Acute Care Productivity Measurement, System Next Steps / Recommendations
CSM 2017 San AntonioFebruary 17, 2017
Jim Dunleavy PT, DPT, MSChair, Academy of Acute Care Task Force on
Productivity/ValueMary Sinnott PT DPT MEd
Committee Member
Outline Review:
Key Elements of 2015 member survey Review key points of the Academy position/ Task
Force Definitions Critical Thinking Clinical Decision Making Review updated measurement system Share the findings from recent use of the new
measurement system Share Task Force Recommendation to the
Academy Board / Next Steps Your input
Task Force Late 2012
New Task Force charged with trying to find a way to help members with the issues related to Productivity, building on the work of the first Task Force
Task Force Members Jim Dunleavy PT, DPT,
MS Chair Gina Surgenor PT Lori Pearlmutter PT Mary Pyfferoen PT Maureen Eaton PT Ed Dobrzykowski PT Daniel Dziadura PT Mary Sinnott PT
Key points from 2015 Member Survey
We wanted to see if our approach, definitions and potential outcome tool elements were understood and generally accepted by practitioners most likely to use it
Survey of membership in Feb-March 2015 591 respondents
98% PT 2% PTA 52.4% Staff PT 9.8% Supervisor 31.5% Manager/Director 53 respondents labeled themselves under 30+ other job titles
77% had 5-20+ years experience in acute care
Current Status: From Acute Care Survey Feb-March 2015 58% of those surveyed indicated their facility was
using an outside consultant for productivity measurement
Current Status: Measuring/Benchmarking in the Dark…. We have just been told that we are now going to be compared to
other "similar" facilities using xxxxxx, but they have declined to tell us which facilities we are being compared to.
I would appreciate some truthful and honest feedback about xxxxx.
Do you know what facilities you are matched with?Do you feel that the stats accurate reflect your performance and, dare I say, productivity?
How do you weigh evals? Do you do 15 minute increments weighted as "1", or is a single charge, one time weight of say "4" equivalent to 60 minutes of time? Do your reevals weigh 2 or 3?
And any additional information you would feel helpful in this conversation would be appreciated. …from acute care listserv
Acute Care Survey Feb-March 2015 What is your productivity Measure?
Visits 36.1%
CPT Code Counts 18.6%
Units of time per visit (15 minutes) 70.0%
Relative value units (RVUs) 17.0%
None of the above 2.0%
All of the above 2.2%
Other: Please describe 7.0%
Other: APC Value weights, avg charge, BTU= 1 min., Time efficient: 59.375%, procedures per visit, Rule of “8”s, “stat assigned by outside consultant
Acute Care Survey Feb-March 2015 Which of the following Measures are You Using
(Select all that Apply)
Acute Care Index of Function 3.0%
AMPAC-6clicks 40.6%
Functional independence measure (FIM) 26.7%
Home Grown measure 5.2%
We do not use any clinical measures 26.3%
Other: Please list the measure(s) you are using 21.4%
Other: 10 min walk, times up and go, Tinetti, Berg, Barthel, Modified FIM, Elderly Mobility Scale, DGI, “FIMish”, FOTO, FSS-ICU, Gait Speed, Kansas,
Physical Therapy has to determine the elements of its own practice and the measures of those elements that
will result in our services being valued by the patient, facility and the
health care system….
"We can’t solve problems by using the same kind of thinking we used when we created them." – Albert Einstein
Establish Assumptions Physical Therapy has value to the patient, the
hospital and the healthcare system in the acute care practice setting Areas of Practice identified as having value:
Early determination of appropriate next level of care Validity and timeliness of discharge recommendations Decrease cost of ICU Stays Impact on LOS Decreased variation of practice Patient / Family / Caregiver / staff education Consultation services Identification of at risk for readmission cases based on
current versus previous level of function and other factors Avoid unnecessary admissions/readmissions in ER
Establish Assumptions In acute care our value is not driven by revenue. It is driven and
determined by: The patient:
timely, clinical outcomes Determine the severity of patient condition Adjusting the intensity(time) of our treatment to meet patient
needs Patient satisfaction
The healthcare facility: Through cost efficient delivery of services:
early determination of next level of care ER: identify patients not needing admission Identify potential readmissions before they leave the first time
managing the clinical care we deliver Determining who needs our care
The healthcare system as a whole: by providing care at the level of value that meets the patient goals and
that the patient proceeds seamlessly to other levels of care
Unique Role of Physical Therapy 30,000 foot view of the patient that takes into
consideration: Acuity/Chronicity Simplicity/Complexity ICF
Health conditions Contextual factors
FUNCTION Triage to the next level of care
Unique Role of Physical Therapy Complex decision making Experience and expertise of staff
Novice vs expert clinicians Ability to prognosticate functional recovery
Appropriate utilization of resources
Establish Assumptions Value:
Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs.*
*Porter ME, What is Value in Healthcare, NEJM Perspective, December 23, 2010
Position Statement – Key Elements Measuring value must be a blended measurement
Patient severity Patient defined outcomes Patient Satisfaction The cost to deliver the care
Measuring “productivity” by time units, visits etc does not determine the value of our care
Shifting Language and Debunking the Myths CPT Codes:
While Hospitals will continue to run on CPT code structures for cost reporting etc. CPT codes/definitions/rules are best suited to
the outpatient environment and do not serve as a good productivity statistical tool
Current definitions/codes not sensitive to patient severity
Current definitions and codes not sensitive to costs of the interventions we provide
Current definitions and codes not sensitive to intensity of the interventions we provide
Educate other care givers: We generate no revenue (except Part B)
The terms ”billable” and “charges are inaccurate We are actually capturing “costs” in an
antiquated way (charge master) Our “cost capture inputs” are contributions to
cost reporting Adopt PTCPS language for severity and
intervention
Decrease Variation in Practice –Working Definitions
Goals: Statements representing the expectation of the
condition of the patient at the time of discharge from acute care (81% agreement)
Prognosis: The determination of the next level of care as defined in
part by the severity of the case and the intensity of the service needed to produce meaningful change in the patient’s condition (60% agreement)
Severity “Lets not reinvent the wheel” (75% agreement)
APTA Severity classification system: www.apta.org/PTCPS/
Decrease Variation in Practice –Working Definitions Intervention/Intensity : (72% agreement)
The amount of time, which is spent in direct contact with the patient: Input into Hospital charge system:
Direct treatment (CPT)
And… Documentation of care Education of patient/family Time spent in care planning
Rounding, clinical team meetings etc
Decrease Variation in Practice –Working Definitions
Intervention/intensity: examples of what should not be included: Staff Meetings Competency assessment Time Clinical Education Time
So Defined where in the system we have value Defined Value and its elements through a position
statement Created new definitions for Goals, severity, prognosis ,
intervention (intensity) that were driven by the membership
Developed and tested x2+ a potential measurement system
….Lets take a look at the system
Task Force Proposal - Measured Value
Make changes to practice based on data sets
Acute Care Physical Therapy
Value
Determine the cost of your care
Input evaluation level and visit
frequency
Evaluate datasets to identify opportunities
for change
Continue data collection and analysis
The Measurement System What we are trying to achieve:
To give our colleagues the ability to collect data on the elements we feel make up the value equation
From this data be able to make meaningful changes in their practice Make better informed decisions regarding amount (intensity)
of their services as it relates to Cost Patient outcomes
Monitor patient types to determine whether are services are necessary
The Measurement System Excel Workbook
Different worksheets for: Determining cost Explanation of evaluation levels Explanation of severity levels Explanation of intervention levels Data sheets for each patient type (up to 25 cases/sheet)
Ortho Neuro Medical
Determining Your Practice Cost
Time Driven Activity Based Costing (TDABC) Approach* (76% agreement) Relatively easy to do Can be adjusted as situations change Allows for variations of cost capture in different facilities Can be utilized in all acute care settings A language Admin/Finance will understand
*Kaplan R., Porter ME, How to solve the Cost Crisis in Healthcare, Harvard Business Review, September 2011
Acute Care Resource Cost
Acute Care Resource Cost
• Above is the data input for a single patient
• There are 25 of these per patient category: Ortho, Neuro, medical
Totals for Each Patient Group
Practice Totals
Practice Totals
Practice Totals
Practice Totals
Practice Totals
Practice Totals
Practice Totals
Testing the Measurement System
November 2016: Call to Academy members to attend a webinar outlining
the measurement system and a call for facilities to test it December 2016:
Task Force reviewed and accepted 36 facilities 36 Facilities were sent a description of the study and
agreement for signature 17 facilities returned agreement
Testing the Measurement System January:
Training Webinar for facilities Given 3 weeks to do approximately 50 patients Asked to review the data set created and discuss whether they
feel the dataset is valuable
Each therapist completed a survey online (N: 101) Conference call after data collection with facilities and
Task Force to Discuss Results Survey data reviewed by Task Force and
recommendations made to the Academy BoD
Survey Results: Facility Demographics Geographic:
Northeast: 2 South: 6 Midwest: 4 West: 5
Location: Rural: 5 Urban: 10 Other: 2
Type: Teaching: 8 Non Teaching: 9
1 – Completely Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Completely Agree N/A – Not Applicable
Q#
N CD D N A CA
1 The measurement of acute care physical therapy has to shift from the concept of productivity (#visits / #units) to a measure of value 101 0% 1% 6% 32% 61%
2 This new measurement system clearly demonstrates the value of our services to the patient
100 0% 20% 29% 44% 7%
3 This new measurement system clearly demonstrates the value of our services to our department/ facility
98 0% 18% 28% 41% 13%
4 This new measurement system clearly demonstrates the value of our services to the American healthcare system
100 0% 20% 28% 44% 8%
5 I agree with the definition of “value”94 0% 5% 14% 60% 21%
6 I agree with the definition of “intensity”99 0% 7% 13% 53% 21%
7 The current patient categories of medical, ortho, neuro are adequate 99 6% 38% 13% 32% 10%
N CD D N A CA8 The cost calculation system was easy to use 52 0% 19% 21% 50% 10%
9 This data can be useful to allocate staff more effectively 66 3% 6% 30% 50% 10%
10 This system is more valuable than visits/units when discussing the need for changes in staffing and programming with my administration 60 0% 5% 25% 58% 12%
11 I would substitute my current daily statistics collection with this system 58 2% 31% 45% 19% 3%
12 I would supplement my current statistics with this system 58 0% 6% 17% 59% 9%
13 I would use this to collect data on our practice on a monthly basis 55 0% 18% 42% 29% 11%
14 I would use this to collect data on our practice on a quarterly basis 54 0% 11% 20% 57% 11%
15 I would use this to collect data on our practice on a six (6)month basis 59 0% 20% 29% 42% 8%
16 I would not use the system at all 62 23% 52% 21% 5% 0%
Task Force Review of Survey Results
• High agreement on needing to move to a productivity measure based on value (Q1)
• While positive, there was a lot of neutral when it came to this showing our value to the stakeholders identified (patient, hospital, healthcare system). The TF discussed this and this might be due to this being a new concept and possibly the cumbersome format of the spreadsheet. (Q2,3,4)
Task Force Review of Survey Results• Continue to have a relatively high degree of
agreement on the definitions which is similar to the findings we received from members in our 2015 survey (Q5,6)
• There is a need for flexibility in setting up patient categories (Q7)
• Fair agreement that the cost calculation was easy to use. This might be affected by the person doing it and their access to some of the amounts needed (Q8)
Task Force Review of Survey Results• While again a High % of neutral answers, there seem to be
some agreement that this would be a tool that could be used for staff allocation and that it would be useful to have this information in discussions on staffing and program development with the facility administration (Q9,10)
• Many saw this as a supplement, not a replacement for their current statistics (Q11,12)
• The utilization of this tool would be through a periodic snapshot of the practice and not daily statistical capture (Q13,14,15)
• There seemed to be high agreement that this type of system, in some improved form, would be valuable (Q16)
Potential Practice Questions to be answered by this data? Are there patient populations that our services bring
limited or no value to? Is our pattern of intensity too high/low? Can we achieve the
same/better outcomes with a different level of care? Same or better outcomes at less cost?
Can we demonstrate value of our services to Administrations/Finance in a better way with this data rather than outside consultant data?
Is this data valuable to begin to have dialogue regarding benchmarking?
Others you might think about…..
Issues / Discussion Patient Satisfaction These measures should be looked as additions to your
current PI Dashboard Will need to establish benchmarks Current application platform (excel spreadsheet)
cumbersome – need to go electronic “Complexity” vs. “Severity” Single visit – One type valuable….another….not so
much
Issues / Discussion What to do about discharged patients prior to
performing the final measure? Utilization of this type of measure appears to be more
practical on a “snap shot” basis (monthly, quarterly) rather than every day
Potential Uses Determine value of our service by patient
population type Questions it can help answer:
What types of cases do we bring the greatest value to? Are there types of patients that gain little to no value from
our care? Who needs us – Who does not?
Will it give us information to change staffing patterns to meet high/low value patient populations?
Assist in determining Prognosis of patient function? Assist in determining FTE enhancement – retraction Effect of patient severity (complexity) on intensity (time) of
our services Data to assist in decreasing variability of practice
Potential Uses Can determine if higher or lower intensity (Tx time) results
in the same clinical outcome. Begin to classify cases by severity (complexity) and then
have data to support studies related to patient discharge and readmission. Are we making a difference?
Enhance the understanding by admin/finance of our value Staffing levels Other Resources
Appears to be able to utilize existing multiple existing clinical measurement tools
Move towards benchmarking – APTA Registry Linkage
Imagine if we had the Data… “Does your facility/hospital use any criteria for labeling
referrals for PT eval inappropriate so that the PT does not have to proceed with the eval?Appreciate any input in this matter. ‘
…from acute care listserv
Summary Physical Therapy, our patients and the facilities where we
practice are best served with a blended approach to measurement that focuses on value that is defined by: Cost patient severity (complexity) treatment intensity the patient’s outcomes
We must standardize our terms now Continue to look for opportunities where we bring value to the
patient, the facility and the healthcare system We must measure our value in a way that is understandable to
different stake holders We must be the catalysts of the change, we cannot wait for
others to “do it to us” We encourage using this data as part of your PI “dashboards”
Summary Task Force recommendations to Academy Board
approved 2/15/17:• Incorporate what we learned from the survey and
incorporate it into the existing excel platform.• Retest this updated version with the same facilities in
order to have people familiar with the system give us input
• Re-Survey• As the above is being done
• Prepare and implement an approach to EMR providers to see if they will incorporate the data sets and to produce reports we need
Task Force Proposal - Measured Value
Make changes to practice based on data sets
Acute Care Physical Therapy
Value
Determine the cost of your care
Input evaluation level and visit
frequency
Evaluate datasets to identify opportunities
for change
Continue data collection and analysis
Academy of Acute Care Physical Therapy
Value / Productivity Round TableFriday February 17, 2017
Crockett A, Hyatt3-5pm
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