System Level Measures Framework questions and answers

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What are System Level and Contributory Measures?

System Level Measures are high level aspirational goals for the health system that align with the five strategic themes of the Health Strategy and other national strategic priorities such as Better Public Service Targets. 

They have a focus on children, youth and vulnerable populations.  System Level Measures are part of the DHB annual planning process and provide an opportunity for DHBs to work with their primary, secondary and community care providers to improve health outcomes of their local population.  

They promote better understanding and use of health information, engagement with people in the design and delivery of health services and better health investment in models of care based on local population needs.

The six System Level Measures introduced from 1 July 2016 are:

  • Ambulatory Sensitive Hospitalisation (ASH) rates for 0–4 year olds (that is, keeping children out of hospital)
  • acute hospital bed days per capita (that is, using health resources effectively)
  • patient experience of care (that is, person-centred care)
  • amenable mortality rates (that is, prevention and early detection)
  • proportion of babies who live in a smoke-free household at six weeks post natal (that is, healthy start)*
  • youth System Level Measure (that is, youth are healthy, safe and supported)*.

*Further details in February 2017.

Refer to the System Level Measures newsletters for an update on the development of these measures.

Contributory measures have a quality improvement focus and are front line service level measurements that show a tangible and meaningful result of the interaction between clinicians and patients. They are locally chosen based on the needs and priorities of communities and district level health services.

For example, contributory measures for ‘Acute hospital bed days per capita’ could include length of stay, acute readmissions and flu vaccinations in the elderly.

The Measures Library for System Level and contributory measures are on the Health Quality Measures New Zealand website.

What happens to the 2015/16 Integrated Performance and Incentive Framework (IPIF) measures – are they no longer a priority?

Two of the five 2015/16 IPIF measures remain National Health Targets: Better help for smokers to quit and Increased immunisation at eight months old.

More heart and diabetes checks and Increased immunisation for two year olds remain DHB non-financial performance measures. These along with Cervical screening coverage are important measures that contribute to the System Level Measures of Ambulatory Sensitive Hospitalisation (ASH) rates for 0–4 year olds, Acute hospital bed days and Amenable mortality rates.

How were the System Level Measures developed?

These six System Level Measures are the result of a clinically led review process over several months. They evolved from an initial list of over 100 measures. A core group for measures development, including 14 sector clinicians from primary and secondary care has been key to measure development and selection. Widespread discussion with clinicians and mangers has also supported this work, including meetings with Primary Health Organisation (PHO) Clinical Governance Groups and DHB alliance leadership teams. There was consultation with 32 groups between July and October 2015 alone.

What happens to the 2015/16 Integrated Performance and Incentive Framework (IPIF) measures – are they no longer a priority?

Two of the five 2015/16 IPIF measures remain National Health Targets: Better help for smokers to quit and Increased immunisation at eight months old.

More heart and diabetes checks and Increased immunisation for two year olds remain DHB non-financial performance measures. These along with Cervical screening coverage are important measures that contribute to the System Level Measures of Ambulatory Sensitive Hospitalisation (ASH) rates for 0–4 year olds, Acute hospital bed days and Amenable mortality rates.

What are the targets for the new System Level Measures?

There is no national target for the System Level Measures.

The improvement milestone for each System Level Measure will be determined by the district alliance leadership teams based on their baseline and trend data. This data is provided by the Ministry of Health on the Nationwide Service Framework Library website.

The improvement milestone will be an appropriate 'number' given the needs and priorities of the district and that improves performance from baseline. The improvement milestones will be approved by the Ministry of Health.

What do DHBs and PHOs need to deliver in each quarter?

 
Key dates
Activity
20 January 2017 Quarter 2 report due – exception reporting (on/off track to meet SLM milestones and mitigation plan where off track)
31 March 2017 Draft 2017/18 improvement plan due to Ministry
20 April 2017 Quarter 3 report due – exception reporting (on/off track to meet SLM milestones and mitigation plan where off track)
30 May 2017 Final 2017/18 improvement plan due to Ministry
20 July 2017 Quarter 4 report due – Performance report against the four SLM improvement milestones. Where the alliances have not met their improvement milestones, the report must include whether:
• there has been an event outside its control that caused the alliance to re-prioritise its activities (for example, water contamination in Hawke's Bay)
• the improvement milestone is closer to being achieved in quarter four than it was in quarter one
• on reflection they consider the improvement milestone was too ambitious and why the alliance over estimated their ability to influence, particularly in year one
• all parties to the improvement plan delivered their commitments and if not why.
30 July 2017 (To be confirmed.) 2017/18 improvement plans approved by Ministry.

All reporting will occur through the DHB quarterly report database.

Will the System Level Measures be measured in DHBs and primary care?

Yes. The System Level Measures rely on the contribution of both DHBs and PHOs at a minimum and will be measured at the district level.

Will the DHBs be financially rewarded for meeting the new System Level Measures, like general practice is?

The current funding arrangements between the Ministry, DHBs and PHOs are not changing at this time. DHBs have considerable flexibility in how they allocate funding across their district, both with contracted providers and with their provider arm.

Where can I find more information on System Level and contributory measures?

The System Level and contributory measures are published on the Health Quality Measures New Zealand Library website.

Can I use measures not listed in the Measures Library as contributory to System Level Measures?

Districts should refer to the Measures Library first for contributory measures. However, if the contributory measures available in the Library are not suitable, districts may choose to use other measures that have been piloted and validated and that contribute to the System Level Measures.

In the spirit of collaboration, the expectation is that if a district has a contributory measure that supports progress towards the System Level Measures that is not in the library, that they submit it for inclusion in the Library so it can be shared with other districts.

How can I add contributory measures to the library?

Districts can ask for measures that are piloted and validated, and that contribute to the System Level Measure(s), to be added to the Measures Library. The Technical Advisory Group will maintain oversight of the Measures Library.

Once you have created an account on the Health Quality Measures New Zealand Library website you can log in and comment on existing measures, or add your own contributory measures.

How will System Level Measures be implemented?

District alliance leadership teams are driving implementation of the new measures.

Further information on this is available on the Nationwide Service Framework Library website where DHB guidance has been provided, including the Guide to using System Level Measure for Quality Improvement.

What is a district alliance?

Currently alliances are a partnership of the DHB of domicile and its PHOs. It is envisaged these alliances will evolve to include highly functioning relationships with other provider groups who serve the same population, eg, midwives, ambulance, pharmacy, etc.

Who should be on an alliance?

The membership of your alliance will include senior representatives from the DHB, PHOs and other contracted providers. Alliance members have the very important role of leading and driving wide engagement across the primary, secondary and community care.

How can I find out more about System Level Measure improvement plans?

Further information on the development of the Plans is available on the Nationwide Service Framework Library website, including the Guide to using System Level Measure for Quality Improvement and exemplar plans from 2016/17.

What will happen to the $23 million incentive pool available for the PHOs?

The $23 million PHO incentive pool will be used to build capacity and capability in primary care, while also rewarding performance. This will help achieve the System Level Measures improvement milestones and the two primary care National Health Targets..

Two capacity and capability payments and one ‘at risk’ performance payment will be paid to PHOs:

  • Payment 1: 25% capacity and capability payment up front in quarter one
  • Payment 2: 50% capacity and capability payment once the Ministry approves the district alliance’s Improvement Plan
  • Payment 3: 25% performance payment in quarter one 2017/18 based on quarter four.

What are the PHO payment dates for 2017/18?

 
Key dates
Payment
15 July 2017 PHO Quarter 1 Payment for 2017/18 (25%) paid
15 September 2017 PHO Quarter 4 Payment for 2016/17 (25%) paid
PHO Quarter 2 Payment for 2017/18 (50%) paid – if 2017/18 plan is approved by Ministry
15 September 2018 PHO Quarter 4 Payment for 2017/18 (25%) paid

What is the 75% capacity and capability payment for?

The 75% capacity and capability payment is to build clinical and non-clinical infrastructure in primary care, for example, information technology, clinical governance and outreach services. The payment can also be used to incentivise contributory measures.

Will the incentives be linked to performance?

Payment 3, the last 25% performance payment will be paid to the PHOs based on quarter four performance of the following three System Level Measures and two primary care National Health Targets:

  • ASH rates for zero to four year olds
  • Acute hospital bed days per capita
  • Patient experience of care
  • National Health Target Better help for smokers to quit
  • National Health Target Increased immunisation for eight-month olds.

How will PHOs be paid?

The payments will be made to the PHOs through their contracted DHB as per current processes.

What happens to the National Health Targets?

The National Health Targets will continue in their current form, including the requirements to meet the national target and report quarterly. PHOs and DHBs are expected to meet the targets identified in each individual National Health Target.

What should the main focus of improvement plans be?

It is important that improvement plans capture how changes are going to be made. That is, what contributory measures are going to be put in place to make a difference to the System Level Measure.

For example, if after analysing your local data for the System Level Measure of ASH rates in 0-4 year olds you find higher than national average and total DHB rates for asthma acute admissions for Māori and Pacific children, you would select the ASH contributory measures most relevant to asthma. If you  refer to the Health Quality Measures NZ website, these measures could be:

These measures are submitted to the Ministry of Health in your improvement plan. They show in a clear, measurable way the actions you are planning take to reduce ASH rates.

What is the patient experience survey?

The primary care patient experience survey is designed to understand patients’ experience of the whole health care system. It has been piloted by some PHOs and is available to others through the National Enrolment Service (NES).

Find out more about the following on the Health Quality & Safety Commission website:

What is an appropriate improvement milestone for Patient experience of care SLM?

The milestone should be determined using the adult inpatient and/or primary care surveys developed by the Health Quality & Safety Commission (HQSC).  The milestone must be a number that either improves or maintains performance from the baseline results. For example, 90% of general practices uptake the primary care patient experience survey by 30 June 2018 or increasing the participation rate of adult inpatient survey by 5% by 30 June 2018.

Who can I speak to for more details?

You can contact Kanchan Sharma, National Programme Manager on (04) 816 3415 or at SLM@moh.govt.nz

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