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Gaining access to accurate benchmarking data is the bread and butter of your case management program. Case managers need good, timely numbers to justify length of stay (LOS) targets and discharge plans.
"The path to a successful, strong case management department is a really good data source," says Sandra Sperry, RN, MPA, senior vice president of clinical resources at Sisters of Charity Health Care System in Staten Island, NY. "Database decisionmaking simply makes sense as you move forward. And, in terms of our own performance standards evolution, we can look at where we are as compared to our competitors and other benchmarks and see how our practices are reflected in the community." For example, Sisters of Charity can link congestive heart failure (CHF) or asthma benchmarks within the state, benchmarks external to New York, and the system’s own internal performance — physician to physician and program to program — and see where opportunities for improvement are.
For about $30,000 a year, your facility can acquire an enormous database that is updated regularly and decision-support software to go with it. Training in use of the software takes less than a day, according to most company representatives. For much less, you can order individually tailored reports by subscription. Consider taking a look at a few software programs that evaluate your facility’s internal practice patterns and costs, identify areas for improvement, and compare them to those of competitors, in-state and beyond.
Purchasing comparative analysis software is a call most likely made by the CEO, CFO, or financial department of your institution. "A major purchase like this would have to go through a capital proposal process at my facility," says Debbie Caskey, RN, administrative director of cardiovascular services for The Jewish Health System in Cincinnati. "First, we’d do a financial analysis and a cost-to-benefit study, then present it to the financial department. We’d have to demonstrate the benefit of the decision-support system over what we could generate ourselves."
Get your hospital’s director of finance or CFO on your side, recommends Kathy Fox, MSN, RN, cardiac service line director for St. Francis Hos pital & Health Centers in Beech Grove, IN. Pre view what’s out there by calling at least three vendors and asking them to come to your facility to demon strate their products, first to you, then to the financial entities who would approve the purchase. "Then," says Fox, "at your next planning or operations council meeting, present the concept. Wait a week, then discuss your proposal in detail. Be armed with specific information on what the products do and what they cost."
Sisters of Charity uses benchmarking data supplied by HealthShare Technology, based in Acton, MA. The facility leases the software, and data are updated every six months.
Statewide database proves useful
"Their product lets us access the SPARCS [Statewide Planning and Research Cooperative System], the database for New York state, and manipulate it to our needs," says Sperry. "We can look at utilization detail by physician or by diagnosis." Each health care organization in New York state is required to submit clinical and financial data to the state, including line-by-line detail on each patient. When accessing SPARCS, you can look at an individual case, but you cannot identify that case by name, number, or social security number. "But I can pull up on my screen a listing of every case in the state over any time frame and build my own data sets from that to help me run focused queries and report on a whole range of variables," says Sperry.
She says physician profiles are essential for critical pathway efforts. "We completed a report on total knee replacement last year. That should have been pretty straightforward from a case management standpoint, but there turned out to be some significant variations in terms of length of stay, cost, and how we delivered care within our own sample from one physician to another." She says her information was "pretty soft and anecdotal" until her facility had access to the database. "Now," she says, "I can substantiate my information by graphs and hard data on how our staff is doing in and among themselves as well as how they look against some of our competitors." She can also benchmark their data against facilities that are optimal performers. "That’s pretty strong stuff," says Sperry, "and it’s not anything physicians have had access to before we got this program."
One factor identified through the studies component of Sisters of Charity’s total knee report was that approximately half of those cases are having dopplers done. "You can get down to detail on X-rays or lab tests," says Sperry, "and I saw the timing of the dopplers, how they were facilitated, and what needs criteria were met."
Physicians look at most data with some degree of suspicion, she says, especially when statistics are not as up-to-date as they should be or are not severity-adjusted. "Nothing is more powerful than having solid timely information and data to help clinicians look at opportunities for improvement and start to shift behavior," she continues. "It’s the best kind of feedback."
Sperry says her facility has seen a significant change in physician response to the information. "The industry is moving forward so fast. Any thing I used to take to the physicians was probably three years old, and I got a been there, done that’ kind of response," Sperry says. The data provided by her decision-support software are current — within six months to a year — and severity-adjusted. You can ask your own questions, then reformat them to delve deeper for different levels of detail.
Sperry says she had a request about a year ago from a general surgeon who wanted to know about Sisters of Charity’s patient base — who they are, where they go for care, and what diagnostic categories they fall into. He also wanted to know how Sisters of Charity compares to other facilities.
"That level of information has not been available to physician leaders or individual practitioners until now," says Sperry. "Physicians are scientifically trained — they do very well when you give them good, hard information. They also do very well when you’re honest with them about the limitations of information." She says your credibility with a group of physicians takes huge strides forward when you are honest with them.
"I think one of the classic mistakes we make is to overestimate the accuracy of our data," says Sperry. "Every database, including New York State’s, has flaws, and you have to be responsible and know and disclose the limits of your database. Once you do that, you can go ahead and develop strong reports."
Sperry’s role at Sisters of Charity is to look at the clinical integration of the facility, as well as cost containment and performance improvement. "What I’m really looking at is how we are making this delivery system function as a vehicle for true continuum of care," she says. "We have all the pieces, but we need to make those pieces work more efficiently. Our physicians need to be able to manage the forest and the trees simultaneously. They need to relate their individual practices to the global picture."
Sperry says if you expect physicians to make global, far-reaching decisions, you have to give them timely, meaningful information that supports those kinds of decisions. "That’s been a significant dichotomy for hospitals, looking at old data and not being clear on its limitations."
She says for a long time, hospitals defined power bases based on the control of information. Clinicians had the clinical data, while the finance department had all the numbers. "You never sat around one table and discussed those matters together," says Sperry. "It’s essential to do that."
She takes information from Sisters of Charity’s internal clinical and financial information systems and compares it to historical performance from years back. "With those data, I can draw a good picture for the physicians."
She points out that to implement a successful case management program, you must feed data back to all levels involved in the process. "Clin ical integration programs are a significant and critical factor in stakeholder management. If you want people to participate, they’ve really got to have a sense of getting immediate feedback — particularly physicians."
McKenzie-Willamette Hospital in Springfield, OR, often sees multiple diagnoses in its largely senior population, and those patients’ care usually is complex. "In the geriatric population, typically more than one body system is in jeopardy," says Ruth Danos, RN, CPUR, the utilization review (UR) coordinator at McKenzie. "Aver age lengths of stay are not easily determined because comorbidities influence the primary diagnoses."
Benchmarks in that facility have to be realistic and timely, and they have to reflect the complexity of the patient population.
Danos’ facility uses Baltimore-based HCIA’s Length of Stay benchmarking tool, in conjunction with the InterQual Clinical Decision Support Criteria (McKessonHBOC, Marlborough, MA). HCIA’s product addresses the illness complexity of patients with multiple diagnoses. The benchmarks are based on all-payer data gathered from inpatient records that represent one-third of the annual discharges from U.S. hospitals. Broken out into five age groups, the LOS ranges are represented as percentiles so the user can determine a more or less aggressive LOS, depending on individual variables.
Using criteria across the continuum
InterQual’s criteria enable the user to determine the appropriateness of admission, continued services, and discharge across the continuum of care. The criteria use clinical indicators to determine the proper level of care, based on the patients’ severity of illness and intensity of service requirements.
"We look for the 50th percentile in HCIA’s data and use that as a standard anticipated LOS if things go well," says Danos. McKenzie runs its HCIA/InterQual reviews on-line.
The staff use HCIA LOS data and InterQual criteria only as guidelines; clinical judgment is required to come up with appropriate care. "Our nurses don’t use just HCIA or InterQual in their decision-making," Danos says. "Those systems depend on their clinical judgment as well." And when the RN sees a need for help on a very complex case, it can be taken to the medical director, who reviews the situation and makes a judgment call on what action needs to be taken. "Those are the train wreck cases," says Danos. But the majority of patients can be managed using a nurse’s clinical judgment along with HCIA and InterQual.
Community Memorial Hospital in Ventura, CA, also uses the electronic version of HCIA LOS data in conjunction with InterQual criteria. Carol Levy, RN, MS, manager of UR and social services there, says InterQual has been around for about 20 to 30 years as a provider of criteria for admission, continued stay, and discharge. But now that all this information is in an automated format, Community Memorial purchased a license to use HCIA as well to fit in with InterQual’s information.
"I was looking for standardized guidelines for our nurses as they do their rounds," says Levy. "They can enter an ICD-9 code and pull up the LOS by patient comorbidity, sex, and age. Then they don’t have to review that chart for a few days — not until the day before the LOS is up."
She says it is only in the past few years that managed care has made inroads into her part of California, meaning hospitals haven’t taken a close look at their data as they compare to other hospitals until recently.
"The HCIA data is a means of comparing ourselves against someone else," Levy says. "It’s a yardstick. If another hospital keeps its CABG patients five days, and our patients stay an average of six, I want to know why. I benchmark against the Western region and the 50th percentile," she says. "That way, I can disregard all the outliers. It gives me an idea of what a patient’s LOS should be simply by knowing his ICD-9 code or diagnosis and the LOS of other patients within that diagnosis and age group. I don’t have to know anything else about the patient."
Community Memorial purchased the electronic version of the HCIA and InterQual programs so staff at the facility could generate reports based on diagnostic code, physician code, and reviewer code. "That information helps me, for example, to have some support for whatever anecdotal evidence I may have on which physicians are keeping patients longer than others," says Levy. It also allows her to look at inter-reviewer reliability.
"I have to make sure all of my nurse case managers are using the same set of criteria to determine whether an admission, a stay, or a discharge is appropriate," says Levy. InterQual’s program allows the case manager to go in and pull up a set of intensive service or severity of illness measures and click on the ones that are appropriate. "That makes it easy for them," says Levy.
Community Memorial is licensed for 242 beds, and Levy supervises a staff of eight and a half full-time employees.
Levy says the MediCal LOS for CHF with no comorbidities is five days. "There’s no good way to account for comorbidities using MediCal data," Levy says. "When you enter the ICD-9 code, you come up with one condition." She says HCIA data are a little better because they allow the user to factor in complexities, but "it’s not perfect. It doesn’t say which comorbidities or how many."
InterQual gives specific information, such as admission criteria for a cardiac patient going into a CCU. "The InterQual criteria give thresholds — parameters to determine whether a patient is sick enough, from their perspective, to be admitted," says Levy. The criteria are guidelines, and not meant to define medical practice.
"InterQual and HCIA represent a sizable investment," says Levy. Community Memorial uses two sets of InterQual criteria — adult and pediatrics — and the company charges a per-bed licensing fee. "We pay $3,500 per year for the license to use the information. HCIA also charges based on the number of beds in your facility; we pay between $600 and $700 a year."
For more information, contact the following sources quoted in this article:
Sandra Sperry, RN, MPA, senior vice president, clinical resources, Sisters of Charity Health Care System, Staten Island, NY. Telephone: (718) 354-5515.
Debra Caskey, RN, administrative director, cardiovascular services, The Jewish Health System, Cincinnati. Telephone: (513) 891-8159.
Kathy Fox, MSN, RN, cardiac service line director, St. Francis Hospital & Health Centers, Beech Grove, IN. Telephone: (317) 783-8367.
Ruth Danos, RN, CPUR, utilization review coordinator, McKenzie-Willamette Hospital, Springfield, OR. Telephone: (541) 726-4504.
Carol Levy, RN, MS, manager, utilization review and social services, Community Memorial Hospital, Ventura, CA. Telephone: (805) 652-5010.