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Finding the pathway to savings |
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Ardentia
: 14 September, 2010 |
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Efficiency savings call for cuts to be made across the board, but how can these be achieved in line with real life patient treatment? Ardentia' Chief Executive, Tom Mulhern, explores some of the key issues. |
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The squeeze is on. We all knew it was coming, but that doesn’t make it any easier to deal with now that it' on us. The drive for efficiency savings is going to be ferocious, and the pressure unrelenting for the foreseeable future.
This means we have to focus on the kind of consideration that was raised by Professor George Kitas, Consultant Rheumatologist and Medical Director from Dudley Group of Hospitals, at a conference of the HFMA in the West Midlands on Service Line Reporting as long ago as Spring 2009. He pleaded for good information to ensure that ‘we cut waste, not care.’
Now that the cuts are going to have to be made, the issue of having the right information to hand is more urgent than ever, if we want to ensure that savings are made in the right places. I believe there are two key areas in which management information will be particularly valuable.
Patient Level Information and Costing
The first of these areas is getting financial information at patient level. This is because eliminating areas of waste, where efficiencies can be gained, is ultimately a task for clinicians changing their practice and this has to be done at an individual patient level.
After all, it is highly unlikely that a whole specialty will be uniformly inefficient, or even a whole consultant team. It' far more likely that a certain type of condition tends to be treated inefficiently, and it is possible that there will be variation at that level too, with some patients with that condition being treated more efficiently than others.
Once the inefficient cases have been identified, they can be individually investigated to establish why the problem arose, and to make sure that it is addressed in the future. Is the problem one of excess theatre time for certain cases? Is a failure to carry out certain diagnostic tests, or to carry them out on time, leading to unnecessary expenditure? Are certain types of cases not receiving medications that would protect them more effectively against hospital-acquired infections?
The answers to these questions emerge at patient level, and will clearly highlight any areas of concern. Those answers can then be used to guide future clinical practice, which is by its nature, focused on individual patients.
Pathfinding
The second area in which reliable information is going to be increasingly needed, concerns patient pathways. While the need for patient level costing is now generally accepted, the importance of this second area is still less well recognised. However, I believe it will prove to be just as vital.
The coalition government has made it clear that it does not intend to allow quality of care to suffer as a result of efficiency savings. Indeed, its early focus on readmissions shows that it is keen to see quality standards improve. The problem is that the means available for evaluating care quality are generally poor.
We’re all aware of the impact of care failures at Mid Staffs hospital, and the repercussions are likely to go on for some time yet with a new enquiry announced by the government. A lot of the scandal was generated by the publication of standardised mortality figures about the Trust. It' therefore interesting that Richard Lilford, Professor of Clinical Epidemiology at the University of Birmingham, recently told the BBC ‘More or Less’ programme, that ‘using mortality as an indication of overall hospital performance is what we would call, in clinical medicine, a very poor diagnostic test.’
Beyond mortality data
As he pointed out, we all die and most of us die in hospital, so overall mortality is of no interest. What we are concerned with is preventable mortality, and he describes the hunt for preventable mortality data within overall mortality as ‘quixotic’.
We could add that not only do we have to eliminate from mortality figures the deaths that were in some sense ‘natural’, i.e. those that could not have been prevented. We also need to add the deaths that took place outside hospital soon after a period of hospital care. A death within 30 days of a hip replacement is probably a highly interesting case to investigate, but it won’t be included in normal hospital mortality figures.
Instead of mortality, Professor Lilford calls for ‘more process-based measurements. What we should look for is whether hospitals are giving the correct treatment.’
This seems trivially obvious, which makes it all the more surprising that we pay so little attention to it. Of course, the reason we spend so little time on process-based measures, is that they are so much more difficult to derive from routinely available data.
This difficulty should not put us off, however, if this kind of measure represents the way we should be going. Pathway analytics tools can provide the patient-level insight that is needed to find out if people are receiving the correct treatment. These tools can link data from the many information silos in hospitals, data about inpatients, outpatients and A and E, with data about pathology, radiology, pharmacy, theatres and the many other departments that deliver care, to identify those areas where care is sub-optimal. After all, it' those areas which should be the focus of management attention.
Costing care pathways
The aim in doing this is to bring these pathways of care together with cost and income information at patient level, so that the overall cost of a pathway can be identified. This way, hospitals will be able to see where their processes are deviating from best practice. If such deviations are associated with excess costs – as they so often are – they know both where there are savings to be driven out, and where there may be care quality problems.
This in turn identifies where cuts can be made without imperilling care quality, and even in many cases actually improving it – giving both efficiency and effectiveness. Costs at patient level, together with a pathways-based approach to understanding hospital processes, will provide hospitals with the means to meet the challenges ahead. |
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