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Patient care being lost in drive to meet targets

Evidence of extensive manipulation of Canberra Hospital emergency department data has underlined long-standing AMA concerns that governments are downplaying quality of care in the push for public hospitals to meet time-based performance targets. An investigation by the ACT Auditor-General’s Office found that treatment records for up to 11,700 emergency department patients were doctored between 2009 and 2012 to show waiting times and lengths of stay shorter than they actually were.

15 Jul 2012

Evidence of extensive manipulation of Canberra Hospital emergency department data has underlined long-standing AMA concerns that governments are downplaying quality of care in the push for public hospitals to meet time-based performance targets.

An investigation by the ACT Auditor-General’s Office found that treatment records for up to 11,700 emergency department patients were doctored between 2009 and 2012 to show waiting times and lengths of stay shorter than they actually were.

In her report, ACT Auditor-General Dr Maxine Cooper found that at least one Health Directorate official had engaged in “seriously inappropriate and improper conduct” in manipulating the data.

In a finding with significant implications for the way in which hospital performance is assessed in future, the auditor reported that although there was no evidence the official had acted under ministerial direction, there had been substantial pressure on her to “improve the publicly reported performance information of the Emergency Department”.

 “The managerial pressure reflects the significant and ongoing focus on the timeliness performance of the Canberra Hospital and the requirements of the National Partnership Agreement,” the auditor’s report said.

The 2011 National Partnership Agreement between the Commonwealth, States and Territory governments set a time limit of four hours within which 90 per cent of all emergency department patients have to be admitted, discharged or referred on for treatment elsewhere.

Under the Agreement, State and Territory governments have to ensure their hospitals meet this target in order to be eligible for reward funding, which the Auditor estimated would be worth around $800,000 a year for the ACT through the next four years.

The performance of hospital emergency departments is also assessed according to the Australasian Triage Scale, which sets patient treatment times according to the severity of their condition.

Category 1 patients are those classified as those who life is under immediate threat, and all in the category must be treated immediately. At the other end of the scale are patients in the “less urgent” category 5, 70 per cent of whom should be treated within two hours of presenting at emergency.

The Audit estimated that in the 12 months to April this year, Canberra Hospital’s records were manipulated such that the timeliness of treatment for category 3 patients (classified as suffering “potentially life-threatening” conditions) was overstated by 19 per cent, and for category 4 patients (“potentially life-serious”) they were overstated by at least 10 per cent.

“This involved changes to at least 5800 patients records out of a total of 43,000 records in one year for these two triage categories,” the audit report said, though it admitted that “the level of over-estimation cannot be established with certainty”.

It found that “very poor systems and practices in the Canberra Hospital” had created ample opportunity for people to manipulate hospital records virtually undetected.

Inquiries in other jurisdictions suggest this is unlikely to be an issue solely in the ACT.

In 2009, the Victorian Auditor-General’s Office warned of “a significant risk of incorrect reporting associated with Emergency Department timeliness performance”, and a 2008 report by Deloitte Touche Tohmatsu found that the majority of public hospitals used the same information system as that so easily manipulated at Canberra Hospital.

The ACT audit report noted that the introduction of the four-hour rule in the United Kingdom was “accompanied by widespread gaming and fraudulent manipulation of hospital data”.

The issue has brought into sharp focus the significant shortcomings of time-based measures in assessing the care provided by hospitals.

The ACT Auditor-General lamented a lack of benchmarks relating to the quality of treatment, rather than its speed – a shortcoming acknowledged by the Director-General of the ACT’s Health Directorate, Dr Peggy Brown.

“The attention placed on Emergency Department timeliness as a performance measure is significantly higher than the attention placed on almost all other parts of the health system,” Dr Brown wrote in response to the audit findings. “The focus on ED timeliness does not take into account broader measures of patient outcome.”

The Auditor-General recommended that hospital performance indicators be reviewed to “include, and give a greater emphasis to, qualitative indicators relating to clinical care and patient outcomes”, a suggestion that Dr Brown said would be adopted by the Health Directorate.

The audit report’s findings and recommendations echo concerns and reservations expressed by the AMA two years ago regarding the setting of time-based targets for public hospital emergency departments.

In a 2010 position paper, the AMA said it “cautiously supports…an aspirational time-based target”, but only as part of a suite of measures, noting that emergency department delays were largely due to capacity constraints elsewhere in a hospital.

“Improving ED waiting times can only occur with investment in whole-of-hospital, and community, capacity,” the position paper said. “This means funding more beds to reduce average bed occupancy rates in hospitals to 85 per cent, and to provide an appropriate quality of care for all hospital patients.”   

In a prescient warning, the paper cautioned that “targets should be used to drive improvements and to identify hospitals needing further investment ands resources. Penalties will only lead to data manipulation and gaming…not lead to improvements in patient care”.

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Published: 15 Jul 2012