Acute Hospital Service Planning

Service Planning for a Tertiary Referral Teaching Hospital

John Lamont

Clinical Services Co-ordinator

Beaumont Hospital

Why plan services ?

• The new environment of limited resources to meet insatiable demand in an era of technologically driven advances in the delivery of healthcare for a population who are better educated and have an enhanced expectation of what a modern health service can do to improve their disposition and quality of life. (?)

The New Millenium

• By the beginning of 2000 the ERHA will be in place

• “Decisions regarding the provision of local services will be made closer to the point of delivery and will facilitate more involvement by local communities in the planning and organisation of their health services.” Minister for Health and Children Nov. 1998

Requirements of the New Authority

• Strategic Planning of services for the region in response to identified and measured need

• Commissioning of services from both the statutory and voluntary sectors

• Overseeing and evaluating the services provided

Steps in devising the Service Plan

• This Years Activity

• This Years Costs

• Next Years Allocation

• Changes in Practice

• Expansion of Existing Services

• Unfunded Developments

• New Services

Management Structure - Beaumont Hospital

M INISTER FO R HEA LTH AND CHILDRE N

P e rso n n e lO ffice r

F in a n c ia l C o n tro lle r

IT P ro je ctM a n a g er

P la n n in g &D e ve lop m e nt

G e n e ra l M a n a g erN o n -C lin ica l

C lin ica l S e rv ice sC o -O rd in a to r

M e d ica lA d m in is tra to r

D ire c to r o fN u rs in g

C h ie f E xe cu tive

B e a um o ntH o sp ita l

B o a rd

‘Strategy Template’

• Planning & Development Officer prepared detailed analysis of patient admission and discharges.

• Also a detailed analysis of the mix of DRGs

• In 1997, reviewed activity figures with Senior Executive colleagues

Review of Activity

• How data is presented– Public / Private mix– Elective / Emergency– Catchment / non-catchment– national / non-national

• Detailed analysis of– Average Length of Stay (ALOS)– Listing of specialties by DRG

The importance of Data

• Numbers are not the only measure but do form a common dimension by which activity can be defined

• Therefore, numerical data is important in defining a contractual obligation with the funding agency (DOHC, ERHA etc)

Draft Template for ERHA I

Monthly Inpatient Activity ReportProvider:Period:

Unit of

Code Specialty Measure

Public Private Public Private Public Private0100 Cardiology No. of Discharges

0300 Dermatology No. of Discharges

0400 Endocrinology No. of Discharges

0600 Otolaryngology (ENT) No. of Discharges

0700 Gastroenterology No. of Discharges

0800 Genito-Urinary Medicine No. of Discharges

Current Month

Children Adults Older Persons

Draft Template for ERHA II

Monthly Day Cases Activity ReportProvider:Period:

Unit of

Code Specialty Measure

Public Private Public Private Public Private0100 Cardiology No. of Cases

0300 Dermatology No. of Cases

0400 Endocrinology No. of Cases

0600 Otolaryngology (ENT) No. of Cases

0700 Gastroenterology No. of Cases

0800 Genito-Urinary Medicine No. of Cases

Current Month

Children Adults Older Persons

Draft Template for ERHA III

Inpatient Capacity ReportMonthly Changes: Actuals in (two months 6 /12 apart)Provider:Period:

Unit ofCode Specialty Measure

Public Private Public Private Public Private0100 Cardiology No. of Beds

0300 Dermatology No. of Beds

0400 Endocrinology No. of Beds

0600 Otolaryngology (ENT) No. of Beds

0700 Gastroenterology No. of Beds

0800 Genito-Urinary Medicine No. of Beds

Current MonthChildren Adults Older Persons

Draft Template for ERHA IV

Monthlt A&E Activity reportProvider: Period:

Triage Unit ofCategory Measure Children Adults Older Persons

1234567

Current Month

Draft template for ERHA V

Monthly Financial reportProvider:Period

Planned Actual Planned ActualPayNon-PayGROSS

IncomeNET

WORKING CAPITALCreditorsDebtorsStockCash in Bank

Current Month YTD

Who is Responsible for Service Plans ?

• At Beaumont, the Planning and Development Officer who is a member of the Senior Executive (SX), has primary responsibility for the production of the Hospital Service Plan

• The initial consultations are with the Divisional Heads who are members of the SX

Hospital Activity Report 1998

Beaumont Hospital - In Patient activity(Discharge Based)

Year to Date: 31st December,1998 SPECIALTY

Target Actual

Day In Pat Tot Day Day Oth Day tot In Pat Tot Var %Var

1362 1610 2972 329 1172 1501 1634 3135 163 5 EAR/NOSE/THROAT

250 240 490 104 78 182 226 408 -82 -17 GYNAECOLOGY

1400 678 2078 1382 1382 1600 2982 904 44 VASCULAR SURGERY

3250 2518 5768 3018 379 3397 1819 5216 -552 -10 GENERAL SURGICAL

40 2200 2240 52 2 54 1990 2044 -196 -9 NEUROSURGERY

2200 1618 3818 300 1812 2112 1519 3631 -187 -5 ORTHOPAEDICS

100 157 257 94 94 115 209 -48 -19 PLASTIC SURGERY

1500 1214 2714 816 965 1781 1073 2854 140 5 UROLOGY

3 20 23 6 6 14 20 -3 -13 DENTISTRY

216 1 217 237 237 5 242 25 12 OPTHALMOLOGY

12 0 12 4 4 10 14 2 17 OTHER

50 50 100 111 111 74 185 85 85 MAXILLO-FACIAL

0 80 80 0 157 157 77 96 TRANSPLANT

350 20 370 389 93 482 26 508 138 37 PAIN-RELIEF

10733 10406 21139 6605 4738 11343 10262 21605 466 2 SUB TOTAL SURGICAL

500 1400 1900 619 619 1211 1830 -70 -4 CARDIOLOGY

750 0 750 302 833 1135 8 1143 393 52 DERMATOLOGY

0 225 225 0 199 199 -26 -12 DETOX

0 615 615 27 27 688 715 100 16 ENDOCRINOLOGY

1800 1350 3150 2480 2480 1451 3931 781 25 GASTROENTEROLOGY

3 600 603 2 2 581 583 -20 -3 GENERAL MEDICAL

0 300 300 1 1 277 278 -22 -7 GERIATRICS

550 195 745 521 521 138 659 -86 -12 HAEMATOLOGY

92 715 807 262 3 265 692 957 150 19 NEUROLOGY

19000 1250 20250 2 23117 23119 1415 24534 4284 21 RENAL

600 1370 1970 357 1 358 1524 1882 -88 -4 RESPIRATORY MEDICINE

0 390 390 2 109 111 429 540 150 38 RHEUMATOLOGY

0 280 280 0 295 295 15 5 INFECTIOUS DISEASES

23295 8690 31985 4053 24585 28638 8908 37546 5561 17 SUB TOTAL MEDICAL

34028 19096 53124 10658 29323 39981 19170 59151 6027 11 TOTAL

Note: Variance = Actual - Target(Total Figures)

SPECIALTY Yearly Target 1999

DayIn

Pat/CasIn

Pat/CatchIn Pat/Non

Catch WL Tot Lab Total Rad Total

EAR/NOSE/THROAT 1400 338 631 631 70 3070 5,700 687GYNAECOLOGY 180 40 135 45 20 420 1,380 139VASCULAR SURGERY 1300 378 158 104 80 2020 14,898 1210GENERAL SURGICAL 1250 1911 327 162 100 3750 69,702 5178NEUROSURGERY 50 1493 102 405 60 2110 45,008 6275ORTHOPAEDICS 2100 1156 243 121 30 3650 15,744 2460PLASTIC SURGERY 100 56 64 0 220 932 96UROLOGY 1500 413 413 274 30 2630 10,050 1150DENTISTRY 0 0 0 0 0OPTHALMOLOGY 220 1 0 0 221OTHER 0 0 0 0 0MAXILLO-FACIAL 100 51 49 0 200 594 123TRANSPLANT 0 140 0 0 140PAIN-RELIEF 380 0 20 0 400 72 11

SUB TOTAL SURGICAL 8580 5977 2142 1742 390 18831 164,080 17,329

CARDIOLOGY 500 1058 107 35 1700 36575 2009DERMATOLOGY 1150 0 0 0 1150DETOX 0 0 225 225 596 112ENDOCRINOLOGY 25 480 47 10 562 11080 710GASTROENTEROLOGY 2200 900 150 100 3350 29857 2124GENERAL MEDICAL 3 480 40 2 525 8093 670GERIATRICS 0 180 40 0 220 11987 934HAEMATOLOGY 520 100 65 30 715 5548 342MEDICAL ONCOLOGY 5400 550 0 0 5950NEUROLOGY 150 250 100 200 700 9713PSYCHIATRY 0 40 0 0 40 1055RENAL 23000 900 100 300 24300RESPIRATORY MEDICINE 300 1000 134 66 1500 35541 3644RHEUMATOLOGY 100 280 26 6 412 8204 924INFECTIOUS DISEASES 0 260 0 0 260 4300 402

SUB TOTAL MEDICAL 33348 6478 1034 749 0 41609 161494 12926

TOTAL 41928 12455 3176 2491 390 60440 325574 30255

1999 Targets

ACTIVITY TYPE - ALL SPECIALTIES D'Chrgs ALOS Bed Days RqdDRG INPATIENTS - DRG/DESCRIPTION

1 1 Craniotomy Age > 17 except for Trauma 550 16.72 91972 183 Esophagitis, Gastroent & Misc Digest 477 5.16 24613 88 Chronic Obstructive Pulmonary Disease 375 11.42 42834 14 Specific Cerebrovascular Disorders 320 23.27 74465 25 Seizure & Headache Age > 17 W/O CC 290 7.09 20576 89 Simple Pneumonia & Pleurisy Age > 17 250 15.64 39097 182 Esophagitis, Gastroent & Misc Digest 247 9.69 23938 215 Back & Neck Procedures W/O Cc 230 11.36 26149 127 Heart Failure & Shock 226 12.57 2841

10 60 Tonsillectomy &/Or Adenoidectomy only 220 2.32 51011 132 Atherosclerosis with CC 220 10.20 224412 138 Cardiac Arrhythmia & Conduction 220 9.69 213113 139 Cardiac Arrhythmia & conduction 200 6.94 138814 478 Other Vascular Procedures w CC 200 19.71 394315 316 Renal Failure 200 11.33 226516 140 Angina Pectoris 186 7.42 137917 243 Medical Back Problems 177 10.55 186718 59 Tonsillectomy &/Or Adenoidectomy only 172 2.79 48019 167 Appendectomy W/O Complicated Principal 171 4.13 70620 73 Other Ear, Nose, Mouth & Throat 170 3.02 514

Top 20 DRGs for 1999 Service Plan

TOTAL 9597 91601Other Inpatients 8915TOTAL INPATIENTS (inc WLI) 18512

1998 1999 TARGETDAY PATIENTS

34028 402431998 1999 TARGET

OUTPATIENTSNumber of new Out Patients Treated 23220Number of Return Out Patients Treated 98964

WAITING LISTTotal number of Patients on List

Top Level Summary for 1999

The role of Divisional Heads

• The services at Beaumont Hospital are divided into four Divisions; – Nursing Division– Medical Division– Clinical Services– Non-Clinical Services

• Each Divisional Head consults in turn with their Heads of Department / Heads of Services / Cogwheels /Nurse Managers

Process of Integrating the Service Plan

• Since 1998, regular meetings have been held involving members of the Senior Executive and the Medical Executive

• Active discussion on audit of transfers from outside catchment area

• Agreed strategy to reduce diagnostic activity• Agreeing a strategy to reduce Waiting Lists within

the overall Service Plan

The Consultative Process - Clinical Services Division

• Introducing the concept of limitation• As service providers in an acute hospital setting,

healthcare professionals are disinclined to place limits on access to their services

• There is a need to define limits, without which the pressure on staff is intolerable

• Move from a demand-led approach to a provision-led approach

Radiology Activity 1998 Totals GEN CAS CT US PRT MRI NUC NVA SCR INT MAM TH BX CRD

Totals 134019 48900 47413 8601 7188 6771 6028 3151 2147 2029 767 637 147 130 110

ACCIDENT & EMERGENCY 41471 162 38803 1810 493 15 63 91 23 8 3

GP & EXTERNAL PATIENTS 21892 15006 86 541 793 41 3035 877 422 580 45 248 123 53 42

IN PATIENTS (inc DAY CASES) 46819 25436 172 4375 3914 6609 1427 1572 1599 876 687 56 24 6 66OUT PATIENTS 23837 8296 8352 1875 1988 106 1503 611 103 565 32 333 0 71 2

Radiology Activity for 1998

Radiology Activity by Specialty 1998IN PATIENTS (inc DAY CASES) Totals GEN PRT CT US NVA NUC MRI SCR INT CAS CRD MAM TH BXTotals 46811 25229 6602 4365 3884 1567 1562 1427 874 659 172 66 56 24 6NEUROSURGERY 7868 3603 1796 1386 98 498 36 397 15 27 9 1 2NEPHROLOGY 5614 2890 587 254 884 301 331 58 73 234 1 1VASCULAR SURGERY 4768 2193 1084 345 401 229 119 104 160 121 6 6RESPIRATORY MEDICINE 4582 2869 475 439 418 46 216 54 34 22 3 2 2 2GENERAL SURGICAL 4270 2087 584 342 569 73 114 130 266 69 31 5GASTROENTEROLOGY 3379 1792 296 337 437 26 148 76 137 121 2 3 2 2ORTHOPAEDICS 3215 2027 598 171 48 6 99 96 11 8 142 9CARDIOLOGY 2609 1427 381 120 193 234 140 28 14 10 3 58 1UROLOGY 2021 1306 229 89 186 29 92 14 42 31 1 2GERIATRICS 1465 1088 37 129 104 5 71 8 20 3NEUROLOGY 1320 664 82 123 67 24 13 316 16 9 1 5RHEUMATOLOGY 1165 758 93 98 110 12 51 15 16 6 2 1 3ENDOCRINOLOGY 965 554 92 92 111 9 52 33 10 8 2 2E.N.T. 868 589 75 79 26 16 7 37 34 2 2 1GENERAL MEDICAL 837 468 57 122 113 5 31 28 8 4 1HAEMATOLOGY 668 354 60 126 54 22 25 12 9 6INFECTIOUS DISEASES 502 272 38 77 56 3 22 17 8 3 3 1 2GYNAECOLOGY 182 142 7 13 18 1 1MAXILLO-FACIAL 158 88 19 25 23 1 2DETOXIFICATION 139 122 12 5PLASTIC SURGERY 128 105 15 2 2 2 1 1PAIN RELIEF 35 10 3 1 21DERMATOLOGY 16 9 1 2 2 1 1OPTHALMOLOGY 15 5 2 1 6 1DENTISTRY 13 8 1 3 1

7 1 1 3 1 1A&E 1 1TISSUE TYPING POOL 1 1

Monitoring Diagnostic Activity as part of Service Plan 1999

1st Quarter 1999

SPECIALITY Bed Days Rad Path

ADM D/C BD Rad Path per ADM per ADM

CARDIOLOGY 61 82 1154 158 2461 18.9 2.6 40.3CARDIOLOGY 68 83 1047 187 3282 15.4 2.8 48.3CARDIOLOGY 34 60 626 93 2393 18.4 2.7 70.4DETOXIFICATION 35 33 655 33 164 18.7 0.9 4.7ENDOCRINOLOGY 189 171 1722 277 3472 9.1 1.5 18.4GASTROENTEROLOGYGASTROENTEROLOGY 225 189 1968 405 5041 8.7 1.8 22.4GASTROENTEROLOGY 196 155 1669 303 4877 8.5 1.5 24.9GASTROENTEROLOGYGENERAL MEDICAL 142 121 947 186 2364 6.7 1.3 16.6GERIATRICS 36 57 1516 274 3337 42.1 7.6 92.7HAEMATOLOGY 21 22 247 69 836 11.8 3.3 39.8INFECTIOUS DISEASES 96 87 1254 150 1645 13.1 1.6 17.1NEPHROLOGY 127 126 1386 462 7721 10.9 3.6 60.8NEPHROLOGY 102 102 1288 282 6493 12.6 2.8 63.7NEPHROLOGY 86 83 1432 438 6429 16.7 5.1 74.8NEUROLOGY 116 97 1099 170 2062 9.5 1.5 17.8NEUROLOGY 52 55 515 101 1090 9.9 1.9 21.0NEUROLOGYONCOLOGY 47 60 451 158 1370 9.6 3.4 29.1RESPIRATORY MEDICINE 215 175 2536 543 5231 11.8 2.5 24.3RESPIRATORY MEDICINE 183 192 2436 507 5350 13.3 2.8 29.2RHEUMATOLOGY 112 103 1191 207 2220 10.6 1.8 19.8

Service Plans as Tools to Manage Expectation

• The primary role of Services Plans is the management of expectations– of the public (patients and their families)– of all the staff

• Medical

• Nursing

• Other Healthcare Professionals

• All other employees

Managing Expectations II

• Managing expectations (contd.)

– of other service providers (HBs, Private Hospitals etc.)

– of the funding agency– of patient support groups

Service Planning - Pie in the Sky ?

• NO !

• Requires good information

• Need for data to be shared between agencies

• Benchmarking

• Past trends can predict future activity to a reasonable degree