Feature / Practical engagement

With increasing recognition that clinical involvement is not just desired but essential to the costing process, a workshop at this year’s HFMA national costing conference set out to discuss three of the big issues in successful engagement

Before any clinical engagement takes place, organisations need to be clear on three issues: who they should engage with (and what data they engage about); when this engagement should take place; and how the engagement should take place.

Who to engage (with what data)

Experience highlights that there are a variety of clinicians who could play a valuable role in patient-level costing, including doctors (from medical directors through to junior doctors), nurses and allied health professionals:

• The start of the process, such as launch and design of a patient-level information and costing system (PLICS), can benefit from engagement with senior clinicians with management responsibilities such as medical directors. They can help identify the requirements clinical managers will have from PLICS, as well as acting as a clinical champions. They can also facilitate invitations to clinical board meetings to introduce the programme.
• Junior doctors and ward leaders can add benefit during the patient costing process. They are close to the clinical activity and at key stages such as when a first cut of cost data is delivered, they can spot cost errors.
• Focusing on activity data can facilitate engagement as it means finance professionals talk to clinicians in their own language: tests, procedures, length of stay. This also provides an opportunity for clinicians to highlight realities of clinical practice. For example, the issue of whether a clinic operates on a named consultant basis or as a team can have an impact on whether it is relevant to report by individual consultant.
• As patient-level costing is rolled out, clinicians at different levels within the trust will ask for reports for their own management needs. If these enable comparison across consultants then, once matched with activity levels, they can aid peer-to-peer comparison. Clinical variation can be illustrated using the ‘information’ element of PLICS. But adding the £ sign can often trigger closer inspection. It can even lead to behaviour change, where clinicians become aware of cost differentials.
• One of the real benefits of using patient costing data can be to eliminate clinical variation and help promote consistency of recording and counting of activity. There are now groups across the country that focus on benchmarking between organisations. Some clinicians are more comfortable and open to this type of benchmarking as it is less personal to their individual practice.

When to engage

Experience suggests that there are three key stages:

• System design There are key decisions about the level of granularity and flexibility needed in the system, as well as integration with other local clinical systems. Operational management as well as medical directors will play a key role at this stage.
• Validation Where reports are available from the costing system it is important to engage with clinicians to validate the underlying data. A patient hotel-style bill can be useful, but it can be confusing if the cost allocation algorithms are not completely transparent. A balance must be struck and, over time, it is likely that presenting data in this way will become a more realistic goal.
• Using information Clinicians will want to use the information from PLICS in different ways according to their local circumstances. Just being able to compare consultants and illustrate clinical variation can generate interest. A balance must be struck to be able to meet the many needs of the organisation: from the requirements of the board through to operational units such as clinics and wards.

How to engage

Engagement is a continuous process, not least because clinicians rotate in and out of trusts and because of natural staff turnover. Many will need to be introduced to PLICS and their knowledge refreshed over time.

In engaging with clinicians, the benefits for them and their patients must be to the fore. PLICS can deliver real rewards for clinicians. It can enable them to do things they couldn’t do before, or couldn’t do so well. It can provide a more robust basis for building business cases or demonstrating the profitability of a service.

When PLICS works well, enabling more robust decision-making, it can help clinicians stand out and be recognised at board level, providing a degree of reward and recognition for their engagement. In some cases, there may also be a link to cost improvement programmes.

Services exposed as loss making or high cost on the back of robust cost data could be asked to contribute more towards the overall efficiency requirement. So it is vital for clinicians to understand their costs to show services can be both profitable and sustainable.

Finally, as clinicians are more and more involved in understanding how their services are funded they can provide invaluable input into tariff design and national price setting. This should promote a virtuous circle, with prices that more closely reflect desired clinical practice prompting further engagement.

Report by Gan Raman, Suzanne Robinson and Leela Barham, members of HFMA Costing Practitioners Group