Prepared by:

Kathy Smith, Manager Performance Analysis

Health System Information and Performance Reporting

June 2016

Surgery Redesign Training Program

NSW Surgery KPIs and You

Overview of presentation

Data for research, evaluation and

monitoring

A look at some Key Data Sources available

to you

The role of data collection

Data for research, evaluation and

monitoring

Before you start:

Need to clearly understand the role data will play in your

project from the beginning.

What is the data required for?

– Background Information and Understanding

– The need to Monitor and Answer Key Questions about your project

or program.

Align data requirement to Program, Policy or Project Goals.

– Clear justification for data to be used in the monitoring/evaluation

– Will the data you use explicitly answer the hypothesis

– Are you really embarking on research?

Key Existing Data & Information Sources:

Tap into Existing Sources of reported data

– This is the Preferred Approach

– Provides immediately useful and comparable data

– NSW Intranet:

http://internal.health.nsw.gov.au/data/access/index.html

– Health Statistics:

http://www.health.nsw.gov.au/hsnsw/Pages/default.aspx

– BHI:

– http://www.bhi.nsw.gov.au/ ,

– http://www.bhi.nsw.gov.au/healthcare_observe

– Regular reporting by MoH including Surgical Dashboard, Monthly

report and for some weekly reports

** Don’t forget your local performance team

NSW Ministry & LHD data sources

Your key sources for a local view

Key source for understanding your patient population

Provides established business process for data collection

monitoring and evaluation

Four key data collections that may be of particular interest

– Admitted Patient Data Collection (aka inpatient data collection)

– Waitlist Data Collection

– Surginet & Surgical information systems

– Emergency Department Data Collection

Unit Record data is available for research and evaluation

– HIE / Safari and Cheryl / ABM Portal

Existing External Reported Data Sources

– Australian Institute of Health and Welfare

– Elective Surgery and Waiting Times

– http://www.aihw.gov.au/national-elective-surgery-waiting-times/

– Australian Hospital Statistics

http://www.aihw.gov.au/pAustralian Bureau of Statistics

– http://www.abs.gov.au/

– World Health Organisation (WHO)

– Data and Statistics http://apps.who.int/ghodata/

– Emergency and Essential surgical care

http://www.who.int/surgery/globalinitiative/en/

– Clinical Excellence Commission

– http://www.cec.health.nsw.gov.au/

Reporting of Elective Surgery measures

( NEST) and other Indicators; NSW Ministry receives and regularly reports on Elective surgery

Data from your LHD

Much of these data are also provided to the Commonwealth

Quarterly and are reported in a variety of publications including

on by the AIHW, the National Health Performance Authority and

on the “myhospitals” website

The surgery dashboard and the monthly performance report are

a key mechanism between the LHDs nd the Ministry around

surgery performance

Reference:

Routine reporting of surgery indicators

Additional Indicators

There are many indicators routinely reported and

available via the MOH,BHI and LHD reporting systems.

These surgery indicators are reported at hospital level &

included in the Monthly performance reporting and

quarterly BHI reports.

– These indicators have agreed definitions and are used

as part of the performance management conversation

between the LHDs and the Ministry.

The Monthly Surgical Services Taskforce Dashboard

Other useful MoH Routine reports – For

internal use only

Monthly Performance Report – includes other useful

information

Whole of Hospital Weekly Snapshot – Some care required

ABM Portal - provides a useful run your own ad hoc

reports

Health Stats - are range of population health focused

information

Nationally agreed and reported Surgery

IndicatorsNationally, under agreement between States and Commonwealth

there is a range of surgery indicators reported.

(a) number of additional patients receiving elective surgery from waiting lists;

(b) number of patients removed from waiting lists for reasons other than admission as an

elective patient;

(c) number and percentage of patients seen within the clinically recommended time by

urgency category;

(d) median waiting time for the 15 indicator procedures (including knee and hip

replacements, cataract surgery, septoplasty, etc);

(e) median waiting times by urgency category;

(f) number of elective surgical episodes with one or more adverse events; and

(g) number of unplanned readmissions within 28 days of discharge from hospital

following an episode of elective surgery.

New Data Collection: A course of last resort

Do not under estimate the complexity of even the simplest data

collection

New Data Collection - Only after other sources exhausted

– Impacts of starting a data collection must be considered

– impact on other staff and other data being collected

– Minimum resource and time requirements

– “who is paying” what is the “opportunity cost”

– Privacy, know your obligations

– Avoid “nice to have” data and data collection - Clear

statement of justification of each and every piece of data

– Avoid the data taking over your project

Data Collection: Some do’s and don’ts

Do

– your homework, be clear of your objectives and document them

– exhaust all avenues for exiting data sources first

– Use standard definitions, clear collection guidelines and pilot

before rolling out full collection

– You have adequate resources

– Seek help from the professionals – See attached

Don’t

– assume knowledge of data collectors – you must provide

definitions, guidelines and ready access to help - pilot your

proposed collection tools

– Don’t dictate, bring your data collectors along with you or suffer the

inevitable fate of poor data quality

Know Your Data Definitions

Use exiting data definitions where they exist

http://internal.health.nsw.gov.au/data/standards/index.html

– Data collection data dictionaries

– NSW Health Minimum Data Set

National Minimum Data Sets – Check out Meteor http://meteor.aihw.gov.au/content/index.phtml/itemId/181162

Many indicator definitions already specified ready for use

– Surgical KPI dictionary

– Service Agreement Indicator and Service Measure

Dictionary

– National KPI catalogue

Need Help ?

Resources in Your LHD / Region

Redesign leader / managers

Clinical Governance Units

Medical Records Department:

Performance and Reporting Units

Casemix and Funding Units

Public Health Units

Library Services

Thank youPlease feel free to contact me:

Kathy Smith: Manager, Performance Analysis

Health System Information and Performance Reporting

Phone: 9391 9778

Email: ksmit@doh.health.nsw.gov.au

Extra Bits MoH Data Collection Reference Resources

General http://internal.health.nsw.gov.au/data/collections/index.html

Surginet http://emr.health.nsw.gov.au/home/my_emr/sbb/surginet_reports

Admitted Patient Data Dictionary

http://internal.health.nsw.gov.au/im/ims/ap/ap-data-dictionary-current-

public.html

Waitlist Collection Terminology

http://internal.health.nsw.gov.au/im/ims/wtc/terminology.html

EDW & HIE: Health Data repositories

– http://internal.health.nsw.gov.au/data/data-warehouses.html

– http://internal.health.nsw.gov.au/data/edward/index.html

– WaLT (Waiting List Tool) Contact your Area Health Service Waiting List Coordinator for

further information

Extra Bits Useful Health Information Management References

ICD10 AM, DRGs, Casemix and Activity Based Funding

http://www.health.wa.gov.au/activity/docs/cch.pdf

General Knowledge on Health Information

http://www.healthknowledge.org.uk/e-learning/health-

information

National Centre for Classification in Health

http://sydney.edu.au/health-sciences/ncch/

Extra Bits General References & Data Sources - cont

General state-wide Statistics for NSW Ministry of Health

– NSW Health Published Reports, http://www.health.nsw.gov.au/reports/index.asp

– Yellow book; http://www.health.nsw.gov.au/reports/index.asp

– Health Statistics NSW, http://www.healthstats.nsw.gov.au/ealth Statistics

– Annual Report: NSW,

http://www.health.nsw.gov.au/pubs/2010/annualreport10.html

– Local LHD: available on the local website

Bureau of Health Information http://www.bhi.nsw.gov.au/home

– Performance Profiles – review by hospital

http://www.bhi.nsw.gov.au/publications/the_insights_series

Australian Council on Healthcare Standards

– http://www.achs.org.au/

Research Methods

http://www.healthknowledge.org.uk/public-health-

textbook/research-methods

http://www.hqip.org.uk/assets/Downloads/Audit-Research-

Service-Evaluation.pdf

http://www.hqip.org.uk/assets/Downloads/Audit-Research-

Service-Evaluation.pdf

http://www.who.int/surgery/globalinitiative/en/

Extra BitsOther Helpful Sites – Research Methods

Indicators and Measures

Understanding leading and Lagging indicators: -

http://www.leanhealthcareexchange.com/?p=4639

Defining Measures

http://www.institute.nhs.uk/safer_care/primary_care_2/mea

surement_for_improvement.html

http://www.institute.nhs.uk/quality_and_service_improveme

nt_tools/quality_and_service_improvement_tools/performa

nce_measures_sheet.html

Link your project to the organisations aims: -

http://www.institute.nhs.uk/quality_and_service_improvement_

tools/quality_and_service_improvement_tools/four_columns_-

_link_your_project_to_the_organisation.html