What are the main points of the management of medical institutions: improve cost control, improve the quality of the case, pay attention to KPI indicators, standardize service behavior, improve cost control.
One, improve cost control
1, is to change the ideological understanding. Recognize the DRG payment as one of the world's more advanced and scientific payment method is recognized as an important means of effectively controlling the unreasonable growth of medical costs, the establishment of a new mechanism of compensation for the operation of public hospitals, to achieve the three parties **** win and promote the promotion of hierarchical diagnosis and treatment to promote the transformation of service mode.
2, is to strengthen the division of labor. DRG as a systematic project, for the hospital, not only involves the construction of information systems, but also involves the case, clinical, quality control and other departments of the collaborative division of labor, which requires a strong coordinating ability, at the same time, clear responsibilities, synergies.
such as: management: the development of effective policies, strengthen training and management, coordination and resolution of conflicts, quality control requirements and violations of prevention requirements; clinicians: standardize diagnostic and therapeutic behaviors and terminology, correctly write the diagnosis and the first page, in the course of the disease and auxiliary examination reports to reflect the support of the basis for the proposed simplification of the process according to the clinical pathway and the relationship between the tiers; quality control department: is responsible for optimizing processes The quality control department is responsible for optimizing the process, supervising the schedule, learning the DRG related documents and related knowledge, using the quality inspection report, and controlling the overall medical quality.
3, is to strengthen the system construction. The system manages, the process manages, the team fights the world. Medical institutions should put the system construction in the first place, through the system first, and constantly standardize the process, improve efficiency and quality of work, reduce management risk. For example, through organizational management and system construction, it assesses whether each department of the hospital actively participates in DRG payment and formulates corresponding measures to guarantee the smooth implementation and effective operation of DRG payment.
The management system construction includes the establishment and assessment of supporting measures such as case management, clinical path management, cost accounting management, and performance appraisal system construction.
Second, improve the quality of the case
1, is the clinical to "write accurate". Correct main diagnosis, comprehensive complications / comorbidities, comprehensive surgical operations, should be standardized, comprehensive and accurate fill in the first page of the case.
If invasive ventilator therapy [greater than or equal to 96 hours] is performed during the actual diagnosis and treatment, omission of this information will result in a different DRG grouping, and the difference in the cost allocated by the health insurance will be very large, and the hospital's loss will be very large.
If missed ventilator therapy [greater than or equal to 96 hours]), admission to the internal medicine group:ET21 Chronic airway obstructive disease with serious complications or comorbidities. Based on historical data from Mianyang City for 2018-2020, it was estimated that there was a loss of $52,823 based on a Medicare allocated cost of $11,446 for a tertiary cost reference.
The same principal diagnosis as the other diagnoses, correctly completed with the principal surgical operation: 96.7201 Ventilator therapy [greater than or equal to 96 hours], prioritized into the MDCA Prior Grouping Diseases and Related Operations group: AH19 Invasive ventilator support ≥ 96 hours or ECMO or Total Artificial Heart Transplantation. According to the historical data of Mianyang City in 2018-2020, it was measured that the Medicare allocated cost of $71,381 with a balance of $7,112 with reference to the cost of tertiary care.
The above case, it can be seen that the resident must truthfully fill in the ventilator treatment in the medical record record (medical record, discharge record, discharge certificate, etc.), medical order form (ventilator treatment start time, stop time), the first page of the case (ventilator treatment must be filled in the surgical operation of the first line of the main surgical operation column), the fee record, etc., and to verify the cumulative time of the ventilator treatment, and the invasive ventilator treatment The invasive ventilator treatment is greater than or equal to 96 hours must not be omitted to fill in the wrong.
In addition to the ventilator time, the omission of a number of key information, such as primary diagnosis, other diagnoses, major surgery/operation, age, neonatal days of admission, type of admission, weight, etc., will also have an impact on the enrollment.
2, is the case to be "programmed correctly". Correctly understand the diagnosis and treatment information, accurate translation of ICD-10 and ICD-9 surgical operation codes.
Such as part of the 00 code in the medical insurance version of the gray code does not enter the group, do not enter the group of medical insurance will not allocate costs, the case of hospitals in full loss. 0000 group (do not enter the group) refers to the diagnosis of disease / surgery or operation code is not standardized and other reasons for not being able to enter the group of cases, including not being able to enter the arbitrary MDC and into a MDC but not be able to enter the MDC of any internal medicine ADRG and so on.
ICDs are not allowed to enter any MDC.
ICD -10 is an etiology-based, multi-axial classification system.ICD classifications are based on four key characteristics of disease: etiology, site, pathology, and clinical presentation. With few exceptions, there will be at least a core component to the disease diagnosis, i.e. site + clinical presentation are the essential parts. The diagnosis of the disease under the physician should be standardized and complete, and the coder's code should be accurate. Coders for 00 code to verify the medical records (medical records, surgical records, discharge certificates, medical orders, examination and test reports, etc.), check the code, as a good translator, with accurate coding to reflect the diagnosis and treatment process. According to the real situation of the medical record, try to prioritize the use of long code entries under the same subheading, followed by the selection of non-00 code entries, and finally 00 code entries.
Example 1: Discharge principal diagnosis: gallbladder stones with acute cholecystitis, no other diagnosis, hospitalized for laparoscopic cholecystectomy, total cost 10,113 RMB.
One, discharge principal diagnosis selected: K80.000 stones with acute cholecystitis, gray code (00 code) not grouped, loss of $10,113,
Two, principal diagnosis selected: K80.000x004 (same subheading as the long code) gallbladder stones with acute exacerbation of chronic cholecystitis, primary procedure: none (omission of primary procedure from the coding), resulting in admission to the internal medicine group: HU15 acute biliary tract disorder, without complications or comorbidities. Based on Mianyang City's historical data for 2018-2020, it was estimated that there was a loss of $5,633 with a Medicare-allocated cost of $4,480 in reference to the tertiary care cost.
Third, the primary diagnosis is selected: K80.000x004 (long code under the same subheading) gallbladder stones with acute attack of chronic cholecystitis, the primary surgery: 51.23 laparoscopic cholecystectomy, and the admission group: HC25 cholecystectomy, without complications or comorbidities. Measured on the basis of the historical data of Mianyang City in 2018-2020, with a tertiary cost reference Medicare allocated cost of $10,431 and a balance of $318.
3, is the financial to "cost accurate". Classification is accurate, the cost is accurate. Finance Division should be based on the "case home page cost classification and medical service charges classification table", strictly do a good job of hospitalization case home page cost categorization, to ensure that each cost category is clear and accurate.
4, is the information to "pass all". In the information system to set up the verification function module, the number of cases, financial information, diagnosis, surgical operations, into the group, the score and other multi-dimensional hospitals and the Bureau of Medical Insurance data verification, to ensure that the hospital and the Bureau of Medical Insurance information consistency. In order to ensure that the data transmission is error-free, it is necessary for the Medical Insurance Section, Information Section, Casework Section, Clinical Departments, and Financial Section to work together to complete the review and proofreading of the uploaded information to ensure that the information is transmitted accurately and comprehensively.
Third, pay attention to KPI indicators
Hospitals should comply with the requirements of the DRG payment method, the introduction of DRG key indicators, and through the application of DRG in performance management, the discovery of problems in a timely manner to rectify and implement, and constantly improve the assessment system.
1, is the total weight is the basis of performance appraisal. In the DRG payment system, on the one hand, the health insurance fund allocation is in accordance with the total weight how much to pay; on the other hand, the total weight number of the overall response to the degree of risk of medical business, time consumption and resource consumption, etc., so to the total weight number as the basis for the assessment of the department or the doctor's assessment incentives.
2, is the case combination index value (CMI value) is the focus of performance appraisal. CMI refers to a department or a doctor's average weight of each case, reflecting the department or the doctor's personal case of the overall characteristics of the admission of the overall CMI value is a relative number, can be compared horizontally, the higher the value of the CMI, the higher the level of difficulty and technical content. Therefore, the CMI value is the focus of departmental or individual performance appraisal, so that it can guide the department or doctor to introduce new technologies, improve the technical level, and optimize the disease structure.
3, is the weight ≥ 2 cases performance assessment to tilt. Weight ≥ 2 cases are generally difficult cases, or three or four level surgery, reflecting the strength and influence of the discipline. Appraisal incentive mechanism, to be conducive to encourage the department and doctors to accept difficult and serious cases, more three or four level surgery.
4, is the time consumption index is a performance appraisal guide. The use of cost consumption index and time consumption index to evaluate the performance of the department or individual, if the calculated value of about 1 that is close to the average; less than 1, that is, lower medical costs or shorter hospitalization; greater than 1, that is, higher medical costs or longer hospitalization.
5. It is the DRG payment gain or loss that is the reference for performance appraisal. Due to the design of rates and weights, can not be 100% accurate, some of the disease will be a more serious loss, which requires scientific analysis of the various types of diseases and budgets, departmental profit and loss assessment, to take into account the public welfare, can not be simple and brutal introduction of the "profit incentives, losses and penalties," the policy.
Four, standardize service behavior
DRG supervision and evaluation of the emphasis on monitoring the focus of shirking patients, decomposition of hospitalization, lower standards of hospitalization, "high coding", reducing the necessary medical services, inducing hospitalized patients to purchase medicines and consumables and other violations. As a medical administrator, you must take the initiative to regulate medical behavior.
1, is to promote the standardization of clinical path. Each department should determine the clinical path suitable for its own diagnosis and treatment technology and diagnosis and treatment level, standardize the behavior of medical services to ensure quality, cost control as the characteristics of the most reasonable medical and nursing care program by disease planning.
2, is to reach clinical **** knowledge. Play the role of performance baton, through the performance appraisal drive to promote the implementation of clinical path, prompting doctors from "passive" to "active", improve the rate of entry, reduce the exit rate. Increase the assessment and punishment of non-compliance. The focus should be on regulating departments or doctors shirking patients, breaking up hospitalization, "high coding", upgrading diagnosis and inadequate services.
3, is quality control. Quality control is the core link of clinical path management, is the most important guarantee of clinical path implementation effect. Clinical path quality control work mainly includes before, during and after the three links. Before the establishment of hospitals and departments of the two quality control system, the development of reward and punishment programs, pre-service training for staff. During the process of quality control, we set up inspection teams to conduct regular inspections and organize regular testing and evaluation. After the event, the final quality assessment, the establishment of clinical path implementation results report feedback system, will be found to notify the relevant responsible person; comprehensive analysis, put forward corrective comments and measures to continuously improve the quality of path management.
V. Improve cost control
Different hospitals have different costs for DRG diseases, and a "cost race" has been formed under DRG payment, which can only be achieved by focusing on solving the problem of "difficult to see a doctor and expensive to see a doctor", and obtaining competitive advantages with low costs and high service quality for the public. Only by focusing on solving the problem of "difficult and expensive medical treatment" of the public, gaining competitive advantage with low cost and obtaining recognition from the public with high service quality can we always stand invincible. Therefore, it is necessary to establish a cost management system adapted to the DRG reform.
1, is the establishment of DRG as the core of the cost accounting system. In accordance with the health insurance payment of DRGs payment budget, strengthen the costing of disease types, determine the cost of DRGs related disease groups of diseases, and analyze and evaluate the unreasonable drug consumption, health material consumption, inspection costs, to eliminate and determine the standard cost. In accordance with the idea of vacating the cage and exchanging the bird, the unreasonable cost is used to pay for the medical technology service function enhancement.
2, is the establishment of clinical specialty operation management system, the formation of the operation team, in-depth clinical front line, analysis of problems in operation and management, put forward targeted development proposals, and guide the clinical departments to improve the level of operation and management; set up a clinical operation assistant in each clinical department, responsible for organizing internal operation analysis, assisting departmental performance management and promoting the reform of the payment method, and other work.
3. It is to improve the cost control mechanism. According to the relationship between average DRG case benefit and cost, the operation of DRG disease groups is evaluated accurately, and the groups are categorized into advantageous disease groups, potential disease groups and disadvantageous disease groups. For advantageous disease groups, key support and incentives are given. For the potential disease groups, on the basis of continuing to do a good job of hierarchical diagnosis and treatment and cost control, continue to cultivate and expand the source of diseases and increase the number of diagnosis and treatment. For disadvantaged disease groups, we will do a good job of evaluating cost-effectiveness, accurately analyzing the main reasons for losses and key aspects, and taking targeted control measures.
In short, the use of DRG payment method not only helps hospitals to standardize medical behavior, medical record writing and diagnostic name, improve the quality of medical records, so that the medical activities of the standardized process, but also promotes the transformation of the hospital management mode to the refinement of the management, to promote the reform of the hospital and to improve the satisfaction of patients.