Ratios Save Lives
ANMF ACT Branch Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework Position Statement
Developed by ANMF ACT Branch 2017
Table of Contents Message from the ANMF ACT Branch Executive..................................................................1 ANMF calls on the Government...................................................................................................2 Mandated Minimum Ratios Framework.................................................................................3 The Right Ratio................................................................................................................................4 Current Workload Management................................................................................................5 Ratios - The Evidence.....................................................................................................................6 Keeping our Nurses and Midwives...........................................................................................9 Skill Mix.............................................................................................................................................10 Cost......................................................................................................................................................11 Summary.........................................................................................................................................14 References........................................................................................................................................15
Australian Nursing and Midwifery Federation ACT Branch
Ratios Save Lives From the ACT Branch Executive Most people are generally surprised to learn that there are no express or enforceable provisions or laws in the ACT governing how many patients can be allocated to a Nurse or Midwife working in the public healthcare system. However, ACT Nurses and Midwives are seeking to have this changed. Recently, the ANMF ACT Branch conducted a survey of its members in preparation for the ACT Public Sector Enterprise Agreement bargaining period. The survey asked whether Nurses and Midwives wanted the introduction of mandatory minimum safe staffing levels, or, in other words, whether they wanted the introduction of a Nurse/ Midwife-to-Patient Ratios Framework. Over 95% of Nurses and Midwives said Yes.
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This is because introducing a Mandatory Minimum Nurse/Midwife-to-Patient Ratios Framework in the ACT public healthcare system will mean there will always be the right number of Nurses and Midwives present to care for Canberrans. It will mean a public healthcare system that is reputable, cost-effective and informed by those delivering the service. But what it will really mean is that the thousands of Canberrans who utilise the ACT public healthcare system every year will receive safe care. There is significant research, from Australia and around the world, that confirms that if a Nurse has more time to provide care to a patient, then the risk of that patient having unintended complications - like infections, pressure injuries and post-operative complications - is far less than if the patient was left unattended. The research also demonstrates that ratios contribute to hospital productivity and efficiency, improved staff satisfaction and equality across the healthcare system. We have seen both Queensland and Victorian Governments commit to Mandated Minimum Nurse/Midwife-to-Patient Ratios in their public health systems, and have gone even further and enshrined them in legislation. It’s time the ACT Community had the same safe Nurse and Midwife staffing levels, and the same protections. Because the evidence is clear - Ratios Save Lives.
Athalene Rosborough President Australian Nursing and Midwifery Federation ACT Branch
Matthew Daniel Secretary
Nurses and Midwives Call On The Government ANMF ACT Branch members call on the ACT Government to implement a Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework. Underlying Principle 1: No changes to current staffing levels during the development of the Framework. Underlying Principle 2: Employ a method for determining higher than Mandated Minimum Ratios where care demand is shown. Underlying Principle 3: Respect the professional clinical judgement of Nurses and Midwives to provide staffing which matches clinical need.
The decision to implement a Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework would represent a milestone in healthcare in the ACT, guaranteeing the right number of Nurses/Midwives to provide safe, patient-centred care to the ACT Community. The ANMF ACT Branch commits to working with the ACT Government to establish a Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework through the ACT Public Service Nursing and Midwifery Enterprise Agreement.
A
95%
poll showed of surveyed ANMF Nurses and Midwives in the ACT Public Sector supported Mandated Minimum Nurse/Midwife-to-Patient Ratios.
Australian Nursing and Midwifery Federation ACT Branch
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Mandated Minimum Ratios Framework Mandated Minimum Nurse/Midwife-to-Patient Ratios is one aspect of a number of critical components of the proposed Framework. The ANMF considers that the Framework should not only determine the right Mandated Minimum Ratio for each ward/clinical unit. It should provide the ability to respond to the complex, changing healthcare environment and incorporate an appropriate and agreed skills mix. The Mandated Minimum Nurse/Midwife-to-Patient Ratio Framework should:
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•
determine agreed data-sets, clinical care indicators and other quantitative and qualitative measures/outcomes, associated with Nurse/Midwife staffing levels, that will be used within the Framework;
•
identify and review professional standards involving specialty specific and Nursing and Midwifery Board of Australia standards with implications for patient safety and/or workload management;
•
review and analyse Mandated Minimum Ratios in other Australian jurisdictions to consider their applicability to the ACT Public Sector healthcare environment;
•
produce a detailed, written and transparent analysis of the information above;
•
establish the absolute minimum level of staffing required to meet safe patient care and patient-centred care principles for each ward/clinical unit;
•
establish an appropriate skill mix within the context of the Mandated Minimum Nurse/Midwife-to-Patient Ratio for each individual ward/clinical unit;
•
outline an agreed methodology for refining Mandated Minimum Nurse/ Midwife-to-Patient Ratios;
•
include an agreed process for reviewing the Mandated Minimum Nurse/ Midwife-to-Patient Ratio for each ward/clinical unit, which can be initiated by Nurses/Midwives or the health service;
•
outline the agreed regime to be instituted to maintain patient safety and ensure reasonable workloads when Mandated Minimum Nurse/Midwife-to-Patient Ratios cannot be met;
•
outline an agreed process for regular reporting, including public reporting; and
•
recognise the professional judgement and decisions of Nurses/Midwives to deploy additional staff, above the Mandated Minimum Ratio, where it is necessary to achieve manageable workloads that guarantee safe, patient-centred care.
Australian Nursing and Midwifery Federation ACT Branch
The “Right Ratio” Healthcare is delivered in a complex environment. Determining the right Ratio for individual wards/clinical units in this environment must occur on the basis of evidence, best practice, patient and staff safety considerations, professional standards and Nursing and Midwifery Board of Australia standards enforceable under the Health Practitioner Regulation National Law (ACT) Act 2010. The ANMF ACT Branch does not seek to prescribe a ‘one size fits all’ approach to determining the appropriate Mandated Minimum Ratios in the absence of relevant information and within the constraints of this position statement. Mandated Minimum Ratios need to be determined within an agreed Framework which is capable of responding to the complex and changing healthcare environment.
“Safe, effective healthcare should be driven by research and evidence. Equally, decisions about Nursing and Midwifery workloads should be informed by the evidence.”
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- ACT Nurse
Australian Nursing and Midwifery Federation ACT Branch
Current Workload Management Nurses and Midwives are concerned about the level of care they can provide to patients because of increasing workload demands. They are also concerned about their ability to meet strict professional standards set by the Nursing and Midwifery Board of Australia. Nurses and Midwives say workload is at tipping point.
"There is no express maximum number of patients a Nurse or Midwife might care for on each shift." - Matthew Daniel, ANMF ACT Branch Secretary
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In most areas of the ACT public healthcare system, the Nursing Hours Per Patient Day (NHPPD) workload management tool is the method used to determine safe levels of care. NHPPD is the target number of direct care hours a patient can expect to receive in each 24-hour period and is used to determine the number of Nurses required on each shift. This nursing workload tool is not fit for purpose because: •
NHPPD targets are out of date: NHPPD targets were developed in 2010 and do not reflect changes to the type and mix of patients on wards, high patient acuity, changes to work practices, models of care and care environments.
•
NHPPD reporting is retrospective: Retrospective reporting does not assist Nurses and Midwives to proactively manage their workloads in real time.
•
NHPPD reports only detail staffing averages: This does not highlight specific days where staffing has been reported to be unsafe.
NHPPD reporting to date is of little value because it does not accurately reflect the actual work demands on Nurses and Midwives. Increased bed numbers on wards due to ‘flexing up’ of beds/opening of ‘unfunded’ beds are not reflected in NHPPD calculations. In such circumstances, higher staffing levels are not matched to increased beds in NHPPD reporting, leading to incorrect claims that staffing levels are above target NHPPD staffing levels. Different methods for determining staffing levels are used in other settings. Again, these targets are not enforceable and do not guarantee safe levels of care and reasonable workloads for Nurses and Midwives.
Australian Nursing and Midwifery Federation ACT Branch
Ratios Save Lives Having the right number of Nurses and Midwives save lives. Just one extra patient added to a Nurse's/Midwife’s workload can impact on safety. Ratios reduce costs, increase efficiency, improve patient flow, decrease waiting times in Emergency Departments and support good patient outcomes. Implementing a Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework guarantees that the right number of Nurses and Midwives are available to provide safe, patient-centred care.
Every additional patient added to a Nurse’s workload, over 4 patients, is associated with:
7% increased
risk of the patient dying within 30 days of admission
[1]
7% increased
risk of failure to rescue [1]
“There is clear evidence to indicate that the number of Nurses on a shift play an important role in patient safety and quality of care.” - Office of the Chief Nursing and Midwifery Officer, Queensland
Australian Nursing and Midwifery Federation ACT Branch
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Research highlights that Nurse staffing levels are implicated in the incidence of: Urinary tract infections[2,3]
Sepsis[4,5,7]
Pressure ulcers[4,5,6]
Shock/cardiac failure[3,4]
Pneumonia[3,4,6,7,8,9]
Postoperative infection[7]
Deep vein thrombosis[3]
Pulmonary failure[4,8]
Upper gastrointestinal bleeding[3,4]
Metabolic derangement[4]
Central nervous system complications[6]
Failure to rescue[1,3,11]
“It is time to act and implement mandated staffing based on the evidence to date.� 7
- Professor Diane Twigg One study in Western Australia[6] using 236,454 patient records and 150,925 Nurse staffing records found significant decreases in Nurse sensitive outcomes due to increased nursing hours. The study showed that higher nursing hours were associated with:
54%
drop in central nervous system complication rates
17%
decrease in pneumonia
37% reduction in ulcer/gastritis/upper gastrointestinal bleed rates 63%
decrease rate of shock/cardiac arrest
42% decrease in sepsis 59% decrease in deep vein thrombosis 26% decrease in mortality rate
Australian Nursing and Midwifery Federation ACT Branch
Every extra patient added to a Nurse’s workload: Increases the chances of a medically admitted child’s re-admission within 15-30 days by 11% [12]
Increases the risk of a surgically admitted child’s likelihood of re-admission by 48%
[12]
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“Every time a Nurse is directed to care for additional patients, the hospital is accepting a higher level of risk on behalf of patients. This just doesn’t sound like safe, patient-centred care.” - ACT Nurse
Australian Nursing and Midwifery Federation ACT Branch
Keeping our Nurses and Midwives High turnover-rates in the nursing and midwifery professions can be attributed to insufficient staffing levels. When Nurses and Midwives are rushed, forced to skip meal breaks and work double shifts, patient safety is put at risk. These factors also drive Nurses and Midwives out of the professions. Constant cycles of Nurse burnout are expensive because healthcare organisations must spend money on advertising, recruitment, and retraining. A US study estimated that “the average cost of turnover for a bedside RN [Registered Nurse] ranges from $US38,900 to $US59,700 resulting in the average hospital losing $US5.13-$US7.86M annually”[13]. Additionally, the intellectual capital of the Nurses and Midwives that leave the sector is lost[14]. High workloads are known to contribute to Nurse job dissatisfaction and influence their decision to resign from their positions[15]. In fact, every additional patient added to a Nurse’s workload increases the chances of burnout by 23%[1]. This is not sustainable.
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“We are setting in stone the number of nurses working on each shift, so patients receive the highest quality and safest care.” - Jill Hennessy, Victorian Health Minister, 2015
Australian Nursing and Midwifery Federation ACT Branch
Skill Mix Ratios are vital. But safe care is also contingent upon an appropriate skills mix. Skill mix is the combination of Registered Nurses (RNs), Registered Midwives, Enrolled Nurses (ENs) and Assistants in Nursing on each shift. Studies demonstrate the importance of skill mix and practice environments in ensuring high-quality, safe healthcare. Higher proportions of RNs result in reduced lengths of stay and fewer adverse events. Significantly, a 10% increase in bachelor-educated Nurses is associated with a 7% decrease in patient mortality[16]. RNs constitute an around-the-clock surveillance system for the early detection of deteriorating patients. The effectiveness of Nurse surveillance is influenced by the number of RNs to assess patients on an ongoing basis[1]. Similarly, hospitals with higher numbers of RNs are associated with reductions in adverse events such as gastrointestinal bleeding, urinary tract infections, sepsis, pressure ulcers, deep vein thrombosis and pneumonia[3,4]. Other benefits of having more RNs include a reduction in medication errors and wound infections[17]. The ANMF ACT Branch recognises the valued skills which ENs bring to the overall skill mix when providing safe, patient-centred care, and will continue to advocate for increased numbers of ENs in the ACT public healthcare system.
“While I have the necessary skills to care for my patients, this doesn’t mean they will receive the best possible, safe care when I have too many patients to care for.” - ACT Nurse
Australian Nursing and Midwifery Federation ACT Branch
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Cost Reviewing costs associated with safe staffing numbers extends beyond the direct financial costs linked to the number of nursing and midwifery staff, and must include consideration of apparent indirect costs, including costs associated with hospital acquired complications (HACs). A HAC is “a complication for which clinical risk mitigation strategies may reduce the risk of that complication occurring�[19]. HACs are costly for patients, often increasing their length of stay and extending the time that a patient is away from work and family. HACs also represent a serious risk to the sustainability of healthcare funding. The likelihood of HACs is higher when staffing levels are inadequate and skill mix is not matched to patient care requirements[16]. Conversely, increasing nursing hours has positive cost benefits in terms of life years gained[20]. Lower nurse staffing levels, for example, are implicated in the incidence of hospital acquired pneumonia which leads to increased lengths of stay and cost.
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A US study estimated that each case of hospital acquired pneumonia led to increased: Length of stay Medical patient:
Cost
2.79 days
[21]
Surgical patient: 4.48 days[21]
Medical patient: $US5,837[21] Surgical patient: $US8,511[21]
There are many other examples of the additional costs associated with increased lengths of stay. For example, lower nursing staff levels are associated with an increase in the number of falls[22] with an increased length of stay of 2.39 days per fall at a cost of $US7,118[21]. Finally, the ANMF ACT Branch reiterates its Underlying Principle 1 (see p.2) and seeks no changes to current staffing levels during the development of the Framework.
Australian Nursing and Midwifery Federation ACT Branch
The Peril of HACs Apart from increased lengths of stay and additional costs arising from HACs, the ACT Public Hospital system may receive reduced funding for HACs. Table 1 outlines the list of nationally agreed HACs that are subject to the Independent Hospital Pricing Authority (IHPA) adopted adjusted funding model. Table 1: List of nationally agreed HACs*[23] No.
Complication
1.
Pressure Injury
2.
Falls resulting in fracture or other intracranial injury
3. 4.
Healthcare associated infection Surgical complications requiring unplanned return to theatre
5.
Unplanned intensive care unit admission
6.
Respiratory complications
7
Venous thromboembolism
8.
Renal failure
9.
Gastrointestinal bleeding
10
Medication complications
11
Delirium
12
Persistent incontinence
13
Malnutrition
14
Cardiac complications
15
Third & fourth degree perineal laceration during delivery
16
Neonatal birth trauma
12
It is important to note that many of the HACs in the table above are reflected in the research on the effects of staffing levels on Nurse sensitive outcomes. By addressing Nurse staffing levels, we would expect to see a reduction in HACs. In terms of the quantum of reduced funding for HACs, Table 2 shows the incremental cost of each HAC, which form the basis for the funding adjustment, as well as the adopted adjustment for each HAC.
*List developed by a Joint Working Party of the Australian Commission on Safety and Quality in Health Care and the Independent Hospital Pricing Authority (IHPA, Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19, July 2017).
Australian Nursing and Midwifery Federation ACT Branch
Table 2 shows, for example, the presence of a renal failure HAC adds, on average, an additional 27.2% to the cost of an episode, while the presence of a persistent incontinence HAC adds 2.3% to the total cost of an episode[24]. The adopted adjustment figure reflects the increased predisposition of some patients to experiencing a HAC during their hospital stay and adjusts the reduction in funding accordingly. Table 2: Incremental cost adjustments by HAC group[25]
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Complication
Final incremental cost
Adopted adjustment
All HACs
9.3%
8.5%
1.
Pressure Injury
16.2%
13.9%
2.
Falls resulting in fracture or other intracranial injury
7.2%
6.7%
3.
4.
Healthcare associated infection Surgical complications requiring unplanned return to theatre
9.4% 11.8%
8.6% 10.5%
5
Unplanned intensive care unit admission*
n/a
n/a
6.
Respiratory complications
18.8%
15.8%
7
Venous thromboembolism
14.0%
12.3%
8.
Renal failure Gastrointestinal bleeding
27.2% 10.7%
21.4% 9.7%
10
Medication complications
8.8%
8.1%
11
Delirium
10.8%
9.7%
12
Persistent incontinence
2.3%
2.2%
13
Malnutrition
7.9%
7.3%
14
Cardiac complications
12.7%
11.2%
15
Third & fourth degree perineal laceration during delivery*
30.1%
23.2%
16
Neonatal birth trauma*
12.2%
10.8%
9.
Essentially, the IHPA model adjusts the funding reduction for an episode of care containing a HAC on the basis of the risk of the patient acquiring the HAC. This means that where a patient has experienced a HAC and that patient is considered low risk for that HAC, the funding is reduced by the full incremental cost. By contrast, where a patient is considered to be a high risk of experiencing a HAC, funding for that episode of care is reduced by a proportion of the full incremental cost of the HAC[26].
* Funding approaches have been developed for each HAC with the exception of third and fourth degree perineal lacerations during delivery, neonatal birth trauma and unplanned intensive care unit admission.
Australian Nursing and Midwifery Federation ACT Branch
The ANMF notes that, in it's submission to the IHPA on the Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19, ACT Health indicated that "ACT is supportive of the proposed risk-adjusted model for HACs"[27]. It is clear that increased lengths of stay and reduced hospital funding linked to HACs pose a double-jeopardy risk to public healthcare affordability. The ANMF ACT Branch Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework provides a blue-print for reducing the incidence of Nurse sensitive outcomes and avoidable HACs.
“The additional cost of ensuring appropriate Nurse bedside hours is recouped through the reduced costs of better service delivery and better patient outcomes.� -Annastacia Palaszczuk, Queensland Premier, 2016
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Summary Nurses and Midwives providing front line care know what is needed to keep patients safe. They know that a Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework will establish evidence-driven, safe staffing levels that will be good for patients. A Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework will encourage Nurses and Midwives to remain within the public healthcare system and support them to provide the care that they want to provide. The ANMF ACT Branch commits to working with the ACT Government to develop and implement the Framework. Because the evidence is clear. Ratios Save Lives.
Australian Nursing and Midwifery Federation ACT Branch
References 1
Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J. & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association. 288(16), pp. 1987-1993.
2 Esparza, S.J., Zoller, J.S., Weatherby White, A. & Highfield, M.E.F. (2012). Nurse staffing and skill mix patterns: are there differences in outcomes? Journal of Healthcare Risk Management, 31(3), pp. 14-23.
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3
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M. & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346(22), pp. 1715-1722.
4
Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M. & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), pp. 244-255.
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Blegen, M.A., Goode, C.J., Spetz, J., Vaughn, T. & Park, S.H. (2011). Nurse staffing effects on patient outcomes. Safety-net and non-safety-net hospitals. Medical Care, 49(4), pp. 406-414.
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Twigg, D., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2010). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48(5), pp. 540-548.
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Mark, B.A., Harless, D.W. & Berman, W.F. (2007). Nurse staffing and adverse events in hospitalized children. Policy, Politics & Nursing Practice, 8(2), pp. 83-92.
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Kane, R.L., Shamilyan, T., Mueller, C., Duvall, S. & Wilt, T.J. (2007). Nurse staffing and quality of patient care. Healthcare Research and Quality, Rockville.
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Cho, S-H., Ketefian, S., Barkuaskas, V.H. & Smith, D.G. (2003). The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research, 52(2), pp. 71-79.
10
Wiltse Nicely, K.L., Sloane, D.M. & Aiken, L.H. (2013). Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing. Health Services Research, 48(3), pp. 972-991.
11
Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M. & Silber, J.H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290(12), pp. 1617-1623.
12
Tubbs-Cooley, H.L., Cimiotti, J.P., Silber, J.H., Sloane, D.M. & Aiken, L.H. (2013). An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions. BMJ Quality & Safety, 22, pp. 735-742.
13 Nursing Solutions, Inc. 2017, 2017 National Health Care Retention & RN Staffing Report. Viewed 6 September 2017, http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/Na tionalHealthcareRNRetentionReport2017.pdf. 14
Li, Y., & Jones, C.B. (2013). A literature review of nursing turnover costs. Journal of Nursing Management, 21, pp. 405-418.
15
Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A.M. & Shamian, J. (2001). Nurses’ reports on hospital care in five countries. Health Affairs, 20(3), pp. 43-53.
16
Aiken, L.H., Sloane, D.M., Bruyneel, L., Van Den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M.D., Moreno-Casbas, M.T., Rafferty, A.M., Schwendimann, R., Scott, P.A., Tishelman, C., van Achterberg, T. & Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet, 383, pp. 1824-30.
17
Hall, L.M., Doran, D. & Pink, G.H. (2004). Nurse staffing models, nursing hours and patient safety outcomes, Journal of Nursing Administration, 34(1), pp. 41-45.
Australian Nursing and Midwifery Federation ACT Branch
18 Lankshear, A., Sheldon, T. & Maynard, A. (2005). Nurse staffing and healthcare outcomes; a systematic review of the international research evidence. Advances in Nursing Science, 28(2), pp. 163-174. 19
Australian Commission on Safety and Quality in Health Care. 2017. Hospital-acquired complications. Viewed 18 December 2017, https://www.safetyandquality.gov.au/our-work/ indicators/hospital-acquired-complications/.
20
Twigg, D., Geelhoed, E., Bremner, A. & Duffield, C. (2013). The economic benefits of increased levels of nursing care in the hospital setting. Journal of Advanced Nursing, 69(10), pp. 2253-2261.
21
Dall, T.M., Chen, Y.J., Sifert, R.F., Maddox, P.J. & Hogan, P. F. (2009). The economic value of professional nursing. Medical Care, 47(1), pp. 97-104.
22 Hinno, S., Partanen, P. & Vehviläinen-Julkunen, K. (2011). Nursing activities, nurse staffing and adverse patient outcomes as perceived by hospital nurses. Journal of Clinical Nursing, 21, pp. 1584-1593. 23
Independent Hospital Pricing Authority, 2018-19, Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19, July 2017, p. 38.
24
Independent Hospital Pricing Authority 2018-19, Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19, July 2017, p. 39.
25
Independent Hospital Pricing Authority 2017, Risk adjustment model for Hospital Acquired Complications – Technical Specifications, July 2017, p. 2.
26
Independent Hospital Pricing Authority 2018-19, Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19, July 2017, p. 41.
27
ACT Health submission to Independent Hospital Pricing Authority, 15 August 2017, regarding IHPA Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19, https://www.ihpa.gov.au/sites/g/files/net636/f/department_of_health_australian_capital_ territory_submission.pdf
Australian Nursing and Midwifery Federation ACT Branch
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