2016/17 Service Agreement Key Performance Indicators and Service Measures Data Dictionary

256 Pages·2012·1.59 MB·English

Information Bulletin
MinistryofHealth,NSW
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2016/17 Service Agreement Key Performance Indicators and
Service Measures Data Dictionary
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Document Number IB2016_036
Publication date 21-Jul-2016
Functional Sub group Corporate Administration - Information and data
Clinical/ Patient Services - Information and data
Population Health - Health Promotion
Personnel/Workforce - Workforce planning
Summary The 2016/17 Key Performance Indicator and Service Measure Data
Dictionary has been developed to support the NSW Ministry of Health
and Local Health Districts in monitoring and reporting on the 2016/17
Service Agreements by providing the relevant information concerning the
definitions for the numerators and denominators, as well as inclusion and
exclusion notes for each of the Performance Measures located within
Schedule E of the Service Agreement.
Replaces Doc. No. 2015/16 Service Agreement Key Performance Indicators and Service
Measures Data Dictionary [IB2015_053]
Author Branch Health System Information & Performance Reporting
Branch contact HSIPR 02 9391 9388
Applies to Local Health Districts, Board Governed Statutory Health Corporations,
Chief Executive Governed Statutory Health Corporations, Specialty
Network Governed Statutory Health Corporations, Affiliated Health
Organisations, Public Health System Support Division, NSW Ambulance
Service, Ministry of Health
Audience Administration, Performance Units, Data collection and data provision
staff
Distributed to Public Health System, Ministry of Health
Review date 21-Jul-2017
Policy Manual Not applicable
File No. 14/4402
Status Active
Director-General
INFORMATION BULLETIN

2016-17 SERVICE AGREEMENT KEY PERFORMANCE INDICATORS
AND SERVICE MEASURES DATA DICTIONARY
PURPOSE
The purpose of this Information Bulletin supports the monitoring and reporting on the
2016-17 Service Agreements between the Local Health Districts and the NSW Ministry
of Health. The Service Agreement is a key component of the Performance Framework
for Health Services, providing a clear and transparent mechanism for assessment and
improvement of performance.
The definitions provided in the 2016-17 Service Agreement Key Performance
Indicators and Service Measures Data Dictionary (refer to Attachment section below)
will assist Health Services and other data users with the calculation and interpretation of
the Key Performance Indicators and Services Measures referenced in the Service
Agreements for 2016-17.
This Information Bulletin supersedes IB2015_053 2015/16 Service Agreement Key
Performance Indicators and Service Measures Data Dictionary.
KEY INFORMATION
The definitions provided in the Data Dictionary will assist Health Services and other data
users with the calculation and interpretation of the Key Performance Indicators and
Services Measures referenced in the Service Agreements for 2016-17. It should be
noted that some KPIs may be calculated differently when applied to different purposes
outside the management of the Service Agreements. The KPIs and Service Measures
contained in this document have been defined specifically with the intent to meet the
reporting requirements under 2016-17 agreements and to align to the NSW Ministry of
Health’s monthly performance monitoring reports. Should you require further assistance
with the definitions or have comments regarding them please contact either the Health
System Information and Performance Reporting Branch or the Data / Policy contacts
listed in the KPI documentation.
The Service Agreement document covers both the Tier 1 and 2 KPIs and Service
Measures. Key Performance Indicators (KPIs), if not met, may contribute to escalation
under the Performance Framework processes. Performance against these KPIs will be
reported regularly to Health Services in the Health System Performance Report
prepared by the Department.
These KPIs have been designated into two categories:
• Tier 1 - Will generate a performance concern when the organisation’s
performance is outside the tolerance threshold for the applicable reporting
period.
• Tier 2 - Will generate a performance concern when the organisation’s
performance is outside the tolerance threshold for more than one reporting
period.

IB2016_036 Issue date: July-2016 Page 1 of 3
INFORMATION BULLETIN

Service Measures: A range of Service Measures are identified to assist the organisation
to improve provision of safe and efficient patient care and to provide the contextual
information against which to assess performance.
Note that the KPIs and Service Measures listed above are not the only measures
collected and monitored by the NSW Health System. A range of other measures are
used for a variety of reasons, including monitoring the implementation of new service
models, reporting requirements to NSW Government central agencies and the
Commonwealth, and participation in nationally agreed data collections. Relevant
measures specified by the National Health Performance Authority and in the Premier’s
Priorities and State Priorities, have been assigned as NSW Health KPIs, Service
Measures or Monitoring Measures, as appropriate.
This year the KPIS and Service Measures are grouped under the eight reporting
domains of:
• Safety and Quality
• Service Access and Patient Flow
• Integrated Care
• Finance and Activity
• People and Culture
• Population Health
• Maternal, Child, Youth and Family Services
• Mental Health Reform.
The performance of LHDs, other Health Services and Support Organisations is
assessed in terms of whether it is meeting the performance targets for individual KPIs:
 Highly Performing - Performance at, or better than, target
 Underperforming - Performance within a tolerance range
 Not performing - Performance outside the tolerance threshold.
As in previous years, the 2016-17 KPI and Service Measure data elements are also
located on the NSW Health Information Resource Directory and are accessible via the
following link:
http://hird.health.nsw.gov.au/hird/view_data_resource_description.cfm?ItemID=22187
Each individual indicator and service measure may be viewed and downloaded via this
portal. Further, additional documentation (where available) for each of the indicators
and service measures (such as specific identification of which fields from the data
warehouse are used for the calculation, sample .sas code, detailed calculation
formulae, etc) may be found under the “Ext Info” tab for each individual indicator and
service measure, which may be downloaded as well.
Supporting Information
2016-17 Service Agreement Key Performance Indicators and Service Measures Data
Dictionary:
(http://hird.health.nsw.gov.au/hird/view_data_resource_description.cfm?ItemID=22187)

IB2016_036 Issue date: July-2016 Page 2 of 3
INFORMATION BULLETIN

ATTACHMENTS
1. Data Dictionary for 2016-17 Service Agreement Key Performance Indicators and
Service Measures

IB2016_036 Issue date: July-2016 Page 3 of 3
2016/17

Schedule E
Key Performance
Indicators and
Service Measures for
the 2016/17 Service
Agreements

NSW Ministry of Health
July 2016
Version 1.01
July 2016

Contact:
Further information regarding this document can be obtained from the Health System
Information & Performance Reporting Branch.
• For queries relating to the documentation, including clarification of definitions:
[email protected]
• For queries relating to how the Service Agreement data is calculated and reported:
[email protected]
VERSION CONTROL
Date ID Item Change
01/12/2015 SPC111 Your Say Survey: Workplace RETIRED for 2016-17
Culture Index
01/12/2015 PH-014A Publically funded Hepatitis C RETIRED for 2016-17
related services – HCV
Treatment Assessment
01/12/2015 PH-009 Needle and Syringe Program – RETIRED for 2016-17
Sterile needles and syringes
distributed
01/12/2015 SSA132 Home Based Dialysis – Transferred from Schedule D for
Proportion of renal dialysis 2016-17
service events that are home
based
01/12/2015 KF-005 Domestic and Family Violence Transferred from Schedule D for
Screening - Routine Domestic 2016-17
Violence Screens conducted
01/12/2015 KF-007 Out of Home Care Health Transferred from Schedule D for
Pathway Program - Children and 2016-17
young people that complete a
primary health assessment
01/12/2015 KF-009 Sexual Assault Services – High Transferred from Schedule D for
priority referrals to Sexual 2016-17
Assault Services receiving an
initial psychosocial assessment
01/12/2015 PH-017A Tobacco compliance monitoring: Transferred from Schedule D for
compliance with the Smoke-free 2016-17
Health Care Policy
01/12/2015 PH-007A Organ and Tissue donation – Transferred from Schedule D for
Family discussed 2016-17
01/12/2015 PH-007B Organ and Tissue donation – Transferred from Schedule D for
Family consented 2016-17
01/12/2005 KQS205 Hospital Acquired Pressure NEW VERSION – expanded
Injuries: Stage 3, 4, Unstageable indicator to include Suspected Deep
and Suspected Deep Tissue Tissue pressure injuries. Numerator
pressure injuries clarified to include instructions for
principal diagnosis exclusions with
condition onset flag reporting and
stays with multiple episodes with
respect to the condition onset flag.
Minor clarification for targets.

01/12/2015 SSQ101 Deteriorating Patients – Rapid Minor update to the policy contact
Response Calls position
01/12/2015 SSQ102 Deteriorating patients – Minor update to the policy contact
unexpected cardiopulmonary position
arrest rate
01/12/2015 KQS201 ICU Central Line Associated Minor clarification on Primary point of
Bloodstream (CLAB) Infections collection.

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Date ID Item Change
01/12/2015 SSQ108, Unplanned hospital readmission Clarification to numerator for
SSQ109, rates for patients discharged readmission diagnosis criteria for all
SSQ110, following management of subcategories; clarification for Knee
SSQ111 targeted conditions and hip replacements and Paediatric
tonsillectomy and adenoidectomy re:
principal procedure.
01/12/2015 SSQ120 Hospital Acquired Venous Minor update to indicator definition;
Thromboembolism Numerator clarified to include
instructions for principal diagnosis
exclusions with condition onset flag
reporting and stays with multiple
episodes with respect to the
condition onset flag. Minor
clarification for targets; clarification of
exclusions; minor update to the
policy contact position
01/12/2015 KSA101 Transfer of Care – patients NEW VERSION – changed name of
transferred from Ambulance to indicator to reflect how it is reported;
Hospital updated all fields, changing from ED
to hospital, expanded details about
which fields to use in the calculation
of the numerator, removed incorrect
exclusion note.
01/12/2015 KSA102 Emergency Treatment Refined indicator definition to clarify
Performance: Patients with Total purpose of ETP; modified departure
time in ED <= 4hrs time business rule for one of the
modes of separation (value ‘05’) to
correct error in previous version;
expanded Departure Time business
rules to clarify calculation
methodology; updated Related
National Indicators
01/12/2015 KSA103a, Elective Surgery Access Minor amendments to Indicator
KSA103b, Performance: Elective Surgery Definition, Numerator Definition (term
KSA103c Patients Treated on Time “priority” replaced by “urgency”),
Target dates and Primary Point of
Collection
01/12/2015 SSA108, Overdue Elective Surgery Minor amendment to Indicator
SSA109, Patients Definition and Comments (term
SSA110 “priority” replaced by “urgency”).
01/12/2015 KSA201 Presentations staying in ED > 24 Minor amendment to title and context
hours
01/12/2015 KSA202 Mental Health: Presentations Minor amendment to title and context
staying in ED > 24 hours
01/12/2015 KSA204 Non-Urgent Patients waiting Amendment of the Indicator
more than 365 days for an initial definition (change from referral
specialist outpatient services received date to referral listing date),
appointment and clarification of formal referral;
minor clarification of Inclusions;
updated Related Policies; updated
Business Owners
01/12/2015 SSA111 Elective Surgery: Activity Updated title; updated Primary Point
compared to previous year of Collection

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Date ID Item Change
01/12/2015 SSA112 Elective Surgery Theatre Minor amendment of Context.
Utilisation: Operating Room
Occupancy
01/12/2015 SSA101, Patients with Total time in ED <= Refined indicator definition to clarify
SSA102, 4hrs purpose of ETP; modified departure
SSA106 time business rule for one of the
modes of separation (value ‘05’) to
correct error in previous version;
expanded Departure Time business
rules to clarify calculation
methodology; updated Related
National Indicators
01/12/2015 SSA126, Breast Screen Participation Major revision of denominator
SSA127, Rates definition; new Context information.
SSA128,
SSA129,
SSA130,
SSA131
01/12/2015 SSQ112, Unplanned and emergency re- Added additional exclusion
SSQ113, presentations to same ED within clarifications; minor amendments to
SSQ125 48 hours Desired Outcome, Indicator
Definition and Related Policies
01/12/2015 PI-03 Hospital In The Home Minor clarification in Inclusions
01/12/2015 MHDA-005 Variation against purchased Minor amendment to Primary Point
volume (%): Mental Health Non- of Collection and Primary Data
Admitted Patient Source for Analysis
01/12/2015 SFA101, Specialist Outpatient Services Minor clarification of Indicator
SFA102 (Service Events) definition and Inclusions
01/12/2015 SFA105 Coding timeliness Clarification of target and Reporting;
minor update to scope and Time Lag
to Available Data
01/12/2015 SFA111 Non-Admitted Patient level data Clarified Denominator definition;
completeness: Patient Level updated Scope, Desired Outcome,
Data Collection Source, Related
Policies.
01/12/2015 SPC112, Workplace Injuries: Return to Minor update to Target (date)
SPC113, work experience
SPC114
01/12/2015 SPC102, Premium staff usage: average Major Revision of definition indicator
SPC103 paid hours per FTE (removing nursing casuals); Update
to Numerator Definition, Context
01/12/2015 SPC105 Leave Liability: Annual reduction Minor updates to dates in document
in the total number of days in (replacing 2015 with 2016)
respect of accrued leave
balances of more than 30 days
01/12/2015 SPC107 Recruitment: Improvement on Minor updates to Time Frame for
baseline average time taken from target, Context, Related Policies
request to recruit to decision to
approve/decline/defer recruitment
01/12/2015 SPC108 Aboriginal Workforce as a Revised Goals, updated Time Frame
proportion of total workforce for target

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Date ID Item Change
01/12/2015 PH-013B, Quit for new life program Updated Related Policies
PH-013C,
PH-013D
01/12/2015 PH-010A HIV testing increase within Update to dates for Indicator,
publicly-funded HIV and sexual Numerator, Denominator; Updated
health services Desired Outcome, Numerator and
Denominator availability, Context,
Related policies, Frequency of
Reporting
01/12/2015 SPC109, Public Service Commission Revised title (previously Your Say
SPC110 (PSC) People Matter Survey Staff Culture Survey); updated
Indicator Definition, numerator
definition, denominator definition,
Target, Context, Goal, desired
Outcome, Data Collection Source,
Primary Data Source, Usable Data
Available From, Frequency of
Reporting, Time Lag to Available
Data
01/12/2015 PH-008A Healthy Children Initiative - Minor wording update to title,
Children’s Healthy Eating and Indicator Definition, Numerator and
Physical Activity Program denominator Definition; Updated
(centre-based early childhood targets; Update to Scope, Goal, Data
service sites) - Adopted Collection Source, Primary Data
Source, Denominator Source,
Denominator Availability, Inclusions,
Exclusions, Context, Related Policies
01/12/2015 PH-008B Healthy Children Initiative - Minor wording update to title;
Children’s Healthy Eating and Updated Targets; update to Data
Physical Activity Program Collection Source, Primary Data
(primary school sites) - Adopted Source, Denominator Source,
Denominator Availability, Related
Policies
01/12/2015 PH-013A, Women who smoked at any time Minor update to Business Owners
SPH007 during pregnancy
01/12/2015 AI-001 Variation against purchased Updated for new NWAU version
volume (%) Acute Inpatient
Services
01/12/2015 PD-001 Variation against purchased Updated Desired Outcome and
volume (%) Public Dental Clinical Related National Indicator
Service
01/12/2015 SA-001 Variation against purchased Updated for new NWAU version;
volume (%) sub and non-acute updated numerator definition to
inpatient services include note on paediatric episodes
01/12/2015 MHDA-001 Variation against purchased Updated for new NWAU version
volume (%) Mental Health Acute
Inpatient Services
01/12/2015 MHDA-002 Variation against purchased Updated for new NWAU version
volume (%): Mental health
Inpatient Activity Non Acute
Inpatients

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