1. The Case for Case Costing
Presentation to TBRHSC SMC
Tuesday, March 19, 2013

2. Contents Brief History What is Case Costing?
Why Invest in Case Costing?
Requirements for Case Costing
Implementation Time Frames
Is TBR Ready?
What’s the first step?
Data Quality Issues/Lessons Learned
Appendix A – HSN OR Workload Capture
Appendix B – How Case Costing is Used
Appendix C – Quinte Health Centre BI
Appendix D – Mount Sinai Hospital Data Placemat
Appendix E – Southlake Data Quality Examples

3. Brief History
1993, thirteen hospitals chosen for Ontario Case Cost Project
1995, second generation of case cost hospitals, 22 added
2005, open invitation extended, 37 facilities added
TBRHSC was not ready
2013, MOHLTC issued it’s five remaining Case Cost licenses prioritizing from a wait list of 20
TBR was not on the list. That ship sailed…
Next, MOHLTC needs to decide what to do about acquiring additional licenses and/or negotiating a contract on behalf of the rest of the province. There might be word of additional licenses in another year.
Will TBRHSC be ready?

4. What is Case Costing?
Collection of case costing data in support of improved management decision making
New views to help answer operational management and planning questions while still providing the necessary departmental management information
Used in the development of hospital funding methodologies
Generate case costs by integrating financial, clinical and statistical data and gather patient-specific data as a by-product of care delivery documentation & communications
Case Costing is not something that is installed and turned on!
Case Costing is a journey, a series of events and readiness!

5. What is Case Costing? Reference: MOHLTC OCCI Chapter 3 Reporting Process

6. Why Invest in Case Costing? Reference: MOHLTC Funding Reform

7. Why Invest in Case Costing
Why Invest in Case Costing? Reference: The Power of Micro-Costing in Quality QBP Funding, Filomena Travassos, Trillium Health Partners, Jan 17/13 OCCI Best Practice Event

8. Requirements for Case Costing
Nursing – nursing workload or patient hours proxy
Allied Health – NWMS and need for comparable workload data across professions
Laboratory – use NWMS and not LMS units
Diagnostic Imaging – use NWMS
Pharmacy – use NWMS and use Medication Profile and not MAR for costing
Operating Room – use door to door not skin to skin time
Obstetrics – neonates require scaling factors
Emergency Room – Relative Value Units RVU/triage level and factor for inpatients
Financial Services – categorizing of costs & auditing
Health Records – quality of patient data & coding
Information Systems – IS Strat Plan must reflect hospital’s business plan to implement & use case costing as IS priorities must be clear & compatible
Linking ADT, patient hours and workload by patient to FC
Materials Management – patient specific supply costing
Overhead and support – allocation methodology

9. Inputs and Outputs of Case Costing Reference: Data Quality Control Process, before Loading into ADS, Jane Chen, UHN, Jan. 17/13 OCCI Best Practice Event

10. Requirements of Case Costing – Nursing Workload
Nursing Workload or a Nursing Workload Proxy is required in order to case cost.
Provincial recommendations suggest actual nursing workload is superior to a proxy.
At Health Sciences North, they were able to demonstrate Operating Room workload is directly proportional to case time and implemented the capture of staff time in their OR information system via customer defined screens.
HSN uses the resulting information to cost resources, schedule OR time and influence practice.
Largest challenge may be on inpatient units unless integrated to avoid duplication of effort

11. Requirements for Case Costing: Milestones
Building Blocks: initial review is to assess the status of the hospital in terms of planning and development of the required case costing systems. The review takes place at the onset of the planning stages.
Pre-Go-Live Check: one to two months before the hospital goes live with collecting patient-specific data. The goal of the review is to examine the data capture, data interface and data quality mechanisms to ensure reliable and valid data from each of the components of the case costing system.
Three Months Test Data: hospital cost data is brought together with the corresponding discharge abstract from CIHI
One Full Year of Data: The costing system is analyzed to ensure accuracy, consistency and comprehensiveness of data collection for a complete fiscal year of cost data. The hospital is to address all issues identified prior to submitting the data.

12. Implementation Timeframes Reference: MOHLTC, OCCI Chapter 1
If any of the major clinical (feeder) systems are missing, or requires overhaul, then it could take up to two years to achieve a solid implementation.
If mature financial systems and the majority of clinical systems are already in place, a time frame of 6 to 8 months would be reasonable to get a working group and assign a dedicated team to focus on each of the following areas:
Implementing the Case Cost System;
Extracting and uploading of files from the various feeder systems;
Developing financial and statistical data to ensure compliance with OHRS requirements;
Developing an allocation routine for TFC costs and reviewing the suitability of the standard allocation bases.

13. Is TBR Ready? What missing & what needs an overhaul?
What resources might be required on a one time basis?
What resources are required on an ongoing basis?

14. What is missing and/or needs an overhaul?
Nursing Workload and Patient Hours Methodology
Inpatient units may apply patient hours methodology in lieu of formal workload
Episodic care areas, OR, Recovery Room and L&D, custom workload capture
Emergency and ambulatory care ability to separate workload of admitted patients
Patient-specific and micro supply costing impacts units with high cost item usage, Materials Management and Pharmacy
Improved Allied Health Workload Capture
Improved Pharmacy and Diagnostics Workload Systems and Validation

15. What resources are required?
Immediate and on-going impact on middle management and operating staff will be additional work for the implementation, ongoing data collection, validation and maintenance.
Some additional work will be intensive on an ad hoc basis to investigate and implement costing solutions by the core team and leadership of impacted areas
Other on-going requirements should be incorporated into and part of existing management and data quality/improvement assessments
In addition to known anticipated case costing benefits and uses, process improvement and efficiencies via elimination of duplicate, manual and redundant processes may be gained

16. What resource $$ are required?
One full time Case Cost Coordinator project and on-going $85,000
Office support & professional development $2,000 per year
Financial Services or other Director case cost administration for implementation and on-going from existing resources provided following PMO support available
Project Management Support 5 hours per week for two years $20,000
IS Support 10 to 20 hours per week for 2 years but demand will not be consistent $70,000
Core team site visits $15,000
Nursing and Allied Health Workload Software licenses and/or custom solutions $100,000 - $200,000
Reports/interfaces $25,000
Annual software support costs $15,000 - $30,000
Nurse Training Hours will be dependant on solution and incorporating on-the-job training as much as possible – estimate 1,400 staff 1 to 2 hours for off the job training $65,000 - $130,000
Case Costing license supplied by MOHLTC
Total estimated annualized one time costs for two year period : $234,500 to $399,500
Estimated annual costs after two year period: $102,000 to $132,000

17. What’s the First Step
SMC decision and commitment is required to start the journey.
Starting the journey, means deciding to champion and support the requirements that lead to readiness
Project Management Office resources
Informatics acceptance
Buy in by management, core, project & functional teams and ultimately front line staff!

18. Data Quality Issues and Lessons Learned

19. Data Quality Issues and Lessons Learned
Even with data quality issues, decisions made with case cost information are better than decisions made without.
Some case cost facilities reluctant to share their data due to anticipated criticism of “garbage” information.
However, most know not to sacrifice the good for the perfect!
Ontario is recognized internationally for good comprehensive data.

20. Data Quality Issues and Lessons Learned
The devil is in the details!
High level cost per case by CMG is not enough
Teams and decision-makers require micro level information
Allocation standards & hospital specific approaches are important
Set up audit programs to ensure the reliability and validity of data produced
Physician engagement is critical
High performing clinical teams need support in
Case Costing and Financial Analysis
Clinical Redesign/Re-engineering/Change Management
Evaluation, Measurement and Benefits Realization

21. Questions? Discussion Next Steps? Appendices follow:
A: HSN OR Workload Capture
B: How Case Costing is Used
C: Quinte Health Centre BI
D: Mount Sinai Hospital Data Placemat
E: Southlake Data Quality Examples

22. Appendix A: Health Sciences North Operating Room Workload Capture
The following two slides are examples of Customer Defined Screens used in HSN’s OR Management System to capture Nursing Workload
Other HSN comments re OR Workload:
Staffing requirements per procedure are dynamic and can be dependant on surgeons, equipment and processes so are reviewed and revised as required
100% Cases performed in the OR have nursing workload
Staff buy in was easy because HSN improved a process, eliminated duplication making it more efficient
Workload captures as part of electronic charting increases compliance and improves data quality
Senior Management commitment was key

23. Appendix A: HSN Operating Room Workload Capture

24. Appendix A: HSN Operating Room Workload Capture

25. Appendix B: How Case Costing is Used
The following four slides give examples of how Case Costing is used:
Organizationally
Provincially
Nationally
Other Uses
Reference: Case Costing The Importance and Impact of Case Costing
Presented by: Nan Brooks, Consultant, MOHLTC
January 17th, 2013 OCCI Best Practice Event

26. Appendix B: Organizational Uses of Case Costing
Model of care development
Standardization of practice
Value for money
Identification of cost drivers
Utilization Reviews
Decision on volumes to perform
Physician impact prior to hiring
Benchmarking

27. Appendix B: Provincial Uses of OCCI
HBAM
QBP
Global carve out values
HIG weights
Utilization
Population based needs
Specific costing models
Value for money analysis
Research and sustainability analysis

28. Appendix B: National Uses of Case Costing
Resource Intensity Weights
CMG Grouping
Hospital Reports
National CIHI Comparison Reports
CIHI – Backbone of Canadian Hospital Reporting Project
Research

29. Appendix B: Other Uses Comorbidities:
Only pre-admit and post admit comorbidities that contributed an additional 25% to the cost of care were included on the comorbidity lists.
Flagged interventions:
E.g. Tracheostomy, Chemotherapy, Mechanical Ventilation are flagged interventions as an indicator of a high cost patient.
Emergency Data are grouped and weighted based on cost information.
Day Surgery data are also weighted based on cost data
Cardiac Catheterization, Dialysis and Oncology clinics also have RIWs based on cost data.
Mental Health CMIs, and Rehab weights are being re-developed using OCCI data.

30. Appendix C: Quinte Health Centre Business Intelligence
Following are three examples of what Quinte Health Centre achieved one year after awarding their RFP for a Business Intelligence system
They achieved the following cost information result with an input file from their Case Cost system
The Case Cost system came before the BI system
6 staff worked on and off on the BI implementation for one year and dedicated hours were equivalent to 2 FTE
This is what they achieved after one year of BI implementation …

31. Appendix C: Quinte Health Centre BI

32. Appendix C: Quinte Health Centre BI

33. Appendix C: Quinte Health Centre BI

34. Appendix D: Mount Sinai Hospital Data Placemat
The following three slides show examples of Mount Sinai’s Data Placement
Called a “Placemat” as it is printed on large paper, pertinent to the called meeting and is the place setting for each attending team member

35. Appendix D: Mount Sinai Hospital Data Placement

36. Appendix D: Mount Sinai Hospital Data Placement

37. Appendix D: Mount Sinai Hospital Data Placement

38. Appendix E: Southlake Data Quality Examples
The following four slides show just a small sample of data quality issues to investigate and resolve
Purchasing item files and consistency in coding
Matching costs and/or workload to the correct patient encounter
Sometimes investigation reveals a legitimate change in practice such as LOS
Coding as unspecified can result in significant variances from provincial results and impact funding

39. Appendix E: Southlake Data Quality Examples

40. Appendix E: Southlake Data Quality Examples

41. Appendix E: Southlake Data Quality Examples

42. Appendix E: Southlake Data Quality Examples