Analysis of the evolution of quality and management indicators in a Central Hospital

1. Analysis of the evolution of quality and management indicators in a Central Hospital Introdução à Medicina I Class 21 Adviser: Alberto Freitas

2. Outline • Indicators • Definition • Function • Diagnoses Related Group • Indicators of Health Care Quality • Indicators of Activity/Production • Indicators of Data Quality • Participant and Methods • Research Question • Aims • Predicted Results • References

3. Indicators: definition In general, indicators are units of measurement for an activity which can be used as guides to monitor and evaluate the quality of care provided to patients(1) and to evaluate the efficiency and effectiveness of a hospital. 1. Geraedts M, Schwartze D, Molzahn T

4. Indicators: function • Trough comparison within intern and external references it is possible to know the changes produced on variables in different moments of its implementation.

5. Indicators: functions Indicators Evaluation Evolution Use data collected to obtain a descripton that allows an Which shows an The analysis and implementation of certain measures should lead to an Improvementofhealthcare

6. Diagnose Related Group (DRG) System used on hospitals that treat acute illness, to classify patients in groups with the same needs.(2) 2. M Bentes, ML Gonsalves, S Tranquada, J Urbano

7. Indicators of Health Care Quality Responsible for an evaluation on how the services provided to patients while they are under medical care at the hospital have changed through time. • Exceptional Hospitalization Episodes • Surgery Length of Stay • Readmissions • Natural childbirth • Medical DRGs complications

8. Exceptional Hospitalization episodes • Short term exceptional hospitalization episodes • Exceptional hospitalization episodes of extended evolution

9. Hospitalization episodes of short duration • Episodes whose time of hospitalization are at or below the lower threshold for exclusion from its Diagnose Related Group(3), which corresponds to 1,96 Standard Deviations below the national average delay for the same DRG; • The time of an hospitalization could be substantially reduced in case of deceased patients, patients transferred to another hospital or those who left against medical advice; 3. IGIF (Instituto de Gestão Informática e Financeira da Saúde)

10. Hospitalization episodes of extended evolution • Episodes whose time of hospitalization are at or above the maximum threshold of a certain DRG (twice the upper threshold minus the average delay of that DRG)(3) • 3. IGIF (Instituto de Gestão Informática e Financeira da Saúde)

11. Surgery Length of Stay • It is an indicator which aims to count the total number of days used by all admitted patients for surgical purposes (with the exception of medical discharge of the same patients). • This indicator is calculated by the sum of the times pre and post surgery. The less pre-operative time, the higher efficiency of the hospital.

12. Readmissions • Hospitalization episodes, consecutive to another episode, which occurred over a period of time equal to or less than 30 days, unless the second episode is ranked in DRGs 249, 317, 409, 410, 465, 466 and 492 (3); • Hospitalizations within a period of 72 hours running from the date of discharge, except in cases where the subsequent internment is not medically related to the former, if it is an oncological episode, if the subsequent hospitalization occurs after leaving against medical advice or if the patient has been transferred to make exams that forced internment, with subsequent treatment at the hospital of origin (4); 3. IGIF (Instituto de Gestão Informática e Financeira da Saúde) 4. http://dre.pt/pdf1sdip/2007/01/01601/00020124.PDF

13. Natural childbirth • It is an indicator that measures the proportion of vaginal births in all births assisted (Natural and Cesarean births), by analyzing the statements of live births in the central hospital in study. • There are many codes for this indicator; they include V27x (in diagnosis) except those relating to cesarean births which are coded 74xx (in procedures).

14. Medical DRGs complications • Complications are situationswhosepresence, togetherwiththeprimarydiagnosis, leads to anextensionoftheinternmentofatleast a dayin 75 or more % ofpatients • As a resultthereisanincreaseofthetimeofhospitalization as well as theresourcesspent • UsedinthesystemofclassificationofDRGs to distinguishpairsofgroupsthatwiththesamecharacteristics (primarydiagnosis, procedures, secondarydiagnosis, age, sexanddestinationafterdischarge) haveoneor more additionaldiagnosis

15. Indicators of Activity/Production • Outpatiens • Newborns

16. Outpatients • Number of patients who left the internment in a hospital with medical discharge in a given year (5) • Totalnumber of patients who no longer reside in their service during the period of time considered, according to the following situations : medical discharge or transference to another hospital, death or transference for another department from the hospital (6) 5. INE (Instituto Nacional de Estatística) 6. DGS (Direcção Geral de Saúde)

17. Newborns • The product of a pregnancy, a child that has just been born, a baby aged up to four weeks (28 days) • They are defined by internment episodes where the code begins with the primary diagnosis “V3”, which means every code is represented as “V3x.xx”.

18. Indicators of Data Quality This indicators allow an evaluation of the quality of the services. • Long Term Hospitalizations without CC • Short Term Undue Hospitalizations • Nonspecific surgery procedures

19. Long Term Hospitalizations without CC • All internment episodes of long term that occured without any medical explanation for that • Normally those are situations when patients have nowhere to go and stay in the hospital for an unlimited period.

20. Short Term Undue Hospitalizations • Hospitalizations that correspond to ambulatory episodes (episode of medical consultation, emergency or additional means of diagnosis and therapy, such as Physiotherapy or Imagery) incorrectly included in the production of hospital DRGs

21. Nonspecific surgery procedures Includes all surgery procedures on operatory room that are not specific, because they haven´t relevance enough for being classified as that.

22. Participants and Methods For this protocol it is going to be used information about inpatient episodes in a Central Hospital since 1990 to 2007. The SPSS will be used to analyze the data of each indicator following specific rules to each one. As reference of DRGs will be used the portaria n.o 110-A/2007, January 23, published by Ministério da Saúde in Diário da República.

23. Research Question Do the indicators show any changes overtime in the quality of the service in the Central hospital?

24. Aims Evaluate the evolution of the indicators mentioned earlier, in a central hospital in Portugal, and try to conclude if there is an improvement of health care over the past 18 years (since 1990).

25. Aims Examine if these developments are independent or are likely to be related. However, our goal is not to propose any solution, regardless of the outcome, since it would require more information and analysis.

26. Predicted results We can expect that with the technological development and the increasing concern on the quality of the services the indicators reveal an improvement of the quality of health care in the last 18 years.

27. References • Geraedts M, Schwartze D, Molzahn T. Hospital quality reports in Germany: patient and physician opinion of the reported quality indicators. BMC Health Serv Res. 2007 Sep 28;7:157. • M Bentes, ML Gonsalves, S Tranquada, J Urbano - Revista de Gestão Hospitalar • IGIF (Instituto de Gestão Informática e Financeira da Saúde) • http://dre.pt/pdf1sdip/2007/01/01601/00020124.PDF • Instituto Nacional de Estatística (INE), Estatísticas da Saúde, 1997, Conceitos e Notas Explicativas • DGS (Direcção Geral de Saúde)

28. Protocol Developed By: • Ana Luísa Fonseca, analcmf@gmail.com • Bárbara Azevedo, barbarazevedo4@hotmail.com • Gonçalo Marinho, marinhogoncalo@hotmail.com • Joana Raquel Santos, joaninha_rnms@hotmail.com • Pedro Tavares, pedro_f_tavares@hotmail.com • Rosana Maia, mimed08227@med.up.pt • Tiago Machado, mimed08233@med.up.pt • José Alberto Silva Freitas, adviser alberto@med.up.pt