Understanding Case Mix Beyond the Number

1

• Understanding Case Mix Beyond the Number
• Huntsville Hospital's Journey

Vincent Bonetti Executive Director
PFS Huntsville Hospital 2009 Annual
Institute June 2009
2
Todays Presentation Ground Rules

• We dont have all the answers -This is just one
  hospitals journey
• We incorporated processes learned from other
  facilities along the way
• We have not finished our journey
• We want to continue to learn from other experts
  please share.
• We are open to interaction during the hour

3
Assumptions we made

• CMI is primarily measuring Medicare, but the
  process will affect all patients
• CMI is not just a Finance number
• CMI is not just a HIM/Coding outcome
• CMI is more vital than ever since MS-DRGs
• CMI is more dangerous than ever
  RAC/MAC/OIG/overdrawn government
• CMI can be affected by focus and attention

4
Our Original Objectives

• Develop a management tool for month to month
  analysis of CMI by both finance and
  administrative clinical teams
• Provide confidence that monthly numbers truly
  reflect actual acuity of the patients we treat
• Educate clinical leaders as to how they can use
  this tool and impact CMI
• Make the tool easy to use and relevant to outcome

5
Our Actual Unstated Objective

• Stop blaming or celebrating coding when CMI
  numbers change stop the insanity
• We kept doing what we were doing expecting
  different results
• Be assured that we are maximizing the recently
  deployed expense of Documentation Specialists
• Educate ourselves
• Educate non-finance leadership team(s)

6
Journey Background

• By starting in the middle of the course
  traditional long standing reports were our only
  tools
• Month over month CMI charts and graphs
• The months volume of cases per MS-DRG
• Physicians profile of MS-DRGs with case volumes
• Cases with CCs, MCCs, etc.
• MDC charts and graphs
• Etc.

• The traditional large team approach was being
  utilized
• COO
• CFO
• CIO
• CMO
• CNO
• COEE (chiefs of everything else)
• HIM
• Revenue cycle
• Decision support
• Case Management
• Physician Advisor

7
Example month over month
8
Example MDC month over month
9
The Journey Taken Realizing a need for change

• Many large group meetings were painful
• Large group acknowledged we were spinning our
  wheels
• We were fortunate that CMI increased after
  MS-DRGs went live, but no one actually knew why
• We agreed to go small allow five
  representatives to report back to large group now
  to be known as The Group of Five
• We agreed to Case Mgmt, Bed Capacity, HIM, Rev
  Cycle and Decision Support

10
Small Group The Group of Five

• The initial few meetings focused on educating
  ourselves
• Did we understand all that went into CMI?
• How could we ascertain the level of understanding
  of others?
• Could we connect the dots between the CMI
  financial impact and the staff on the floor?
• How could we fully understand the processes of
  day-to-day life of our patients?
• What was the value of reviewing literally
  hundreds of data elements sliced and diced in
  hundreds of ways?

11



Enterprise CMI Gears
CMI/Expenses Matrix
Documentation
Discharge Disposition
DNFB
Discharge Planning
POA
Revenue Integrity
Vice President Goals
DRG/MSDRG Education
Model Unit
Admission Status
Case Management
Never Events
Coding Query
12
Small Group

• The Group of Five reached out to key leaders of
• Surgery, Cardiology, Emergency Department's,
  Direct Admits, Labor and Delivery
• The Group of Five conveyed what was learned and
  asked for feedback while inviting participation
  from unit leaders
• Leaders acknowledged importance of this project
  mostly!
• Leaders cooperated in instructing Group of Five
  about day to day processes of each area involved
• Leaders agreed to provide input about how to best
  convey objectives to others

13
Small Group

• After four meetings with each service unit
• The Group discovered the difficulty of blending
  CMI with the daily life on the unit their focus
  is each patients need at that moment (painful
  realization)
• The Group also discovered what not to make
  important (the actual case mix number)
• Created present day process flow
• Created future state desired
• Created gap report
• Included process change needs
• Included Technology needs
• Included FTEs required to accomplish objectives
• Discovered outside tool

14
Outside Tool

• Worked with vendor Real Time Medical Data
• Uses real paid claim data
• Has data for all claims paid by Alabama FI
• RTMD has the ability to make comparisons of all
  essential data.
• HOWEVER is strictly a reactive reporting tool
  based on previous experience within your
  institution.
• The tool provides the facts, it does not provide
  the analysis and possible needed changes The
  Group of Five does this.

15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
Gap Report

• Presented gap report to large group
• Educated large group
• Convinced them of the need to spend money and
  support change's with Medical staff, Case Mgmt,
  Nursing, etc.
• Asked VPs to schedule us for any and all
  staff/physician meetings
• Created road show for hospital departments and
  physician offices/groups
• Created high level is it working review
• Incorporated Real Time Medical Data
• Left it up to individual VPs to ask for support

20
The original goal was to understand case mix
beyond the number

• How one hospital determined to drive expertise
  and understanding of Case Mix.  The goal was to
  provide the enterprise a 'report card' that drove
  more than conversation.  We discovered it truly
  does take a village to understand and respond to
  this increasingly important number.  Ultimately
  winding up with physician participation, outcomes
  management, finance, intake management, HIM,
  nursing, decision support, quality and
  administration as routine partners in this
  routine discussion.  We started from a single
  report with lots of data to a multi-disciplinary
  team that reviews and reports monthly on
  information learned from many levels of data. 
  Ultimately we understood the most important
  question to be answered was.............you will
  have to come listen to find out.

21
Question and Answer

• The answer is How do you monitor and measure the
  daily quality of all providers that treat our
  patients?
• CMI is a merely a result, not what is to be
  managed.
• CMI cant be managed, people and processes must.

22
Conclusion reached and moving forward

• Quality of documentation is essential
• This indicator cannot be effected only patient
  care can/should be.
• Individual unit needs must be the focus
• Everyone CANNOT be educated about everything
• Especially outside daily core role of individual
• STRONG leadership required
• Talk about the process to all individuals often
  
• Talk honestly about process

23
Thank You!
QUESTIONS !!!