Benchmarking develops buy-in for pathways
Data-driven system wins over physicians
With managed care driving the trend toward outpatient services and capitation, health care facilities are rushing to implement clinical pathways across the continuum. But without benchmarking as a foundation for pathway development, you may find yourself lagging behind in the race to be more competitive and efficient, warns Robert Murray, MD, director of clinical resource management at Children’s Hospital in Columbus, OH, the sole pediatric facility serving 37 counties.
"We wanted to look at the process of delivering care across the entire pediatric community," he says. "The question was, could we set up a program that emphasized outpatient treatment and follow through?"
So far the answer is yes. Children’s Hospital has implemented seven clinical pathways this year with 14 more to come in the next six months. (See pathway implementation schedule, p. 173.) Murray, along with administrators from the case management department, prioritized pathway development by pinpointing high-cost DRGs, assessing internal variability, and benchmarking against external sources.
Such preparation takes time, but it can make or break actual pathway implementation and physician buy-in, Murray says. "You must have sound data not only to help you select which pathways would be most advantageous to develop, but also to get physicians to realize how they are practicing in relation to their peers."
He explains his three benchmarking basics:
1. Identify high-cost DRGs.
By initially tackling common yet costly diagnoses such as asthma, bronchiolitis, and seizures, administration ensures it is implementing pathways that will have the greatest financial impact on the facility. To identify which diagnoses were candidates for pathway development, Murray and an oversight team reviewed the literature and obtained benchmarking data from Pediatric Hospital Information System, a product of Child Health of America in Shawnee Mission, KS.
Then they created a bubble graph in which the location and size of the bubble demonstrated the number of admitting diagnoses in terms of costs and variability of practice patterns. (See chart on identifying candidate diagnoses for pathways, p. 173.)
"Essentially, this told us where to start. It enabled us to not only to select diagnoses that were important to the hospital budget, but also ones that were highly variable and thus, likely candidates for pathways," he says. "By selecting those diagnoses that have the greatest impact, we’re being efficient with our pathway process."
2. Assess internal variability.
Team members then graphed average lengths of stay (LOS) by attending physician and created a scattergram of charges per case that illustrated variability within diagnosis, he adds. Physicians also received a profile of tests, procedures, and nursing services according to DRG. (See chart on appendicitis charges per patient, p. 173.)
"We wanted to show physicians how their practice patterns compared with each other and get them discussing variability," Murray explains. "Some physicians were discharging patients within two days and others three to four days. Some were ordering more lab tests than others. We wanted them to address why."
3. Benchmark against external sources.
Finally, for each diagnosis under pathway development, the team members prepared a bubble chart that compared the average charges per case and average LOS with about 10 hospitals nationwide and five within Ohio. (See inpatient asthma cases chart, p. 174.)
"These charts allowed us to identify institutions we should be benchmarking our processes against and set a target for the pathway," Murray says. "Writing a pathway is more than thinking through assessment, treatment, evaluation, but asking Who does this better? How do they do it? Can we emulate it?’"
Putting the puzzle together
These kinds of information are necessary components of a "scientific challenge puzzle" Murray adds. "At first, the staff may feel threatened, but after they see the data, they become engaged and begin to tackle the challenges of the data. It’s fun to watch the transformation," he says.
Murray also makes sure key leaders in the physician community serve on each pathway team to facilitate buy-in and consensus. "We build the team around these leaders who are recognized as everyone by being experts in their area and highly skilled clinically," he says. "They need to be well-established in their community practices so when they make pronouncements, they will be trusted."
A candidate for physician leader also should understand the benefits of pathways and be able to articulate them to other physicians in the community. "This way, the message is not perceived as coming down from administrators but rather from their peers."
It’s important to continue physician feedback after the pathway is implemented, Murray says. For example, a statistical control chart provides insight into practice trends over time. Above and below the line denoting the pathway’s projected charge per patient per DRG, is a band representing a 15% variance. As implementation progresses, the dots, which indicate cases, should fall within that range of acceptable charges.
"Anything outside of the dotted line is considered a variant case," Murray explains. "It gives the physicians an opportunity to pull the chart, to research why this case cost $10,000 more than the $5,000 allocated by the pathway," he says.
Perhaps the answer may be an infection or co-morbidity that complicates data, in which case the variability is recognized as normal, he says. "Or it may mean that a patient wasn’t discharged soon enough, adding to the expense of the case without affecting the outcome."
Physicians also receive a graph that profiles the average charges of each physician per diagnosis and indicates where their performance falls relative to the pathway charges and their peers. "It enables them to identify diagnoses and to prioritize their focus and attention," Murray says. (See appendicitis charges by physician, p. 174.)
However, Murray cautions that physicians must understand that pathways are not meant to "supplant their clinical judgment. There are many reasons that might legitimately exclude a patient from a pathway, so variations are both acceptable and expected."
He does ask physicians to document their reasons for varying from the path. "We can incorporate their insights into pathway revision. Clinical pathways are a dynamic process. You don’t just do them once and put them on a shelf."
[Editor’s note: For more information, contact Robert Murray, MD, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205-2696. Telephone: (614) 722-3485.]
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