Financial summary

The total cost of providing health services to rural and regional areas in Western Australia in 2017-18 was $1.78 billion. Results for 2017–18 against agreed financial targets (based on Budget statements) are presented in Table 3.

Full details of the WA Country Health Service’s financial performance during 2017–18 are provided in the financial statements.

Table 3: Actual results versus budget targets for WA Country Health Service

	2017-18 Target ($'000)	2017-18 Actual ($'000)	Variation +/- ($000)	Explanation of Variance
Total cost of services	1,692,773	1,779,570	86,797	Key Factors: Expenditures on continuing and new services for which funding had not been included in the initial target but were the subject of budget adjustments throughout the year and at Mid-year Review. Impact of asset revaluation decrements
Net cost of services	1,066,863	1,109,409	42,546	Key Factors: Expenditures on continuing and new services for which funding had not been included in the initial target but were the subject of budget adjustments throughout the year and at Mid-year Review. Commonwealth and Other Grants received for services not included in the initial target but were the subject of budget adjustments throughout the year and at Mid-year Review. Impact of asset revaluation decrements.
Total equity	2,579,148	2,475,159	-103,989	Delays in the Capital Works program and asset revaluation decrements.
Approved full-time equivalent staff level (salary associated with FTE)	7,794.9	7,773.3	-21.5	Reduced staffing levels in the first half of the year resulting in part from delays in the commencement of new programs.

Summary of key performance indicators

Key performance indicators (KPIs) assist the WA Country Health Service to assess and monitor the extent to which State Government outcomes are being achieved.

• Effectiveness indicators provide information that aids in the assessment of the extent to which outcomes have been achieved through the resourcing and delivery of services to the community.
• Efficiency indicators monitor the relationship between the service delivered and the resources used to provide the service.

Key performance indicators also provide a means to communicate to the community how the WA Country Health Service is performing. A summary of the WA Country Health Service key performance indicators' performance against targets is given in Table 4.

Note: Table 4 should be read in conjunction with detailed information on each key performance indicator found in the disclosure and compliance section of this report. The KPIs are prepared based on the latest available information.

Table 4: Actual results versus KPI targets

Key performance indicator	Target	Actual
OUTCOME 1: PUBLIC HOSPITAL BASED SERVICES THAT ENABLE EFFECTIVE TREATMENT AND RESTORATIVE HEALTHCARE FOR WESTERN AUSTRALIANS
Unplanned hospital readmissions of public hospital patients within 28 days for selected surgical procedures (per 1,000 separations)
a) Knee replacement	≤ 26.2	37.9
b) Hip replacement	≤ 17.2	21.8
c) Tonsillectomy & Adenoidectomy	≤ 61.0	61.6
d) Hysterectomy	≤ 41.3	15.8
e) Prostatectomy	≤ 38.8	40.4
f) Cataract surgery	≤ 1.1	0.4
g) Appendicectomy	≤ 32.9	39.2
Proportion of elective waitlist patients waiting over boundary for a reportable procedure:
a) % Category 1 over 30 days	0%	8.7%
b) % Category 2 over 90 days	0%	9.4%
c) % Category 3 over 365 days	0%	4.8%
Total	0%	5.5%
Hospital infection rates (Healthcare-associated Staphylococcus aureus bloodstream infections (HA-SABSI) per 10,000 occupied bed-days in public hospitals)	≤ 1.0	0.64
Survival rates for sentinel conditions:
a) Stroke
i 0-49 years	≥ 94.3%	100%
ii 50-59 years	≥ 92.4%	97%
iii 60-69 years	≥ 92.8%	95.9%
iv 70-79 years	≥ 89.5%	96.5%
v 80+ years	≥ 80.9%	85.2%
b) Acute Myocardial Infarction (AMI)
i 0-49 years	≥ 99.2%	100%
ii 50-59 years	≥ 98.9%	100%
iii 60-69 years	≥ 98.1%	100%
iv 70-79 years	≥ 96.1%	96.8%
v 80+ years	≥ 91.7%	90.1%
c) Fractured Neck of Femur (FNOF)
i 70-79 years	≥ 98.9%	100%
ii 80+ years	≥ 95.3%	96%
Percentage of admitted Aboriginal and Non-Aboriginal patients who discharged against medical advice	≤ 0.77%	1.7%
Percentage of live-born term infants with an Apgar score of less than 7 at 5 minutes post delivery	≤ 1.8%	1.6%
Rate of total hospital readmissions within 28 days to an acute designated mental health inpatient unit	≤ 12%	17.2%
Percentage of contacts with community-based public mental health non-admitted services within seven days post discharge from an acute public mental health inpatient unit	≥ 75%	75.6%
Average admitted cost per weighted activity unit	$7,285	$6,119
Average Emergency Department cost per weighted activity unit	$7,043	$7,292
Average non-admitted cost per weighted activity unit	$7,160	$6,035
Average cost per bed-day in specialised mental health inpatient units	$1,713	$1,728
Average cost per treatment day of non-admitted care provided by public clinical mental health services	$542	$591
OUTCOME 2: PREVENTION. HEALTH PROMOTION AND AGED AND CONTINUING CARE SERVICES THAT HELP WESTERN AUSTRALIANS TO LIVE HEALTHY AND SAFE LIVES
Response times for emergency air-based patient transport services (Percentage of emergency air-based inter-hospital transfers meeting the statewide contract target response time for priority 1 calls)	≥ 80%	78.9%
Percentage of patients who access emergency services at a small rural or remote Western Australian hospital and are subsequently discharged home	92%	90.4%
Average cost per bed-day for specialised residential care facilities, flexible care (hostels) and nursing home type residents	$321	$557
Average cost per person of delivering population health programs by population health units	$233	$374
Cost per trip of patient emergency air-based transport, based on the total accrued costs of these services per the total number of trips	$7,235	$7,121
Average cost per trip of Patient Assisted Travel Scheme (PATS)	$377	$440
Average cost per rural and remote population (selected small rural hospitals)	$390	$401

Improvements towards emergency department access

Emergency departments are specialist multidisciplinary units with expertise in managing acutely unwell patients for their first few hours in hospital. With an increasing demand on emergency departments and health services, it is imperative that health service provision is continually monitored to ensure the effective and efficient delivery of safe high-quality care.

Percentage of emergency department patients seen within recommended times (major rural hospitals)

When patients first enter an emergency department they are assessed by specially trained nursing staff to determine how urgently treatment is required. The aim of this process, known as triage, is to ensure treatment is given in the appropriate time and should prevent adverse conditions arising from deterioration in the patient’s condition.

The triage process and scores are recognised by the Australasian College for Emergency Medicine and are recommended for prioritising those who present to an emergency department. A patient is allocated a triage score between 1 (immediate) and 5 (least urgent) that indicates their treatment acuity. Treatment should commence within the recommended time of the triage category allocated (see Table 5).

Table 5: Triage category, treatment acuity and WA performance targets

Triage Category	Description	Treatment Acuity	Target
1	Immediate life-threatening	Immediate (≤ 2 minutes)	100%
2	Imminently life-threatening	≤ 10 minutes	≥ 80%
3	Potentially life-threatening or important time-critical treatment or severe pain	≤ 30 minutes	≥ 75%
4	Potentially life-serious or situational urgency or significant complexity	≤ 60 minutes	≥ 70%
5	Less urgent	≤ 120 minutes	≥ 70%

By measuring this indicator, changes over time can be monitored that assist in managing the demand on emergency department services and the effectiveness of service provision. This in turn can enable the development of improvement strategies that ensure optimal restoration to health for patients.

In 2017-18, the proportion of WA patients in major rural hospital emergency departments who were seen within recommended time was at or above the minimum benchmarks for all triage categories (see Table 6).

Table 6: Percentage of major rural hospital emergency department patients seen within recommended times by triage category 2017-18.

Triage Category	2017-18 Performance	Target
1	100%	100%
2	89%	≥80%
3	78.8%	≥75%
4	80.8%	≥70%
5	97.6%	≥70%

Percentage of emergency attendances with a triage score of 4 and 5 not admitted

Typically, patients who are clinically assessed as Australasian Triage Score (ATS) 4 and 5 at presentation to an emergency department are attending as lower acuity and are subsequently treated within the emergency department but may not require admission to an inpatient ward.

For a large number of country hospitals, triage 4 and 5 attendances may reflect the availability of primary care services and out-of-hours general practice options in that community. Where these services are unavailable or restrictive, community members may need to attend a rural hospital emergency department or service for treatment.

In 2017-18, the percentage of emergency department attendances triaged as category 4 and 5 and not admitted can be seen in Table 7.

Table 7: Percentage of major rural hospital emergency attendances with a triage score of 4 and 5 not admitted.

Triage Category	2016-17 (%)	2017-18 (%)
4 – Semi Urgent	91.3	91.1
5 – Non-Urgent	97.7	97.7

Clinical governance and performance

Robust systems and standards are essential for high quality health care. Independent assessment and testing of these systems and standards is important for assurance and improvement.

Clinical governance describes the system through which health organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. This is achieved by creating an environment where there is transparent responsibility and accountability for maintaining standards and by striving for excellence in clinical care. The WA Country Health Service Clinical Governance Framework, endorsed in early 2018 has been developed to ensure that patients receive safe and high quality healthcare and that there are effective organisational safety and quality systems in place to achieve this.

Quality and standards

The Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme provides the national coordination of accreditation processes required of Australian health services and the WA Country Health Service is fully accredited. The Australian Council on Safety and Quality has developed the National Safety and Quality Health Standards (NSQHS) to guide health service organisations and boards in their responsibility and obligation for clinical governance of their organisation. Accreditation under the NSQHS Standards and National Standards for Mental Health Services forms part of this assurance. In May 2018 the Pilbara region completed a rigorous fiveday external assessment against the ten NSQHS Standards and National Standards for Mental Health Services (NSMHS) and has received positive feedback in advance of the official report.

The Australian Council on Healthcare Standards also oversees accreditation under the EQuIPNational Corporate Health Service Standards for corporate services with oversight of healthcare facilities, such as our regional and central corporate offices. Corporate accreditation includes the ten NSQHS Standards and is a comprehensive accreditation and quality improvement program that facilitates alignment between the corporate service and its health facilities.

The application of the same standards across the organisation promotes high quality and safe care for consumers by ensuring that there are standard practices between our corporate offices and all of our hospitals and community based services.

In December 2017 Ms Christine Dennis, Chief Executive Officer of the Australian Council on Healthcare Standards presented the WA Country Health Service with a certificate to formally recognise the successful achievement of our accreditation under the corporate standards which was undertaken in May 2017. The WA Country Health Service is the first public health service in WA to achieve corporate accreditation under the NSQHS Standards.

[Photo (PDF only): Ms Christine Dennis, Chief Executive Officer Australian Council on Healthcare Standards presents Board Chair Professor Neale Fong with EQuIPNational Corporate Health Service Standards accreditation certificate.]

Learning from clinical incidents

The WA Country Health Service is proud of the improvements we continue to make in ensuring safe and high quality care for our patients. We strive to provide the very best, high quality consumer-centred care. In 2017-18 we achieved this for the vast majority of our patients. However, like other health services, despite the very best intentions of our dedicated staff, a small proportion of patients unfortunately experience poor outcomes which is contributed to by the care they receive.

We are committed to providing an open and transparent environment that supports and encourages our staff to report incidents in the event that something does not go to plan. Similarly, we are committed to full and open communication with patients and their families. It is internationally recognised that systems that support proactive reporting and investigation of clinical incidents are essential for learning to inform system improvements that reduce avoidable harm to patients.

In 2017-18 the WA Country Health Service utilised learnings from our clinical incident reporting and investigations to strengthen our services in the following areas:

• We continued the development of our Patient Safety Matters publication. Patient Safety Matters is a newsletter style publication that we provide to our clinicians. We use the themes that we identify through our clinical incident monitoring and reporting, combined with de-identified real clinical incidents to promote discussion between clinicians and share learnings across our many hospitals and health services. The publication highlights opportunities for improvement and provides practical guidance on how to approach similar situations, including links to evidence based resources.

In 2017-18 the publication included topics such as inter-hospital transfers, team communication and checking procedures required prior to surgical procedures.

• Falls by patients in health care facilities can lead to injury and other medical complications. Older people and patients with cognitive impairment are at increased risk of falls when they enter our facilities. As such a key part of our patient safety focus is to continually improve our practices to reduce the incidence of patient falls. Based on the national A better way to care program published by the Australian Commission on Safety and Quality in Health Care we are also making improvements to ensure there is early recognition and response to patients with cognitive impairment (dementia and delirium) so they receive high quality care and the risk of falls and subsequent complications is reduced.
• In early 2018 the WA Country Health Service Board and Executive approved a two-year plan to improve the safety and quality of care and services for our consumers. This includes specific actions to improve access and outcomes for people with Mental Health conditions; improve early recognition and management of patients with sepsis; and an independent process for patients and families to call staff for assistance if they are concerned about the health of the person in our care (Call and Respond Early program).
• Measuring access to emergency care and elective surgery is one way in which the WA Country Health Service ensures timely and equitable access to care as delays to treatment can affect health outcomes. We continually measure and monitor the times people need to wait for treatment, be that in a WA Country Health Service emergency department, or on a waiting list for elective surgery. Our performance against these indicators is tracked and monitored at an operational, Executive and Board level, and appropriate strategies implemented to improve performance.

Notwithstanding the significant effort we invest in ensuring safe and high quality care for our patients, sometimes the health care does not go to plan. In these instances clinical incidents are reported and assigned a Severity Assessment Code (SAC) rating that guides the level of investigation that is to take place. SAC 1 clinical incidents are the most serious category resulting in serious harm or death that is, or could be, specifically caused by health care rather than the patient’s underlying condition or illness. All SAC 1 clinical incidents are investigated in line with the WA Health Clinical Incident Management Policy. We have a well-developed approach to the review of these clinical incidents and this includes oversight at the highest level by our Board Safety, Quality and Performance Committee.

During 2017-18, there were 137 incidents reported with a Severity Assessment Code rating of ‘1’ (SAC 1). These incidents represent a very small proportion of the 124,000 annual admissions, over 450,000 outpatient appointments and nearly 400,000 patients who presented to our emergency departments. One third of the SAC 1 events resulted in no harm to the patient but were considered “near misses” that may have but did not cause harm, often through the timely intervention of our staff.

Of the 137 SAC 1 incidents, the patient outcome was noted as follows:

Patient outcome	Number
Death	38
Serious harm	54
No harm (near miss that may have but did not cause harm, either by chance or through timely intervention)	45
Total	137

WACHS applies a low threshold for reporting clinical incidents. Consistent with this approach, there were also 11 incidents that were originally reported as SAC 1 and were declassified following investigation findings that the health care provided was determined not to have contributed to the poor patient outcome and only factors related to the patient’s clinical condition were identified.

One SAC 1 clinical incident reported in 2017-18 met the criteria for reporting as a national sentinel event (Medication error). National sentinel events are a discrete set of SAC 1 events that are considered wholly preventable and caused serious harm or death to a patient. Sentinel events occur infrequently and are independent of a patient’s condition.

Preventing healthcare associated infections

Healthcare-associated infections are the most common complication affecting patients in hospitals. They cause patients pain and suffering, prolong hospital stays and can cause significant morbidity and mortality. They also utilise significant human and financial resources for healthcare facilities.

At least half of healthcare-associated infections are thought to be preventable with infection prevention and control practices rather than inevitable complications of medical care and all healthcare facilities should aim to eliminate these infections. The reporting of hand hygiene compliance and surveillance of Staphylococcus aureus blood stream infections are infection prevention and control strategies that were incorporated into the National Healthcare agreement in 2009 as quality improvement processes to reduce Healthcare Associated Infections (HAI).

Effective hand hygiene is one of the most effective strategies in preventing healthcare associated infections. Hand Hygiene is a process that reduces the number of microorganisms on hands through the use of soap (non-antimicrobial and antimicrobial) and water or the application of an alcohol-based antimicrobial agent to the hands. The Australian Commission on Safety and Quality in Health Care introduced the National Hand Hygiene Initiative with the aim to improve hand hygiene compliance among health care workers and reduce transmission of infection. The National Hand Hygiene Initiative includes hand hygiene compliance auditing which is conducted nationally three times a year. The hand hygiene audit reviews compliance with the five key moments when healthcare workers should perform hand hygiene.

In 2017, 20,716 hand hygiene moments were captured in the national hand hygiene audits in WA Country Health Service hospitals. Our overall result has remained consistently above the national hand hygiene benchmark set by the Australian Health Ministers’ Advisory which was raised in 2017 from 75% to 80%.

[Chart 1 (PDF only): WACHS rate of hand hygiene compliance by national audit period (Note, approximate values only) Mar 2016: 87%; Jun 2016: 86%, National Hand Hygiene benchmark 75-78%; Oct 2016: 87%, National Hand Hygiene benchmark 79-80%; Mar 2017: 86%, National Hand Hygiene benchmark 80%; Jun 2017: 87%, National Hand Hygiene benchmark 80%; Oct 2017: 85%, National Hand Hygiene benchmark 80%; Mar 2018: 87%, National Hand Hygiene benchmark 80%; Jun 2018: 87%, National Hand Hygiene benchmark 80%.]

Healthcare associated infections (HAIs) are one of the most common causes of unintended harm suffered by health consumers. Staphylococcus aureus is a type of bacteria, often found on the skin of healthy people that can cause an infection of the bloodstream after a patient receives medical care or treatment in hospital.

Contracting a Staphylococcus aureus bloodstream infection while in hospital can be life threatening and hospitals aim to prevent these cases. The WA Country Health Service contributes to the surveillance of Healthcare-associated Staphylococcus aureus bloodstream infections (HA-SABSI) through the Healthcare Infection Surveillance Western Australia (HISWA) program. HA-SABSI’s are measured as a rate of infection using the number of beds occupied by patients each day. The nationally agreed benchmark set under the National Healthcare Agreement (NHA) is a rate of less than 2.0 per 10,000 days of patient care for public hospitals in each State and Territory, however the Healthcare Infection Surveillance Western Australia (HISWA) has a lower benchmark of less than or equal to 1.0 per 10,000 bed days.

Healthcare-associated Staphylococcus aureus bloodstream infection rates at WA Country Health Service hospitals have remained within the HISWA “performing” target rate during 2016-17 and 2017-18. In 2017-18 (Q1 -3) 38% of the reported HA-SABSI in WA Country Health Service hospitals were related to intravascular devices and 31% related to a surgical procedure. The intravascular device related HA-SABSI rate has decreased from 0.35 in 2016- 17 to 0.27 in 2017-18 (Q1 -3).

[Chart 2 (PDF only): Healthcare-associated Staphylococcus aureus bloodstream infection rate per 10,000 acute bed days in WACHS hospitals.
WACHS HA-SABSI rate per 10,000 acute bed days: 2016/17 - Q1 0.75, Q2 0.16, Q3 0.82, Q4 0.63; 2017/18 - Q1 0.75, Q2 0.45, Q3 0.83; HISWA performing rate between 0.0 and 1.0 per 10,000 bed days = 1.0; WACHS Average HA-SABSI rate per 10,000 acute bed days Q1 16/17 - Q3 17/18 = 0.6.