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Dr-SIR
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Others
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1. APPROACH
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The definition of “efficiency” as per Dr-SIR is:
The “work unit” generation capacity of a health care professional (Technician, nurse, under training Doctor, Resident / Medical Officer / Postgraduate Trainee or a specialized Doctor) against actual “work units” generated in a specified time period by these professionals.
A Work Unit is defined as “work generated by a technician of “average professional percentile standing” in a time period of one minute in normal circumstances”. Keeping the definition of Work Unit as a base, co-efficients of the same are developed for professionals in other categories such as nurses, medical residents or specialists.
The perspective of Dr-SIR research is to help health care providers (Teaching/ General Hospital, Semi-Teaching, and HMO) to monitor, audit and assess the performance of each health care professional, department and unit that delivers health care services. Dr-SIR goal is to identify inefficiencies, increase productivity, recommend ideal staffing pattern to attain maximum output with less costly labor and hence help in planning hospital administrative tasks such as resource allocation, forecast requirement of beds and equipment.
The input required to find the efficiency of a professional are the time spent by all categories of professionals according to their skills and qualifications. This gives the ideal capacity of a professional to generate Work Units in a given period of time. In order to find the actual Work Unit generated, the inputs consists of number of patients admitted, patients examined in OPD etc in respective departments.
The work output layout/ architecture incorporates a logical and systematic pattern of work contribution by all categories of professionals in all the diagnostic and clinical activities as indentified by Dr-SIR, involving six clinical and diagnostic specialties in a hospital set up on a unified scale. It monitors and evaluates the work output in terms of ‘work units’ with in a specified period of time.
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Reference: AHRQ: Health Care Efficiency Measures: Identification, Categorization, and Evaluation April 2008
Efficiency is an attribute of performance that is measured by examining the relationship between a specific product of the health care system (also called an output) and the resources used to create that product (also called inputs). A provider in the health care system (e.g., hospital, physician) would be efficient if it was able to maximize output for a given set of inputs or to minimize inputs used to produce a given output.
“Three approaches, readmission, procedure rates, and cost-effectiveness, that has been used to measure "efficiency" but would not be classified as efficiency measures under our definition and typology.”
Most of the existing systems are based on the above stated approaches.
Reference: Physician productivity discussion paper:
American Academy of Family Physicians. A physician who sees four patients in two hours and a physician who sees four patients in an hour are equally productive, in terms of the number of patients seen. However, the physician who sees four patients in an hour is more efficient (all other things being equal) and, thus, may require fewer resources (in terms of space, personnel, etc.). As noted, productivity becomes a measure of efficiency when it includes a common unit of input, such as time and expertise, and standards of productivity may become standards for efficiency evaluation and improvement.
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2. WORK FLOW BASED SYSTEM
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Dr-SIR is a complete work flow/ referral based system especially designed for the health care setup. There are various professional categories working in a diagnostic and clinical set up of a hospital i.e:
i) Technicians
ii) Nurses
iii) Doctors/Medical Officers/ Trainee Resident
iv) Specialists
v) Head of the departments.
The above mentioned categories have been created based on:
a) Expertise by virtue of academic qualifications
b) Training and Experience
These professional categories work in various specialties and departments of the clinical and diagnostic set ups of a hospital namely:
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Surgery and Allied Specialties (13 Specialties) |
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Medicine and Allied Specialties (12 Specialties) |
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Anesthesiology |
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Psychiatry |
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Radiology |
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Pathology |
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While working in their respective specialties, various activities in context of patient assessment, diagnosis and treatment are under-taken by these individuals, ranging from:-
Patient registration to the O.P.D. (Out Patients Department) to admission in the wards, to surgery.
Irrespective of the nature of the activity whether it is:
i) Examining the patient in the OPD or emergency.
ii) Taking a ward round.
iii) Conducting a surgery.
iv) Treating a patient in the ICU or the CCU.
v) Conducting a diagnostic test in the Radiology or Pathology.
Every activity requires expertise at different levels under various stressful situations.
Based on above mentioned activities, in qualitative terms, the interrelation ship of the work performed by the various category of individuals in varying stressful situations needs to be quantified on a unified scale, which can be applied as a universal on any hospital, or any individual working in any category or tier of a hospital. The scale or unit thus being derived at is called the "Work Unit".
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Most of other health care efficiency measurement systems are Patient, episode or treatment-centric or CPT disease code based system.
Reference: AHRQ: Health Care Efficiency Measures: Identification, Categorization, and Evaluation April 2008 “Despite the importance, there has not been a systematic and rigorous process in place to develop and improve efficiency measurement as there has been for other domains of performance.”
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3. STANDARDIZATION OF ALL HOSPITAL CLINICAL AND DIAGNOSTIC ACTIVITIES
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Dr-SIR has standardized or set benchmarks for all treatments, operatives and diagnostic activities performed by various categories of professional in a hospital setup on a unified scale in terms of time frame, acceptable rate of complications or misdiagnosis etc.
Dr-SIR then measures performance against benchmarks and strengthen process improvement in a hospital setup.
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Reference: Physician productivity discussion paper:
American Academy of Family Physicians. Full-time or part-time status is another physician characteristic that can impact a physician’s productivity. Part-time physician’s spend fewer hours in direct patient care, have fewer patient encounters, and, as a result, tend to generate fewer RVUs than their full-time colleagues. Thus, they appear less productive in an absolute sense. However, when these absolute measures of productivity are adjusted based on a common unit of input (e.g., patients seen per hour), part-time physicians may be as or more efficient than their full-time colleagues.
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4. UNIFIED SCALE OR YARDSTICK FOR MEASURING PERFORMANCE
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Dr-SIR “Work Unit” is a scale applied as in case of “Calories” or “B.T.U”. Work Units, in simple terms means, the effort while performing a clinical or diagnostic activity by a technician of average professional percentile standing, in a time period of one minute under normal circumstances.
“Work Unit” has been calculated/ derived as a universal for calculating the efficiency/ actual work output/ or work generation capacity of any of the five categories of professionals (Head of Department, Specialist/Consultant, Medical Officer/Residents, Nurse, Technician) for any specified time period performing, any professional activity in any work situation in a hospital set up individually or in a group. One of the major objectives of ‘Dr SIR’ is to create a unified universality of approach in terms of patient care, while standardizing the level of expertise, treatment time frames and technology, so as to attain optimization of returns, both in terms of professional’s involvement and financial investment.
Work Units generated, accurately reflect the actual work performed by a professional as an individual or working under assistance of higher professional caliber, professional skill, experience and the designation required for each activity.
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The use of relative value units (RVUs) as a measure of physician productivity appears to be growing.
Relative Value Units constitute one part of the entire RBRVS system.
Resource Relative Value Scale (RBRVS), which is a standardized fee schedule used by Medicare to reimburse physicians. Under RBRVS, each Current Procedural Terminology (CPT) code is assigned a work RVU, as well as an RVU for practice expenses and malpractice expenses.
Under RBRVS, each Current Procedural Terminology (CPT) code is assigned a work RVU, as well as an RVU for practice expenses and malpractice expenses.
Reference: Physician productivity discussion paper:
American Academy of Family Physicians. The intent of the work component of RVU is to represent the “average” work done by a physician of “average” efficiency in performing a particular service.
Therefore, it is not justified to award a low productive physician the same work RVUs as against a better physician.
Further, RVUs, like traditional productivity measures, are geared toward a fee-for-service environment. They may not work as well in capitated and other environments where generating patient encounters and CPT codes are not the emphasis. Two physicians providing the same service would generate the same RVUs, regardless of the patients’ insurance or the physicians’ respective charge schedules.
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5. ELEMENTS OF WORK UNIT
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Total work is defined by the following factors:
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Time required to perform the service accordingly by various professionals category.
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Professional Co-efficient that is based on technical skill (qualification, research/publications , experience, physical effort).
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Work Situation Co-efficient that reflects the Psychological stress associated with the service performed such as while operating a case.
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Work Units are calculated on the real time basis, using the above parameters/factors and the number of patients examined and diagnosed/admitted by each health professionals (Head of Department, Specialist/Consultant, Medical Officer/Residents, Nurse, and Technician).
Professional Co-efficient
This is an evaluation ranking for a professional in a health care setup. The "Professional Co-efficient" of individuals in all professional categories is calculated on professional “base line constant”. Actual work Unit generated by professionals of various categories on the same activity differs due to different ‘Professional Co-efficient’ and other parameters such as time spend on a particular activity and work situation co-efficient.
Dr-SIR calculates efficiency using
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1.
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Generalized Set of Values
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2.
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Specified Set of Values
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In case of evaluation in "Generalized set of values” the professional co-efficient remains constant.
In case of evaluation on specific set of values the professional co-efficient becomes a dynamic which constantly changes as per professional’s qualification research publication and experience (P.E.R & A.P.A.R).
A.P.A.R stands for Academic publication/achievement Rubber. A.P.A.R points are evaluated on the basis of National/International Research/paper done independently or as team and Invention Points (Revolutionary/Appreciable).
P.E.R stands for Professional Experience Rubber. P.E.R is calculated on the basis of Actual Work Unit Generated by each professional i.e
162500 WU = 0.1 P.E.R
Professional Rubber affects the Professional Co-efficient of a professional.
One P.E.R is approximate work units generated by a medical Officer/Resident in a period of one year with one day off every six working days and public holidays and putting in seven to eight work hours (including 20% jump over time) by a Medical Officer/Resident of an average professional percentile standing (ie 60 to 75 percentile).
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The work RVUs are intended to reflect the relative:
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Time required to perform the service.
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Technical skill and physical effort.
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Mental effort and judgment.
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Psychological stress associated with the physician’s concern about iatrogenic risk to the patient.
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But Work RVU is pre-determined numbers assigned to services that establish the differing amounts of physician work associated with them. For example, a service with a work RVU of "2" would be considered to involve twice as much physician work as a service with a work RVU of "1." This model does not reflect accurate physician productivity.
RVUs are not a perfect measure of physician productivity. Universal consensus on all of the work RVUs for all of the CPT codes does not exist. Another limitation is that RVUs depend on appropriate CPT coding, so physicians who code incorrectly impact their productivity relative to the actual work they did.
The traditional and more recent measures of physician productivity does credit professional past experience, qualification, research and inventions or his teaching activities.
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6. KNOWLEDGE BASED SYSTEM
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Dr-SIR is knowledge based expert system, which has an inbuilt capacity to constantly monitor and analyze the effectiveness and efficiency of various departments, units and staff in a hospital setup.
As a result, with valuable reports generated through this system, the management, with the passage of time, can increase the work output, decrease cost per unit and increase in staff satisfaction. This creates a better working environment in hospitals and most importantly assists the physicians and the hospital managers to improve decision making.
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Most of the decision based system is developed for disease management, resource management (MIS based).
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7. EVIDENCE BASED STRATEGIC REPORTS
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With the passage of time Dr-SIR helps in increasing work output and decreasing cost per unit. The system identifies the deficiencies and reasons for the positive or negative variances for decision makers. The negative or positive variances in work output helps to pinpoint the reasons-of-why! It also helps to monitor the provision of best quality medical care to the patients by virtue of highlighting the various indicators like the probable rate of misdiagnosis, complications etc for various treatment and diagnostic procedures.
It analyzes whether the professional services in the hospital, department or by an individual are being underutilized or over-utilized. In case of being underutilized, it pinpoints the causative factors and in case of being over-utilized, it analyzes the adverse effects it can have on the treatment process.
Accordingly, managers will be able to forecast and take preventive measures to better manage the healthcare system.
Thus a complete Decision Support System is available to healthcare decision makers that allows for the quantification of professional efforts, manage work load.
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Physicians who are more productive (i.e., who see more patients, spend more time in direct patient contact, generate more RVUs, etc.) are more likely to consume more practice resources (e.g., staff time, supplies, etc.) and generate more related practice costs than their less productive colleagues. Consequently, resources and costs, especially variable costs, may be allocated based on the same measures used for physician productivity. Such kind of information does not help decision makers to monitor performance accurately, forecast work load and take preventive measures.
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8. QUANTIFICATION OF WORK EFFORT INDIVIDUALLY AND AS A GROUP
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Work Units are calculated not only for just physician but for all other categories that are involved in performing a service. Professional categories are Professors, Specialist/Consultant, Medical Officers/Residents, Nurse Practitioners and Technician.
As a group, Work Units are also calculated for under supervision activities.
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Other available systems quantify and measures work output of only Physician and nurse practitioners individually.
Reference: AHRQ. Arguments against this application of RVUs include: intra-group competition for complex cases or those with procedures; creation of RVUs by “slow” physicians through liberal diagnostic test utilization, which drives up the level of service designation and the work component of the RVU; and, lack of clarity relative to the impact of non-physician ED providers (nurse practitioners and physician assistants).
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9. GROUP PERFORMANCE
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There are number of professional activities in a hospital set up where the medical professionals act together as a team. Four categories of professionals i.e. technician, nurse, resident doctors and board certified doctors in a non teaching hospital. In teaching hospital, the category of board certified doctor is further classified as assistant/ associate professor and professor/ head of department) as such in a teaching hospital, there are five (5) categories of professions.
The Professional Percentile Standing of professionals of each category may be different. For example, while performing a surgical operation, a very bright Head of Department / Professor may be supported by a very average Assistant Professor who in turn may be assisted by a below average or moderate resident doctor followed by an exceptionally brilliant nurse, who finally is assisted by an average Technician. The final work output would then be the result of their joint efforts where by components of one efficient category of professional would be compromised by team efforts of an other professional of an other category or in the same category who may be of very average professional percentile standing, so on and so forth.
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This feature of staffing pattern or combination is not provided by any system, the way Dr-SIR does.
Reference: Gauging Emergency Physician Productivity Are RVUs the Answer.htm)
Use of non-physician providers (NPPs) such as nurse practitioners and physician assistants alters the system importantly.
For example, an inefficient Emergency Physician may focus on supervision of a relatively large number of NPP cases, thus generating a significant number of RVUs.
This potential issue may be overcome through attention to NPP scope of practice and parallel tracking of individual EP oversight of NPP cases. Exclusion of NPP-initiated or managed cases is an option.
However, the inherent responsibilities and medico-legal risk of NPP oversight argues in favor of including NPP cases in the RVU profit share calculation for the EPs.
Reference: AHRQ - April 2008: “Under our definition, a provider in the health care system.
(e.g., hospital, physician) would be efficient if it was able to maximize output for a given set of inputs or to minimize inputs used to produce a given output.”
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10. ASSESSMENT, AUDIT AND MONITORING OF HOSPITAL WORK OUTPUT, DEPARTMENTAL AND INDIVIDUAL PROFESSIONAL
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Dr-SIR audits, evaluates and monitors the work output by all categories of professionals in their specified area of work, against bench marked layouts and the standard deviations.
Since all patients curative activities carried out by every category of professionals will be quantifiable, as such in simple statistical terms a constant assessment; audit and monitoring of the hospital work out put can be carried out for any specified time period. The “Work Units” generating capacity of a hospital for a specified time period can be determined, besides the “Work Units” actually generated. The central reasons of insufficient “Work Units” generated and subsequent financial loss thus incurred, analyzed.
On the same basis the departmental and individual performances can be assessed. A major added advantage of the use of this expert system will be that every professional can be further assessed and evaluated in terms of his/ her own professional performance.
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Other system audit and monitor hospital work output in terms of Finance and revenue generated. They basically help insurance agencies to asset and audit the charges as incurred by providers on various disease CPT codes.
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11. HOSPITAL PLANNING
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By estimating the Work Units generated by each individual in your professional team, Dr-SIR generates over a billion combinations of the staffing patterns of the most optimal professional combinations which would deliver the maximum amount of Work Units, thus making it possible to handle the maximum patient load.
Dr-SIR can estimate the patient load that a potential facility would be catering to, based on past patient data and then estimate the resource and equipment requirements.
Dr-SIR makes it very easy for you to estimate what resource and professional combinations would ensure the smoothest running operations and the highest rate of return on your investment.
It will help you further in running and establishing your facility by helping you to assess the capacity for quality treatment for each specialty and category within the healthcare system.
Dr-SIR can determine if your Specialist Unit and Professorial Unit are generating sufficient Work Units to be qualified as Teaching Unit.
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Some of the current approaches to plan and design hospital are:
1. AHRQ Annual Highlights, 2006, Preparing for Public Health Emergencies
The AHRQ tool, called the Bioterrorism and Epidemic Outbreak Response Model (BERM), helps health officials predict the number and type of staff needed to dispense drugs and triage patients after a bioterrorism attack or during a disease epidemic. (This approach is referred as disease management)
2. BNET: Forecasting demand and capacity requirements
Healthcare Financial Management, August, 2004 by Chris Myers, Trent Green
http://findarticles.com/p/articles/mi_m3257/is_8_58/ai_n6154186?tag=rbxcra.2.a.1
A growing number of hospitals and health systems are factoring the expected impact of medical advances (along with other key variables such as demographic changes, market-share targets, and use of physician extenders) into physician resource planning efforts as well.
Although anticipating the impact of scientific discovery and technology development can be arduous and is in some ways an exercise in crystal-ball gazing, doing so is critical to ensuring that hospitals evaluate the impact of a broader set of environmental factors on future demand and capacity requirements. In the end, the real value of such an activity is often less in identifying forecasted volumes and more in identifying key variables (e.g., specific technologies, physician resource changes, and efficiency gains) that may affect hospital volumes and capacity.
(This approach is based on medical and technology advances)
3. BNET: Four Methodologies to Improve Healthcare Demand Forecasting
Healthcare Financial Management, May, 2001 by Murray J. Cote, Stephen L. Tucker
http://findarticles.com/p/articles/mi_m3257/is_5_55/ai_75215156/pg_1?tag=artBody;col1
Although many quantitative forecasting methods exist, four common methods of forecasting are percent adjustment, 12-month moving average, trend line, and seasonalized forecast. These four methods are all based upon the organization's recent historical demand.
Forecasts based on historical demand provide baseline data for making final forecasts of demand for the organization's services. But such forecasts assume that other factors will be unchanged. Healthcare financial managers know that change is perhaps the only constant for the future. Therefore, knowledge of both the internal (e.g., changes in productivity and capacity) and external variables/environments (e.g., changes in demographics, healthcare demand patterns, technology, payment mechanisms, and competition) must be factored into final forecasts.
(This approach is based on quantitative forecasting methods)
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