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St. Michael’s involves physicians, staff in funding action plans

Toronto, January 13, 2014

By Cyndy De Giusti, vice-president, Communications and Public Affairs

St. Michael’s Hospital has always prided itself on its approach to quality – and a key dimension of quality is efficiency. More and more, the hospital is looking at its operations through a lens of value – improving the quality of patient care while reducing costs.

“When the new Ontario provincial funding formula was introduced to hospitals, St. Michael’s tackled its result on HBAM [Health-Based Allocation Model] and the Quality Based Procedures with zeal,” said Dr. Robert Howard, the hospital’s president and CEO. “Our first numbers were not very good but we have really been able to turn them around.”

The first work was with HBAM results. During this phase, Finance and Decision Support worked with managers to make sure that inpatient, community and outpatient costs were carefully separated so that the right costs were assigned to the right program.

Then, the hospital turned to QBPs. The successful QBP approach includes four prongs: get the data right, standardize, conduct quality improvement projects where warranted and advocate with the government when a different viewpoint needs to be considered.

“We work directly with the clinicians – physicians, clinical leader/managers and health care professionals – to look at how performance metrics for each QBP compare with provincial averages or specific peers,” said Tomi Nieminen, director of Decision Support. “We also assess best practice opportunities presented in each specific QBP clinical handbook.”

Also on the team are representatives from the hospital’s performance group, informatics and health records.

Again, the work has been effective in identifying opportunities to focus on specific quality initiatives, reducing case costs, improve our data and also helping clinicians and leaders understand the new funding environment.

“One of St. Michael’s great strengths is a high level of engagement between the hospital and physicians,” said Anne Trafford, vice-president for quality, performance and information management, and chief information officer. “Once the physicians understood the implications of their decisions for QBPs, they were very willing to look at both standardization and quality improvement projects.”

Two examples really demonstrate the success to date: endoscopies and hip replacements.

St. Michael’s is a national and provincial leader in complex therapeutic endoscopies. Each year, physicians perform about 14,000 procedures. According to government data, 1,200 were considered specialized and therefore being considered for funding adjustments in 2014-15.

Physicians felt the specialized number was low so the QBP team did chart reviews of the entire 2012-13 caseload. They found that several of the specialized cases were missed in the coding process because of an information gap between physician notes and coding requirements. When correctly coded, the number of complex cases went from 1200 to 2,800.

The long-term answer to make it easier for coders? A simple sticker system that physicians now use to indicate specialized cases. As Nieminen commented, “Sometimes it is the low tech answer that works.”

In the case of hip replacements, the internal QBP team’s four-pronged approach identified St. Michael’s costs as an opportunity. The data clearly showed that the cost of hip replacement devices was a major contributor to a higher cost per case than elsewhere.

The orthopedic surgeons took the information away and came back with a standardized protocol about which devices would be used with different aged patients. The work reduced the average case cost by over $300.

The work on new QBPs continues but the next area of work will be to educate the broader hospital staff and physician community on the kinds of costs that matter in the new funding environment so that everyone understands his or her role in cost reduction.

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.