The effects of bonus payments on emergency service performance in Victoria

Objectives: To review and analyse the system effects of the Emergency Service Enhancement Program (ESEP): bonus payments made to public hospitals to improve access to care for patients attending emergency departments. Design: A review of the first 3 years' performance data, obtained from the Victorian Emergency Department Minimum Dataset (VEMD). Setting: 21 public hospital emergency departments in Victoria, Australia (population 4.5 million), with about 700 000 patient attendances per year. The ESEP began in April 1995. Main outcome measures: The ESEP indicators of emergency department and inpatient bed access: occasions of "ambulance bypass" (emergency department unable to accept patients arriving by ambulance); emergency waiting times for Category 1, 2 and 3 patients (National Triage Scale) compared with agreed national performance thresholds; and "access block" (>12 hours' waiting time in the emergency department before admission to hospital). Results: The number of occasions of ambulance bypass per quarter decreased from 600 in 1994 to fewer than 100 in 1997 (P < 0.001). Despite an increased proportion of patient encounters in triage categories 1, 2 and 3 (31% v. 23%), zero waiting times for Category 1 patients were consistently adhered to, and adherence to waiting time thresholds for Category 2 and 3 patients improved significantly (P < 0.001, R-2 = 0.74; and P < 0.035, R-2 = 0.37, respectively), particularly for Category 2 patients. The number of patients waiting longer than 12 hours in emergency departments decreased nonsignificantly (P = 0.3, R-2 = 0.1). Conclusion: Our results show that the ESEP has produced sustained improvements in all the indicators linked with bonus payments.