More concise performance targets needed for acute care system

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The provision of a more concise and focused set of performance targets for the acute care system in Ireland, to facilitate subsequent analysis and easy identification of where performance could be improved, has been recommended in  an official report presented to Health Minister, Stephen Donnelly and Minister for Public Expenditure, NDP Delivery and Reform, Paschal Donohoe, in March.

It encouraged review of the existing list of HSE acute care performance indicators, providing a concise list of KPIs and targets against which hospital performance can be actively monitored and managed.

Spending Review process “Hospital Performance: An Analysis of HSE Key Performance Indicators,”* was carried out to provide insights and a greater evidence base for policy decision making in this area.

The aim of the analysis is to provide a data driven assessment of hospital performance based on published HSE key performance indicators. The Department of Health said this  supported active management of hospital performance across the healthcare system, allowing policymakers and practitioners to identify investment needs and best practices improvements to enhance clinical outcomes and increase efficiency. This work aligned with Sláintecare Reform Programme 1, Project 1 which aimed to improve hospital productivity through optimised use of capacity, improve patient flow and achieve reconfiguration of hospital services. 

The paper said a growing divergence between hospital expenditure and activity had been observed since 2017 which motivated consideration of performance The paper provided an overview of hospital performance across the years 2017-2021 by analysing 18 published Key Performance Indicators (KPIs) at a Regional Hospital Area (RHA) level, hospital model level, and at an individual hospital level covering three aspects of hospital performance –  Emergency Department Services, Acute Medical/Surgical Services, and Medical Safety. 

KPIs analysed include ED waiting times, incomplete treatment, day of surgery admissions, and delayed transfer of care, highlighting areas where policy interventions could be focussed to improve the delivery of acute care service.

The report said, “Variation in performance was observed across hospitals and regions for each area examined, but also relative to HSE set targets. In some cases, hospitals with significant and persistence non-compliance with HSE performance targets can be identified for a given KPI, highlighting the need for subsequent analysis to identify drivers and potential remediatory interventions that could be utilised.”  

The authors acknowledged that performance on the KPIs examined had a multitude of drivers including varying demographics, healthcare needs, management practices/processes or resources available in each hospital, and that this was a key limitation of the analysis. They said the identification of hospital performance relative to KPIs remained valuable as it enabled agile identification of areas for additional exploration and remediation within the acute care system.

 Minister for Health, Stephen Donnelly, welcomed the publication saying,  “The development of a robust understanding of the drivers of hospital performance will enable the implementation of effective policy. This analysis provides an understanding of hospital performance through the lens of Regional Health Areas. This analysis will be vital to the development of strong governance and management structures within Regional Health Areas to drive improved hospital performance.”  

Findings of the report:

  • ED Waiting Times:   Wide variation in ED wait times across hospitals was observed. At a hospital level, 23 out of 26 (88%) hospitals were below the HSE designated target of 70% admissions within six hours. ED wait time performance in hospitals was persistent across years, indicating that interventions to reduce long waits had been potentially ineffective. The literature demonstrated that ED wait times could have significant clinical consequences for patients, so further remediatory actions should likely be taken to reduce these costs.
  • Incomplete Treatment in ED Settings: Incomplete treatment represents a patient safety concern and an inefficiency in the provision of emergency department services. Relative to the HSE set target – < 6.5% – substantial differences in hospital performance was identified, with performance varying from 16.7% of patients having incomplete treatment in one hospital to 1.3% in another. 
  • Acute Medical Assessment Unit (AMAU) Utilisation: Potential under-utilisation of AMAUs was observed across the acute care system, with 19 out of 29 hospitals having AMAU discharge rates below HSE targeted level. Effective utilisation of AMAUs has been shown in the literature to reduce hospital average length of stay (ALOS), reduce ED wait times for beds, improve the rate of appropriate treatment, and reduce all-cause in-hospital mortality. The report said further research was needed to determine potential interventions for increasing AMAU utilisation, and whether current targets could be refined to account for differences in patient and hospital characteristics such as patient complexity.
  • Elective Day-Of-Surgical-Admission: HSE Model of Care guidelines outline numerous benefits from admission of patients on day of surgery. Compliance for hospitals on this metric was mixed, with 22 out of 30 hospitals having day of surgery admission rates above 70% (compared to a national HSE target of 80%). A few hospitals were identified as underperformers on this metric, with one having a day of surgical admission rate of 16.5%. The report said further analysis was therefore required to explore whether improvements could be made for a select group of hospitals on this metric.
  • Delayed Transfer of Care: Delayed Transfers of Care have a material impact on bed utilisation levels in Irish hospitals, with 7% of all bed days used attributable to patients suitable for discharge. The HSE has set a target for Delayed Transfers of Care affecting 200k discharges in 2019, falling to 175k in 2021. In 2019 a total of 240,000 beds were subject to delayed transfer of care, with this dropping to 141,666 in 2021. Substantial regional and hospital level variation in the level of delayed transfer of care was also identified, with for example 10% of bed days used in one region attributable to patients awaiting discharge compared to just 4% in another region
  • Patient Safety: Hospital acquired infections (HAIs) and medication incidents pose costs for both hospitals and patients. The report found incidence of HAIs was spread across all hospitals, although hospitals of greater complexity appeared to have higher rates of infection for Staph infections, while no clear linkage was present for C. difficile infections. It said a greater focus on mitigating the spread of C. difficile, CPE, and S. aureus might be a cost-effective strategy to improve hospital performance, although further research would be required to determine what achievable reductions in HAIs were in each hospital model or RHA.

Recommendations

  • Review of the HSE Acute care active performance management system: Non-compliance with HSE specified key performance indicators was observed for many hospitals for all years examined. The  report said the persistence of below target performance across years, and the non-comparability of some KPIs across hospitals drew into question the efficacy of the current regime in promoting active performance management and policy intervention. The Authors would encourage a review of the existing list of HSE acute care performance indicators, providing a concise list of KPIs and targets against which hospital performance can be actively monitored and managed.
  • Learnings and identification of areas for active performance management: This paper identifies hospitals and regions that had the highest and lowest levels of compliance for each KPI examined. While the drivers of performance on these metrics was multi-factoral, performance across each KPI nonetheless might enable a more systematic approach to identifying improvements to the acute care delivery. Areas for further examination included the drivers of long ED wait times, high rates of incomplete treatment, under-utilisation of AMAUs and the rates of healthcare acquired infections in some hospitals.

Remediatory Interventions to improve hospital performance: Where appropriate, focused interventions to improve hospital performance on designated KPIs should be undertaken such as the in the areas outlined above. The benefits of improved performance on designated KPIs are in most cases quantifiable, so the level of potential investment to be undertaken should be reflective of this with costs commensurate or lower than potential benefits. 

Conor Clancy, Conan Shine, Mark Hennessy, Irish Government Economic and Evaluation Service, Research Services & Policy Unit, Department of Health