Sess YR 8.1
Surgeon Sess YR 9.1
Voc Regist General Pract YR 1
Voc Regist General Pract YR 2
Voc Regist General Pract YR 3
Voc Regist General Pract YR 4
Voc Regist General Pract YR 5
NW26 Health Serv Med Pract YR 1
NW26 Health Serv Med Pract YR 2
NW26 Health Serv Med Pract YR 3
NW26 Health Serv Med Pract YR 4
NW26 Health Serv Med Pract YR 5
NW26 Health Serv Med Pract YR 6
NW26 DMO (Non Procedural)
NW26 DMO (Non Procedural)
NW26 DMO (Non Procedural)
NW26 DMO (Non Procedural)
NW26 DMO (Non Procedural)
NW26 DMO (Non Procedural)
NW26 DMO (Procedural)
NW26 DMO (Procedural)
NW26 DMO (Procedural)
NW26 Senior Med Officer YR1
NW26 Senior Med Officer YR2
NW26 Senior Med Officer YR3
NW26 Senior Med Officer YR4
Nw26 Consultant YR 1
Nw26 Consultant YR 2
Nw26 Consultant YR 3
Nw26 Consultant YR 4
Nw26 Consultant YR 5
Nw26 Consultant YR 6
Nw26 Consultant YR 7
Nw26 Consultant YR 8
Nw26 Consultant YR 9
Rate Description
Registrar Yr 1
Registrar Yr 2
Registrar Yr 3
Registrar Yr 4
Registrar Yr 5
Registrar Yr 6
Registrar Yr 7
Senior Registrar Yr 1
Senior Registrar Yr 2
Supervised Med Off Yr 1
Supervised Med Off Yr 2
Supervised Med Off Yr 3
Supervised Med Off Yr 4
Supervised Med Off Yr 5
Supervised Med Off Yr 6
Supervised Med Off Yr 7
Supervised Med Off Yr 8
Supervised Med Off Yr 9
Trainee Medical Administrator Yr 1
Trainee Medical Administrator Yr 2
Trainee Medical Administrator Yr 3
Trainee Medical Administrator Yr 4
Trainee Medical Administrator Yr 5
Rate ID
DHTH02
DHTH03
DHTH04
DHTH05
DHTH06
DHTH07
ME05.1
ME06.1
ME07.1
ME08.1
ME09.1
ME10.1
ME11.1
ME12.1
ME13.1
MEO10.1
MEO11.1
MEO5.1
MEO6.1
MEO7.1
MEO8.1
MEO9.1
MTP01.1
Rate Description
Trainee Public Health Physician Yr 2
Trainee Public Health Physician Yr 3
Trainee Public Health Physician Yr 4
Trainee Public Health Physician Yr 5
Trainee Public Health Physician Yr 6
Trainee Public Health Physician Yr 7
Registrar Year 1.1
Registrar Year 2.1
Registrar Year 3.1
Registrar Year 4.1
Registrar Year 5.1
Registrar Year 6.1
Registrar Year 7.1
Senior Registrar Year 1.1
Senior Registrar Year 2.1
Registrar Year 6.1
Registrar Year 7.1
Registrar Year 1.1
Registrar Year 2.1
Registrar Year 3.1
Registrar Year 4.1
Registrar Year 5.1
Trainee Psychiatrist Year 1.1
Registrars:
Rate ID
DCRG01
DCRG02
DCRG03
DCRG04
DCRG05
DCRG06
DCRG07
DDSR01
DDSR02
DESM01
DESM02
DESM03
DESM04
DESM05
DESM06
DESM07
DESM08
DESM09
DFTM01
DFTM02
DFTM03
DFTM04
DFTM05
129
DFTM06
DFTM07
DGTP01
DGTP02
DGTP03
DGTP04
DGTP05
DGTP06
DGTP07
DHTH01
Trainee Medical Administrator Yr 6
Trainee Medical Administrator Yr 7
Trainee Psychiatrist Yr 1
Trainee Psychiatrist Yr 2
Trainee Psychiatrist Yr 3
Trainee Psychiatrist Yr 4
Trainee Psychiatrist Yr 5
Trainee Psychiatrist Yr 6
Trainee Psychiatrist Yr 7
Trainee Public Health Physician Yr 1
MTP02.1
MTP03.1
MTP04.1
MTP05.1
MTP06.1
MTP07.1
VCRG01
VCRG02
VCRG03
Trainee Psychiatrist Year 2.1
Trainee Psychiatrist Year 3.1
Trainee Psychiatrist Year 4.1
Trainee Psychiatrist Year 5.1
Trainee Psychiatrist Year 6.1
Trainee Psychiatrist Year 7.1
Nw26 Registrar Yr 1
Nw26 Registrar Yr 2
Nw26 Registrar Yr 3
Rate ID
VBRM01
VBRM02
VBRM03
Rate Description
Nw26 Resident Medical Officer Yr1
Nw26 Resident Medical Officer Yr2
Nw26 Resident Medical Officer Yr3
Resident Medical Officers:
Rate ID
DBRM01
DBRM02
DBRM03
Rate Description
Resident Medical Off Yr 1
Resident Medical Off Yr 2
Resident Medical Off Yr 3
Interns:
Rate ID
DAI001
Rate Description
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
For 2013/14 only 36 sites are considered for this indicator. These are the sites
selected by the Activity Based Funding (ABF) Reporting team.
Of the 36 ABF sites, only those which have interns and/or RMOs are included in
scope.
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 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
130
Purpose of the This indicator is used to show the proportion of a medical grouping (i.e. graduates)
against the full medical workforce to ensure the correct levels to sustain training and
data
safe patient care are maintained within the WA Health system.
Source of the
definition
Version
Workforce Directorate, WA Health.
number 1.1
Approval date
20130605
131
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.
Proportion of new Medical Graduates to other Medical Staff and to Total
Medical Staff
Related
Metadata
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.
132
(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 nonnursing 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.
‘Other’ nursing, although calculated as part of the overall nursing group,
will not be included in the ABF 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.
133
Payment recoups can have impacts on the grouping percentages at some
sites. This can slightly overestimate or underestimate groupings at some
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
0111
0113
0116
0117
0211
Account code description
Nursing Services
Casual Nurses
Enrolled Nurses
Enrolled Mental Health Nurses
Agency nurses
Graduate Nurses
:
Rate ID
ENE001
ENE011
ENE1.1
MST1.1
NEA001
NEA011
REMEB1
RGN1.1
Rate Description
ENROLLED NURSE EBA LEV 1
NSG ASSIST EBA LEV 1
ENROLLED NURSE EBA LEVEL 1.1
MIDWIFE STUDENT - REGISTERED NURSE L1.2.1
REGISTER M/CRAFT YR1 4WK
REG GEN NURSE L1-1 4WK
ENROLLED MHN EB YR1 4WK
REGISTERED GENERAL NURSE LEVEL 1.1
Junior Nurses:
Rate ID
ENE002
ENE012
ENE1.2
NEA012
NEA013
RGN1.2
RGN1.3
Rate Description
ENROLLED NURSE EBA LEV 2
NSG ASSIST EBA LEV 2
ENROLLED NURSE EBA LEVEL 1.2
REG GEN NURSE L1-2 4WK
REG GEN NURSE L1-3 4WK
REGISTERED GENERAL NURSE LEVEL 1.2
REGISTERED GENERAL NURSE LEVEL 1.3
Experienced Nurses:
Rate ID
ALL.1
EME.3
EME.4
EME.5
EME.6
ENE003
ENE004
ENE005
ENE013
Rate Description
ALL CLASSIFICATIONS.1
ENROLLED MENTAL HEALTH NURSE EBA.3
ENROLLED MENTAL HEALTH NURSE EBA.4
ENROLLED MENTAL HEALTH NURSE EBA.5
ENROLLED MENTAL HEALTH NURSE EBA.6
ENROLLED NURSE EBA LEV 3
ENROLLED NURSE EBA LEV 4
ENROLLED NURSE EBA LEV 5
NSG ASSIST EBA LEV 3
134
ENE031
ENE1.3
ENE1.4
ENE2.1
ENE3.1
ENE4.1
NEA014
NEA015
NEA016
REMEB2
REMEB3
RGN1.4
RGN1.5
EN SCHOOL NURSE EBA L2
ENROLLED NURSE EBA LEVEL 1.3
ENROLLED NURSE EBA LEVEL 1.4
ENROLLED NURSE EBA LEVEL 2.1
ENROLLED NURSE EBA LEVEL 3.1
ENROLLED NURSE EBA LEVEL 4.1
REG GEN NURSE L1-4 4WK
REG GEN NURSE L1-5 4WK
REG GEN NURSE L1-6 4WK
ENROLLED MHN EB YR2 4WK
ENROLLED MHN EB YR3 4WK
REGISTERED GENERAL NURSE LEVEL 1.4
REGISTERED GENERAL NURSE LEVEL 1.5
Senior Nurses:
Rate ID
ASEE1.1
ASEE1.2
ASEE2.1
ENAS01
ENAS02
ENSAS1
ENSAS2
FRM2.1
FRM2.2
FRM2.3
FRM2.4
NEA005
NEA006
NEA007
NEA008
NEA009
NEA017
NEA018
NEA019
NEA021
NEA022
NEA023
NEA024
NEA026
NEA027
NEA028
NEA029
NEC021
NEC022
NEC023
NEC024
REMEB4
REMEB5
REMEB6
RGN1.6
RGN1.7
RGN1.8
RGN1.9
SCA2.1
SCA2.2
SCA2.3
SCA2.4
Rate Description
ADVANCED SKILL EN EBA L 1.1
ADVANCED SKILL EN EBA L 1.2
ADVANCED SKILL EN EBA L 2.1
ADVANCED SKILL EN EBA L 1
ADVANCED SKILL EN EBA L 2
ADV SKILL SCHOOL EN L1
ADV SKILL SCHOOL EN L2
FBC REGISTERED MIDWIFE L2.1
FBC REGISTERED MIDWIFE L2.2
FBC REGISTERED MIDWIFE L2.3
FBC REGISTERED MIDWIFE L2.4
REGISTER M/CRAFT YR5 4WK
FBC REG M/WIFE L2-1 4WK
FBC REG M/WIFE L2-2 4WK
FBC REG M/WIFE L2-3 4WK
FBC REG M/WIFE L2-4 4WK
REG GEN NURSE L1-7 4WK
REG GEN NURSE L1-8 4WK
REG GEN NURSE L1-9 4WK
S-DEV/CLIN/A-MAN L2-1 4WK
S-DEV/CLIN/A-MAN L2-2 4WK
S-DEV/CLIN/A-MAN L2-3 4WK
S-DEV/CLIN/A-MAN L2-4 4WK
SCHOOL NURSE L2-1 4WK
SCHOOL NURSE L2-2 4WK
SCHOOL NURSE L2-3 4WK
SCHOOL NURSE L2-4 4WK
COMMUNITY M/WIFE L2-1 4WK
COMMUNITY M/WIFE L2-2 4WK
COMMUNITY M/WIFE L2-3 4WK
COMMUNITY M/WIFE L2-4 4WK
ENROLLED MHN EB YR4 4WK
ENROLLED MHN EB YR5 4WK
ENROLLED MHN EB YR6 4WK
REGISTERED GENERAL NURSE LEVEL 1.6
REGISTERED GENERAL NURSE LEVEL 1.7
REGISTERED GENERAL NURSE LEVEL 1.8
REGISTERED GENERAL NURSE LEVEL 1.9
CLINICAL NURSE LEVEL 2.1
CLINICAL NURSE LEVEL 2.2
CLINICAL NURSE LEVEL 2.3
CLINICAL NURSE LEVEL 2.4
SRN’s and Above
Rate ID
NEAS01
Rate Description
SENIOR REG NSE L 1 4WK
135
NEAS02
NEAS03
NEAS04
NEAS05
NEAS06
NEAS07
NEAS08
NEAS09
NEAS10
SRN1.1
SRN2.1
SRN3.1
SRN4.1
SRN5.1
SRN6.1
SRN7.1
SRN8.1
SRN9.1
SR10.1
All “AG4”
rate IDs
All ‘AP2
and AP4’
rate IDs
All ‘AS4’
rate IDs
SENIOR REG NSE L 2 4WK
SENIOR REG NSE L 3 4WK
SENIOR REG NSE L 4 4WK
SENIOR REG NSE L 5 4WK
SENIOR REG NSE L 6 4WK
SENIOR REG NSE L 7 4WK
SENIOR REG NSE L 8 4WK
SENIOR REG NSE L 9 4WK
SENIOR REG NSE L 10 4WK
SENIOR REG NURSE LEVEL 1.1
SENIOR REG NURSE LEVEL 2.1
SENIOR REG NURSE LEVEL 3.1
SENIOR REG NURSE LEVEL 4.1
SENIOR REG NURSE LEVEL 5.1
SENIOR REG NURSE LEVEL 6.1
SENIOR REG NURSE LEVEL 7.1
SENIOR REG NURSE LEVEL 8.1
SENIOR REG NURSE LEVEL 9.1
SENIOR REG NURSE LEVEL 10.1
HSU GEN DIV
HSU PROF DIV
HSU SNR OFF DIV
‘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.
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
For 2013/14 only 36 sites are considered for this indicator. These are the
sites selected by the Activity Based Funding (ABF) Reporting team.
Of the 36 ABF sites, only those which have graduate and/or junior nurses
are included in the analysis.
Formula
Numerator
Nurse grouping (either the graduate, junior, experienced, senior or SRN
and above grouping)
Denominator
Sum of graduate, junior, experienced, senior, SRN and other nursing.
Calculation
Numerator divided Denominator expressed as a percentage for the
grouping.
136
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
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
definition
Workforce Directorate and the Nursing and Midwifery Office, WA Health
Version number
1.1
Approval date
20130605
137
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: JanuaryJune 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
138
lodgement date falling within the specified collection time period.
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
Scope
Data exclude reporting entities such as HCN, HIN, Drug and Alcohol
Office, and DoH at Royal Street.
Includes:
• 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
definition
Operational Plan 2010-11 report definition for PI 4.9.
Version number
3.0
Approval date
20130605
139
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).
This list is not exhaustive and other employees classified as
managers or supervisors should be included.
140
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:
Formula
•
Joondalup Health Campus
•
Peel Health Campus
•
Drug and Alcohol Office.
Numerator: Number (headcount) of WA health managers and
141
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/201205_code_of_prac.pdf
Version number
2.1
Approval date
20130719
142
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)
9
NNNNNNN.NN
Data Values
Inclusions
Grouping
1. Nursing and
Nursing Support
2. Medical
3. Medical Support
Account Code
111
113
116
117
118
181
182
183
184
185
186
189
191
192
193
194
195
114
115
131
132
133
134
135
143
Description
Nursing Services
Casual Nurses
Enrolled Nurses
Enr'lld Mental Hlth Nurse
Assistant In Nursing
Salaried Medical Officers
Salaried Medical Practitioners
Salaried Radiology (Medical Imaging)
Salaried Radiotherapy
Salaried Pathology
Salaried Dental Officers
Salaried Other
Sessional Clinical
Sessional Radiology (Medical Imaging)
Sessional Radiotherapy
Sessional Pathology
Sessional Other
Registered Dental Nurse
Dental Clinic Assistant
Radiology (Medical Imaging)
Radiotherapy
Pathology
Dietitians
Podiatry
136
137
138
139
140
141
142
143
144
145
146
147
148
149
172
121
122
151
152
153
154
155
156
157
161
162
168
171
4. Admin & Clerical
5. Hotel Services
6. Site Services
Exclusions
Chapliancy
Health Promotions
Rehabilitation Assistance
Other Medical Support Services
Dental Technician
Dental Therapists
Occupational Therapy
Pharmacy
Physiotherapy
Social Work
Technical
Speech Pathology
Psychologists
Other Ancillary Services
Aboriginal Health Worker
General Admin & Clerical
Clinical Admin Support
Catering
Cleaning Services
Orderlies & Transport
Patient Support Assistants
Laundry & Linen
Stores & Supply
Home Ancillary Worker
Engineering Maintenance Services
Grounds & Gardens
Security Services
Other Categories
Account Group for Agency Staff (0210)
Office of Health Review
Peel Health Campus
Joondalup Health Campus
Mental Health Commission WA
Drug and Alcohol Office
144
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
data
The intention is to capture the employer liability in hours. This
information can be used to monitor and report on annual leave and
long service leave entitlements.
Source of the
definition
Workforce Division and Health Corporate Network, Department of
Health.
145
Version number
V1.4
Approval date
20130605
146
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 MedicalSessional 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.#
Data Values
Inclusions
Grouping
1. Nursing and
Nursing Support
2. Medical
Account Code
111
113
116
117
118
181
182
183
147
Description
Nursing Services
Casual Nurses
Enrolled Nurses
Enr'lld Mental Hlth Nurse
Assistant In Nursing
Salaried Medical Officers
Salaried Medical Practitioners
Salaried Radiology (Medical Imaging)
184
185
186
189
191
192
193
194
195
114
115
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
172
121
122
151
152
153
154
155
156
157
161
162
168
171
3. Medical Support
4. Admin & Clerical
5. Hotel Services
6. Site Services
Exclusions
Office of Health Review
Joondalup Health Campus
Peel Health Campus
Mental Health Commission WA
Drug and Alcohol Office
148
Salaried Radiotherapy
Salaried Pathology
Salaried Dental Officers
Salaried Other
Sessional Clinical
Sessional Radiology (Medical Imaging)
Sessional Radiotherapy
Sessional Pathology
Sessional Other
Registered Dental Nurse
Dental Clinic Assistant
Radiology (Medical Imaging)
Radiotherapy
Pathology
Dietitians
Podiatry
Chapliancy
Health Promotions
Rehabilitation Assistance
Other Medical Support Services
Dental Technician
Dental Therapists
Occupational Therapy
Pharmacy
Physiotherapy
Social Work
Technical
Speech Pathology
Psychologists
Other Ancillary Services
Aboriginal Health Worker
General Admin & Clerical
Clinical Admin Support
Catering
Cleaning Services
Orderlies & Transport
Patient Support Assistants
Laundry & Linen
Stores & Supply
Home Ancillary Worker
Engineering Maintenance Services
Grounds & Gardens
Security Services
Other Categories
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
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 available from Oracle
Discoverer 10G.
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
definition
Workforce Division
Resource Strategy & Infrastructure Division
149
Performance Activity & Quality Division
Version number
1.1
Approval date
20130605
150
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

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.
PMR-12-070a Average Monthly Total FTE (Financial View)
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.
151
Limitations
Reported Data Validation Items
Format
Numeric
9
NNNNN.#
Data Values
Inclusions
Grouping
1. Nursing and
Nursing Support
2. Medical
3. Medical Support
4. Admin & Clerical
5. Hotel Services
Account Code
111
113
116
117
118
181
182
183
184
185
186
189
191
192
193
194
195
114
115
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
172
121
122
151
152
153
154
155
152
Description
Nursing Services
Casual Nurses
Enrolled Nurses
Enr'lld Mental Hlth Nurse
Assistant In Nursing
Salaried Medical Officers
Salaried Medical Practitioners
Salaried Radiology (Medical Imaging)
Salaried Radiotherapy
Salaried Pathology
Salaried Dental Officers
Salaried Other
Sessional Clinical
Sessional Radiology (Medical Imaging)
Sessional Radiotherapy
Sessional Pathology
Sessional Other
Registered Dental Nurse
Dental Clinic Assistant
Radiology (Medical Imaging)
Radiotherapy
Pathology
Dietitians
Podiatry
Chapliancy
Health Promotions
Rehabilitation Assistance
Other Medical Support Services
Dental Technician
Dental Therapists
Occupational Therapy
Pharmacy
Physiotherapy
Social Work
Technical
Speech Pathology
Psychologists
Other Ancillary Services
Aboriginal Health Worker
General Admin & Clerical
Clinical Admin Support
Catering
Cleaning Services
Orderlies & Transport
Patient Support Assistants
Laundry & Linen
156
157
161
162
168
171
6. Site Services
Exclusions
Stores & Supply
Home Ancillary Worker
Engineering Maintenance Services
Grounds & Gardens
Security Services
Other Categories
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
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
153
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
definition
Workforce Division
Resource Strategy and Infrastructure Division
Performance Activity & Quality Division
Version number
1.1
Approval date
20130605
154
2.7 Processes Coding (PC) KPIs
There are 2 PC PIs proposed in the 2013-14 PMF, including 1 Health Service measure.
155
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

Guide for Use
Total Separations
 Submitted Cases
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
156
numerator prior to the denominator. Therefore, if alterations
are made to separations dates it is possible to have differing
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

Australian Health Care Agreements

Correctional Facility
 Reciprocal Health Care Agreement
Numerator/Denominator
Exclusions
HMDS Value
21
29
30

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”.
157

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 batch and case number is kept.
Denominator
Scope

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.

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
percentage.
Verification Rules
0 -100% inclusive.
158
by
denominator,
expressed
as
a
Data Collection Identification Items
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
Governance Items
Purpose of the data
Extracted within 4 weeks of the end of the previous month.
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
Version number
 Health Service, Information Management and Reporting
V2.1
Approval date
20130605
159
2.8 Processes Finance (PF) KPIs
There are 5 PF PIs proposed in the 2013-14 PMF, including 3 Health Service measures.
160
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
Report Parameter
Values:
FR (SUM) - Balance Sheet - GL Account Lines
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.
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
161
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
convert them to positive values.
162
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
163
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)
Exclusions
Scope
NurseWest/other nursing agencies do not provide the following staffing
types:
• Patient Care Assistants
• Assistants in Nursing (AIN)
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
Joondalup Health Campuses
Formula:
Numerator:
Denominator:
Calculation:
Count the total number of records where Date is within the reporting
period and Outcome = ‘Filled’ .
Count the total number of records where Date is within the reporting
period
The proportion of public hospital requested nursing shifts filled by
NurseWest/other nursing agencies = numerator/denominator x 100
(expressed as a percentage).
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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 1.1
Approval date
20130605
165
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
Data Values
Inclusions
5
NNN.NN%
>=0% or <=100%
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
166
Exclusions
Scope
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
Invoices processed by the Country Pay Group (WACHS)
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 Financials 11i – Accounts 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
167