Data Collection and Quality Management

Aim: To explain the DRG funding system and its relationship to quality

management

Diagnosis Related Groups (DRGs)

• A patient classification system which provides a means of relating the type of inpatients a hospital treats (ie. its Casemix) to the costs incurred

Bed Ratio (1995)

• Aust. 4.3 per 1000 of pop.

• UK - 2.1 per 1000 of pop

• Netherlands 4.1; Denmark 4.1

• France 5.0; Germany 7.2

• Since 1985 fall in bed ratio in public and private sectors

In the Past, Hospital Billing on the Basis of:

• Number of days in hospital

• Category of care

• Category of hospital (A,B,C,D)

• Type of procedure (Cwth Medical Benefit Schedule)

• Other specialist tests billed separately

Casemix requires recording of the following patient

information:• Name of patient

• Admission date

• Principle diagnosis (at discharge)

• Other diagnoses

• Operating room procedures

• Other surgical procedures

• Discharge date and status

Changed Incentives

• Old system provides economic incentives to keep patient in hospital

• New system provides incentives to reduce patient stay

DRG data collection allows:

• Comparison of outcome quality and comparison of costs

• Hospital performance comparisons

• Ward performance comparisons

• Doctor performance comparisons

Casemix Advantages

• More information to assess quality and outcome

• Potential for more accountability and equity in the distribution of the health $

• Greater knowledge and choice for health consumers

Classifications can help:

• Indicate whether re-admission rates are abnormally high

• Find and fix problems of poor outcome for rehabilitation patients

• Decide how resources should be allocated between hospitals and departments

• Planning bed and staff numbers for new facilities

Need for Effective Data Input (the Auditor General of Vic.

found:• Patient medical records not updated and

endorsed by VMOs

• Checking of VMO claims infrequent

• Treating of private patients during publicly funded theatre sessions

• Overservicing related to pre and post-operative consultations

Access Indicators

• Waiting times for elective surgery

• Accident and emergency waiting times

• Outpatient waiting times

• Variations in intervention rates

• Separations per 100000 of population

Quality Indicators

• Rate of emergency patient readmission within 28 days of separation

• Rate of hospital acquired infection

• Rate of unplanned return to theatre

• Patient satisfaction

• Proportion of beds accredited by the Aust. Council on Healthcare Standards

Quality Indicators

• Unplanned readmissions

• (0.8% in ACT - 6.3% in NT)

• Return to operating theatre

• (0.1% in Tas. - 4.2% in NT)

• Hospital acquired bacteraemia

• (0.03% in SA - 0.3% in Tas)

• ACHS Accreditation (16% Qld - 64%NSW)

Pathways of Care Assist Quality management

A pathway is a staged plan that notes the appropriate use and timing of procedures in relation to patient

recovery

Developing a pathway

• Practitioner team select a client group or case type

• Set a time frame (e.g. arrival at hospital to 6 months after discharge)

• Map out typical expected care • Set up plans and record deviations for

individual patients• Evaluate outcome

Pathways Help Identification and Control of Risk

• Risk is the potential for an unwanted outcome

• Risk management is about the prevention of unwanted outcomes through providing quality care; preventing untoward events and gaining comprehensive, objective, consistent and accurate communication

Integrated Care Management

• Multidisciplinary approach to pathway development

• Involve patients and their carers

• Variance from the pathway is to be expected and must be documented

Benefits of Pathways

• Reduces patient uncertainty and makes them and the family partners in care

• Eliminates duplication and unexplained variation in clinical practice of team

• Improves resource utilisation and communication

• Enables multidisciplinary audit through goal setting, outcome monitoring and variance tracking

Pathways are a research tool

• Pathways allow information about typical and atypical treatments or groups of patients to be gathered as a result of a combined research and service delivery process

• They can be used by a single group, by two organisations comparing practices, or at a much broader level, to continuously improve practice

The Quality in Aust. Health Care Study

• Reviewed over 14000 patient admissions in 28 hospitals in NSW and SA

• Found 16.6% involved an adverse event; half of which were assessed as highly preventable

• Compares with the Harvard Medical Practice Study which reviewed 30,000 records and found 3.7% adverse events

Screening Criteria

• Unplanned readmission within 28 days3.4%

• Death or cardiac arrest 1.7%

• Transfer to acute care facility 2.8 %

• Transfer to intensive care unit 1.1%

• Booked theatre cases cancelled 0.6%

• Length of stay more than 35 days 0.4%

• Return to operating theatre within 7 days 0.4%

Follow-up

• Change relevant hospital policy

• Present case at postgraduate meeting

• Undertake a quality assurance program

• Discussion or counselling of doctor

• Review of the doctor’s clinical privileges or reporting the cases to the hospital’s insurer

Policy changes included:

• Restricting some drug prescribing

• Revised protocols for reporting vital signs

• Eliminating use of multidose drug vials

• Guidelines re fitness for anaesthesia

• Protocols for managing patients with alcohol withdrawal, haematemesis and malaena, and cerebrovascular accident

NSW Health Care Complaints Act 1993

• A complaint may be made to the Health Care Complaints Commission concerning:

• Professional conduct of a health practitioner, a health service or a health provider, even though at the time the complaint is made the provider is not qualified or entitled to provide the service concerned

A Complaint may be made by:

• Anybody, including the client concerned

• a parent or guardian of the client

• a person chosen by the client for the purposes of making the complaint

• a health service provider

• a member of Parliament

• the Director-General or the Minister

Referral of Complaint

• The Commission may refer a complaint to another person or body for investigation if further information is required

The Need for Reliable, Transparent Outcome Data

• Need for a longitudinal patient record (patient held ‘smart cards’) for Medicare record

• Need for access by service purchasers and by patients to information about service contractors and their outcomes

• Provide for a duty of care/duty to inform and place confidentiality requirements in codes of practice?

A National Risk Management Approach

• Health act where the health practitioner has a duty of care and duty to inform

• Maintain the system of universal health care provision and government price control through the CMBS

• Use Medicare as the spine for data driven quality management

• Coordinate all health service delivery