Local Hospital Network strategic objectives and indicators

The ACT Local Hospital Network Directorate (ACT LHN) consists of a networked system that includes the Canberra Hospital and Health Services, Calvary Hospital, Clare Holland House and Queen Elizabeth II Family Centre. The ACT LHN has a yearly service level agreement (SLA) which sets out the delivery of public hospital services and is agreed between the ACT Minister for Health and the Director General of the ACT LHN. This SLA identifies the funding and activity to be delivered by the ACT LHN and key performance priority targets. The ACT Government manages system-wide public hospital service delivery, planning and performance, including the purchasing of public hospital services and capital planning, and is responsible for the management of the ACT LHN.

The following strategic indicators include some of the major performance indicators implemented under the requirements of the National Health Reform Agreement.

Strategic objective 1: Percentage of elective surgery cases admitted on time by clinical urgency

Strategic indicator 1: Percentage of elective surgery cases admitted on time by clinical urgency

 

Clinically recommended time by urgency category 2013
Target1
2013
Result
Urgent - admission within 30 days is desirable for a condition that has the potential todeteriorate quickly to the point that it may become an emergency 97% 97.6%
Semi-urgent - admission within 90 days is desirable for a condition causing some pain,dysfunction or disability which is not likely to deteriorate quickly or become an emergency 66% 65.7%
Non-urgent - admission at some time in the future is acceptable for a condition causing minimal or no pain, dysfunction or disability, which is not likely to deteriorate quickly and which does nothave the potential to become an emergency2 86% 90.4%

 

Notes:
1 Targets are based on calendar year data in accordance with national reporting requirements.
2 Health Directorate establishes a 365-day maximum desirable waiting time for category 3 non-urgent patients.

Strategic objective 2: Improved emergency department timeliness

Strategic indicator 2.1: The proportion of emergency department presentations that are treated within clinically appropriate time frames

 

  2013
Target1
2013
Result
One (resuscitation, seen immediately) 100% 100%
Two (emergency, seen within 10 mins) 80% 63%
Three (urgent, seen within 30 mins) 75% 50%
Four (semi-urgent, seen within 60 mins) 70% 57%
Five (non-urgent, seen within 120 mins) 70% 86%
All presentations 70% 61%

 

Strategic indicator 2.2: The proportion of Emergency Department presentations whose length of stay in the emergency department is four hours or less

 

  2013
Target1
2013
Result
The proportion of Emergency Department presentations who physically leave the EmergencyDepartment for admission to hospital, are referred for treatment or are discharged, whose totaltime in the Emergency Department is within four hours. 65% 59%

 

Notes:
1 Targets are based on calendar year data in accordance with national reporting requirements.

Strategic objective 3: Maximising the quality of hospital services

The following four indicators are a selection of the patient safety and service quality indicators that are used to monitor ACT public hospital services. The targets provide an indication of the desired outcomes over time. Given the nature of the indicators, small fluctuations during a particular period can skew results. The success in meeting these indicators requires a consideration of performance over time rather than for any given period.

This indicator represents the quality of theatre and post-operative care.

Strategic indicator 3.1: The proportion of people who undergo a surgical operation requiring an unplanned return to the operating theatre within a single episode of care due to complications of their primary condition

 

  2013-14
Target1
2013-14
Result2
Canberra Hospital <1.0% 0.6%
Calvary Public Hospital <0.5% 0.3%

 

Notes:
1 Hospital targets are based on similar rates for peer hospitals, based on the Australian Council of Healthcare Standards (ACHS).
2 Canberra Hospital & Health Services (CHHS) results have only been reported to May 2014 due to the larger cohort of patients that need to be clinically reviewed. As this process can take some time, results for CHHS have been reported from 1 July 2013 to 31 May 2014.

Strategic indicator 3.2: The proportion of people separated from ACT public hospitals who are readmitted to hospital within 28 days of their separation due to complications of their condition (where the re-admission was unforeseen at the time of separation)

This indicator highlights the effectiveness of hospital-based and community services in the ACT in the treatment of persons who receive hospital-based care.

 

  2013-14
Target
2013-14
Result1
Canberra Hospital <2.0% 1.2%
Calvary Public Hospital <1.0% 0.5%

 

Notes:
1 Canberra Hospital & Health Services (CHHS) results have only been reported to May 2014 due to the larger cohort of patients that need to be clinically reviewed. As this process can take some time, results for CHHS have been reported from 1 July 2013 to 31 May 2014.

Strategic indicator 3.3: The number of people admitted to hospitals per 10,000 occupied bed days who acquire a staphylococcus aureus bacteraemia infection (SAB infection) during their stay

This provides an indication of the safety of hospital-based services.

 

  2013-14
Target
2013-14
Result1
Canberra Hospital <2 per 10,000 1.2 per 10,000
Calvary Public Hospital <2 per 10,000 0.3 per 10,000

 

Note:
1 Very small numbers can cause fluctuations in the results for this strategic indicator.

Strategic indicator 3.4: The estimated hand hygiene rate

The estimated hand hygiene rate for a hospital is a measure of how often (as a percentage) hand hygiene is correctly performed.

It is calculated by dividing the number of observed hand hygiene 'moments' where proper hand hygiene was practised in a specified audit period, by the total number of observed hand hygiene 'moments' in the same audit period.

 

  2013-14
Target
2013-14
Result
Canberra Hospital 70% 72.5%
Calvary Public Hospital 70% 75.6%