Performance Indicators for Hospitals Participating in the VICNISS Type 1 Surveillance Program July 2008 - June 2009

October 2008

Hospital participation and performance are included in the Government’s Statement of Priorities and Performance Framework.

The Statements of Priorities are the key accountability agreements between Health Services and the Minister for Health. The annual agreement ensures delivery or substantial progress towards the key shared objectives of financial stability, improves access and waiting times, and quality of service provision.

A copy of the 2008-09 Statement of Priorities and Performance Framework Business Rules can be found at: www.health.vic.gov.au/hospital-performance/index.htm.

These Performance Indicators 2008-09 (PDF File 30kb, opens in new window) as detailed below, are also available to download as a PDF document.
Notice of Inability to Undertake VICNISS Surveillance Activities - As advised in the VICNISS eBulletin April 2008, if a hospital is unable to undertake the surveillance activities as listed in the Performance Indicator document for any period of time, formal notification to the VCC is required by completing the form Notice of Inability to Undertake VICNISS Surveillance Activities (PDF File 23 kb, opens in new window). This notification needs to be signed by the Infection Control Coordinator and the Infection Control Executive Sponsor. This information will then be forwarded to the Department.
Due dates for the submission of data to the VICNISS Coordinating Centre for 2008 – 2009 are also available along with other VICNISS Key Dates.

This document lists the VICNISS Hospital Participation Indicators and the VICNISS Data Quality Indicators for all hospitals participating in Type 1 surveillance activities.

These Performance Indicators have been endorsed by the VICNISS Advisory Committee and the Department of Human Services.

The VICNISS Coordinating Centre is required to report hospital level indicators to the Department of Human Services.

1. VICNISS Type 1 Surveillance Hospital Participation Indicators

Required Surveillance Activities

1.1 Intensive Care Units

1.1.1 Central line associated bloodstream infections in Adult Intensive Care Units - collect data continuously and submit to the VICNISS Coordinating Centre quarterly.
1.1.2 Central line associated bloodstream infections in Neonatal Intensive Care Units - collect data continuously and submit to the VICNISS Coordinating Centre quarterly.
1.1.3 Peripheral line associated bloodstream infections in Neonatal Intensive Care Units - collect data continuously and submit to the VICNISS Coordinating Centre quarterly.

1.2 Surgical Site Infections

1.2.1 If coronary artery bypass grafts surgery is performed data must be collected continuously and submitted to the VICNISS Coordinating Centre quarterly.
1.2.2 If more than 50 hip arthroplasty procedures are performed annually, data must be collected continuously and submitted to the VICNISS Coordinating Centre quarterly.
1.2.3 If more than 50 knee arthroplasty procedures are performed annually, data must be collected continuously and submitted to the VICNISS Coordinating Centre quarterly.
NOTE: If only one of the above applies, data from at least 1 other VICNISS Surgical procedure must be collected continuously and submitted to the VICNISS Coordinating Centre quarterly. If none of the above apply, data from at least 2 other VICNISS Surgical procedures must be collected continuously and submitted to the VICNISS Coordinating Centre quarterly..

2. VICNISS Type 1 Surveillance Data Quality Indicators

2.1 Quarterly surveillance data submitted within 1 week of the required date (as specified by VICNISS Coordinating Centre).
2.2 For surgical procedure groups, a minimum of 90% of risk factor data must be complete for all procedures submitted.
2.3 Complete organism data including antibiotic resistance patterns to be submitted for all SSI and CLABSI infections.
2.4 Complete surgical antibiotic prophylaxis data be submitted for all SSI procedures under surveillance.