Performance Monitoring and
Dashboards for Hospitalists
Leslie Flores MHA, SFHM
Housekeeping
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Questions?
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– We will wait and address questions at the end of the
session.
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Copies of the slide set will be available via the
CHMB website at
www.chmbinc.com
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For questions, contact Lacey Buquet at
Leslie Flores MHA, SFHM
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Former hospital executive in
Southern California
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Partner, Nelson Flores
Hospital Medicine Consultants
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Advisor to the Society of
Hospital Medicine for practice
management issues
Agenda
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Why is it important to have a formal
performance monitoring process?
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What types of metrics should you be
measuring?
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Key data and analysis considerations
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Steps in developing a dashboard
Why Have a Dashboard, Report Card,
Performance Report, etc.?
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Understand how you’re performing
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Reduce variation
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Demonstrate value
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Identify trends
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External comparisons
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Reward good performance
Performance Report, etc.?
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To drive change
– Identify areas for improvement – Hawthorne effect
Decide what to measure Set targets Generate and analyze reports Distill key indicators into a dashboard Develop an action plan
Suggested Approach
7WHAT TO MEASURE?
Take a Balanced
Approach
Key Hospitalist Performance Domains
Descriptive Metrics
Work Effort and Productivity Clinical Quality
Resource Management Service and Satisfaction Financial
Quality
Resources
Financial
Service
Productivity
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
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
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
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
Quality
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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
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
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
Resource Management
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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.
Service and Satisfaction
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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
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Patient complaints
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Satisfaction surveys
Financial
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Hospitalist program cost center
– Performance to budget
– Financial support/stipend/loss per FTE
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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
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
DATA/ANALYSIS CONSIDERATIONS
Understand Your Environment
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Each organization has a unique culture,
goals, priorities, operational habits
– Terminology
Understand Data Sources and
Limitations
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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
Limitations
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Limitations
– Completeness and accuracy of inputs – Reliability of reporting methodologies
• Attribution issues
– Availability and timeliness – Sample size
Decide What Types of Analyses
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Individual vs. group?
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Snapshot vs. trend?
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Comparison to . . .
– Internal peer group? External peer group? Survey data? Established target?
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Statistical analysis options
– Average vs. median
– Arithmetic mean vs. geometric mean
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
Blinded or Un-blinded?
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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
What To Do With All This Information?
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High-level assessment
– Is this a plausible representation?
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What does this information
mean for your practice?
– Opportunities for improvement – Is the information actionable?
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Distill key metrics into a
dashboard or report card
CREATING YOUR DASHBOARD
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?
Creating a Dashboard
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Pick a handful of key indicators (10 – 15)
– Important to hospitalists AND stakeholders – Readily measurable
– Consistently available – Seen as valid
Creating a Dashboard
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Make it simple, short and attractive
– Show results graphically where possible
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Ensure the dashboard is regularly produced
– Routinely distributed to all hospitalists and key stakeholders
• “Push” vs. “pull”
Just Do It!
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Precise metrics and format are important –
but the most important thing is to
have
a
dashboard
– And that it is updated and distributed regularly
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Don’t let uncertainty about metrics and
format paralyze you
Common Challenges
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Consistent access to meaningful, reliable,
timely data
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Who “owns” dashboard production?
– Manual work to produce the dashboard
• Look for IT solutions
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Ensuring the dashboard serves as a stimulus
to action
– Build in accountability mechanisms
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 12.9Average 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
19 7 15 5 18 9 210 204 23 0 18 8 14 4 94 100 88 35 83 19 2 19 2 19 2 19 2 19 2 19 2 19 2 19 2 13 8 96 82 96 82 0 50 100 150 200
Current Month Actual Monthly Target
38 8 20 3 36 0 41 0 34 4 40 4 36 5 25 5 17 5 16 8 14 5 50 15 2 34 5 34 5 34 5 34 5 34 5 34 5 34 5 34 5 24 8 17 3 14 8 17 3 14 8 0 50 100 150 200 250 300 350 400
450 Current Month wRVUs vs. Target
Current Month Actual Monthly Target
1,916 1,412 0 0 0 0 0 0 0 0 0 0 0 500 1,000 1,500 2,000 2,500
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Target Total Enc-Equiv
3,419 3,298 0 0 0 0 0 0 0 0 0 0 0 500 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
53
XYZ Hospitalist Group Page 2 - Revenue Cycle
ABC Hospital For the month of: Jan-10
Monthly Statistics:
1.78Average wRVUs per encounter-equivalent 1.80 Target wRVUs per encounter-equivalent
15Total "No Charge" or un-billed encounters 0 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
$48.37Average 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
74.2% This month's proportion of Medicare patients
89%Order set usage this month > 95% Target order set usage
86%VTE Risk Assessments Performed on Admission 85% VTE Risk Assessment Target
92%Medication Reconciliation Complete on Discharge > 95% Medication Reconciliation Target
Core Measures:
77%"Heart Failure Discharge Instructions" performance 100% "Heart Failure Discharge Instructions" target
45.0% 58.0% 82.0% 64.0% 0% 20% 40% 60% 80%
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
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
4.2 3.8 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
55
XYZ Hospitalist Group Page 4 - Service Indicators
ABC Hospital For the month of: Jan-10
4.8Current Physician Satisfaction Survey score > 4.5 Physician Satisfaction Survey score target
4.4Current Nursing Satisfaction Survey score > 4.5 Nursing Satisfaction Survey score target
0Number of patient complaints this month 0 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
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• 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
• 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
59
• 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 Mimi Thornton Regional Mgr., Southwest
Ingenious Med, Inc.
678-501-6237 mimi.thornton@ingeniousmed.com www.ingeniousmed.com Ron Anderson Director CHMB Inc. 760-520-1340 ron@chmbinc.com www.chmbinc.com
