Feature / Doors open on patient level

West Hertfordshire Hospitals is already seeing benefits from its first cut of service line reporting data, based on patient level costing. But as data is refined and clinicians start to drill down into the data, much more is possible. The trust’s Phil Bradley describes the journey so far

The West Hertfordshire Hospitals NHS Trust (WHHT) is on a journey of transformation. A significant deficit in 2006/07 has been converted into two years of surplus and the trust is now applying for foundation status. A big contribution to this has been an integrated approach to service line reporting (SLR) and patient level costing (PLC) and making service line management part of the ‘business as usual’. 

In October 2009 WHHT produced patient level information and costing system (PLICS) information for quarter one. This was made accessible to clinicians, business managers, service managers and finance managers via the intranet. It covers 29 service lines with more to be added in the next financial year.

Second quarter results and process refinements are progressing well, engagement is growing and service line management is becoming a reality.

Even this early, the trust can give clinicians and managers access to SLR and PLC data over the web at any level of granularity from trust-wide to individual patient episode, as well as work back from the patient bills to the general ledger. With the click of a button, users can move round the data, switching from a patient’s bill to see length of stay, age, OPCS (procedure) and ICD (diagnosis) codes, spells, number of finished consultant episodes per spell, critical care days, theatre minutes, prosthesis costs and responsible consultant.

Activities performed are linked to resources consumed – increasing awareness of the activities carried out by clinicians and of the importance of updating job plans and other programmed activities.

The trust has been able to introduce an internal support services tariff model, so users of services such as pathology and radiology are better informed about the cost of these activities and see them clearly on patient bills.

In addition, access to the data in this way has given the trust a better insight into the true costs of outsourced work compared with work carried out within the trust. An added benefit has been that it has also been used to produce and submit reference costs.

The deeper understanding from SLR and PLC has already highlighted areas where data accuracy can be enhanced.  We have improved on the quality of data used in Q1 by updating clinicians’ job plans, recording activities in a more user-friendly format, and more reliably breaking down central costs such as building depreciation for each service line. 

A key outcome is to ensure service line personnel are involved in decisions about new systems and incorporate SLR requirements into the specifications – most recently, the new theatre system.  The trust has identified areas where it needs to change data recording within systems such as its CMIS maternity system and made changes in the way pathology tests are counted and recorded. 

The full SLR roll-out is under way, starting with service and business manager training. All will be given access via the intranet to the SLR model once trained. In the next year, the trust expects to update its SLR and PLC results on a monthly basis.

The case for SLR

From the outset, the WHHT board was enthusiastic about SLR and its natural connection with PLC. Both were seen as essential to the delivery of process and service improvement across the trust and as supporting the foundation trust application.

The implementation plan was challenging – initially set at 12 months from start to first data – but achievable. Time was at a premium, so the trust was keen to use SLR/PLC software that had been thoroughly tried and tested. 

With capital in short supply, it had to deliver value for money. The software also needed to meet the future requirements of the trust as well as more immediate needs. The trust was looking for four key elements of functionality: PLC, business analysis modelling, front end service line and performance reporting and data quality improvement.

An advert was placed in the Official Journal of the European Union in March 2008, followed the next month by a detailed system specification sent to all selected responders.

The resulting tenders were assessed against weighted criteria, including their experience with large NHS acute providers, technical capability, solution cost and ability to meet the timescale. Six shortlisted suppliers showed solutions over three days in June 2008 and were evaluated by a multi-disciplinary panel.

Visits to NHS reference sites were also undertaken before the preferred supplier  was chosen – Bellis-Jones Hill Healthcare Management Solutions, supplying the Prodacapo Service Line Management System, later extended to incorporate QlikView as the front end. Contracts were signed that August.

Service lines

The service lines within WHHT reflect the trust’s specialties. SLR and PLC enable clear identification of resources (both pay and non-pay), people and the work (activities) they perform. It therefore links expenditure under the control of service managers to activities undertaken by their staff and by clinical support services and the charges for these services. Clinical support services can also see the cost of their activities.  And at the overview level, the trust gets a clear picture of the operational and financial aspects and how each of the service lines are working.

The next step is for service line managers to use the information to develop the organisation structure and management framework within which clinicians and business managers can plan service activities, set objectives and targets, track their service’s financial and operational activities, and manage performance.

To understand the potential of service line management, it is helpful to look at a specific service line – trauma and orthopaedics (T&O), demonstrated in the figures (above).

The PLICS dashboard for T&O (figure 1, previous page) shows overall revenue and profitability, the number of episode/ attendances, unit cost, revenue and profit per patient and per FCE for T&O as a whole.

While the high level shows a relatively healthy overall margin (more than £1m or some 14%), the system enables the trust to look at the contributions made by each consultant to this overall margin, although case mix and other local issues would also need to be allowed for in any analysis.

The point of delivery can also be factored in (figure 2, previous page). In this case the data suggests the trust needs to look at why profit varies by point of delivery.

Drilling further into non-elective admissions, it can be seen that there are some patients where the trust is making a loss (figure 3, previous page). This may be something the trust can change. Or it may be a tariff-issue or an infrequent high-cost patient. But understanding where the profits and losses arise and how the costs are built up is hugely powerful in managing the service.

In the highlighted example (figure 3, previous page), the hip procedure patient has a cost of £43,346 compared with an income

of £18,417, which leads to a loss of £24,930. Drilling down into the patient’s attributes revealed a length of stay of 128 days.

Knowing that revenue for the first 95 days (the trim point) is fixed and that each day after attracts £251 (see figure 4, facing page), questions can now be asked. Why was the length of stay 128 days? What could the trust have done better? Was this an isolated case? Who was the consultant?

These questions and others can help the trust understand how it can add value to the patient pathway and reduce costs.

WHHT has made good progress in its implementation of SLR and PLC. But critical to its success had been a rigorous and objective procurement process and an experienced implementation partner, proper resourcing of the project and solid board commitment from the outset.

Although a considerable amount of work and effort has already gone into the project, the trust recognises it is just at the start of the SLR/PLC process.

It now needs to develop the accuracy and buy in over the remaining months of 2009/10, so that it has a robust system, which clinicians are signed up to, to support the further development of WHHT.