Trust Board - 7 October 2010
Service Line Reporting Update
EXECUTIVE
RESPONSIBILITY
Steve Shanahan
Finance Director
AUTHOR (if
different from
above)
Jill Price
Assistant Director Financial Management
Stuart Smith
Business Manager Financial Planning
CORPORATE
OBJECTIVE
CO5 Ensuring a clinically viable and financially sustainable
organisation;
Enclosure 5
KEY FACTS
• Service Line Reporting including patient level costing is complete for data for
the financial year 2009/10.
• The outputs from the costing system have been extracted into Mede Analytics
including dashboards and full drill down facility to patient level, with access for
Divisional Managers, Service Delivery Managers and Divisional Finance
Managers.
• Commitment to continually develop the project, working with clinical and non
clinical staff.
EXECUTIVE
SUMMARY
• The attached report illustrates the process that has been
completed to produce an initial view of patient level
costing and service line reporting.
• The integration of Service Line Reporting (SLR) into the
business planning process is considered one of the key
factors in the further development of this process within
the Trust.
• Considerable work undertaken to construct both a data
management system to collate and store patient activities
( e.g. diagnostic tests) and then designing and populating
a costing engine to use the patient activity data to
allocate costs and income from the general ledger to an
individual patient level, ensuring outputs can be
consolidated at a level matching the Trust’s Divisional
Structure.
SLR Update October 2010
Sheet 1
RECOMMENDATIONS
The Trust Board is asked to NOTE :
•The SLR/Patient Level process that has been
undertaken.
• The updated I&E statements by Service Delivery
Unit and specialty
•Completion of the data transfer to Mede Analytics
which allows detailed analysis
•The updated Design of Dashboards
•Continued work with key staff within the divisions to
refine and develop the project
•Continued work on 1st Quarter 2010/11 data.
The Shrewsbury and Telford Hospital NHS Trust
Section One – The Process
The integration of Service Line Reporting (SLR) into the business planning process
is considered one of the key factors in the further development of this process within
the Trust. It gives us the ability to produce enhanced and genuinely credible
financial management information at patient episode level, allowing clinicians and
managers to work closely together in developing the Trust’s Service Lines
Regular Service Line Reporting and Patient Level Costing information also has the
ability to significantly impact the Trust’s Cost Improvement Programme, helping it to
set differential targets based on Service Line Reporting information and helping
managers understand where cost improvements can be achieved.
The key objective of SLR is to provide a system that produces Service Line
Reporting and Patient Level Costing information for both management and clinicians
to help obtain real insight into performance and profitability and provides an objective
basis for identifying opportunities for improvement. It allows the Trust to deep-dive
into its own performance and provides patient episode level costs that help better
understand the factors that influence patient outcomes, performance and profitability
by specialty, consultant and point of delivery.
The Trust appointed Bellis-Jones Hill in November 2009 to support their
implementation of Service Line Reporting and Patient Level Costing using the
Prodacapo Service Line Management System, using our existing Mede Analytics
system to provide reporting functionality.
Our first objective was to produce a model using the current information available (
6months data for 2009/10) to provide a basis for which discussions with managers
and clinicians could take place in order to develop a robust and detailed Service Line
Reporting tool. This model has now been developed to include all of 2009/10.
Detailed below are the tasks and stages we have had to complete in order to achieve
this along with the re-designed I&E format outputs and initial design of the SLR
dashboard.
SLR Update October 2010
Sheet 2
The Shrewsbury and Telford Hospital NHS Trust
Section Two – Inbound Data Staging Area (IDSA)
The Implementation of the first PLC model required two separate work streams, the
Inbound Data Staging Area and the Prodacapo costing model build.
Pathology
1,601,191 lines of data
Theatres
High Cost Drugs
26,509 lines of data
631,867 lines of data
Inbound Data Staging Area (IDSA)
The IDSA is a data warehouse management and collation tool that stores the data
gathered from the bespoke systems used within the Trust. Although the IDSA has a
degree of flexibility to accept data in various formats, it was still necessary to liaise
with the administrators of these systems to ensure the data is provided in a useable
format that adds value to the costing process. Once the required data is provided in
a suitable format the IDSA is dependant on the system administrators to provide
same information being provided routinely in an identical format.
Inbound Data Staging Area
(IDSA)
Radiology
Ward Stay Data
252,422 lines of data
185,711 lines of data
SLR Update October 2010
Sheet 3
All of the data sources contain all work carried out by the departments at a patient
level with the exception of the pharmacy data which only attributes the high cost
drugs to a patient level the remaining drug costs, such as ward stock, are mapped
through to the patient via an alternative method. For example the ward stock of
drugs would be apportioned to the particular ward and then from the ward to the
patient based on the ward stay data set.
The Shrewsbury and Telford Hospital NHS Trust
Section Two – Inbound Data Staging Area (IDSA)
Once these feeds had been imported they needed to be mapped to a patient,
therefore we import the activity data for the same 12 month period.
Inpatients
The data from the departmental systems is then mapped to an individual patient
attendance or episode. Some of the data is able to link directly to the patient,
however, some data has to mapped by applying a set of rules which use an
approximation in the absence of a direct link. For example the pathology data maps
to a patient using the patient ID and date of test, therefore if a patient has a blood
sample in an outpatient attendance, the pathology tests may not be carried out on
the same day meaning a direct link will not be established, the rules will look to link
the costs to the correct outpatient attendance.
122,770 episodes
103,673 spells
Direct Access
Currently at profit centre level
Not patient level
Inbound Data Staging Area
(IDSA)
A&E
103,099 attendances
Outpatients
301,697 attendances
SLR Update October 2010
Sheet 4
The Shrewsbury and Telford Hospital NHS Trust
Section Three – Prodacapo Costing Engine System
Prodacapo Costing Engine System
General Leger Extract
9,767 cost lines
Expense Category
175 Created
Resources
377 Created
The Prodacapo software takes the expenditure from the Trusts general ledger and
allocates on the basis of either information from activity held in the support systems
(eg bed days) or another assigned allocation method which is directly input into the
costing system such (eg therapists) or even a combination of the two. For example
Consultant time is split into the points of delivery (Daycase, outpatient etc) based on
their job plan, and then allocated onto patient level.
The diagram below represents the flow of information from the general ledger before
being attached to a cost driver, and helps to explain why this part of the process is
the most resource intensive.
Activities
3,131 Created
Cost Driver
3,300 Created
Patient Level
Patient Attributable
Activity
SLR Update October 2010
Sheet 5
The Shrewsbury and Telford Hospital NHS Trust
Section Three – Prodacapo Costing Engine System
General Ledger
This extract from the ledger will cover all expenditure lines and are the combination
of a cost centre for example Med Staff General Surgery and an expense type such
as Consultant.
Expense Category
At this stage the expense types within the ledger are grouped into a general expense
category for example a General Surgery consultant and a General Medicine
consultant would fall under the same expense category of consultant.
Resources
The expense categories are then mapped to a resource, so the consultant expense
category could be split into consultant inpatient, outpatient, theatre etc. Similarly a
ward pay cost category could be broken into ward nursing pay and ward admin pay
costs.
Activities
The resources are linked to a more specific activity, this activity may be for consultant
A Inpatients cost or Ward Z nursing costs. At this stage the cost categories are
determined, (e.g. nursing costs, drugs costs) which will then be used within the I&E
statement. These are aimed to be a summarised version of our expenses types
within our general ledger. We are limited to a maximum 18 cost categories within
Prodacapo,
Cost Drivers
At this point every activity is linked to a cost driver that will take the costs to a patient
level or, for some activities, the costs will be cascaded down through another activity
before finally being allocated to a patient.
SLR Update October 2010
Sheet 6
The Shrewsbury and Telford Hospital NHS Trust
Section Four – Reporting Patient Level Costing
Reporting Patient Level Costing
Patient Level Costing
15,796,103 lines of data
Patient Level Income
670,237 lines of data
The reporting of the patient level information is now shown in Mede Analytics to
ensure there is a single reference point for this management information within the
Trust. In order to achieve this we have developed a process to extract the data from
the costing system and provide a front end analytical tool within Mede Analytics.
Data Extraction
The data extraction from Prodacapo to Mede comes from two datasets. The first
looking at the patient level costs and the second providing the patient level income.
The patient level costing contains the volumes it does as it exports the details of the
cost drivers linked to each patient, therefore for some patients they have in excess of
40 lines of data linked to them.
Mede Analytics
SLR Update October 2010
Sheet 7
The Shrewsbury and Telford Hospital NHS Trust
Section Five – Mede Analytics SLR Dashboard
Mede Analytics SLR Dashboard
The Patient Level Costing/Service Line Reporting area within Mede was built to our
specifications and includes many of the charts suggested by Monitor. The opening
dashboard allows users to specify a Division, SDU or specialty.
Further dashboards have been developed to show performance at a consultant and
HRG Level.
SLR Update October 2010
Sheet 8
The Shrewsbury and Telford Hospital NHS Trust
Section Five – Mede Analytics SLR Dashboard
Specialty A
£6,313,900
Metrics
Total Income
Total Direct/Indirect Cost
Direct Costs
Direct Pay Costs
Nursing
Consultants
Other Clinical
Non-clinical
Total: Direct Pay Costs
£1,105,497
£804,184
£720,005
£155,197
£2,784,883
Drug Costs
Supplies
Other Direct Costs
Total: Direct Non Pay Costs
£319,669
£34,883
£78,890
£433,442
£3,218,327
Within Mede Analytics we have now re-designed the I&E statement to show EBITDA,
finance and overhead costs (Corporate services and Estates). The updated
statement also shows the number of records and the percentage of the total Trust
income. It is also beyond to drill down to an individual patient level. An example of a
I&E statement is shown.
Direct Non Pay Costs
Total: Direct Costs
Indirect Costs
Allied Healthcare Professionals
Radiology
Pathology
Theatre
Other Services
Prosthetics
Hotel Services
Pharmacy
Other Costs
Total: Indirect Costs
Total: Total Direct/Indirect Cost
£140,909
£54,895
£346,245
£667,066
£342,770
£41,692
£54,701
£20,795
£0
£1,669,072
£4,887,399
£1,426,501
Site Costs
Corporate Costs
Total: Overhead Costs
£312,526
£440,380
£752,906
£5,640,305
£673,595
10.67%
£125,036
£548,559
8.69%
Contribution
Overhead Costs
Cost
EBITDA
EBITDA %
Finance Costs
Total Profit
Profitability
Other Measures
22,531
2.42%
No. of Records
% Total Income
SLR Update October 2010
Sheet 9
The Shrewsbury and Telford Hospital NHS Trust
Section Five – Mede Analytics SLR Dashboard
Service Delivery Unit
Total Income
Total Direct/Indirect Cost
Contribution Overhead Costs
EBITDA
Finance Costs
Total Profit
Profitability
Cancer
303 - CLINICAL HAEMATOLOGY
800 - CLINICAL ONCOLOGY (previously RADIOTHERAPY)
Total: Cancer
Critical Care
190 - ANAESTHETICS
320 - CARDIOLOGY
361 - NEPHROLOGY
Total: Critical Care
Emergency Care
110 - TRAUMA & ORTHOPAEDICS
180 - ACCIDENT & EMERGENCY
Total: Emergency Care
Medicine
300 - GENERAL MEDICINE
302 - ENDOCRINOLOGY
330 - DERMATOLOGY
340 - RESPIRATORY MEDICINE
400 - NEUROLOGY
410 - RHEUMATOLOGY
430 - GERIATRIC MEDICINE
Total: Medicine
Surgery
100 - GENERAL SURGERY
101 - UROLOGY
120 - ENT
130 - OPHTHALMOLOGY
140 - ORAL SURGERY
141 - RESTORATIVE DENTISTRY
143 - ORTHODONTICS
150 - NEUROSURGERY
160 - PLASTIC SURGERY
170 - CARDIOTHORACIC SURGERY
301 - GASTROENTEROLOGY
Total: Surgery
Women & Childrens
171 - PAEDIATRIC SURGERY
420 - PAEDIATRICS
421 - PAEDIATRIC NEUROLOGY
501 - OBSTETRICS
502 - GYNAECOLOGY
600 - GENERAL MEDICAL PRACTICE
Total: Women & Childrens
Total: OTHER
Total: All
£6,796,105
£11,973,946
£18,770,051
£7,053,167
£9,761,590
£16,814,757
-£257,062
£2,212,356
£1,955,294
£996,922
£1,241,354
£2,238,275
-£1,253,984
£971,002
-£282,981
£152,763
£278,521
£431,284
-£1,406,746
£692,481
-£714,265
-20.70%
5.78%
-3.81%
£6,021,846
£8,742,050
£10,722,509
£25,486,405
£8,234,773
£8,441,945
£7,241,287
£23,918,005
-£2,212,927
£300,104
£3,481,222
£1,568,400
£1,010,152
£1,381,249
£1,767,363
£4,158,764
-£3,223,079
-£1,081,144
£1,713,859
-£2,590,364
£89,183
£423,852
£314,848
£827,884
-£3,312,262
-£1,504,996
£1,399,011
-£3,418,248
-55.00%
-17.22%
13.05%
-13.41%
£23,945,270
£9,151,183
£33,096,453
£20,012,231
£9,925,324
£29,937,555
£3,933,038
-£774,141
£3,158,898
£2,704,734
£1,848,934
£4,553,668
£1,228,305
-£2,623,075
-£1,394,770
£962,999
£512,271
£1,475,270
£265,305
-£3,135,346
-£2,870,041
1.11%
-34.26%
-8.67%
£39,336,924
£175,681
£1,402,850
£160,451
£2,248,876
£550,581
£856,529
£44,731,891
£34,232,727
£81,685
£1,395,418
£241,469
£1,270,841
£358,780
£201,838
£37,782,758
£5,104,197
£93,996
£7,432
-£81,018
£978,035
£191,801
£654,691
£6,949,133
£4,669,565
£12,771
£250,866
£37,716
£154,270
£57,440
£31,830
£5,214,460
£434,632
£81,224
-£243,434
-£118,734
£823,764
£134,360
£622,860
£1,734,673
£1,001,295
£2,850
£59,450
£4,061
£34,689
£20,075
£5,753
£1,128,172
-£566,663
£78,375
-£302,884
-£122,795
£789,075
£114,286
£617,107
£606,501
-1.44%
44.61%
-21.59%
-76.53%
35.09%
20.76%
72.05%
1.36%
£24,906,522
£6,741,835
£6,313,900
£8,814,822
£2,556,558
£65,999
£1,044,000
£20,401
£198,742
£140,931
£8,920,018
£59,723,728
£21,876,770
£5,760,595
£4,887,399
£8,000,433
£3,546,230
£35,274
£968,307
£13,527
£168,181
£65,594
£9,224,535
£54,546,845
£3,029,751
£981,240
£1,426,501
£814,389
-£989,672
£30,725
£75,693
£6,874
£30,562
£75,337
-£304,517
£5,176,883
£2,978,054
£841,726
£752,906
£1,159,163
£476,234
£8,195
£169,979
£2,781
£26,314
£13,469
£1,392,873
£7,821,694
£51,697
£139,514
£673,595
-£344,774
-£1,465,906
£22,530
-£94,286
£4,093
£4,248
£61,868
-£1,697,389
-£2,644,811
£767,246
£178,727
£125,036
£239,207
£118,373
£1,509
£30,352
£457
£9,035
£4,063
£400,052
£1,874,059
-£715,550
-£39,214
£548,559
-£583,981
-£1,584,279
£21,021
-£124,639
£3,636
-£4,787
£57,804
-£2,097,441
-£4,518,871
-2.87%
-0.58%
8.69%
-6.62%
-61.97%
31.85%
-11.94%
17.82%
-2.41%
41.02%
-23.51%
-7.57%
£1,293
£11,812,079
£53,112
£8,225,091
£17,887,136
£1,667
£37,980,378
£43,010,204
£262,799,110
£901
£13,942,202
£17,060
£6,217,138
£13,760,310
£267
£33,937,878
£21,587,361
£218,525,160
£393
-£2,130,123
£36,052
£2,007,952
£4,126,827
£1,399
£4,042,500
£21,422,842
£44,273,949
£37
£36
£382,676 -£4,614,912
£688
£31,847
£512,396
£226,279
£223,201 £1,560,266
£5
£1,346
£1,119,002 -£2,795,138
£1,547,403 £14,422,105
£8,403,074
£712,044
2.78%
-39.07%
59.96%
2.75%
8.72%
80.77%
-7.36%
33.53%
0.27%
SLR Update October 2010
£320
£73
£2,102,113 -£4,232,236
£3,518
£32,535
£1,269,278
£738,675
£2,343,360 £1,783,467
£48
£1,351
£5,718,636 -£1,676,136
£5,453,335 £15,969,508
£35,158,832 £9,115,118
Sheet 10
Access to the PLC/SLR section in Mede is currently restricted to Divisional, SDU and
Finance managers to allow additional validation of the methodology used for the 12
months and establish areas for development before future iterations of the model are
made available to more users. Obviously this data will contain sensitive information
around the cost of members of staff, therefore procedures will be introduced to
mitigate the risks associated with this.
It is now possible to begin deep-diving into any specialty that requires further analysis
to help understand any variances. The table shows the SDU and specialty
breakdown.
With the data now fully available for analysis within Mede, the costing team will be
working with the divisions to validate and develop the underlying assumptions within
this current model. With the help, support and understanding of key clinical and non
clinical staff within the divisions we aim to ensure of future models reflect their
additional knowledge and understanding, producing outputs that are agreed with all
parties involved.
The Shrewsbury and Telford Hospital NHS Trust
Section Six – Outstanding Issues
We have changed the way we are reporting overheads, as some of the overhead
costs were being reported as part of the Indirect costs, the changes we made ensure
that any costs that sit outside of Divisions 1,2 and 3 will be reported as overheads.
We have also completed the local validation of the 2nd six months of 2009/10. These
revisions are now visible within Mede Analytics.
Work also continues on the 1st Quarter 2010/11 data.
Another issue that arises as a result of this process is the effect of Partially
Completed Spells. Income and spell activity for an individual will only be recorded
once they are discharged, but the support systems will be recording and counting
that patient’s use of resources from their date of admission, generating legitimate
cost but with no income or activity to match these against. Conversely, some spells
activity will be showing the total income for the spell in one period when most of the
costs were incurred and recorded within the previous period. Over a longer period
and with a stable bed base, these issues will even themselves out, but within our
particular 12 month model this had led to a net costs being apportioned back to
specialty without patient income to match.
Maintaining the costing model is proving to be more resource intensive that originally
anticipated, due to the volume of new cost lines that are being created within the
General Ledger. However, as we progress through further iterations of the model
this process should become further automated and therefore freeing the resource
time to develop the costing data following feedback.
SLR Update October 2010
Sheet 11
The Shrewsbury and Telford Hospital NHS Trust