Post on 29-Aug-2020
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NRG’s UnleashedDiegem November 27, 2014
Marie-Laurence de Lannoy
Luc Van Aken
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Agenda
� NRG definition
� Attribution of NRG to Nurse Care Periods (NCP’s)
� Relative Weigths
� Market Share
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Abreviations
� NCP = Nursing Care Period / Zorgepisode / Episode de soin
� NRG = Nursing Related Group
� PI = Principal Indicator
� SI = Secondary Indicator
� RW = Relative Weights / Relatieve Gewichten / Poids Relatifs
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NRG definitionNurse Care Profile per NRG
STEP 1:
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� Nurse Care Periods (NCP) – 3 groups
� 24 hour NCP
� < 24 hour NCP without transfers (short stay)
� < 24 hour NCP – transfer (transfer)
� NRG’s for
� 24 hour NCP’s – 21 NRG’s
� < 24 hour NCP’s – 11 NRG’s
� For < 24 hour NCP’s – transfer : 31 (20+11) NRG’s are applicable (differentation in Relative
Weight)
NRG Definition
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� An NRG is the Care Profile for a selected group of NCP’s in comparison with the
Global Care Profile
� Define the Global Care Profile (24 hour NCP / <24 hour NCP)
� Selections of NCP’s per NRG
� The Care Profile is calculated for each selection of NCP’s / for each NRG
� For these selections of NCP’s / NRG’s, the Care Profile is compared with the Global Nurse
Care Profile
� RIDIT methodology to define the Care Profiles and compare them
NRG Definition
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NRG Definition – Selections24 hour NRG’s
NRG Prefix
nurse unit
Bedindex Additional criteria
L1 - Surgical
Intensive Care
INT CI, HI 1. Type of DRG = S (surgical) or (if DRG unknown) stay in OK
(prefix nurse unit = OPR and bedindex = OP) during the stay
2. Age on admission >= 14 years
L2 – Non-surgical
Intensive Care
INT DI, HI 1. Type of DRG is not S (surgical) or (if DRG unknown) no stay
in OK (prefix nurse unit = OPR and bedindex = OP) during the
stay
2. Age on admision >= 14 years
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NRG Definition – Selections24 hour NRG’s
NRG Prefix Nurse
Unit
Bedindex Additionnal criteria
L3 – Pediatric Intensive Care INT EI Age on admission between 29 days and 18 year
L4 – Neonatale Intensive Care INT NI Age on admission <= 28 days
L5 – Care for complicated wounds BRU BR
L6 – Obstetric care on day of delivery
(mothers)
DIV AR, OB, M,
MI
Day of delivery
L7 – Maternity Care DIV M 1. At least 1 item of W100, W200, W300, W400
during the stay
2. W100 or W200 not scored during the NCP
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<24 Hour NRG’s (not transfers)
NRG Prefix Nurse
Unit
Bedindex Additionnal criteria
S1 - preoperative care NCP before passing OR
S2 - postoperative care NCP after passing OR
S3 - care in recovery OPR Day of passing OR
S4 – obstetric care – day of delivery
(mother)
DIV AR, OB Day of delivery (mother)
S5- prenatal obstetric care (mother) DIV AR, OB W100 or W200 scored during the NCP and W400
not scored during the NCP
S6 – postnatal obstetric care (mother) DIV AR, OB W100 and W200 not scored during the NCP and
W400 scored during the NCP
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<24 Hour NRG’s (transfers)
NRG Prefix
nurse unit
Main
Bedindex
Additional criteria
T1 - Surgical Intensive Care INT CI, HI 1. Type of DRG = S (surgical) or (if DRG unknown) stay in OK
(prefix nurse unit = OPR and bedindex = OP) during the stay
2. Age on admission >= 14 years
T2 – Non-surgical Intensive
Care
INT DI, HI 1. Type of DRG is not S (surgical) or (if DRG unknown) no stay
in OK (prefix nurse unit = OPR and bedindex = OP) during
the stay
2. Age on admision >= 14 years
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Cleaning Data
� The NCP’s with an extreme low (or extreme high) number of nursing items are
excluded from the definition of the NRG care profile.
� Extreme low (and extreme high) – defined by NRG
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Frequency Items
� Items for which the score reflects the number of times (occurence) that the item is
performed.
� The frequency items are:
― B300, D200, E100, E200, E300, E400, F400,F500, H100,H200, H300, H400, H500, I100,
L100, L200, L300, L400, L500, N100, N200, N300, N400, N500, V200, V300, V400, V500,
W200, W400, Z200
� The score categories are defined differently for each item based on the real data
of the hospitals
� The RSI values and RIDITS are calculated per item and per score category.
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Compressing from 91 Items to 78 Items
� Some items are grouped under 1 item following time-competence weights
― B200 : B210 - B250
― B400 : B410 – B440
― C100 : C110 – C120
― D100 : D110 – D130
― F100 : F110 – F120
― R100 : R110 – R130
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� Ridit Score (globally)
� Calculation of the ridit score (RSI) per item per score for all NCP’s
(no selection, distinction between 24 hour NCP’s / <24 hour NCP’s)
� This Ridit Scores (RSI) are the base for the calculation of the RIDIT values of each item
within each NRG
RIDIT Methodology
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� Example of Ridit Score (globally)
� 10.000 NCP’s
� Item A100
• Not scored (value 0) : 8.000 NCP’s (80%)
• Scored (value 1) : 2.000 NCP’s (20%)
� RIDIT score for item A100
• Value 0 : (0 + 8.000/2) / 10.000 = 0,40
• Value 1 : (8.000 + 2.000/2) / 10.000 = 0,90
RIDIT Methodology - RSI
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� RIDIT value (within NRG)
� For a selection of NCP’s (f.i. Geriatrics) – 200 NCP’s
• A100
– Not scored (value 0) : 180 NCP’s (90%)
– Scored (value 1) : 20 NCP’s (10%)
• RIDIT for item A100 for Geriatrics
– ( (180 * 0,40) + (20 * 0,90) ) / 200 = 0,45
• RIDIT less than 0,5 = A100 less performed in geriatrics than globally
RIDIT Methodology - RIDIT
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� RIDIT value (within NRG)
� For another selection of NCP’s (f.i. SP neuro) – 200 NCP’s
• A100
– Not scored (value 0) : 20 NCP’s (10%)
– Scored (value 1) : 180 NCP’s (90%)
• RIDIT for item A100 for SP
– ( (20 * 0,40) + (180 * 0,90) / 200) = 0,85
• RIDIT higher than 0.5 = A100 more performed in SP than globally
RIDIT Methodology - RIDIT
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� Calculation of Ridit Score (RSI) values for every nurse item for every score value
for the whole group of NCP’s
� Selection of groups of NCP’s for each NRG
� Calculation of the Ridit value for every nurse item for the selected group of
NCP’s for each NRG
� Definition of the Care Profile for each NRG based on those RIDIT values
� Orange = more performed than globally (RIDIT > 0.5)
� Grey = less performed than globally (RIDIT < 0.5)
3M Online Benchmark Portal: NRG profiles
NRG Definition
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� Calculation of the Principal Indicator for every NCP used to define the Care Profile of the NRG:
Average [ RIDITOrange + (1 - RIDITGrey) ]
� Formula of PI for NRG Geriatrics
= average [ RIDITA100 + (1 - RIDITB100) + … + RIDITZ300 + RIDITZ400 ]
NRG Definition – Principal Indicator
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� Example for NRG Geriatrics and 2 NCP’s
NRG Definition – Principal Indicator
NRG G RIDIT NCP 1 RIDIT NCP 2
A100 0.55 0,45
B100 0.45 0,55
B200 0.51 0,49
Z200 0.30 0,70
Z300 0.70 0,30
Z400 0.60 0,40
Principal Indicator 0,60 0,40
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� For every NRG
� Calculation of the Principal Indicator for every NCP used to define the Care Profile of the NRG
� Fix the P25, P50 and the P75 values of the Principal Indicators for each NRG (Boxplot of each NRG)
� These PXX values will be used later in the assignment of the class to each NRG for each NCP.
NRG Definition – Principal Indicator and Boxplot
NRG 1 NRG 2 NRG 3
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� In some cases the calculation of the Principal Indicator will not be enough to
assign a unique NRG to each NCP (see later).
� In that case, calculation of a Secondary Indicator will be needed.
� To calculate the Secondary Indicator, a selection of items will be retained based
on the extreme RIDIT values of the items within an NRG
� The most specific items : extremely more performed than globally
� The most non-specific items : extremely less performed than globally
3M Online Benchmark Portal: NRG profiles - Items and Ridit values
NRG Definition – Secondary Indicator
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� List of NRG’s defined
� For each NRG
� Profile of items to calculate the Principal Indicator
� Boxplot to assign a class of correspondence
� Profile of items to calculate the Secondary Indicator
NRG Definition - Result
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Attribution of NRG to Nurse Care Periods (NCP’s)One unique NRG for each NCP
STEP 2:
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� For each NCP in the hospital, for each of the 31 NRG’s: calculation of the Principal Indicator (after application
of some limitations)
� Based on the P25, P50, P75 values of the Principal Indicator of each NRG (as previously described),
a class of correspondence is defined:
• If PI < P75 , class =3
• If P50 < PI < P75, class = 2
• If P25 < PI < P75, class = 1
• If PI < P25, class = 0
3M Online Benchmark Portal:Comparison of NRG's and hospital's care profiles
Assignment of NRG to Nurse Care Periods (NCP’s)
NRG 1 NRG 2 NRG 3
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Assignment of a NRG to a NCP
� 24h NCP’s � 24h NRG’s
� < 24h NCP’s � < 24h NRG’s
� For NCP’s with less than a minimum number of items (FOD/SPF 2011 : 3), no
NRG is calculated. To those NCP’s the NRG NULL is assigned.
� Further limitations are applied on the NRG’s that can be assigned to a NCP (see
next slides)
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Further Limitations
NRG Age Further limitation
1 >= 1 year
2 >= 1 year
3 <= 18 years
4 < 1 year
5 >= 1 year The NCP is not in class 1 or higher for one of the NRG’s 1-4
6 >= 1 year At least 1 item under W100, W200, W300, W400 during the stay
7 >= 1 year At least 1 item under W100, W200, W300, W400 during the stay
8 >= 1 year At least 1 item under W100, W200, W300, W400 during the stay
9 < 1 year
10 < 1 year During the NCP at least 1 item under V200, V300, V400 with a score higher than the average of
the reference poupulation
11 <= 18 year
12 >= 1 year
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Further Limitations
NRG Age Further limitation
13 >= 1 year
14 >= 60 years
15 >= 1 year
16 >= 1 year
17 >= 1 year
18 >= 1 year
19 >= 1 year
20 >= 1 year
21 >= 60 years
22 Not the last period of the stay
23 Not the first period of the stay and not in a nurse unit with prefix OPR
24
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Further Limitations
NRG Age Further limitation
25 >=1 year At least 1 item under W100, W200, W300, W400 during the stay
26 >=1 year At least 1 item under W100, W200, W300, W400 during the stay
27 >=1 year At least 1 item under W100, W200, W300, W400 during the stay
28 < 1 year Not the last NCP of the stay
29 Not the last NCP of the stay
30 Last NCP of the stay
31 < 1 year Not the first period of the stay
32 Not the first period of the stay
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Priority
� After the calculation of the PI values per NCP per NRG
� Distinction in application between NRG’s 1-5 and NRG’s 6-32
― For NRG’s 1-5 (intensive care NRG’s),
• The PI value of the NCP must be >= minimum value of the PI in the group on which the NRG is defined
• If the PI value < minimum PI value, the NRG can not be assigned to the NCP
― For all NRG’s 6-32 (non-intensive care NRG’s)
• The PI value must be >= average RIDIT for the NCP
• If the PI value < average RIDIT for this NCP, the NRG can not be assigned to the NCP
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� Within NRG’s retained after application of the LIMITATIONS and the PRIORITY
� The NRG with the highest class for the PI value is assigned to the NCP
� After application of all these rules, there are 3 possibilities
• There is only 1 NRG in the highest class : assign this NRG
• There are more than 1 NRG in the same highest class : calculate the SI and assign
based on the SI
• There is no NRG after appliation of the priority rules : calculate the SI for the NRG’s which
are applicable and assign the NRG with the highest SI value, calculate the PI value of this
assigned NRG and define the class
Assignment of NRG to Nurse Care Periods (NCP’s)
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� To each NCP, there is an NRG and a class assigned
Attribution of NRG - Result
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Relative WeightsBased on the results of the Delphi Study
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� Based on the Delphi study, POINTS are calculated for each Nurse Item for each
score following:
� The time necessary to perform the item
� The competence necessary to perform the item
� The Relative Weights of the NRG’s are calculated based on the Delphi points for
the nurse profile of the NCP’s assigned to the NRG’s (>< NCP’s selected to
define the NRG’s)
Relative Weights
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Relative Weights
� Example : 2 NCP’s for NRG 12 - class 1.
� For NCP 1 we found
― A100 – score 1
― B500 – score 1
― D200 – score 4
� The weighted scores for NCP 1
― A100 : 5,46
― B500 : 2,73
― D200 : 29,12
― Total : 37,31
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Relative Weights
� For NCP 2 we found
― A100 – score 1
― B440 – score 2
― D500 – score 2
� The weighted scores for NCP 2
― A100 : 5,46
― B440 : 4,85
― D500 : 3,64
― Total : 13,95
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Relative Weights
� The average of the weighted scores of NRG 12 – class 1 : (37,31 + 13,95)/2 =
25,63
� Relative weight of NRG 12 – class 1 = 25,63
� This is the relative weight allocated to each NCP to which NRG 12 – class 1 is
assigned.
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3M Online Benchmark Portal: Relative weights per observation day
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Market shareImpact on financing
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� Which hospital needs complementary resources because the nurse activity is
higher, more intensive, …. than ‘on average’?
� At this moment (financing 2014-2015) limited to CD, E, I
� Group CD
• All NCP’s in a nurse unit with prefix DIV and linked to bedindex C, D, CD, (L)
• Exclusion of NCP’s to which an Intensive NRG is assigned (see further for defintion)
� Group E
• All NCP’s in a nurse unit with prefix DIV and linked to bedindex E
• Exclusion of NCP’s to which an Intensive NRG is assigned (see further for defintion)
Market Share
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� Group I
• All NCP’s in nurse units with prefix INT or other nurse units which are linked to CI, DI, EI, HI
• All NCP’s excluded from the 2 previous groups because an Intensive NRG is assigned to these NCP’s
Market Share
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Financing
� How to define ‘Intensive NRG’ to exclude NCP’s from group CD or group E and
assign them to group I?
― We look for the 24 hour NRG to the lowest relative weight for NRG 1-5 class 1.
― For instance, when we look at the results of the FOD/SPF, the lowest relative weight for
NRG 1-5 class 1 (24 hour NRG’s) is 107.
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Financing
� This means that all NCP’s (in CD or E) to which there is assigned a NRG (1-5)-
class with a relative weight equal to or higher than 107 are excluded from group
CD or group E and assigned to group I.
� In the results of the FOD/SPF, it means that NCP’s with a NRG (1-5)-class in
RED will be excluded from the first two groups and assigned to group I
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� Calculation of Relative Weight per observation day per patient
� Calculation of the median of the relative weights per observation day for bed
index CD (over all hospitals)
� Calculation of the difference between the relative weight and the median for each
hospital, for each observation day, for bed index CD
� If negative difference (relative weight < median), ignore
� If positive difference (relative weight > median), retain for further calculations
Market Share – Next Steps
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Bed index CD
Median CD
RW per patient per observation day
Observation days
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Median CD
Median INT
Bed index INTRW per patient per observation day
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� Sum all positive differences (RW – Median bed index CD) for the hospital
= Hospital Positive Difference
� Sum all positive differences of all hospitals
= Total Positive Difference
� Calculate the Market Share of each hospital
Market Share = Hospital Positive Difference / Total Positive Difference
� Market Share = share of the budget to be allocated
� Application (transition from ‘old’ system to ‘new’ system) will be spread over
several years (3?)
Market Share
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NRG – The Future
�NRG’s are developed for hospital financing
�BUT NRG’s open new possibilities
― Comparing and evaluating nurse profiles and nurse needs
• Between nurse units (intrahospital and interhospital)
• Between APR-DRG’s (pathologie)
• Between patients – visits within a same APR-DRG
― Calculation of nurse need per patient – visit and comparison with real nurse time allocation
― Allocation of nurse costs to patients – visits, a new step in the cost calculation of patients
― Planning admissions and nurse allocation
― …
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Questions?