Performance Monitoring and Dashboards for Hospitalists

Performance Monitoring and Dashboards for Hospitalists Leslie Flores MHA, SFHM April 29 and 30, 2014

2 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 ron@chmbinc.com

3 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.? 5 Understand how you re performing Reduce variation Demonstrate value Identify trends External comparisons Reward good performance

Why Have a Dashboard, Report Card, Performance Report, etc.? 6 To drive change Identify areas for improvement Hawthorne effect

7 Suggested Approach Set targets Generate and analyze reports Distill key indicators into a dashboard Develop an action plan Decide what to measure

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 Resources Service 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

13 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

16 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)

17 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

18

19 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

20 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

21

22 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.

24

25

26 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

27 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

Source: Society of Hospital Medicine s 2012 State of Hospital Medicine Report 28

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 35

36 Understand Your Environment Each organization has a unique culture, goals, priorities, operational habits Terminology Analytical methods

Understand Data Sources and Limitations 37 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

Understand Data Sources and Limitations 38 Limitations Completeness and accuracy of inputs Reliability of reporting methodologies Attribution issues Availability and timeliness Sample size Sheer volume of data

39 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

42 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

CREATING YOUR DASHBOARD 43

Creating Your Dashboard 44

45 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?

46 Creating a Dashboard Pick a handful of key indicators (10 15) Important to hospitalists AND stakeholders Readily measurable Consistently available Seen as valid Actionable

47 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

48 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

49 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

50

51

Page 1 - Productivity XYZ Hospitalist Group ABC Hospital For the month of: Jan-10 250 200 150 100 50 0 Current Month Encounter-Equivalents vs. Target Total Encounter-Equivalents Trend 2,500 197 155 189 210 204 230 188 192 192 192 192 192 192 192 144 192 94 138 100 88 83 96 82 35 96 82 2,000 1,500 1,000 500 0 Current Month Actual Monthly Target 1,916 1,412 0 0 0 0 0 0 0 0 0 0 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Target Total Enc-Equiv 52 450 400 350 300 250 200 150 100 50 0 388 345 203 345 360 345 Current Month wrvus vs. Target 410 345 344 345 404 345 Current Month Actual 365 345 255 345 175 248 168 173 Monthly Target 145 148 50 173 152 148 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 Total wrvus Trend 3,419 3,298 0 0 0 0 0 0 0 0 0 0 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Target Total Enc-Equiv 183 Total EKG interpretations 7.8% % of total encounters 148 Total shifts worked during the month 337 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 shift 1,802 Total E&M and other encs 76.7% % of total encounters 2348 Total encounters of all types

Page 2 - Revenue Cycle XYZ Hospitalist Group ABC Hospital For the month of: Jan-10 Quarterly CPT Code Distribution - Admissions Quarterly CPT Code Distribution - Subsequent Visits Last Year Total This Qtr Mark Lenny Kareem Jack Irene Hank Geetha Freda Edgar Diana Charlie Bruce Anne Last Year Total This Qtr Mark Lenny Kareem Jack Irene Hank Geetha Freda Edgar Diana Charlie Bruce Anne 10% 11% 4% 18% 13% 18% 15% 12% 19% 26% 19% 26% 26% 22% 44% 15% 40% 33% 28% 57% 55% 38% 46% 54% 59% 49% 57% 60% 64% 32% 69% 49% 48% 53% 45% 37% 35% 33% 39% 26% 24% 29% 17% 14% 14% 0% 20% 40% 60% 80% 100% 21% 99221 99222 99223 Quarterly CPT Code Distribution - Discharges 38% 36% 52% 47% 54% 48% 49% 65% 63% 60% 76% 73% 85% 81% 79% 62% 64% 48% 53% 46% 52% 51% 35% 37% 40% 24% 27% 15% 19% 0% 20% 40% 60% 80% 100% 99238 99239 Last Year Total This Qtr Mark Lenny Kareem Jack Irene Hank Geetha Freda Edgar Diana Charlie Bruce Anne 15% 27% 29% 28% 24% 34% 33% 33% 33% 35% Monthly Statistics: 38% 1.78 Average wrvus per encounter-equivalent 1.80 Target wrvus per encounter-equivalent 15 Total "No Charge" or un-billed encounters 0 Target "No Charge" or un-billed encounters Quarterly Statistics: 49% 54% 52% 59% 31% 14% 40% 38% 40% 69% 40% 48% 53% 17% 68% 26% 56% 33% 51% 29% 43% 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 28% 26% 26% 31% 31% 27% $48.37 Average net professional fee collections per wrvu $50.00 Target net professional fee collections per wrvu 13% 19% 19% 15% 6% 8% 12% 0% 20% 40% 60% 80% 100% 99231 99232 99233 53

Page 3 - Quality Indicators XYZ Hospitalist Group ABC Hospital For the month of: Jan-10 DRG Assurance Query Response Trend 1.28 This month's case mix index 100% 82.0% 74.2% This month's proportion of Medicare patients 80% 64.0% 58.0% 89% Order set usage this month 60% 45.0% > 95% Target order set usage 40% 54 86% VTE Risk Assessments Performed on Admission 85% VTE Risk Assessment Target 92% Medication Reconciliation Complete on Discharge > 95% Medication Reconciliation Target Core Measures: 20% 0% 6 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Target > 95% Query Response Rate Severity-Adjusted ALOS Trend 5.5 77% "Heart Failure Discharge Instructions" performance 100% "Heart Failure Discharge Instructions" target 5 4 3 4.2 3.8 3.6 2 1 0 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Target < 3.9 Average Length of Stay (Sev. Adj.) 20.0% Readmission Rates Trend $6,000 $5,216 $5,087 $4,898 $4,630 Severity-Adjusted Cost per Case Trend 15.0% 10.0% 16.0% 12.6% 9.4% 8.8% $5,000 $4,000 $3,000 5.0% 1.9% 2.2% 1.6% 1.7% $2,000 $1,000 0.0% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec $0 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 72-Hr Readmissions 30-Day Readmissions Target < 4,249 Average Cost per Disch (Sev. Adj.)

Page 4 - Service Indicators XYZ Hospitalist Group ABC Hospital For the month of: Jan-10 Percent of Discharge Orders Written by 10A 55 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 68.0% 61.0% 58.0% 54.0% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Disch Orders by 10A Target 60% Percent of Discharge Summaries Complete at Discharge 100.0% 85.0% 88.0% 90.0% 80.0% 72.0% 60.0% 40.0% 20.0% 0.0% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec D/S Complete @ Discharge Target 85% 80% 60% 40% 20% 52% Press Ganey Patient Satisfaction Scores 62% 56% 48% 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% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec "Physician" Question %tile Rank Target 0 Number of patient complaints this month 0 Patient complaints target

Source: Measuring Hospitalist Performance: Metrics, Reports and Dashboards, Society of Hospital Medicine 2006 56

Source: Crimson a product of The Advisory Board 57

58 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

59 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? 60 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

61 Contact Us Leslie Flores Partner Nelson Flores Hospital Medicine Consultants 760-771-3323 leslie.flores@nelsonflores.com www.nelsonflores.com Ron Anderson Director CHMB Inc. 760-520-1340 ron@chmbinc.com www.chmbinc.com Mimi Thornton Regional Mgr., Southwest Ingenious Med, Inc. 678-501-6237 mimi.thornton@ingeniousmed.com www.ingeniousmed.com