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Performance Monitoring and Dashboards for Hospitalists Leslie Flores MHA, SFHM April 29 and 30, 2014
Performance Monitoring and Dashboards for Hospitalists Leslie Flores MHA, SFHM April 29 and 30, 2014
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
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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
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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
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Why Have a Dashboard, Report Card, Performance Report, etc.?
• To drive change – Identify areas for improvement – Hawthorne effect
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Decide what to measure
Set targets
Generate and analyze reports
Distill key indicators into a dashboard
Develop an action plan
Suggested Approach 7
WHAT TO MEASURE?
Take a Balanced Approach
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Key Hospitalist Performance Domains
Descriptive Metrics
Work Effort and Productivity
Clinical Quality
Resource Management
Service and Satisfaction
Financial
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Quality
Resources
Financial Service
Productivity
In Reality, There’s Lots of Overlap 10
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
11
12
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
13
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Management Reports – RVU Metrics
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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21
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
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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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24
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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
Coding Intensity 30
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
CPT Distribution 32
Management Reports – Key Performance Indicators
Operational Reports – Rejections and Denials Analysis
DATA/ANALYSIS CONSIDERATIONS
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Understand Your Environment
• Each organization has a unique culture, goals, priorities, operational habits – Terminology – Analytical methods
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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
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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
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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 44
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
How often will the dashboard be distributed? How best to show performance against targets?
Assign Responsibility
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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XYZ Hospitalist Group Page 1 - ProductivityABC Hospital For the month of: Jan-10
183 Total EKG interpretations 7.8% % of total encounters 148 Total shifts worked during the month337 Total stress tests 14.4% % of total encounters 12.9 Average billable encounter-equivalents per shift this month
26 Total bedside procedures 1.1% % of total encounters 11.0 Target billable encunter-equivalents per shift1,802 Total E&M and other encs 76.7% % of total encounters2348 Total encounters of all types
197
155
189 21
0
204 23
0
188
144
94 100
88
35
83
192
192
192
192
192
192
192
192
138
96 82 96 82
0
50
100
150
200
250Current Month Encounter-Equivalents vs. Target
Current Month Actual Monthly Target
388
203
360 41
0
344 40
4
365
255
175
168
145
50
152
345
345
345
345
345
345
345
345
248
173
148
173
148
050
100150200250300350400450
Current Month wRVUs vs. Target
Current Month Actual Monthly Target
1,916
1,412
0 0 0 0 0 0 0 0 0 00
500
1,000
1,500
2,000
2,500
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Total Encounter-Equivalents Trend
Target Total Enc-Equiv
3,419 3,298
0 0 0 0 0 0 0 0 0 00
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Total wRVUs Trend
Target Total Enc-Equiv
53 XYZ Hospitalist Group Page 2 - Revenue CycleABC Hospital For the month of: Jan-10
Monthly Statistics:
1.78 Average wRVUs per encounter-equivalent1.80 Target wRVUs per encounter-equivalent
15 Total "No Charge" or un-billed encounters0 Target "No Charge" or un-billed encounters
Quarterly Statistics:
Target Actual< 10% 16.1% Submitted claims that were rejected< 2% 1.8% "Clean" claims that were denied
> 85% 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
12%22%
15%4%
19%19%18%
26%13%
44%11%
26%10%
18%26%
59%64%
15%57%28%
33%38%
60%54%
32%40%
49%55%
46%57%
29%14%
69%39%
53%48%45%
14%33%
24%49%
26%35%
37%17%
0% 20% 40% 60% 80% 100%
Anne
Bruce
Charlie
Diana
Edgar
Freda
Geetha
Hank
Irene
Jack
Kareem
Lenny
Mark
Total This Qtr
Last Year
Quarterly CPT Code Distribution - Admissions
99221 99222 99223
59%35%
15%24%
28%33%33%
52%54%
29%33%
49%27%
34%38%
29%14%
69%68%
53%48%
40%17%
33%40%
40%26%
31%38%
56%
12%51%
15%8%
19%19%
27%31%
13%31%
26%26%
43%28%
6%
0% 20% 40% 60% 80% 100%
Anne
Bruce
Charlie
Diana
Edgar
Freda
Geetha
Hank
Irene
Jack
Kareem
Lenny
Mark
Total This Qtr
Last Year
Quarterly CPT Code Distribution - Subsequent Visits
99231 99232 99233
81%60%
85%73%
49%36%
63%21%
48%47%
54%65%
38%52%
76%
19%40%
15%27%
51%64%
37%79%
52%53%
46%35%
62%48%
24%
0% 20% 40% 60% 80% 100%
Anne
Bruce
Charlie
Diana
Edgar
Freda
Geetha
Hank
Irene
Jack
Kareem
Lenny
Mark
Total This Qtr
Last Year
Quarterly CPT Code Distribution - Discharges
99238 99239
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XYZ Hospitalist Group Page 3 - Quality IndicatorsABC Hospital For the month of: Jan-10
1.28 This month's case mix index74.2% This month's proportion of Medicare patients
89% Order set usage this month> 95% Target order set usage
86% VTE Risk Assessments Performed on Admission85% VTE Risk Assessment Target
92% Medication Reconciliation Complete on Discharge> 95% Medication Reconciliation Target
Core Measures:
77% "Heart Failure Discharge Instructions" performance100% "Heart Failure Discharge Instructions" target
45.0%
58.0%
82.0%
64.0%
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
DRG Assurance Query Response Trend
Target > 95% Query Response Rate
1.9% 2.2% 1.6% 1.7%
16.0%
12.6%
9.4% 8.8%
0.0%
5.0%
10.0%
15.0%
20.0%
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Readmission Rates Trend
72-Hr Readmissions 30-Day Readmissions
4.23.8
3.6
5.5
0
1
2
3
4
5
6
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Severity-Adjusted ALOS Trend
Target < 3.9 Average Length of Stay (Sev. Adj.)
$5,216$5,087$4,898 $4,630
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Severity-Adjusted Cost per Case Trend
Target < 4,249 Average Cost per Disch (Sev. Adj.)
55 XYZ Hospitalist Group Page 4 - Service IndicatorsABC Hospital For the month of: Jan-10
4.8 Current Physician Satisfaction Survey score> 4.5 Physician Satisfaction Survey score target
4.4 Current Nursing Satisfaction Survey score> 4.5 Nursing Satisfaction Survey score target
0 Number of patient complaints this month0 Patient complaints target
58.0%
68.0%61.0%
54.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Percent of Discharge Orders Written by 10A
Disch Orders by 10A Target 60%
72.0%
85.0% 88.0% 90.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Percent of Discharge Summaries Complete at Discharge
D/S Complete @ Discharge Target 85%
52% 48%56%
62%
0%
20%
40%
60%
80%
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Press Ganey Patient Satisfaction Scores
"Physician" Question %tile Rank Target
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Source: Measuring Hospitalist Performance: Metrics, Reports and Dashboards, Society of Hospital Medicine 2006
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Source: Crimson – a product of The Advisory Board
• 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, team-building and leadership development, patient experience training
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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
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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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How Can We Help?
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Contact Us Leslie Flores
Partner Nelson Flores Hospital Medicine Consultants
760-771-3323 [email protected]
www.nelsonflores.com
Mimi Thornton Regional Mgr., Southwest
Ingenious Med, Inc. 678-501-6237
[email protected] www.ingeniousmed.com
Ron Anderson Director
CHMB Inc. 760-520-1340
[email protected] www.chmbinc.com
