maximising the use of costing data learning to speak the

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Maximising the use of costing data learning to speak the same language

Scott Hodgson Head of costing

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A bit about NUH

• Large Acute Teaching Hospital in UK

• Located in the heart of Nottingham split across three campuses

• Provide acute service to over 2.5m residents

• Provide specialist service for a further 3-4m people across the region

• Major Trauma Centre

• CQC viewed NUH as a ‘good’ Trust

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NUH in numbers

• £934m turnover in 2016/17

• 71,006 Outpatient appointments per month

• 1,932 elective patients per month

• 6,892 day case patients per month

• 16,303 Emergency Department patients per month

• 1.4m patients per year

• 90 wards, around 1,700 inpatient beds

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• Use of PLICS and clinical engagement

• How we implemented

• Challenges and successes

• What next

The brief

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PLICS at NUH – timeline2010 Implemented PLICS in October – clinicians involved in selection process

2011 Steady roll out across all DirectoratesEstablished PLICS Board and Data Quality Panel – both clinician led

2012 Focussed on data quality rather than roll outIncreased the number of data feeds (e.g. Therapies)

2013 HFMA Costing Award WinnersFinancial Management engagement (key to Directorate buy-in)Moved to monthly PLICS (August 2013)

2014 MAQS gold was the aim of DQP – used this to target resourcesSpecific Roll out plan targeting business analysts and clinicians – scorecards

2015 Launch consultant built app with intuitive reportingChange culture – knowledge workers – leadership programme

2016 PLICS 2.0 the next step…’shifting the middle’

2017 Launch of ‘wave’ process – results focussed

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Impact on Clinicians

• Incomprehensible

• Unbelievable

• Disengagement

• Antipathy

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Responding to our customer

• To personalise the data being viewed.

• To streamline the desired data to the viewer.

• A more intuitive path to patients bill.

• Clearly define areas of concern.

• Clinical involvement is at the heart of our PLICS development at NUH

• Focus on the I in PLICS

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PLICS view of Patient time line

• Allows clinicians to see that early discharge saves money – as well as better outcome for patient and Trust (more beds!)

• Comparisons between ‘high performing’ and ‘low performing’ consultants very powerful

• Helps to stimulate and drive change.

• Best in Class is the target for patient pathway and patient outcomes.

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Detailed breakdown showing costs per day during patients stay

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Red Days & DTOC costs (April - December 2017)

Red Days & DTOC cost by Point of Delivery

Episode.PODCodeLabel LOS Total Cost Red Days Red Days Cost% Cost Red Day DTOC daysDTOC day costs % DTOC Cost

AE: ACCIDENT AND EMERGENCY ATTENDANCE 152,790 £29,708,708.76 0 £0.00 0.00% 0 £0.00 0.00%

DC: DAY CASE 62,182 £64,511,769.28 0 £0.00 0.00% 0 £0.00 0.00%

EL: INPATIENT - ELECTIVE 68,434 £104,335,778.49 2,154 £1,164,503.93 1.12% 432 £199,680.12 0.19%

NEL: INPATIENT - NON-ELECTIVE 424,230 £300,725,759.13 41,731 £18,356,877.34 6.10% 12,935 £5,196,806.95 1.73%

OPFA: OUTPATIENT FIRST ATTENDANCE 262,182 £46,597,782.50 0 £0.00 0.00% 0 £0.00 0.00%

OPFUP: OUTPATIENT FOLLOW-UP ATTENDANCE 438,724 £74,251,343.06 0 £0.00 0.00% 0 £0.00 0.00%

OPPROC: OUTPATIENT PROCEDURE 138,688 £34,356,499.63 0 £0.00 0.00% 0 £0.00 0.00%

OTH : OTHER 102,008 £101,076,725.89 0 £0.00 0.00% 0 £0.00 0.00%

1,649,238 £755,564,366.73 43,885 £19,521,381.27 2.58% 13,367 £5,396,487.07 0.71%

Red Days & DTOC cost by Weekday

ResourceWeekday Total Cost Red Days Red Days Cost % Cost Red DayDTOC days DTOC day costs % DTOC Cost

Mon £118,664,948.98 6,053 £2,745,623.57 2.31% 1,979 £819,764.06 0.69%

Tue £125,306,681.59 6,407 £3,053,937.36 2.44% 1,881 £819,866.35 0.65%

Wed £124,915,132.87 6,524 £3,111,137.31 2.49% 1,907 £819,888.45 0.66%

Thu £125,327,674.47 6,510 £3,099,557.92 2.47% 1,866 £806,138.18 0.64%

Fri £161,287,035.26 6,367 £3,058,565.34 1.90% 1,915 £806,849.91 0.50%

Sat £51,778,130.60 6,056 £2,284,981.99 4.41% 1,935 £678,408.14 1.31%

Sun £48,284,762.96 5,968 £2,167,577.79 4.49% 1,884 £645,571.98 1.34%

£755,564,366.73 43,885 £19,521,381.27 2.58% 13,367 £5,396,487.07 0.71%

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Red Days by reasonServData.RedDesc LOS Total Cost Red Days Red Days Cost % of Red Days

- 1,649,235 £738,217,329.87 4,542 £2,174,344.41 10.35%

Package of care - awaiting start/restart date 13,377 £1,417,013.20 3,064 £1,417,013.20 6.98%

Rehab bed (other hospital) 10,362 £1,198,630.08 2,670 £1,198,630.08 6.08%

Xrays / scans / interventional radiology procedure 11,461 £1,140,263.48 2,282 £1,140,263.48 5.20%

Social Worker screening/assessment 10,165 £847,806.38 2,058 £847,806.38 4.69%

Specialty bed 5,947 £810,219.59 1,595 £810,219.59 3.64%

Specialty team review (not own ward) 8,416 £785,036.60 1,833 £785,036.60 4.18%

Placement - Nursing/Residential 7,237 £777,997.45 1,937 £777,997.45 4.41%

Social Worker allocation 9,364 £763,700.74 1,860 £763,700.74 4.24%

DST (Decision Support Tool) date 8,393 £719,756.22 1,888 £719,756.22 4.30%

NULL 8,421 £715,788.08 1,719 £715,788.08 3.92%

Surgical procedure 4,980 £713,888.55 1,196 £713,888.55 2.73%

Assessment bed 6,046 £685,660.58 1,775 £685,660.58 4.05%

Repatriation to another NHS hospital 5,503 £556,946.71 1,191 £556,946.71 2.71%

Xrays/scans need performing 5,339 £508,763.90 1,054 £508,763.90 2.40%

Care Home - assessment/feedback by existing or new 4,459 £430,173.20 981 £430,173.20 2.24%

Awaiting access to City community stroke rehab 1,898 £350,106.59 846 £350,106.59 1.93%

STOC assessment and review 5,041 £341,499.74 750 £341,499.74 1.71%

Family discussion/dispute/uncontactable 3,637 £326,320.28 787 £326,320.28 1.79%

HUB decision 4,586 £269,476.87 730 £269,476.87 1.66%

Medical procedure (e.g. Endoscopy/LP etc) 2,312 £264,047.86 486 £264,047.86 1.11%

Fast track to current or new care home 1,897 £234,894.78 551 £234,894.78 1.26%

Nurse Assessor - Continuing Care Assessment 3,147 £230,387.51 601 £230,387.51 1.37%

Housing/Homeless issues 1,693 £184,170.82 470 £184,170.82 1.07%

MDT (Multi-disciplinary team) meeting 1,795 £157,959.55 355 £157,959.55 0.81%

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PLICS 2.0 – THE FUTURE

SHIFT THE MIDDLE

vs

NAME AND SHAME

• LOS

• Theatre time

• DNA’s

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PLICS supporting the wave process

• Targeted at outlier specialties• Data packs – balanced scorecard• Multidisciplinary team• Supported by central teams• 8 week intense programme• Executive level challenge• Outputs feed into PMO for management of Financial Efficiency

Programme – with target of 10% over 2 year time frame

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3 behaviours for PLICS to engage clinicians in improving quality & margins

• Publish and debate results with all clinicians being mindful of the stages of information grief.

• Understand what is driving diversity in cost and plug in new sources of data as they become available

• Support debate and understanding in specialty and governance meetings

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PLICS – Future developments

• System wide PLICS using CTP and the NHSi portal• Linking costs with other performance indicators• Self service dashboards• Continuous roll out and engagement• Wave – Cohort D/E/F

• RESULTS – NOT JUST NICE TO DO EXERCISE!!

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Challenges and Successes

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The data is

wrong

DENIAL

It does not

apply to me

ANGER

I will get the

correct data

BARGAINING

There is

nothing I can

do about it

DEPRESSION

Acceptance

and action

RESOLUTION

CLINICAL LEADERS

PLICS

LEADERSHIP

The five stages of data grief

NUH wave programme 2017/18

Aspire Refine

Pre-Process (8th January-19th January) Week 1-4 (22nd January-16th February) Week 5-8 (19th February-16th March)

Assess & ArchitectEngage & Aspire Confirm &

Challenge

Refine,

Plan &

Deliver

Set-Up & Plan Discovery

Pre-Process

Individual data pack to be sent out to

specialties by 5th January including financial

& strategic indicators.

Individual specialty meeting to run through

data pack so specialties have a thorough

understanding of the data and why the

specialty is taking part in the process. Also

agree any further data requirements to

support success.

Specialty to engage staff for ideas & link in

key stakeholders (Internal & External)

Hypothesis Generation of ideas across Pay, Non-Pay &

Income opportunities into a MECE tree.

Build ‘sandpit’ of data in weekly meetings with support

network (Better for You, Finance (PLICS), Information &

Insight, Consultant Lead, Procurement, Strategy)

Prioritise/De-prioritise areas of opportunity with sound

reasoning for each including levers and metrics.

Calculate a range of financial efficiencies for prioritised

areas.

Prepare Elevator Pitch for Confirm & Challenge

Refine plans where appropriate based on Confirm

& Challenge feedback.

Complete detailed implementation plans in

MATRIX system (including aims, milestones,

KPI’s, values, timescales & QIA’s where

appropriate) including individual specialty

meeting with PMO to sign off plans.

Prepare final Elevator Pitch for Confirm &

Challenge

Complete Survey Monkey Feedback

FINAL Confirm & Challenge: 19th March

INTERIM Confirm & Challenge: 19th February

DEADLINE FOR INTERIM PAPERS – 14th February at 7pm

DEADLINE FOR PROJECTS INTO MATRIX &

FULLY COMPLIANT– 9th March

Confirm &

Challenge

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Issue tree with prioritised

branches

Rationale for prioritisation and

levers of improvement

Priorities inputted into the Trust PMO Matrix system following training and support from

PMO team.

Your inputs are then downloaded and submitted to the CET Panel for the Confirm and

Challenge

Final Confirm & Challenge

Interim Confirm & Challenge

Confirm and Challenge outputs

Targets and estimated size of

opportunity

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Role Responsibility

Deputy Programme Director

• Overall organisation of the programme• Challenge as a critical friend, coach, and advise of process expectations,

tools and techniques• Attendance at speciality meetings• Support SGM/AGM on completion of documentation for confirm and

challenge sessions • Provide weekly update on overall programme to Exec Sponsor & FEP

steering group

Business Partner/Finance Support

• Identify data sources and conduct required analysis to support discussion & provide costings to confirm & challenge documentation

• Attend all team meetings as required• Contribute to brainstorming and creation of outputs

Business Analyst • As above

Roles and Responsibilities

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Role Responsibility

Lead Clinician • Contribute to brainstorming and creation of outputs• Attend all team meetings as required• Get buy-in and engagement from colleagues• Facilitate clinic input into data requests and analyses• Sign off all confirm and challenge documents• Lead the presentation at confirm and challenge sessions • Ensure that plans are made an operational reality

Senior Nurse Representative

• As above but Clinician will lead the presentation at the Confirm & Challenge sessions

SGM/AGM • Facilitate meetings (scheduling, agenda setting)• Follow-up on actions from meetings• Lead completion of templates for confirm and challenge sessions & enter all

the projects into the Matrix system by the deadlines• Contribute to brainstorming and creation of outputs • Facilitate data requests and analyses• Provide advice, support and challenge


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Role Responsibility

Executive Sponsor

• To provide any additional support or guidance to the team or Deputy Programme Directors during the process.

• Receive and respond to regular weekly updates on progress from your link Deputy Programme Director.

• Participate in Interim and Final Confirm and Challenge Panels• Engage with team as much as possible during the process, helping to unblock

specific issues if/as they arise

Corporate Support

• PLICS – support building of data within ’sandpit’• Consultant Lead – support & coach Lead Clinician • Intelligence & Information – Preparation of pre-workshop data packs, support

for specific data analysis & support around the development of KPI’s, modelling and trajectory plotting

• Procurement & ICT – support linked to any non-pay or ICT opportunities• Strategy – support linked to STP & forward look of services including

sustainability & growth


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MECE issue tree -Gynae

How do we improve the financial viability of Gynae?

Review of efficiency of service

HRG analysis focus on deficits

Reduce pay and non pay overspends

Reduce drug costs

Reduce agency locum / WLI spend

Maximise profit making opportunities

L1 L2 L3 Levers

Improve income position

Coding improvement

Review opportunities for in session theatre utilisation

Reducing / stopping over the counter prescribing on wards

Opportunities for cheaper alternatives e.g. Mirena / Levosert

Recruit to substantive post and new consultant post

Identify where service is an outlier vs peers

Enable more income with same resources

CSU review of in –session utilisation, reasons and barriers

Gynae

Id. co morbidity opportunities through with with Civil Eyes

Medical outliers significantly reduced and level 2 HDU step down beds from CC on Loxley

Focus on ICD10 codes with clinical review

Additional daycase lists utilised

Increasing proportion of activity to the domino effect; ELDCOPROC – 500+ electives with 1 day LoS (incl. TOP)

Share data & solutions at Divi Days & implement changes

Bowel prep for elective admissions undertaken at home or alternative to Ward to create bed day savings

Recliner chairs on Loxley end bay to increase DC throughput

Utilise existing capacity, reduce WLI’s; pay savings Improve bed occupancy and flow

Red / Green days improve discharge plan management

Opportunities for pass through drugs with CCG’s

Substantive nursing re-directed to care for level 2 pts and agency nursing reduced

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Wave financial results over 4 years…

Cohort Planned Forecast Actual Year Planned Forecast Actual

1 £10,976,051 £9,957,667 £9,704,674 15/16 £7,841,670 £7,682,194 £7,585,959

2 £1,991,871 £1,917,410 £1,850,372 16/17 £7,508,264 £7,104,504 £6,962,929

3 £3,629,889 £3,529,766 £3,619,659 17/18 £6,074,504 £5,925,859 £4,150,664

4 £814,274 £815,071 £718,636 18/19 £4,295,456 £4,211,883 £1,583,236

5 £144,300 £129,155 £124,322 19/20 £7,818,962 £7,134,963 £0

6 £224,241 £233,339 £212,410 20/21 £1,517,420 £1,517,420 £0

7 £5,045,436 £4,890,189 £3,147,560 £35,056,276 £33,576,823 £20,282,788

A £4,087,580 £3,938,592 £546,530

B £4,480,278 £4,503,278 £358,625

C £3,662,356 £3,662,356 £0

£35,056,276 £33,576,823 £20,282,788

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Changing practice after understanding

the financial impact of DELAYED

TRANSFERS OF CARE

Get

Do

See

3 - The results have been

• Improved reporting of medically fit date.• Improved completion of documentation to

support complex discharges• Improved discharge planning• Increase daily complex discharges• Improved system transparency of cost of delays

2 – Behaviour and culture changes

have been established.

Systems have been improved in wards to support identification of the medically fit date.

A cadence of accountability has established regular monitoring has been under taken and reported to the System Resilience Group.

1 - PLICS has been used to identify the cost of each patient on a

day by day basis allowing me to identify how much has been spent on the patients care after their medically fit for discharge date. In many cases this turned another wise financially profitable episode of care into a financial loss for the Trust

Tasso Gazis : Consultant in Diabetes Medicine

PCT Code Activity LOS Total Cost

Cost Past

Section 5 Date

Cost Past

Planned

Discharge Date

Days Past

Section 5

Days Past

Discharge

Date

1,176,220 1,590,964 £764,465,932 £5,669,653.89 £3,882,053.31 11,189 7,574

04K 431,096 569,082 £220,872,057 £2,544,568.45 £1,803,753.78 5,152 3,355

04L 198,375 260,345 £101,733,243 £1,023,942.45 £651,529.71 1,994 1,311

- 4,159 17,177 £90,602,181 £0.00 £0.00 0 0

04N 142,575 189,595 £75,804,099 £795,845.67 £487,458.23 1,503 952

04M 119,708 160,547 £63,759,713 £698,582.75 £427,343.83 1,409 915

03X 64,995 88,345 £36,866,727 £312,819.17 £268,646.39 624 520

04R 33,259 48,214 £28,737,734 £32,133.73 £52,470.10 52 98

04E 39,425 52,912 £28,074,524 £53,161.29 £39,223.85 85 89

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Changing practice after understanding

the COST OF RESOURCES IN HEALTH

CARE OF OLDER PEOPLE

Get

Do

See


• Reduction in length of stay• Earlier diagnostic testing• Improved discharge planning• Supports frailty unit model



Systems have been put in place to monitor diagnostic testing, meaningful discussion are now taking place around clinical variation.

Increased engagement and understanding of costs

Understanding patient pathway cohorts

Meaningful discussions around clinical variation

1 - PLICS has been used to shift a paradigm from a focus on

reducing costs through internal trading to being able to look at whole pathway costs and how increases in diagnostic costs can reduce length of stay and improve overall profitability of the service.

Aamer Ali : Consultant in Health Care of Older People

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Changing practice after

UNDERSTANDING THE COST OF

CATARACT SURGERY

Get

Do

See


• Improved productivity of theatre lists.• Less variation in theatre time per case as

standard procedure is followed.• Changes in the Day Case Unit allowing

improved theatre turn around time

2 – Behaviour and culture

changes have been established.

The PLICS data enabled meaningful engagement with clinicians using real information.

A cadence of accountability has established regular monitoring has been under taken

Changes to Theatre scheduling and list planning

1 - PLICS has been used to identify patients undergoing Cataract

Surgery. I noticed that some cataract theatre lists are profitable whilst others are loss making. I was able to identify that only difference causing the higher costs is number of cases per list

Anwar Zaman : Consultant Ophthalmologist

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UNDERSTANDING THE FINANCIAL

IMPACT OF MAJOR TRAUMA CENTRE

COSTS

Get

Do

See


• Improved reporting of major trauma costs.• Improved clinical coding of major trauma patients• Improved understanding of the major trauma

pathway and interdependencies• Focus on discharge planning and supported

rehabilitation



Systems have been improved in wards to support the major trauma pathway.

A cadence of accountability has established - A service line has been established for Major Trauma

1 - PLICS has been used to flag each major trauma patient

allowing me to identify what resources and services are used by patients coming through the major trauma centre. We’ve also identified clinical coding issues which will have an impact on financial position of the service.

Adam Brooks : Consultant surgeon

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UNDERSTANDING THE COST OF

DAY SURGERY IN PLASTICS

Get

Do

See


• Elective surgery moved towards day surgery unless case of need –saving £750k p.a.

• Consultant on-call weekly rota aimed at reducing LOS and rapid response to Trauma and ED patients

• First Trust to use telemedicine for Burns patients. Use of web-cam in ED will allow diagnosis by on-call Consultant in Burns Unit via tablet/PC. This will reduce unnecessary admissions to Burns Unit

• All patients to have pre-op assessment which will reduce cancelled ops

2 – Behaviour and culture changes have been established.

Systems have been improved and rotashave been redesigned to reduce length of stay.

Change of service model – Elective to Daycases

Understanding of limited resources

A cadence of accountability has been established regular monitoring has been under taken and reported to the consultant group

1 - PLICS highlighted that patients with certain procedure codes

when treated as a day case are profitable but when treated as an elective inpatient are loss making. I also noticed the Burns Unit which has a higher ratio of staff to patients than most wards was being used for these relatively simple elective procedures.

Jason Neil-Dwyer : Consultant in Plastic Surgery and Burns

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Making Complex Breast Reconstruction Cost Effective

Operation Time: 7.5 hours mean (Comparable to UK

peers)

International Gold Standard: 4 hours

Working Group

• Multidisciplinary Theatre team visited expert UK unit

• Attended British Association Plastic and Reconstructive

Surgery Scientific Meeting

• Current process mapped and new process mapped,

• Additional consultant on each case

• Two scrub nurses

Outcome

• 2 cases in 0830-1800 extended day list – 9.5 hours

• 37% reduction in theatre costs

• Very team dependent

0"

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0" 10" 20" 30" 40" 50" 60" 70" 80" 90" 100" 110" 120"

Cost%per%case%(£)%

Number%of%cases%

National%Unit%Cost%for%Free%Perforator%Flap%Breast%Reconstruction%JA14Z%HES%2013/14%

National"Data"Set"

NOTTINGHAM"UNIVERSITY"HOSPITALS"NHS"TRUST"

National"Tariff"

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Managing cost in Single Prolonged Stay CasesHighly complex patients often severely unwell, treated primarily in other trust or service

• Case notes audit

• Processes mapped - PLICS costs mapped to

process

Findings

• Resource cost : Multiple theatre visits

• Time cost : LOS

• Consultant cover system resulted in review by

different consultants at different times no continuity

• Decisions taken at multiple grades

Solution

• Altered job planning

• Daily consultant ward rounds formalised.

• Hot week system in pipeline pending job plans

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Remapping Elective PathwayDaycase the Norm

As familiarity with PLICS increased consultants started to feel more accountable

• LOS 0 days analysis– Benchmarking Daycase Basket

• Incurred staffing costs of full ward nursing dependency £350-£500

• Model of inpatient care for procedures where patient ambulatory incurring significant cost

• Each consultant challenged on basis PLICS costs to voluntarily transfer elective lists into vacant day case capacity

• Saving estimated £750k p.a.

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Thank You

Scott HodgsonHead of Costing

[email protected]

maximising the use of costing data learning to speak the

Documents