1. Data Collection and Quality Management Aim: To explain the DRG funding system and its relationship to quality management

2. Diagnosis Related Groups (DRGs) A patient classification system which provides a means of relating the type of inpatients a hospital treats (ie. its Casemix) to the costs incurred

3. Bed Ratio (1995) Aust. 4.3 per 1000 of pop. UK - 2.1 per 1000 of pop Netherlands 4.1; Denmark 4.1 France 5.0; Germany 7.2 Since 1985 fall in bed ratio in public and private sectors

4. In the Past, Hospital Billing on the Basis of: Number of days in hospital Category of care Category of hospital (A,B,C,D) Type of procedure (Cwth Medical Benefit Schedule) Other specialist tests billed separately

5. Casemix requires recording of the following patient information: Name of patient Admission date Principle diagnosis (at discharge) Other diagnoses Operating room procedures Other surgical procedures Discharge date and status

6. Changed Incentives Old system provides economic incentives to keep patient in hospital New system provides incentives to reduce patient stay

7. DRG data collection allows: Comparison of outcome quality and comparison of costs Hospital performance comparisons Ward performance comparisons Doctor performance comparisons

8. Casemix Advantages More information to assess quality and outcome Potential for more accountability and equity in the distribution of the health $ Greater knowledge and choice for health consumers

9. Classifications can help: Indicate whether re-admission rates are abnormally high Find and fix problems of poor outcome for rehabilitation patients Decide how resources should be allocated between hospitals and departments Planning bed and staff numbers for new facilities

10. Need for Effective Data Input (the Auditor General of Vic. found: Patient medical records not updated and endorsed by VMOs Checking of VMO claims infrequent Treating of private patients during publicly funded theatre sessions Overservicing related to pre and post- operative consultations

11. Access Indicators Waiting times for elective surgery Accident and emergency waiting times Outpatient waiting times Variations in intervention rates Separations per 100000 of population

12. Quality Indicators Rate of emergency patient readmission within 28 days of separation Rate of hospital acquired infection Rate of unplanned return to theatre Patient satisfaction Proportion of beds accredited by the Aust. Council on Healthcare Standards

13. Quality Indicators Unplanned readmissions (0.8% in ACT - 6.3% in NT) Return to operating theatre (0.1% in Tas. - 4.2% in NT) Hospital acquired bacteraemia (0.03% in SA - 0.3% in Tas) ACHS Accreditation (16% Qld - 64%NSW)

14. Pathways of Care Assist Quality management A pathway is a staged plan that notes the appropriate use and timing of procedures in relation to patient recovery

15. Developing a pathway Practitioner team select a client group or case type Set a time frame (e.g. arrival at hospital to 6 months after discharge) Map out typical expected care Set up plans and record deviations for individual patients Evaluate outcome

16. Pathways Help Identification and Control of Risk Risk is the potential for an unwanted outcome Risk management is about the prevention of unwanted outcomes through providing quality care; preventing untoward events and gaining comprehensive, objective, consistent and accurate communication

17. Integrated Care Management Multidisciplinary approach to pathway development Involve patients and their carers Variance from the pathway is to be expected and must be documented

18. Benefits of Pathways Reduces patient uncertainty and makes them and the family partners in care Eliminates duplication and unexplained variation in clinical practice of team Improves resource utilisation and communication Enables multidisciplinary audit through goal setting, outcome monitoring and variance tracking

19. Pathways are a research tool Pathways allow information about typical and atypical treatments or groups of patients to be gathered as a result of a combined research and service delivery process They can be used by a single group, by two organisations comparing practices, or at a much broader level, to continuously improve practice

20. The Quality in Aust. Health Care Study Reviewed over 14000 patient admissions in 28 hospitals in NSW and SA Found 16.6% involved an adverse event; half of which were assessed as highly preventable Compares with the Harvard Medical Practice Study which reviewed 30,000 records and found 3.7% adverse events

21. Screening Criteria Unplanned readmission within 28 days3.4% Death or cardiac arrest 1.7% Transfer to acute care facility 2.8 % Transfer to intensive care unit 1.1% Booked theatre cases cancelled 0.6% Length of stay more than 35 days 0.4% Return to operating theatre within 7 days 0.4%

22. Follow-up Change relevant hospital policy Present case at postgraduate meeting Undertake a quality assurance program Discussion or counselling of doctor Review of the doctor’s clinical privileges or reporting the cases to the hospital’s insurer

23. Policy changes included: Restricting some drug prescribing Revised protocols for reporting vital signs Eliminating use of multidose drug vials Guidelines re fitness for anaesthesia Protocols for managing patients with alcohol withdrawal, haematemesis and malaena, and cerebrovascular accident

24. NSW Health Care Complaints Act 1993 A complaint may be made to the Health Care Complaints Commission concerning: Professional conduct of a health practitioner, a health service or a health provider, even though at the time the complaint is made the provider is not qualified or entitled to provide the service concerned

25. A Complaint may be made by: Anybody, including the client concerned a parent or guardian of the client a person chosen by the client for the purposes of making the complaint a health service provider a member of Parliament the Director-General or the Minister

26. Referral of Complaint The Commission may refer a complaint to another person or body for investigation if further information is required

27. The Need for Reliable, Transparent Outcome Data Need for a longitudinal patient record (patient held ‘smart cards’) for Medicare record Need for access by service purchasers and by patients to information about service contractors and their outcomes Provide for a duty of care/duty to inform and place confidentiality requirements in codes of practice?

28. A National Risk Management Approach Health act where the health practitioner has a duty of care and duty to inform Maintain the system of universal health care provision and government price control through the CMBS Use Medicare as the spine for data driven quality management Coordinate all health service delivery