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Slide 2 NHS Care Records Service Slide 1 SUS Release 11 Best Practice & Readmissions Training Presentation 1 Slide 3 NHS Care Records Service Slide 2 Agenda Purpose of todays session Best Practice Readmissions Slide 4 NHS Care Records Service Slide 3 APC Best Practice 2012/13 Slide 5 NHS Care Records Service Slide 4 APC Best Practice Introduction The Department of Health introduced Best Practice in Tariffs 2010/11 with the aim of reimbursing providers for improving the quality of care. The aim is to incentivise Providers to provide High Quality and Cost Effective care. The incentive is a National Best Practice Tariff. Best Practice initially addressed four high volume areas; cataracts, fragility hip fracture, gall bladder and acute stroke, chosen due to the significant and unexplained variation in practice and clear consensus of what clinical best practice constituted. In 2011/12 Best Practice was extended to cover a further five clinical areas and to cover the use of Daycase admissions. Slide 6 NHS Care Records Service Slide 5 APC Best Practice APC Best Practice Adjustment to Tariff Best Practice Tariff (BPT) in SUS is treated as an adjustment to tariff and not a separate National Best Practice tariff The Adjustment may take the National Tariff down to a Base Tariff which is then used locally as a base to uplift to an increased Tariff once local data has been reviewed e.g. fragility hip fracture and stroke Other BP adjustments are negative with no local uplift as the Best Practice tariff for relevant activity is set at a level lower than the standard elective (or non-elective) APC tariff DH policy Slide 7 NHS Care Records Service Slide 6 APC Best Practice APC Best Practice has been extended again in 2012/13 with the following effects: There are now approximately 40 service areas that are assigned BPT flags that may be eligible for Best Practice Tariff adjustment Best Practice Tariff (BPT) adjustments applied to APC Spells only Slide 8 NHS Care Records Service Slide 7 APC Best Practice BPTBPT DescriptionSUS/GRPBPTBPT DescriptionSUS/GRP BP01Fragility hip fractureGRPBP28Simple mastectomy with or without axillary surgeryGRP BP04Cataract Best PracticeSUSBP29Excision of breastGRP BP05StrokeGRPBP30 Excision of breast with sentinel lymph node biopsy or axillary sampleGRP BP10Repair of umbilical herniaGRPBP31Sentinel lymph node biopsy/Axillary sampleGRP BP11Primary Repair of inguinal herniaGRPBP32Axillary clearanceGRP BP12Repair of recurrent inguinal herniaGRPBP33TonsillectomyGRP BP13Repair of femoral herniaGRPBP34SeptoplastyGRP BP14Operations to manage female incontinenceGRPBP35Epileptic seizureGRP BP15Therapeutic arthroscopy of shoulderGRPBP36Abdominal painGRP BP16Bunion operationsGRPBP37Lower gastro-intestinal haemorrhageGRP BP17Dupuytrens fasciectomyGRPBP38Self harmGRP BP18Endoscopic resection of prostate (TUR)GRPBP39CellulitisGRP BP19Endoscopic resection of prostate using laserGRPBP40Chest painGRP BP20Primary hip replacementGRPBP41SyncopeGRP BP21Primary knee replacementGRPBP42 Appendicular fractures not requiring immediate fixationGRP BP22Embolisation for GI bleedGRPBP43Acute headacheSUS BP23Thoracic EVARGRPBP44AsthmaSUS BP24 Angioplasty and stenting for peripheral artery diseaseGRPBP45Lower respiratory tract infections without COPDSUS BP25 Angioplasty and stenting for diabetic foot diseaseGRPBP46Pulmonary embolismSUS BP26TIPSGRPBP47Renal/ureteric stonesSUS BP27 Percutaneous excision of benign breast lesionsGRPBP48DVTSUS Slide 9 NHS Care Records Service Slide 8 APC Best Practice Specialised Service Codes and Best Practice Flags This year the Grouping process will output separate Specialised Service Codes (SSC) and Best Practice flags The format of these flags is the same between the Local Payment grouper and the SUS Grouper The Grouper formats are: Specialised Service Code (SSC) = SSnn e.g. SS08 Best Practice = BPnn e.g. BP36 Note: Making this change ensures that the difference between BPT and SSC flags is much clearer for users from a processing and output perspective. Slide 10 NHS Care Records Service Slide 9 APC Best Practice Flags from the Grouper for Best Practice are produced at Spell level Flags from the Grouper for Best Practice are DISTINCT i.e. only one distinct value per Spell. However you can have multiple flags per Spell (but not the same flag multiple times) Local Grouper outputs the SSC and BPT flags into a file xxx_File_rel (where xxx is the filename provided at run time) RowNoProvSpNoIterationSpellFlag 11810000240531SS08 11810000240531BP36 11810000240532BP39 39610000243381BP41 40510000243401BP41 40510000243401SS08 40510000243402SS23 Example output from Local/SUS Grouper Slide 11 NHS Care Records Service Slide 10 APC Best Practice BPT Action Indicators BPT Indicator 1 BPT Indicator 1 Action BPT Indicator 2 BPT Indicator 2 Action BPT Indicator 3 BPT Indicator 3 Action BPT Indicator 4 BPT Indicator 4 Action BPT Indicator 5 BPT Indicator 5 Action All Best Practice Flags whether they are SUS or Grouper derived will be ordered from the Lowest to Highest e.g. (BP01 to BP47) The five Best Practice Indicators will be populated by the first five flags from the ordered Best Practice flags Slide 12 NHS Care Records Service Slide 11 APC Best Practice Invalid Combinations Slide 13 NHS Care Records Service Slide 12 APC Best Practice New BPT Action Indicator attribute displays status of BPT flag Values are:- Invalid (Failed Combination Check) Adj Tariff (The BPT has a National BPT Adjustment) Opt Tariff (The BPT has an Optional Adjustment) Multi (The BPT has an Optional and National Adjustment) No Tariff (the BPT has no adjustments) BPT Indicators where the ACTION Indicator is NULL will be used to derive a Best Practice Tariff adjustment BPT Indicators where the ACTION Indicator is Invalid will NOT be used to derive a Best Practice Tariff adjustment Note: The BP Combination Indicator(APC Spell extract) contains Null as this attribute is no longer used. Slide 14 NHS Care Records Service Slide 13 APC Best Practice Short Stay Emergency (SSEM) To apply Best Practice for Spells that have an HRG and Length of Stay that qualifies for a Short Stay Emergency Tariff SUS will apply the following rules. Record the HRG Short Stay Emergency Tariff on the Spell Record the HRG National Non Elective Emergency Tariff on the Spell Using the Spell attributes that contribute to a BPT adjustment check if the Spell is qualified for an adjustment There are two outcomes possible: (see next slide) Slide 15 NHS Care Records Service Slide 14 APC Best Practice Short Stay Emergency (SSEM) Outcome 1: Tariff adjustment is qualified and will: 1.Apply the National Non Elective Emergency Tariff as the Initial Tariff 2.Apply the adjustment to the Initial Tariff 3.Record Adj Tariff in the BPT Action attribute 4.Remove the recorded Short Stay Tariff as it is no longer relevant. Slide 16 NHS Care Records Service Slide 15 Best Practice Short Stay Emergency (SSEM) Outcome 2: NO BPT adjustment is qualified and will: 1. Apply the Short Stay Emergency Tariff as the Initial Tariff 2.Record No Tariff in the BPT Action attribute 3.Remove the recorded National Non Elective Emergency Tariff as it is no longer relevant. Slide 17 NHS Care Records Service Slide 16 APC Best Practice Apply BPT Adjustments In SUS PbR 2012/13 the following attributes from the Spell will be used to match against reference data to derive if an adjustment for BPT is qualified. Slide 18 NHS Care Records Service Slide 17 APC Best Practice Apply BPT Adjustments In SUS PbR 2012/13 the following attributes are retrieved from the reference data table when a BPT adjustment is qualified. Note: SUS will apply each of the BPT Indicators together with the required attributes. If a match is found the Tariff Adjustment will be recorded and the appropriate BPT Indicator Action will be populated with the value taken from BPT ACTION INDICATOR in the reference data. Note: An Optional Tariff is output for information & local purposes and does not contribute to the Final PbR Tariff or any Market Forces Factor calculations. Slide 19 NHS Care Records Service Slide 18 APC Best Practice HRG CODE UNBUN DLED HRG CODE BP INDICAT OR ADM TYPE ADM SUBTYP E SPELL MIN AGE SPELL MAX AGE SPELL MIN LOS SPELL MAX LOS CDS GROUP TYPE BPT ACTION INDICAT OR TARIFF ADJUST MENT OPT TARIFF ADJUST MENT Column 1 Column 2 Column 3 CZ05YALLBP33ELEALL0130032000APCAdj Tariff-342 CZ13VALLBP34DAYALL999 032000APC Multi Tariff1034 Spell Core HRG Admission Type (Derived) BPT Indicator 1 BPT Indicator 1 Action BPT Indicator 2 BPT Indicator 2 Action BPT Indicator 3 BPT Indicator 3 Action BPT Indicator 4 BPT Indicator 4 Action BPT Indicator 5 BPT Indicator 5 Action Tariff Initial Amount National Tariff Financial Adjustment National Optional APC BPT Adjustment PbR Final Tariff CZ05YELEBP33Adj Tariff 1,078-342 736 CZ13VDAYBP33No TariffBP34Adj Tariff 1,23510341,245 Row 1 Row 2 Row 3 Row 4 Slide 20 NHS Care Records Service Slide 19 APC Best Practice APC Spell Extract attributes BPT Flags SSC Flags BPT Indicator BPT Action Indicator Tariff Adjustment Optional Tariff Adjustment Slide 21 NHS Care Records Service Slide 20 APC Best Practice Number of BPT Indicators Number of distinct Best Practice Tariff Indicators (BPTs) - count regardless of a BPT Adjustment being applied or BPT Invalid Combinations. This reflects the number of BPT that have been allocated by the Grouper or SUS Count does not include phantom Spells or Spells where all episodes have been deleted. Where this occurs count will be NULL Slide 22 NHS Care Records Service Slide 21 APC Best Practice Number of Specialised Service Code Indicators The Number of distinct Specialised Service Codes (SSCs) based on Grouper output - count for PbR Included activity only. Whether the SSC is eligible for a top-up is not considered for this count Count does not include phantom Spells (Spells where all episodes have been deleted). Where this occurs count will always be NULL Slide 23 NHS Care Records Service Slide 22 APC Best Practice Optional APC BPT Adjustment While the field may contain a s value, it is for information only and does not contribute to the Final Tariff. The adjustment may be applied locally but will not attract Market Forces Factor (MFF) Note: The BPT Action Indicator will contain Multi if both Tariff Adjustment (+/- value in ) which is added to the total payment for the Spell and Optional Tariff Adjustment are populated within APC extracts Slide 24 NHS Care Records Service Slide 23 APC Best Practice Length of Stay (LOS) A new length of stay check (LOS) check has been introduced for all APC Spells with a BPT flag when applying adjustment Spells are checked to ensure that the length of time that a patient spends in hospital is BETWEEN a maximum and minimum Spells which fall outside of the maximum or minimum length of stay for that procedure will not qualify for appropriate adjustments. The BPT Action will be No Tariff Slide 25 NHS Care Records Service Slide 24 Readmissions Slide 26 NHS Care Records Service Slide 25 Readmissions Readmissions in 2011/12 High Level Detail Readmissions policy was introduced in April 2011. This meant that Commissioners could retain funds for Spells that are deemed a readmission in order to make investments in other areas in an attempt to reduce the number of readmissions. To support this policy, readmission activity in SUS for 2011/12 was processed using readmission pathway logic with details output in a Managed Service Readmissions extract available to Commissioners only. Slide 27 NHS Care Records Service Slide 26 Readmissions High Level Detail For 2012/13 SUS Readmissions logic will cover: Multiple Years covers 2011/12 and 2012/13 SUS will flag Spells in a pathway that are: Parent (First Admission), Child (Follow-on Admission) or Both Validation results will now be shown at a Spell level as opposed to at a Pathway level Slide 28 NHS Care Records Service Slide 27 Readmissions How a Readmissions Pathway is created: 1.Child Spells Identified 2.Child Spells Validated 3.Readmissions Path Created 4.Parent & Child Spells identified in Pathway 5.Parent & Child Spells Validated Slide 29 NHS Care Records Service Slide 28 Readmissions Step 1 Identifying Eligible Child Spells SUS will look at incoming APC Spells to find eligible child Spells using the criteria shown below. Where it finds a match RAP Spell Type and RAP Eligible Child will be populated. a)Only Spell that are Admission Sub Type = EMR - The admission must be an emergency b)Spell In PbR/Not in PbR = 0 - The PbR qualified indicator must be zero, telling SUS that the Spell is to be tariffed c)Total National Tariff > = 0 the Tariff Total National must be greater than or equal to ZERO If all are passed then RAP Eligible Child = Y and RAP Spell Type = Child If a Spell passes (a) but fails on either (b) or (c) then RAP Eligible Child = N and RAP Spell Type = Child Slide 30 NHS Care Records Service Slide 29 Readmissions Step 2 - Validate Child Spells Only Spells which are marked as RAP Eligible Child = Y are picked up by SUS for validation against the Reference Data. Once a Spell is validated against the reference data: A Spell that passes (no hits) then DH TARIFF ADJ CHILD = Y A Spell that fails (has a hit) then DH TARIFF ADJ CHILD = N Slide 31 NHS Care Records Service Slide 30 Readmissions Attributes used in Child Validations PBR QUALIFIED IND CHILD SPELL PATIENT AGE CHILD SPELL CORE HRG CHILD SPELL UNB HRG CHILD SPELL PRIM DIAG CHILD SPELL SECND DIAG COUNTRY CODE CHILD SPELL TFC CHILD SPELL MAIN SPECIALITY CHILD SPELL ADM SUBTYPE Slide 32 NHS Care Records Service Slide 31 Readmissions Step 3 Create Readmissions Pathway Once child Spells have been identified and validated SUS will link the Spells that fall within the interval (30 days) from child Spell admission date to parent Spell discharge date into a readmissions pathway To ensure that same day readmissions are included the gap between the Discharge Date and Readmission date is calculated from the actual discharge date The data used to find potential parents of the identified child Spells is all held in the post reconciliation marts Slide 33 NHS Care Records Service Slide 32 Readmissions Step 4 - Identify Parent & Child Spells within the Readmissions Pathway SUS will now identify Parent from Child Spells with the Readmissions pathway always working from the last Child back in time. Step 5 Apply Validations SUS will perform Parent validation checks on pairs of eligible Spells. Slide 34 NHS Care Records Service Slide 33 Readmissions AttributeValuesMeaning RAP Eligible ParentY or NY = Eligible N = Not Eligible RAP Eligible ChildY or NY = Eligible N = Not Eligible RAP DH Tariff Adjustment Parent Y or N Y = Valid as a Parent according to DH business Rules N = Invalid as a Parent defined by DH business Rules RAP DH Tariff Adjustment Child Y or N Y = Available for adjustment according to DH business Rules N = Excluded from adjustment by DH business Rules New Readmission Attributes in 2012/13 Slide 35 NHS Care Records Service Slide 34 Readmissions Spell ID Adm Subtype RAP Spell Type Spell in PBR / Not in PBR RAP_Elig_Child DH_ADJ_Chil d RAP_Elig_ParentDH_ADJ_Parent Validation Parent Validation Child S1ELEPARENT0 YY S2EMRCHILD0YY Processing Outcomes Using the matching criteria and processing steps this is the simplest pathway with just two Spells. Spell 1 - This Spell has been identified as an elective admission, is a Parent Spell with a PQI of zero and is eligible for adjustment. Spell 2 - This Spell has been identified as an emergency admission and is Child Spell only with a PQI of zero and is eligible for adjustment. Both Spells have passed validation tests as the DH ADJ Parent and DH ADJ Child are both set to Y and the Validation Parent and Validation Child are both NULL. Slide 36 NHS Care Records Service Slide 35 Readmissions Spell ID Adm Subtype RAP Spell Type PQIRAP_Elig_ChildDH_ADJ_ChildRAP_Elig_ParentDH_ADJ_Parent Validation Parent Validation Child S1ELEPARENT0 YY S2EMRBOTH0YYYY S3EMRCHILD0YY Processing Outcomes Using the matching criteria and processing steps here are some of the possible outcomes Spell 1 - This Spell has been identified as an elective admission, is a Parent Spell with a PQI of zero and is eligible for adjustment. Spell 2 - This Spell has been identified as an emergency admission and is both a Parent and Child Spell with a PQI of zero and is eligible for adjustment on both Spells before further validations. Spell 3 - This Spell has been identified as an emergency admission and is Child Spell only with a PQI of zero and is eligible for adjustment. Slide 37 NHS Care Records Service Slide 36 Readmissions Spell ID Adm Subtype RAP Spell Type PQIRAP_Elig_ChildDH_ADJ_ChildRAP_Elig_ParentDH_ADJ_Parent Validation Parent Validation Child S1ELE0 S2EMRBOTH0Y N YY VC4 S3EMRCHILD0YY Further Validations Spell 2 - This Spell has been identified as an emergency admission with a PQI of zero and is both a Parent and Child Spell. When further validations on pairs of Parent and Child Spells are carried out, Spell 2 - Spell Type - Both, has VC4 populated in the Validation Child column causing the DH_ADJ_Child. To be set to N S2 is not a Valid Child therefore it does not need a Parent, however S2 is a valid Parent to spell S3. Slide 38 NHS Care Records Service Slide 37 Readmissions Spell ID Adm Sub type RAP Spell Type PQI RAP Elig Child DH ADJ Child RAP Elig Parent DH ADJ Parent Validation Parent Validation Child Admission DateDischarge Date S1ELEPARENT0 YY 01/04/201315/04/2013 S2EMRERROR0 10/04/201330/04/2013 S3EMRCHILD0YY 30/04/201302/05/2013 Errors Spell S2 is considered as an ERROR since the Admission date (10 th April) is before the previous Discharge date (15 th April). A Spell that is considered as ERROR is not used in any processing in readmissions. Slide 39 NHS Care Records Service Slide 38 Readmissions Same Day Transfers SUS will flag same day transfers between providers in a Readmissions pathway using reference data from 2012/13. Only Spells which fall within this financial year are can be identified as a same day transfer and can be seen in the Readmissions extract in the attributes Transfer Out and Transfer In. RAP Spell Transfer Out Identifies whether an emergency or non-emergency transfer forms part of the RAP and identifies the TRANSFER OUT Spell. Transfer processing will be applied at Spell level and the Spell relating to the transferring Provider will be identified as TP1 A Spell can be both a TRANSFER OUT and a TRANSFER IN or may be NULL RAP Spell Transfer In Identifies whether an emergency or non-emergency transfer forms part of the RAP and identifies the TRANSFER IN Spell. Transfer processing will be applied at Spell level and the Spell relating to the receiving Provider will be identified as TC1 A Spell can be both a TRANSFER OUT and a TRANSFER IN or may be NULL Slide 40 NHS Care Records Service Slide 39 Slide 41 NHS Care Records Service Slide 40