Performance Monitoring and Dashboards for Hospitalists

Performance Monitoring and
Dashboards for Hospitalists
Leslie Flores MHA, SFHM
April 29 and 30, 2014
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Housekeeping
• Questions?
– Type them into the “Questions” box in the
GoToWebinar panel on the right side of your screen at
any time.
– We will wait and address questions at the end of the
session.
• Copies of the slide set will be available via the
CHMB website at www.chmbinc.com
• For questions, contact Lacey Buquet at
[email protected]
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Leslie Flores MHA, SFHM
• Former hospital executive in
Southern California
• Partner, Nelson Flores
Hospital Medicine Consultants
• Advisor to the Society of
Hospital Medicine for practice
management issues
4
Agenda
• Why is it important to have a formal
performance monitoring process?
• What types of metrics should you be
measuring?
• Key data and analysis considerations
• Steps in developing a dashboard
• Sample reports and dashboards
Why Have a Dashboard, Report Card,
Performance Report, etc.?
•
•
•
•
•
•
Understand how you’re performing
Reduce variation
Demonstrate value
Identify trends
External comparisons
Reward good performance
5
Why Have a Dashboard, Report Card,
Performance Report, etc.?
• To drive change
– Identify areas for improvement
– Hawthorne effect
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7
Suggested Approach
Generate
and analyze
Set targets reports
Decide
what to
measure
Distill key
indicators
into a
dashboard
Develop an
action plan
8
WHAT TO MEASURE?
Take a Balanced
Approach
9
Key Hospitalist Performance Domains
Descriptive Metrics
Work Effort and Productivity
Clinical Quality
Resource Management
Service and Satisfaction
Financial
10
In Reality, There’s Lots of Overlap
Quality
Productivity
Service
Resources
Financial
11
Descriptive Metrics
• Not performance per se, but these metrics
inform discussions about performance
– Volume
• Number and types of services
– Acuity
• CMI
• Top diagnoses or DRGs
– Payor mix
12
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Work Effort and Productivity
– Shifts worked per physician
• Number and type
– Clinical productivity
• Encounters and wRVUs
• Number of patients seen per shift
– Other work effort
• Committee meetings
• Academic work
• Performance improvement projects
14
Management Reports – RVU Metrics
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Quality
• What to measure here is evolving quickly
– Hospital Value-Based Purchasing metrics
• Clinical Process of Care domain
– Heart failure discharge instructions
– Pneumonia initial antibiotic selection
• Patient Experience of Care domain
– Communication with doctors
• Outcome domain
– 30-day O/E mortality (AMI/HF/pneumonia)
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Quality
– Readmission rates
• 72-hour
– Did focus on LOS management result in patients being
discharged too early?
• 30-day
– How good are care transitions and post-discharge follow-up?
– Other TJC core measures
• e.g. stroke core measures
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Quality
• Care transitions measures
– PCP notification of admissions and discharges
– Percent of patients with follow-up appointment
scheduled prior to discharge
– Proportion of discharge summaries dictated or
entered on the date of discharge
– Percent of time the discharge summary
medication list matches that given to the patient
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Quality
– Percent of patients with more than one attending
hospitalist
• A measure of physician-patient continuity
– Compliance with order sets and pathways
– PQRS measures
– Percent of required VTE risk assessments
performed on admission
– Percent of diabetes patients managed within
target glucose range
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Resource Management
– Severity-adjusted ALOS
• Comparison to non-hospitalist peer group, external
peer group (e.g., Premier, Crimson, etc.) or Medicare
GMLOS
– Severity-adjusted average cost per discharge
• Major ancillary categories like imaging, clinical
laboratory and pharmaceutical costs
– Avoidable/denied days as a percent of total days
– Utilization of consultants
23
Resource Management
• Patient flow variables
– ED admission notification to initial hospitalist order time
– ED admission notification to hospitalist in-person visit
– Time elapsed between ED call/page & hospitalist call-back
– Percent of discharge orders entered before 10:00 a.m.
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Service and Satisfaction
• Citizenship
– Attendance at hospitalist group meetings
– Participation on hospital/medical staff committees
and performance improvement initiatives
– Working extra shifts or otherwise helping out
when needed
• Patient complaints
• Satisfaction surveys
– PCPs, ED physicians, specialists, nursing staff
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Financial
• Hospitalist program cost center
– Performance to budget
– Financial support/stipend/loss per FTE
• Revenue cycle performance
–
–
–
–
–
–
–
Charge capture rate and/or charge lag
Total charges and collections by provider
CPT code utilization
Average net collections per wRVU
Days in A/R
Claim edits, rejection and denial rates
PQRS performance
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Source: Society of Hospital Medicine’s 2012 State of Hospital Medicine Report
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Coding Intensity
Operational Reports - E&M Utilization
Andrews, James
Brandon, Kim
Davidson, Tom
Garcia, Fred
Liget, Vicki
Marnet, Stewart
Rodriquez, Mary
Thompson, Ed
Wynn, David
Yasini, Shabar
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CPT Distribution
Management Reports – Key Performance Indicators
Operational Reports – Rejections and Denials Analysis
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DATA/ANALYSIS CONSIDERATIONS
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Understand Your Environment
• Each organization has a unique culture,
goals, priorities, operational habits
– Terminology
– Analytical methods
Understand Data Sources and
Limitations
• Common sources of data
– Hospital ADT, clinical, EHR, and financial systems
– Practice management and revenue cycle software
– Third-party data warehouses
• Premier, Crimson, Truven, UHC, CHMB
– Medicare data
– Third party survey data
• MGMA, AMGA, Sullivan Cotter, ECG, SHM
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Understand Data Sources and
Limitations
• Limitations
– Completeness and accuracy of inputs
– Reliability of reporting methodologies
• Attribution issues
– Availability and timeliness
– Sample size
– Sheer volume of data
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Decide What Types of Analyses
• Individual vs. group?
• Snapshot vs. trend?
• Comparison to . . .
– Internal peer group? External peer group? Survey
data? Established target?
• Statistical analysis options
– Average vs. median
– Arithmetic mean vs. geometric mean
40
The Problem of Attribution
• Which hospitalist? Hospitalist or consultant?
• Many metrics are best reported at the group level
– Mortality and readmission rates
• Some metrics best reported by admitting provider
– Initial antibiotic selection for pneumonia
• Some metrics best reported by discharging physician
– HF discharge instructions
• Some practices allocate credit based on the proportion
of days each hospitalist cared for the patient
– Patient satisfaction or LOS
41
Blinded or Un-blinded?
• Usually best to present performance data
about individual hospitalists un-blinded
– Example:
• Each doctor sees every other doctor’s wRVU reports
with names attached
Note: where attribution is an issue, it’s usually better to blind the data
or report it at the group level
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What To Do With All This Information?
• High-level assessment
– Is this a plausible representation?
• What does this information
mean for your practice?
– Opportunities for improvement
– Is the information actionable?
• Distill key metrics into a
dashboard or report card
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CREATING YOUR DASHBOARD
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Creating Your Dashboard
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Steps in Creating Your Dashboard
Choose Dashboard Metrics
Of all the information
available to you, which
few metrics should be
presented in the
monthly dashboard?
Set Performance Targets
Who/what is the
comparison group?
What is the range of
acceptable
performance?
Design Dashboard Format
Assign
Responsibility
How often will the
dashboard be
distributed?
How best to show
performance against
targets?
Who is responsible for
producing source data?
Who is responsible for
preparing and
distributing the
monthly dashboard?
Who is responsible for
following up?
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Creating a Dashboard
• Pick a handful of key indicators (10 – 15)
– Important to hospitalists AND stakeholders
– Readily measurable
– Consistently available
– Seen as valid
– Actionable
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Creating a Dashboard
• Make it simple, short and attractive
– Show results graphically where possible
• Ensure the dashboard is regularly produced
– Routinely distributed to all hospitalists and key
stakeholders
• “Push” vs. “pull”
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Just Do It!
• Precise metrics and format are important –
but the most important thing is to have a
dashboard
– And that it is updated and distributed regularly
• Don’t let uncertainty about metrics and
format paralyze you
– Plan to revise metrics and format periodically
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Common Challenges
• Consistent access to meaningful, reliable,
timely data
• Who “owns” dashboard production?
– Manual work to produce the dashboard
• Look for IT solutions
• Ensuring the dashboard serves as a stimulus
to action
– Build in accountability mechanisms
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Page 1 - Productivity
XYZ Hospitalist Group
ABC Hospital
Current Month Encounter-Equivalents vs. Target
250
Total Encounter-Equivalents Trend
230
0
83
82
96
35
88
82
100
96
50
1,916
1,412
1,500
94
138
144
192
192
192
192
2,000
188
204
210
192
192
192
155
189
197
192
100
Jan-10
2,500
200
150
For the month of:
1,000
500
0
0
0
0
0
0
0
0
0
0
0
Jan
Current Month Actual
Target
Monthly Target
Current Month wRVUs vs. Target
3,500
365
Aug Sept Oct
Nov Dec
Total Enc-Equiv
3,419 3,298
3,000
152
148
50
173
2,000
145
148
168
173
2,500
175
248
255
345
345
345
345
344
404
410
345
345
203
345
360
388
Jul
Total wRVUs Trend
4,000
345
450
400
350
300
250
200
150
100
50
0
Feb Mar Apr May Jun
1,500
1,000
500
0
0
0
0
0
0
0
0
0
0
0
Jan
Current Month Actual
183 Total EKG interpretations
337 Total stress tests
26 Total bedside procedures
1,802 Total E&M and other encs
2348 Total encounters of all types
Monthly Target
7.8%
14.4%
1.1%
76.7%
% of total encounters
% of total encounters
% of total encounters
% of total encounters
Feb Mar Apr May Jun
Target
Jul
Aug Sept Oct
Nov Dec
Total Enc-Equiv
148 Total shifts worked during the month
12.9 Average billable encounter-equivalents per shift this month
11.0 Target billable encunter-equivalents per shift
Page 2 - Revenue Cycle
XYZ Hospitalist Group
ABC Hospital
For the month of:
Quarterly CPT Code Distribution - Admissions
Last Year
26%
Total This Qtr
Mark
26%
44%
18%
38%
19%
33%
Edgar
19%
24%
Diana 4%
14%
45%
48%
53%
15%
22%
0%
14%
59%
20%
40%
99221
99222
60%
80%
100%
24%
48%
38%
65%
35%
54%
Jack
46%
47%
Irene
52%
21%
79%
Geetha
63%
Freda
64%
49%
Diana
73%
27%
85%
Bruce
15%
60%
Anne
40%
81%
0%
20%
40%
99238
19%
60%
99239
19%
53%
24%
19%
68%
15%
8%
69%
35%
15%
14%
51%
59%
20%
29%
40%
99232
60%
12%
80%
99233
Monthly Statistics:
Target
< 10%
< 2%
> 85%
51%
Charlie
27%
48%
Quarterly Statistics:
37%
36%
Edgar
31%
40%
28%
0%
13%
17%
15 Total "No Charge" or un-billed encounters
0 Target "No Charge" or un-billed encounters
53%
48%
Hank
33%
31%
33%
1.78 Average wRVUs per encounter-equivalent
1.80 Target wRVUs per encounter-equivalent
62%
Lenny
Kareem
33%
Freda
99231
52%
Mark
52%
99223
76%
Total This Qtr
Hank
Geetha
26%
26%
40%
54%
Anne
Quarterly CPT Code Distribution - Discharges
Last Year
29%
Bruce
29%
26%
40%
Irene
Charlie
64%
12%
28%
43%
49%
Diana
69%
38%
31%
33%
Edgar
39%
57%
15%
34%
Jack
6%
56%
27%
Lenny
33%
28%
38%
Kareem
60%
Freda
Anne
26%
32%
Geetha
Bruce
Mark
54%
26%
Charlie
35%
49%
13%
Hank
Total This Qtr
49%
40%
Jack
Last Year
37%
55%
11%
Irene
17%
46%
10%
Lenny
Kareem
57%
18%
80%
100%
Jan-10
Quarterly CPT Code Distribution - Subsequent Visits
Actual
16.1% Submitted claims that were rejected
1.8% "Clean" claims that were denied
89.0% Denied claims paid upon appeal
$48.37 Average net professional fee collections per wRVU
$50.00 Target net professional fee collections per wRVU
100%
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Page 3 - Quality Indicators
XYZ Hospitalist Group
ABC Hospital
For the month of:
100%
1.28 This month's case mix index
74.2% This month's proportion of Medicare patients
82.0%
80%
89% Order set usage this month
> 95% Target order set usage
60%
Jan-10
DRG Assurance Query Response Trend
64.0%
58.0%
45.0%
40%
86% VTE Risk Assessments Performed on Admission
85% VTE Risk Assessment Target
20%
0%
Jan
92% Medication Reconciliation Complete on Discharge
> 95% Medication Reconciliation Target
Feb Mar
Apr May
Target > 95%
Jun
Jul
Aug Sept Oct
Nov Dec
Query Response Rate
Severity-Adjusted ALOS Trend
Core Measures:
6
5
77% "Heart Failure Discharge Instructions" performance
100% "Heart Failure Discharge Instructions" target
5.5
4.2
4
3.8
3.6
3
2
1
0
Jan
Feb Mar
Apr May
Target < 3.9
Readmission Rates Trend
$6,000
Average Length of Stay (Sev. Adj.)
$4,898 $4,630
$2,000
1.9% 2.2% 1.6% 1.7%
$1,000
0.0%
Feb Mar
Nov Dec
$3,000
9.4% 8.8%
Jan
Aug Sept Oct
$4,000
12.6%
5.0%
$5,216 $5,087
$5,000
16.0%
10.0%
Jul
Severity-Adjusted Cost per Case Trend
20.0%
15.0%
Jun
Apr May
Jun
72-Hr Readmissions
Jul
Aug Sept Oct
30-Day Readmissions
Nov Dec
$0
Jan
Feb
Mar
Apr May
Target < 4,249
Jun
Jul
Aug Sept Oct
Nov Dec
Average Cost per Disch (Sev. Adj.)
55
Page 4 - Service Indicators
XYZ Hospitalist Group
ABC Hospital
For the month of:
Jan-10
Percent of Discharge Orders Written by 10A
80.0%
68.0%
70.0%
61.0%
58.0%
60.0%
54.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Jan
Feb
Mar
Apr
May
Jun
Jul
Disch Orders by 10A
Aug
Sept
Oct
Nov
Dec
Oct
Nov
Dec
Target 60%
Percent of Discharge Summaries Complete at Discharge
100.0%
80.0%
85.0%
88.0%
90.0%
Feb
Mar
Apr
72.0%
60.0%
40.0%
20.0%
0.0%
Jan
May
Jun
Jul
D/S Complete @ Discharge
Press Ganey Patient Satisfaction Scores
80%
60%
52%
48%
56%
Aug
Sept
Target 85%
4.8 Current Physician Satisfaction Survey score
> 4.5 Physician Satisfaction Survey score target
62%
4.4 Current Nursing Satisfaction Survey score
> 4.5 Nursing Satisfaction Survey score target
40%
20%
0%
Jan
Feb
Mar
Apr
May
Jun
Jul
"Physician" Question %tile Rank
Aug
Sept
Target
Oct
Nov
Dec
0 Number of patient complaints this month
0 Patient complaints target
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Source: Measuring Hospitalist Performance: Metrics, Reports and Dashboards, Society of Hospital Medicine 2006
57
Source: Crimson – a product of The Advisory Board
How Can We Help?
• Hospitalist practice management consultants
• Leslie Flores, MHA and John Nelson, MD
• Helping clients build successful new hospitalist programs and enhance the
effectiveness and value of existing programs since 2004.
• Collectively we’ve worked with more than 300 sites
• Services:
– Start-ups, comprehensive practice assessments, compensation
plans, staffing/scheduling models, integration of APPs, teambuilding and leadership development, patient experience
training
58
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How Can We Help?
• Founded in 1999 by physicians
• 25,000 users across 900 healthcare facilities
– 12,000 Hospitalist Users
• Patient encounter platform that increases quality and
revenue by streamlining and automating the following key
areas:
–
–
–
–
–
Care Coordination and Communication
Quality Enhancement and Cost Reduction
Coding, Compliance, and Documentation
Revenue Cycle Management
Data Analytics and Business Intelligence
How Can We Help?
•
Since 1995, serving 4,000+ physicians nationwide
•
Comprehensive RCM Solution for Hospitalists
–
11% Average Collections Increase
–
8 Days Decrease in Days Charges in AR (DAR)
–
Integrated Electronic Charge Capture Solutions
–
Advanced Reporting and Analytics Engine - CURVE
•
Consulting, Credentialing and Group Formation
•
Systems Integration, Interfaces, Data Conversions
•
Coding, Education and Training
• Contact us to arrange for a comparative assessment of your
current RCM Results
• Deliverables include a complete practice Dashboard
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Contact Us
Leslie Flores
Ron Anderson
Nelson Flores Hospital
Medicine Consultants
CHMB Inc.
Partner
Director
760-520-1340
[email protected]
www.chmbinc.com
760-771-3323
[email protected]
www.nelsonflores.com
Mimi Thornton
Regional Mgr., Southwest
Ingenious Med, Inc.
678-501-6237
[email protected]
www.ingeniousmed.com