Trust Board Clinical Efficiency Dashboard Mark Avery Associate Director of Operations 25 February 2009 Executive Summary It was agreed through the November Finance & Performance Committee (FPC) that a quarterly update of the operational arrangements for monitoring and improving Clinical Efficiency would be provided to the Trust Board (and monthly to FPC). This report shows the performance for Quarter 3. This work is designed to support delivery of the Trust s priorities including: DQHH, FT application, HCC health check, and the delivery competitive services for patients, primary care clinicians and commissioners. It was agreed that this should also be reviewed at the Trust Board. The Risk & Quality Committee (RAQC) ratified the range of measures to be used. We can only be sure to improve what we can actually measure Lord Darzi, High Quality Care for All, June 2008 The Green, Amber and Red flags against each of the indicators reflect performance against the national benchmarks which are derived from HES data (Hospital Episode Statistics) submitted by all NHS Trusts each quarter. The report indicators have now been duplicated for Quarter 3 using local systems. We are now able to interrogate a greater level of detail to explore areas of interest or concern. A high level action plan has been set out against each of the highest priority measures.
INTRODUCTION & CONTEXT Building upon clinical efficiency work undertaken as part of the Performance Review process and previous reporting of clinical efficiency measures, the Trust Board requested a quarterly update to the Efficiency Scorecard initially presented in November. Action plan have since been agreed through the FPC with timescales for further improving monitoring Clinical Efficiency and Effectiveness going forward. The CE Dashboard has been reviewed at the FPC, and the appropriateness of the range measures has been considered and approved by the Risk & Quality Committee (RAQC). This paper therefore provides: updated Clinical Efficiency Dashboard for Q3 2008/9 indicating direction of travel against the previous quarter progress report against actions agreed for further development of monthly reporting and monitoring an update on operational actions taken to address priority issues Future Clinical Efficiency reporting will be to the Trust board through the FPC in order to support the Trusts strategic objectives: DQHH, FT application, HCC health check, and the delivery of competitive services for patients, primary care clinicians and commissioners. DASHBOARD QUARTER 3 2008/9 The RAG thresholds have been set using national quartile benchmarks derived from the NHS Institute for Innovation & Improvement productivity measures. (With the exception of the length of stay measure: percentage of bed days beyond HRG trimpoint, which has been developed as requested by the board, to focus on excess beddays, rather than the potential achievable reduction in length of stay used for national benchmarking) For further detail, see Appendix A Clinical Efficiency & Effectiveness Dashboard (including specialty breakdown.) 2 P a g e
LENGTH OF STAY ANALYSIS Further detail has been also been requested on Length of stay indicators in particular. Previous presentations to the Board have shown that approximately half our bed days are occupied by patients over the age of 80. This analysis supports that, showing a marked increase in bed days over trim point for older patients. In fact there is a considerable stepchange increase for patients over the ago of 60. The table below shows three Healthcare Resource Groups (HRGs) with the greatest number of bed days beyond the trim point. Appendix B Length of Stay Analysis by admission type & age band shows this in greater detail, by Division Defining Terms Spells, HRGs & Upper Trim Points The following table is provided as a definitions summary of the more common terms used for HRG analysis. HRG Spell Spell duration Electives Outliers HRGs are a means of aggregating health data into groups of interventions that are of a similar cost and of a similar nature and complexity. Hospital admission data is recorded using diagnostic and procedure codes. These codes are then grouped into HRGs by software known as the HRG Grouper. The HRG groups inform payment of hospitals under the methodology known as payment by results (PbR), as each HRG has a nationally fixed tariff. An admission. The spell length is time in days from admission date to discharge date. Spells are sometimes called finished hospital stay (FHS) and should not be confused with finished consultant episode (FCE). The length of an admission in days; sometimes known as length of stay (LOS) Non emergency admissions generally have lower costs when compared to emergency admissions. Events that have unusual characteristics. In relation to HRGs these usually are admissions where the LOS (i.e. length of admission) is longer than expected. The expected range of LOS for a given HRG is defined by values known as trim point s. Trim point A statistically derived length of stay that denotes the upper end of a range of expected length of stays for an admission with a given HRG Excess bed days The number of additional days of an admission for a given HRG over and above the trim point. It is derived mathematically as follows: spell duration upper trim point for a specific HRG = excess bed days. Excess bed days are only calculated when the spell duration is greater than the trim point. Adapted from information on the British Medica Journal (BMJ) Health Intelligence website [http://healthintelligence.bmj.com] 3 P a g e
The following analysis uses the number of bed days over trim point as a proxy for excess bed days. The length of stay may appear excessive for particular HRGs for a number of reasons: An indication of inefficient care pathways Groups of patients waiting for assessment, or placement with social services (Delayed Transfers of Care) Income opportunity. For example, spells with longer than expected lengths of stay may be due to the complexity of case mix not being correctly recognised due there being insufficient detail in the medical record. Co morbidities or complications not picked up through clinical coding may result in a given spell being mapped to a more routine (less expensive) HRG than may actually be appropriate for the resources consumed. Appendix C shows this in greater detail at HRG level and by age group and Division, but is only a sample of what is available. The value of this reporting is being able to drill to areas of with potential for improvement. The reports show HRGs that are most likely to result in an excessive length of stay. We can also examine length of stay for a particular Division, Specialty, or HRG (or any combination) over time Note that the drop off spells showing for the more recent time periods is because we can only analyse HRGs for spells that have been fully coded. Unknown HRGs are not included in the analysis. Total Patients, Occupied Bed Days & Excess Bed Days by Month (of Discharge) 4 P a g e
EFFICIENCY DASHBOARD DEVELOPMENT ACTION PLAN (COMPLETED) Update of actions previously agreed at Trust Board, FPC & RAQC Now completed Action Responsibility Timescale Update Efficiency Dashboard to be updated with Quarter 1 2008 9 data as soon as it becomes available, and circulated to Trust Board members MA As soon as available Ministerial sign off of the national indicators (due some months ago) was delayed until Jan Identify appropriate peer group and investigate developing the reports to use appropriate peer group benchmarks rather than using national comparisons exclusively MA 31 January 09 Peer group comparisons are available at specialty level against the national indicators on the existing scorecard. Develop further internal measures of Clinical Efficiency and Effectiveness measures to provide information that is more up to date and responsive to internal priorities e.g. Theatre utilisation & change length of stay measure to focus on bed days. MA 31 January 09 Theatre utilisation included in report and other indicators signed off through RAQC Monthly reports to the Finance & Performance Committee to be developed (monitoring against quarterly benchmarks) ND / MA 31 January 09 Work with information & IT data warehouse teams to replicate the appropriate clinical efficiency measures ourselves rather than rely on external benchmarking from Dr Foster / CHKS With JW & WH NOTE: production of Monthly internal reports is predicated upon information & IT data warehouse duplicating the measures using our own data Develop Divisional action plans to address shortfalls / maximise performance through the Performance Review process. Set expectations and manage progress towards upper quartile performance. NOTE: Action plans tie in with service improvement & development work, some of which may have a significant lead in time. Expected timescales for delivery will be clarified as the action plans are developed ND / MA + Divisional Directors & Chairs 31 January 09 + Ongoing Part of the Performance Review process. Action trackers implemented to monitor. Divisional & departmental specific information has been shared & regular updates are available. Support the Information team through the clarification of operational needs and priorities for management information MA Dec 08 / Jan 09 Quarterly reporting to Trust Board ND / MA Ongoing from Jan 09 The need was established to focus on Length of Stay. Much more detailed analysis required at HRG level to identify and target the areas with greatest potential to release bed days MA Jan 09 Reported to Trust Board in January. Update attached as Appendix B TRACKED ACTIONS FROM CORPORATE MEETINGS (BOARD, RAQC & FPC) RAQC 5 December 2008 08/182.3 Secondly, subject to the Chair s approval, the Committee decided that the indicators in the report are those which should be measured by the Clinical Efficiency Report. The Director of Operations undertook to discuss this point with the Committee s Chair when she returns from her lecture tour. ND FPC 18 November 2008 08/129.3 Clinical efficiency dashboard An operational summary is to be provided underneath each indicator. Director of Operations/Associate 21 Jan 09 Dir of Operations 5 P a g e
OPERATIONAL UPDATE & ACTIONS TAKEN IN PRIORITY AREAS LENGTH OF STAY (LOS) ACTIONS / UPDATE Areas for potential improvement Analyse all inpatient stays by length of stay to identify where improvements in the discharge process will have the greatest impact Develop efficiency measures using LOS beyond trim point as a proxy for potential excessive length of stay at HRG level Develop prioritised action plan based upon HRGs that could potentially deliver the greatest savings in bed days (consequently this will also have significant financial benefit but this is not the sole aim) Action taken: Planning for discharge early on admission or preadmission for elective patients. A new standardised ward handover sheet has been introduced in January 2009 to provide Expected Discharge Date (EDD) data in a format that can be quickly compiled to provide up to date predicted discharge position trust wide Use predictive discharge methods to reduce variation and to help eliminate delays e.g. Medicine division using average LOS for each of the top 20 conditions as a starting point for discharge planning Key issues to manage and future actions Involve patients and their families or carers in discharge planning (so they are prepared and can make their own arrangements) Planning and managing discharge (i.e. involving social services early if required) Setting protocols for common conditions (where possible) Regular decision ensuring ward rounds at least once a day Review need for criteria based discharge processes. Costs and implications of improving 7 day working DAY CASE RATE The Day Case rate measure shows a significant decline from previous reports. This is due to the way the new PAS defaults to one day length of stay, rather than zero when day cases are entered. A number of day cases, have been interpreted as elective inpatients incorrectly, particularly earlier in the year. For next month, we will explore the reporting options to reclassify the day cases with one day length of stay as day cases to provide a more accurate interpretation. Areas for potential improvement Patients kept in overnight for non clinical reasons Patients planned to be day cases but coded as inpatients Assess data entry / data quality Use and organisation of theatres Improved profile of Clinical leadership (national evidence suggests that where there is an identified clinical lead, the commitment to improve day surgery rates is increased) Key issues to manage / future actions undertake a baseline diagnosis of day case potential in the Trust (by comparing current day case rate performance to best practice day case rates, for key day surgery procedures, individually) undertake a campaign for re education and training for full implementation of coding rules monitor performance and learning 6 P a g e
PRE OPERATIVE BED DAYS Areas for potential improvement The Trust has strict clinical criteria for bringing patients in the day before elective surgery, and all elective admissions are assessed on this basis. Therefore by far the majority of elective surgery undertaken takes place on the day of surgery and where it does not, it is for clinical reasons. East and North Hertfordshire NHS Trust are Currently GREEN (upper quartile) against national benchmarks on the efficiency dashboard. This is therefore not a priority for focus but will continue to be monitored. REDUCING OUTPATIENT DNAS Areas for potential improvement Further reduction in lost appointments due to DNAs Action taken: Telephone calls to patients to confirm attendance not universal coverage. Key issues to manage and future actions Review of follow up practices / procedures at specialty level to ensure patients require appointments Pilot mobile text messaging service in a specific specialty Project plan in place to move to direct booking service for all specialties on choose and book system. FIRST TO FOLLOW UP OUTPATIENT ATTENDANCE RATIOS Areas for potential improvement East and North Hertfordshire NHS Trust are Currently GREEN (upper quartile) against national benchmarks on the efficiency dashboard. This is not to say that there are not further gains to be made, but this is not an immediate priority for focus. Action taken: Implementation of follow up policy agreed with PCT and incorporated into trust wide access policy. Monthly monitoring of ratios at specialty level through performance review process. Key issues to manage and future actions Increase in demand may lead to continued pressures on services and increased complexity so need to continue to monitor levels regularly. CONCLUSION The Trust Board is asked to note the development of the information reporting capability to duplicate the national productivity indicators using local systems, thereby combining the ability to benchmark against others whilst retaining the flexibility to access to underlying data so that specific issues can be explored to the necessary level of detail. The Board is also asked to consider the format for future reports. The proposed format for future quarter end efficiency reports (run one month in arrears to allow sufficient time for the completion of coding) is for the Board to be provided with the Efficiency Dashboard, supplemented by year to date Length of Stay analysis and a summary of actions taken. i.e. Quarter 4 2008/9 Efficiency Dashboard & Lenth of Stay Analysis to be reported to the May 2009 Board. In the meantime, the FPC will continue to receive monthly updates (also run one month in arrears to allow sufficient time for the completion of coding). 7 P a g e
Appendix A 8 P a g e
Appendix B 9 P a g e
Appendix C 10 P a g e