BIU Acute Hospital Division Key Performance Indicator Metadata 2016 BIU Acute Hospital Division ...

183 Pages·2016·4.33 MB·English

Health Service Executive
BIU Acute Hospital Division

Key Performance Indicator
Health Service Executive
Metadata 2016
BIU Acute Hospital Division

Based on NSP and DOP 2016 KPIs
Key Performance Indicator

Metadata 2016
Key Performance Indicators
UK(OsstPoaedfIur of OgNirccec)noeet l :.y R A O Oe Uc tfo ntfis ir rilev c ye ee d Service KPPlaI nTintlien g 2016 QVA RaeNgDpaSoOiPrnP t/se t d SoDuBraIcUtea to KAA/QPAccuItcc aTiecvlyesiitptssyy/se C IP Hor le ra&e pl naa oCl n /t rPd h a H yt/ Ie RP ee prioordt FrReeqpuoerntc y ENTxaa2prt0egio1ce5tnteK a/dPl I s 20P1Aor5ouC2jtT0etU1uc5tAre nLd Ex2p0e1Tc6at erNgdae tAti oc/tn vaitl y RN/e aCptaHoiotrO nt e a/dl CIEHHOG1 DCMHOH2G KPIsRC C2HS0IO 1H36G UCLHHO H4G SCSHWOH5G SaCoHltOa 6HG ChilCdHreOn7s HG
Activity HG Level
Beds Available AA12 AAccttiivvee BIDnea-dpy saB tAeiedvnast i/ l*a P*bllaec es ** DDOOPP BBIIUU AAccccccttiieevvssiittssyy//AA MM MM 110,,959104 120,0,52043 120,,082044 NNaattiioonnaall
Discharge Activity ∞
A3 Active Access/A
Inpatient Cases
NSP ABF ctivity M M 621,205 621,205 National 128,488 94,669 95,207 45,502 120,480 111,927 24,931
ge Activity AA45 AAccttiivvee IDnapyactaiesne tC Waseeisg h(itnecdlu Udneist sdialysis) NNSSPP AABBFF AAccccccttiieevvssiittssyy//AA MM MM 1 , 0 1632,37,16827 1 , 0 1 632,731,6827 NNaattiioonnaall 113831,,643125 121103,,899527 14954,,895488 4506,,444700 121082,,795808 18956,,300300 2287,,973340
Dischar A6 Active Day Case Weighted Units (includes dialysis) NSP ABF Accctievsitsy/A M M 1,010,025 1,010,025 National 197,773 192,818 138,455 66,569 197,076 181,503 35,832
A7 Active Total inpatient & day cases Cases ∞ Access
NSP ABF /Activity M M 1,634,923 1,634,923 National 309,903 308,626 241,065 101,972 323,468 297,227 52,661
A8 Active Shift of Day case procedures to primary care Access/A
NSP TBC ctivity M M New KPI 2016New KPI 2016 Up to 10000 National
A9 Active Emergency Care Access/A
- New ED attendances NSP BIU ctivity M M 1,104,131 1,102,680 1,102,680 National 235,703 173,765 154,305 57,007 190,383 182,833 108,684
A10 Active - Return ED attendances Access/A
NSP BIU ctivity M M 84,042 94,948 94,948 National 23,781 14,785 13,258 4,113 22,032 10,146 6,833
are A11 Active - Other emergency presentations Access/A
C NSP BIU ctivity M M 89,276 94,855 94,855 National 14,155 2,768 6,709 27,375 22,318 21,249 281
ncy
e
erg Inpatient discharges
m (Note this section previously detailed Inpatient Admissions but has
E A12 Active been modified to align with HIPE data which is discharged based)
Emergency Inpatient Discharges
Access/A
NSP ABF ctivity M M New KPI 2016New KPI 2016 408,879 National 82,077 58,877 62,681 29,799 80,149 77,214 18,082
Access/A
A13 Active Elective Inpatient Discharges
NSP ABF ctivity M M New KPI 2016New KPI 2016 95,430 National 18,172 13,625 9,838 8,543 21,812 16,591 6,849
Access/A
D) A14 Active Maternity Inpatient Discharges NSP ABF ctivity M M New KPI 2016New KPI 2016 116,890 National 28,239 22,167 22,686 7,158 18,518 18,122 0
P
ents (O A15 Active ONou.t poaf tnieenwt sa nd return outpatient attendances NSP BIU Accctievsitsy/A M M 3,189,749 3,242,424 3,242,424 National 725,756 610,041 477,568 220,327 579,649 478,675 150,408
Outpati A16 Active Owuatrpfaartiine nhta eAmtteantodlaongcye csl i-n Nices)w : Return Ratio (excluding obstetrics and NSP BIU Accctievsitsy/A M M New KPI 2016New KPI 2016 1 : 2 National 1 : 2 1 : 2 1 : 2 1 : 2 1 : 2 1 : 2 1 : 2
Births
Births A17 Active Access/A
Total no. of births
NSP BIU ctivity M M 66,705 65,977 65,977 National 15,198 10,019 13,583 4,726 12,748 9,703
Inpatient & Day Case Waiting Times
A18 a&b Active % of adults waiting <15 months for an elective procedure (inpatient Access/A
or day case) NSP NTPF ctivity CP M M 100% 90% 95% National
es
m % of adults waiting <8 months for an elective procedure (inpatient and
ng Ti A19 a&b Active day case) NSP NTPF Accctievsitsy/A CP M M 100% 66% 70% National
aiti
W % of children waiting <15 months for an elective procedure (inpatient
Case A20 a&b Active and day case) NSP NTPF Accctievsitsy/A CP M M 100% 95% 95% National
& Day A21 a&b Active %an odf d cahyil dcaresen) waiting < 20 weeks for an elective procedure (inpatient Access/A
nt NSP NTPF ctivity CP M M 100% 55% 60% National
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pati A22 Active % of people waiting < 15 months for first access to OPD services Access/A
In NSP NTPF ctivity CP M M 100% 90% 100% National
A23 Active % of people waiting < 52 weeks for first access to OPD services Access/A
NSP NTPF ctivity CP M M 100% 85% 85% National
Colonoscopy / Gastrointestinal Service AA2245 AAccttiivvee C%%coo oollooffn nppooeessooccppoollppeey yww o /aar GiiOttiiannGsggDt r<<o 41in 3wt eweseetieknska sfl o fSore lalronvw iucierngge an tr ecofelorrnaol sfcoorp ryoutine NNSSPP BBIIUU AAccccccttiieevvssiittssyy//AA CCPP MM MM 110000%% 15020%% 17000%% NNaattiioonnaall
Emergency Care and Patient Experience Time
A26 Active % of all attendees at ED who are discharged or admitted within 6 Access/A
hours of registration NSP BIU ctivity CP M M 95% 67.8% 75% National
atient A27 Active %ho oufr sa lol fa rtetegnisdteraetsi oant ED who are admitted or discharged within 9 NSP BIU Accctievsitsy/A M M 100% 81.3% 100% National
and P A28 Active % of ED patients who leave before completion of treatment NSP BIU Accctievsitsy/A Q Q <5% <5% <5% National
ncy Care nce Time A29 Active % of all attendees at ED <24 hours NSP BIU Quality M M 100% 96% 100% National
EmergeExperie A30 Active %ED o wf pitahtiine n9t hs o7u5r syears or over who were discharged or admitted from NSP BIU Accctievsitsy/A M M New KPI 2016New KPI 2016 100% National
Patient Profile aged 75 years and over AA3312 AAccttiivvee P%%ada oomtiffe ipatntlatel t adPiet rwtnoetifntsihl deaien taet e6gsn e haddgoi enu7dg5rs 7Ey oD5ef a yarreegsag earidsnst d7ara5 not dyivo eeonarv r*es*r a antd E oDv werh *o* are discharged or DDOOPP BBIIUU AQccctuieavsiltisty/yA MM MM 9T5B%C 1322..60%% 1935%% NNaattiioonnaall
Acute Medical o ServicesPatient CPA1 Active A%wc iotuhft iemn M6e dheiodcauiclr apsl a APtMiaetnAietUsn trw ePhgroios tcareraests idioninsgc harged or admitted from AMAU NSP AMP - CP Quality M M 95% 65.5% 75% National
Access t A33 Active A%chc orcoef nsroso lutootgi nSiceea rplvlyai ctsieceshnetsd uolne dIn *p*atient and Day Case Waiting lists that are DOP Accctievsitsy/A M M 90% 79.8% 90% National
Ambulance Turnaround Times A34 Active A%aatmm oEbbfD uua ltmlaoan nbwccuehel aet Tnonuc aterchnsce ate rhapoamtut a bnhnudaol vaTtehnim ecaer et csicmarelelw ( icn dleteeacrrlv aaarnle dos f at ≤hv ea6 i0rlae mbaldeini)nuetesss ofrfo tmhe a rrival Access/A
NSP TBC ctivity M M New KPI 2015New KPI 2015 95% National
Health Care Associated Infections
CPA2 Active Rate of MRSA bloodstream infections in acute hospital per 1,000 bed Q1 mth
days used NSP HPSC Quality in arrears Q <0.057 0.054 <0.055 National
Rate of new cases of Clostridium Difficile associated diarrhoea in
CPA3 Active
acute hospitals per 10,000 bed days used Q1 mth
NSP HPSC Quality in arrears Q <2.5 2.1 <2.5 National
Median hospital total antibiotic consumption rate (defined daily dose
CPA4 Active
per 100 bed days) per hospital
NSP HPSC Quality Bi Bi 83 86.4 80 National
ns CPA5 Active Alcohol Hand Rub consumption (litres per 1,000 bed days used)
o NSP HPSC Quality Bi Bi 25 28 25 National
d Infecti CPA6 Active %(W cHoOm)p 5li amnocem oefn htso ospf ihtaaln sdt ahfyf gwieitnhe tuhsei nWg othrled nHaetaioltnha Ol hragnandi shaytgioienn’es
ate audit tool NSP HPSC Quality Bi Bi 90% 87.2% 90% National
oci
Ass CPA7 Active Hospital acquired S. Aureus bloodstream infection/10,000 BDU **
e DOP HPSC Quality M M New KPI 2016New KPI 2016 <1 National
ar
C
ealth CPA8 Active Hospital acquired new cases of C. difficile infection/ 10,000 BDU ** DOP HPSC Quality M M New KPI 2016New KPI 2016 <2.5 National
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% of current staff who interact with patients that have received
CPA9 Active
mandatory hand hygiene training in the rolling 24 month **
DOP HPSC Quality M M New KPI 2016New KPI 2016 100% National
Percentage of patients colonized with multi-drug resistant organisms
(MDRO) that can not be isolated in single rooms or cohorted with
dedicated toilet facilities as per national MDRO policy within 24 hours
CPA10 Active
of laboratory detection of MDRO (in the cases of newly-identified
cases), or immediatley on admission to hospital (in the case of
previously identified cases) **
DOP HPSC Access M M New KPI 2016New KPI 2016 0% National
Adverse Events Data not
nts A35 Active Pagoestdo 1p6e ryaetaivres+ W *o*und Dehiscence - Rate per 1,000 inaptient cases DOP Access/Activity Q Q avai2la0b1l5e Q4 TBC National
e Eve A36 Active In Hospital Fractures - Rate per 1,000 inpatient cases aged 16 years+ avDaailtaab lneo Qt 4
ers ** DOP Access/Activity Q Q 2015 TBC National
dv Data not
A Foreign Body Left During Procedure - Rate per 1,000 inpatient cases
A37 Active available Q4
aged 16 years+ **
DOP Access/Activity Q Q 2015 TBC National
Activity
Based A38 Active Activity Based Funding (MFTP) model
Funding HIPE Completeness - Prior month: % of cases entered into HIPE NSP HPO Access/Activity M M >95% 93% >95% National
(MFTP)
Average Length of Stay
CPA11 Active Medical patient average length of stay (contingent on <500 delayed
h of Stay CPA12 Active dSuisrcghicaargl pesa)tient average length of stay NSP HPO AQccueaslsit/yA M M 5.8 7.2 7 National
ngt NSP HPO ctivity M M 5.1 5.5 5.2 National
e
e L A39 Active ALOS for all inpatient discharges excluding LOS over 30 days Access/A
erag NSP HPO ctivity M M 4.3 4.6 4.3 National
Av A40 Active ALOS for all inpatients ** Access/A
DOP HPO ctivity M M 5.0 5.5 5 National
Outpati Outpatients (OPD)
ents A41 Active New attendance DNA rates ** Access/A
(OPDD) DOP BIU ctivity M M 12% 12.9% 12% National
P
O
ogy CPA13 Active DNeor. mofa ntoelwo gdye OrmPaDtology patients seen ** Access/A
ol DOP BIU ctivity M M 40,215 41,732 41,700 National
at
m
er CPA14 Active New: Return Attendance ratio ** Access/A
D DOP BIU ctivity M M 1 : 2 1 : 1.6 1 : 2 National
matology OPD CPA15 Active RNhoe. uomf naetwol orhgeyu OmPaDtology patients seen ** DOP BIU Accctievsitsy/A M M 13,500 13,818 13,800 National
u
he CPA16 Active New: Return Attendance ratio ** Access/A
R
DOP BIU ctivity M M 1 : 4 1 : 3.7 1 : 4 National
urology OPD CPA17 Active NNoeu. orof lnoegwy OnePuDrology patients seen ** DOP BIU Accctievsitsy/A M M 15,400 16,994 16,900 National
Ne CPA18 Active New: Return Attendance ratio ** Access/A
DOP BIU ctivity M M 1 : 3 1 : 2.7 1 : 3 National
Stroke
CPA19 Active % acute stroke patients who spend all or some of their hospital stay in Stroke Access/A Q6 mths
an acute or combined stroke unit ** DOP Prog ctivity in arrears Q 50% 67.8% 50% National
Stroke CPA20 Active %th roofm pabtoielynstiss with confirmed acute ischaemic stroke who receive NSP SPtrrookge Accctievsitsy/A iQn a6r mretahrss Q 9% 12.1% 9% National
% of hospital stay for acute stroke patients in stroke unit who are
CPA21 Active
admitted to an acute or combined stroke unit Stroke Access/A Q6 mths
NSP Prog ctivity in arrears Q 66% 53.7% 50% National
Heart Failure HF
CPA22 Active Rate (%) re-admission for heart failure within 3 months following programm Access/A Q6 mths
discharge from hospital ** DOP e ctivity in arrears Q 20% 6.7% 20% National
e
art Failur CPA23 Active Mdeecdoimanp eLOnsSa ftoerd p haetaiernt tfsa ialudrme i*tt*e d with principal diagnosis of acute DOP progHreaF mm Accctievsitsy/A iQn 6a rmretahrss Q 6 7 6 National
Hedrome CPA24 Active %HF p partoiegnrtasm wmiteh daucruitneg dtehceoirm hpoesnpsitaatle sdt ahye *a*rt failure who are seen by progHraF mm Access/A Q6 mths
n
ary Sy Acute Coronary Syndrome DOP e ctivity in arrears Q 80% 85.8% 80% National
on CPA25 Active % STEMI patients (without contraindication to reperfusion therapy) Access/A
or who get PPCI NSP ACS - CP ctivity Q 85% 83% 85% National
C
e
ut CPA26 Active % reperfused STEMI patients (or LBBB) who get timely PPCI Access/A
Ac NSP ACS - CP ctivity Q 80% 68.4% 80% National
Surgery
CPA27 Active % of elective surgical inpatients who had principal procedure
Access/A
conducted on day of admission
NSP HPO ctivity M M 70% 69.4% 75% National
y
er
urg CPA28 Active % day case rate for Elecctive Laparoscopic Cholecystectomy Access/A
S NSP HPO ctivity M M >60% 38.3% >60% National
Reduction in bed day utilisation by acute surgical admissions who do
CPA29 Active not have an operation ** Access/A
DOP HPO ctivity M M 5% Reduction 10% 5% Reduction National
Time to Surgery A42 Active T%oip mo LfeO e tSmo: e0Sr,u g1reg onercr yy2 )hip fracture surgery carried out within 48 hours (pre- NSP HPO Accctievsitsy/A M M 95% 84.5% 95% National
Surgery A43 Active SScuhrgeedruyled waiting list cancellation rate ** DOP Accctievsitsy/A CP TBC New KPI 2016New KPI 2016 New KPI 2016 National
Hospital Mortality A44 Active HSatnoadsn pcdilatinardilc iMasle ocdro tMnadloiitrtytioanlit *y* Rate (SMR) for inpatient deaths by hospital DOP CP Accctievsitsy/A A New KPI 2016New KPI 2016 TBC National
n
o Re-admission
Re-missi CPA30 Active % of emergency re-admissions for acute medical conditions to the Access/A
ad same hospital within 28 days of discharge NSP HPO ctivity CP M M 9.6% 10.8% 10.8% National
% of surgical re-admissions to the same hospital within 30 days of
A45 Active Access/A
discharge
NSP HPO ctivity M M <3% 2.0% <3% National
P New KPI
M CPA31 % of all medical admissions via AMAU **
A 2016
DOP TBC Quality CP M M New KPI 2016New KPI 2016 35% National
n
MedicatioSafety ence A46 Active MNacoeu.dt oeicf hamotiesopdniitc Saaaltsfi oerentyp i norctideedn atss a(a %s porfo bveidde dda tyos tuhsee dst’ate claims agency) in NSP QPuraoligty Quality Q Q New KPI 2015 0.12% ≤0.12% National
eri
nt Exp A47 Active P%a otife hnot sEpxitpaelsri egrnocuep s conducting annual patient experience surveys Not yet
Patie amongst representative samples of their patient population NSP CP Accctievsitsy/A A 100% rep2o0rt1e5d in 100% National
Dialysis Modality ∆
Dialysis Modality CPA32 Active Haemodialysis patients Treatments ** DOP CP Accctievsitsy/A Bi Bi 225514,,010244 227715,,623286- 228985,,049268- National 4401,,333630- 5513,,815777- 6602,,500400- 2256,,952899- 6602,,500400- 4580,,927272-
CPA33 Active Home Therapies Patients Treatments ** Access/A 85,060 86,300 - 9,065- 18,130- 23,568- 8,158- 23,568- 8,158-
DOP CP ctivity Bi Bi 94,440 87,161 90,647-93,259 National 9,327 18,652 24,247 8,393 24,247 8,393
Delayed Discharges AA4489 AAccttiivvee DNNeool..a ooyffe bbdee Dddi sds scauhybasj relgocestst t t oh droeulagyhe dde dlaisycehda rdgisecsharges NSP BIU AAccccctieevssitssy//AA M M New KPI 2016 225,250 <183,000 National
NSP BIU ctivity M M New KPI 2016 577 <500 National
e HR-Compliance
anc A50 Active European Working Time Directive compliance for NCHDs - <24 hour
pli shift Access/A M in
m NSP CP ctivity arrears N 100% 98% 100% National
o
C
HR- A51 Active European Working Time Directive compliance for NCHDs - < 48 hour Access/A M in
working week
NSP CP ctivity arrears M 100% 75% 95% National
National Early Warning Score (NEWS) AA5523 AAccttiivvee N%a%pcra ouootgtffieo rHaa nlHolma osclmpl siEpniteaiiatcrlalasyll s wWs atiatnahfdrf n i swmiinnhpggol elS ehmc asoepvrneeet c ba(iNateileEotynWn htoSrof)a sNipnEietWdal Ssin i nth ael lC cOlinMicPaAl SaSre as of NSP CP AAccccctieevssitssy//AA Q Q 100% 100% 100% National
NSP CP ctivity Q Q >95% 63.6% >95% National
Irish Maternity Early Warning Score (IMEWS) AAA555456 AAAccctttiiivvveee I%%%Srci soooohrfffe mhhM)oo a*asst*tppeeiirttrnaanillitssty yww u Eiinttahhirt lsiiymm/ Whppolleeasmmrpnieetinannlgttsaa Swttciiooiotnnhre ooi m(ffI IPMpMEleEWEmWWSeS S(n)P tfaoaetri dopinrae togrifnc Ia MEnatEr Wlpya SWtieanrtnsing DNNOSSPPP CCCPPP AAQccccccttuiieevvassiilttssityy//yAA QQQ QQQ New11 K00P00I%% 2016New1 7K08P0%I% 2016 111000000%%% NNNaaatttiiiooonnnaaalll
Clinical Guidance
al nce A57 Active % of maternity units/ hospitals with implementation of the guideline Access/A
ClinciGuidea A58 Active f%o ro cf lainccuitael hhaonspdiotvaelsr wini tmh aimteprlneimtye snetravtiicoens of the guideline for clincial NSP CP Accctievsitsy/A Q Q New KPI 2016New KPI 2016 100% National
handover NSP CP ctivity Q Q New KPI 2016New KPI 2016 100% National
National Standards
National Standards AA5690 AAccttiivvee %N%S ooSffB HHHoossppiittaallss wwhhoo hhaavvee ccoommmpleetnecde dfi rssetc aosnsde sassmseesnstm aegnatin asgta tihnest the NSP CP AAccccctieevssitssy//AA Q Q New KPI 2016New KPI 2016 95% National
NSSBH NSP CP ctivity Q Q 95% 80% 100% National
% Maternity Units which have completed and published Maternity
A61 Active Patient Safety Statements and discussed at Hospital Management Maternity
Team each month NSP Prog Quality M M New KPI 2016New KPI 2016 100% National
% of Acute Hospitals which have completed and published Patient
A62 Active Safety Statements and discussed at Hospital Management Team each
month ** DOP CP Quality M New KPI 2016New KPI 2016 100% National
A63 Active Number of nurses prescribing medication
NSP CP Quality A New KPI 2016New KPI 2016 100 National
A64 Active Number of nurses prescribing ionising radiation (x-ray)
NSP CP Quality A New KPI 2016New KPI 2016 55 National
COPD
CPA34 Active Mean and median LOS (and bed days) for patients admitted with Access/A 7.8 7.6 7.6
COPD ** DOP HPO ctivity CP M Q 5 5 5 National
CPA35 Active % re-admission to same acute hospitals of patients with COPD within Access/A
D 90 days ** DOP HPO ctivity CP M Q 24% 27% 24% National
P
O
C CPA36 Active No. of acute hospitals with COPD outreach programme ** Access/A
DOP CP ctivity CP M Q 15 15 18 National
Access to structured Pulmonary Rehabilitation Programme in acute
CPA37 Active hospital services ** Access/A
DOP CP ctivity M Bi 28 sites 27 33 sites National
Asthma
CPA38 Active % nurses in secondary care who are trained by national asthma
a programme ** Access/A
m DOP CP ctivity Q Q New KPI 2016New KPI 2016 70% National
h
Ast
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m
h
Ast CPA39 Active No. of asthma emergency inpatient bed days used ** Access/A Q1 mth
DOP HPO ctivity in arrears Q New KPI 2016New KPI 2016 3% Reduction National
CPA40 Active No. of asthma emergency inpatient bed days used by <6 year olds ** Access/A
DOP HPO ctivity Q Q New KPI 2016New KPI 2016 5% Reduction National
Diabetes
CPA41 Active Number of lower limb amputation performed on Diabetic patients ** Access/A Not yet
DOP HPO ctivity A 40% reported ≤488 National
es
bet CPA42 Active Average length of stay for Diabetic patients with foot ulcers ** Access/A Not yet
a
Di DOP HPO ctivity A 40% reported ≤17.5 days National
% increase in hospital discharges following emergency admission for
CPA43 Active
uncontrolled diabetes **
DOP HPO Access A New KPI 2016New KPI 2016 ≤10% National
Epilepsy Q1
epsy CPA44 Active Reduction in median LOS for epilepsy inpatient discharges ** DOP HPO Accctievsitsy/A reipno Qrt3ed Q red1u0c%ti on 0% 2.5 National
pil Q1
E
CPA45 Active % reduction in the number of epilepsy discharges ** Access/A reported 10%
DOP HPO ctivity in Q3 Q reduction 11.4% 10% reduction National
Blood Policy
CPA46 Active Access/A
No. of units of platelets ordered in the reporting period **
DOP CP ctivity M 21,178 21,000 21,000 National
olicy CPA47 Active % of units of platelets outdated in the reporting period ** DOP CP Accctievsitsy/A M <8 % <5% <5% National
P
ood CPA48 Active % usage of O Rhesus negative red blood cells ** DOP CP Accctievsitsy/A M <11% <14% <14% National
Bl
CPA49 Active % of red blood cell units rerouted ** Access/A
DOP CP ctivity M <5% <4% <4% National
CPA50 Active % of red blood cell units returned out of total red blood cell units Access/A
ordered ** DOP CP ctivity M <1% <1% <1% National
reportable events A65 Active R%ehnee oagpflaot ghhreto samsebprelivetnia ctel eswv seti.ht n*hat* tsp h a ativeen ptsr oacbeosuste ds eins ipgnla,c dee floivre prya r&ti ceipvaaltuivaet ion of DOP BJoulngee rAccess/Activity A New KPI 2016rDeapQtoat2r ot n2e ob0dte1 u d6nuteil 100% National
Outpatients (OPD) A66 Active O%u otfp Caltiineincitasn (sO wPiDth) individual DNA rate of 10% or less ** DOP Access/Activity M New KPI 2016New KPI 2016 70% HG
A67 Active Ratio of compliments to complaints **
DOP Access/Activity M New KPI 2016New KPI 2016 TBC National
National Cancer Programme
Symptomatic Breast Cancer Services
NCCP1 Active No. of patients triaged as urgent presenting to symptomatic breast
clinics
NSP NCCP NCCP M M 16,000 16,800 16,800 National
No. of non urgent attendances presenting to Symptomatic Breast
NCCP2 Active
clinics **
DOP NCCP NCCP M M 24,000 23,500 24,000 National
Number of attendances whose referrals were triaged as urgent by the
NCCP3 Active cancer centre and adhered to the HIQA standard of 2 weeks for
urgent referrals ~**
DOP NCCP NCCP M M 15,200 16,100 16,000 National
es
vic % of attendances whose referrals were triaged as urgent by the
er Ser NCCP4 Active cuargnecenrt creefnetrrrea alsnd adhered to the HIQA standard of 2 weeks for
nc NSP NCCP NCCP M M 95% 96% 95% National
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ast Number of attendances whose referrals were triaged as non- urgent
atic Bre NCCP5 Active bf1o2yr twnhoeeen ck-ausn)r gc*ee*rn tc erenftererr aanlsd ( Nadoh. eorfefedr etod tahne a HpIpQoAin sttmanednat rtdh aotf f1a2ll sw weeitkhsi n
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o DOP NCCP NCCP M M 22,800 19,300 22,800 National
pt
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y
S % of attendances whose referrals were triaged as non- urgent by the
NCCP6 Active cancer centre and adhered to the HIQA standard of 12 weeks for non-
urgent referrals (% offered an appointment that falls within 12 weeks)
NSP NCCP NCCP M M 95% 82% 95% National
Clinic Cancer detection rate: no. of new attendances to clinic, triaged
NCCP7 Active
as urgent, which have a subsequent diagnosis of breast cancer ** rolling 12
DOP NCCP NCCP mths M >1,100 >1,100 National
Clinic Cancer detection rate: % of new attendances to clinic, triaged as
NCCP8 Active
urgent, which have a subsequent diagnosis of breast cancer rolling 12
NSP NCCP NCCP mths M >6% 11% >6% National
Lung Cancer
NCCP9 Active No. of patients attending rapid access lung clinic in designated cancer
centres NSP NCCP NCCP M M 3,000 3,300 3,300 National
Number of patients attending lung rapid clinics who attended or were
NCCP10 Active offered an appointment within 10 working days of receipt of referral
in designated cancer centres **
DOP NCCP NCCP M M 2,850 2,800 3,135 National
er
nc % of patients attending lung rapid clinics who attended or were
a
ng C NCCP11 Active oinf fdeeresidg naant eadp pcoainnctemr ecnetn wtrietshin 10 working days of receipt of referral
u
L
NSP NCCP NCCP M M 95% 86% 95% National
Clinic Cancer detection rate: Number of new attendances to clinic,
NCCP12 Active DOP NCCP
triaged as urgent, that have a subsequent diagnosis of lung cancer ** rolling 12
NCCP mths M >825 >825 National
Clinic Cancer detection rate: % of new attendances to clinic, triaged as
NCCP13 Active
urgent, that have a subsequent diagnosis of lung cancer rolling 12
NSP NCCP NCCP mths M >25% 29% >25% National
Prostate
NCCP14 Active
No. of centres providing surgical services for prostate cancers **
DOP NCCP NCCP M M 7 8 7 National
No. of patients attending the prostate rapid access clinic in the cancer
NCCP15 Active
centres
NSP NCCP NCCP M M 2,500 2,600 2,600 National
Number of patients attending prostate rapid clinics who attended or
NCCP16 Active were offered an appointment within 20 working days of receipt of
referral in the cancer centres **
e DOP NCCP NCCP M M 2,250 1,630 2,340 National
at
ost % of patients attending prostate rapid clinics who attended or were
Pr NCCP17 Active offered an appointment within 20 working days of receipt of referral
in the cancer centres
NSP NCCP NCCP M M 90% 62% 90%
Clinic Cancer detection rate: Number of new attendances to clinic
NCCP18 Active
that have a subsequent diagnosis of prostate cancer ** rolling 12
DOP NCCP NCCP mths M >780 >780 National
Clinic Cancer detection rate: % of new attendances to clinic that have
NCCP19 Active
a subsequent diagnosis of prostate cancer rolling 12
NSP NCCP NCCP mths M >30% 38% >30% National
Radiotheraphy
NCCP20 Active No. of patients who completed radical radiotherapy treatment
(palliative care patients not included) **
DOP NCCP NCCP M M 4,700 4,900 4,900 National
hy No.of patients undergoing radical radiotherapy treatment who
herap NCCP21 Active ctoo mtrmeaetn bcye dth ter eraatdmiaetinotn w ointhcionl o1g5i swt o(prkailnliga tdivaey sc aorfe b peaintige ndtese nmoetd ready
ot included) **
adi DOP NCCP NCCP M M 4,230 4,153 4,410 National
R
% of patients undergoing radical radiotherapy treatment who
commenced treatment within 15 working days of being deemed ready
NCCP22 Active
to treat by the radiation oncologist (palliative care patients not
included)
NSP NCCP NCCP M M 90% 84% 90% National
Rectal NCCP23 Active RNeoc. toafl centres providing services for rectal cancers ** DOP NCCP NCCP M M 8 13 8 National
System Wide KPI's
Syste
m A68 Active Service Arrangements/ Annual Compliance Statement
% of number of Service Arrangements signed
Wide NSP Access/Activity M 100% 100% 100% National
KPI's
A69 Active % of the monetary value of Service Arrangements signed
NSP Access/Activity M 100% 100% 100% National
A70 Active % of Annual Compliance Statements signed
NSP Access/Activity A 100% 100% 100% National
Service User Experience
A71 Active % of complaints investigated within 30 working days of being
acknowledged by the complaints officer
NSP Access/Activity M 75% 75% 75% National
Serious Reportable Events
% of Serious Reportable Events being notified within 24 hours to the
A72 Active
Senior Accountable Officer and entered on the National Incident
Management System (NIMS) NSP Access/Activity M 75% 75% 75% National
% of investigations completed within 120 days of the notification of
A73 Activethe event to the Senior Accountable Officer
NSP Access/Activity M 90% 62% 90% National
Safety Incident reporting
A74 Active% of safety incidents being entered onto NIMS within 30 days of
occurrence by hospital group/ CHO
NSP Access/Activity Q New KPI 2016New KPI 2016 90% National
% of claims received by State Claims Agency that were not reported
A75 Activepreviously as an incident To be set in
NSP Access/Activity A New KPI 2016New KPI 2016 2016 National
Dialysis ∆ includes all hospitals, contracted units and home therapies
∞ Discharge Activity in Divisional Operational Plan target 2016 are based on Activity Based Funding (ABF) and weighted units (WU) activity supplied by HPO. Discharge Activity in NSP 2016 was based on data submitted by hospitals to BIU. Dialysis activity is included in day cases ABF and weighted units.
** These KPI's are not in NSP
Acute Division - Beds Available
1 KPI title Beds Available - In-patient beds.
2 KPI Description Average Inpatient Beds Available are beds which are currently occupied or ready for occupation.
A1
3 KPI Rationale To track the number of in-patient beds available in a hospital for use by inpatients.
Indicator Classification Please tick Indicator Classification this indicator applies to:
q Person Centred Care  Effective Care q Safe Care
(National Standards for Safer
q Better Health and Wellbeing  Use of Information q Workforce
Better HealthCare)
 Use of Resources q Governance, Leadership and Management
4 KPI Target Target 2016: 10,804
5 KPI Calculation
Count
6 Data Source Sourced from Hospitals
Data Completeness Coverage all acute hospitals 100%
Data Quality Issues All acute hospitals reporting
7 Data Collection Frequency Indicate how often the data to support the KPI will be collected:
qDaily qWeekly  Monthly qQuarterly qBi-annually qAnnually
qOther – give details:
8 Tracer Conditions As per description no. 2 above
9 Minimum Data Set BIU – Acute MDR
10 International Comparison Yes, this is an internationally recognised metric (AUS, CAN, GB, ECHI)
11 KPI Monitoring KPI will be monitored :
qDaily qWeekly  Monthly qQuarterly qBi-annually qAnnually qOther –
give details:
Please indicate who is responsible at a local level for monitoring this KPI:
12 KPI Reporting Frequency Indicate how often the KPI will be reported:
qDaily qWeekly qMonthly qQuarterly qBi-annually qAnnually qOther – give
details:
13 KPI report period Indicate the period to which the data applies
 Current (e.g. daily data reported on that same day of activity, monthly data reported within the
same month of activity) June data reported in June report
o Monthly in arrears (June data reported in July)
q Quarterly in arrears (quarter 1 data reported in quarter 2)
q Rolling 12 months (previous 12 month period)
q Other – give details:
14 KPI Reporting Aggregation Indicate the level of aggregation – for example over a geographical location:
 National oRegional q LHO Area  Hospital  Hospital Group
q County q Institution q Other – give details:
15 KPI is reported in which Indicate where the KPI will be reported:
reports?  Performance Assurance Report (NSP) ¨ CompStat qOther – give details:
16 Web link to data
http://www.hse.ie/eng/services/Publications
17 Additional Information This KPI is noted in Divisional Operational Plan 2016
Contact details for Data Manager Derek McCormack, BIU Acute, Tel: [phone] E:[email protected]
/Specialist Lead
National Lead and Division National Director Acute Hospitals Division, Dr. Steevens Hospital, Dublin 8.
Tel [phone].