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British Association of Day Surgery www.bads.co.uk
Best Practice Tariffs for Day Surgery: Does it pay?
Mark Skues
President
British Association of Day Surgery
British Association of Day Surgery www.bads.co.uk
Remits
• An update and overview on Best Practice Tariff
• Redesigning the pathway to maximize income, day surgery and reduce length of stay
• Engaging and educating clinicians in tariff and optimizing ways of working
• List combination optimization for economic viability
British Association of Day Surgery www.bads.co.uk
Overview
• What is Tariff?
• History of Best Practice Tariff
• What’s in it for you?
British Association of Day Surgery www.bads.co.uk
What is Tariff?
“From patient notes to pound
notes”
British Association of Day Surgery www.bads.co.uk
What is Tariff?
One payment for an operation funds everything.
British Association of Day Surgery www.bads.co.uk
How it works
Operation
• OPCS classification (>8900)
• Cholecystectomy: J18.3
• Laparoscopic: J18.3 + Y75.2
HRG Code
• GA10C Open Cholecystectomy without CC
• GA10D Laparoscopic Cholecystectomy with length of stay 1 day or more without CC
• GA10E Laparoscopic Cholecystectomy with length of stay 0 days without CC
• GA10F Open or Laparoscopic Cholecystectomy with CC
British Association of Day Surgery www.bads.co.uk
How it works
CC
• Co-morbidities – Additional conditions that the patient might come into hospital with that increase the complexity of the primary intervention
• Complications – Events during treatment that again increase complexity
British Association of Day Surgery www.bads.co.uk
How it works
CC
• Co-morbidities • Old myocardial infarction
• Chronic ischaemic heart disease, unspecified
• Atrial fibrillation and flutter
• Chronic obstructive pulmonary disease, unspecified
• Insulin-dependent diabetes mellitus without complications
• Rheumatoid arthritis, unspecified
• Calculus of gallbladder without cholecystitis
• Unspecified disorder of adult personality and behaviour
British Association of Day Surgery www.bads.co.uk
How it works
CC
• Complications • Acute laryngopharyngitis
• Hypotension due to drugs
• Cardiac arrhythmia, unspecified
• Volume depletion
• Fluid overload
• Disorientation, unspecified
• Cardiac arrest with successful resuscitation
• FB accidently left in body cavity or op wound following a procedure
British Association of Day Surgery www.bads.co.uk
Financial Incentivisation
Four years ago;
Approach to BADS by the NHS PbR Team
“How do we provide appropriate payment for Day Surgery activity?”
• Reduce tariff based on reduced cost?
• No... Enhance tariff as a financial incentive
British Association of Day Surgery www.bads.co.uk
Laparoscopic Cholecystectomy: ‘Best Practice’ Tariff
2009:
Day case: £1365
In-patient: £1365
For 2010-11: Day case: £1694 In-patient: £1369
British Association of Day Surgery www.bads.co.uk
Further Day Case Incentivisation 2013-4
Breast Surgery: Mastectomy, SLNB, Axillary Clearance
ENT: Tonsillectomy, Septoplasty, Mastoid Ops
Orthopaedics: Dupuytren’s, Subacromial decompression, Bunion ops
Gynaecology: Female incontinence surgery, O/P Hysteroscopy/Sterilisation
Urology: Resection of Prostate, O/P Cystoscopy
General Surgery: Laparoscopic Cholecystectomy, Hernia Repair
British Association of Day Surgery www.bads.co.uk
Best Practice Tariffs 2013-14 Day Case I/P
Axillary Clearance £1889 £1589
Mastectomy £2020 £1720
TVT £1126 £926
Hernia Repair £1102 £802
Subacromial decompression £2595 £2395
“Bunion” ops £832 £632
Dupuytren’s Fasciectomy £2479 £2279
Laparoscopic Cholecystectomy £1694 £1369
Tonsillectomy £1106 £806
Septoplasty £1111 £911
Mastoid Ops £2126 £1826
With CC
£2023
£2163
£1126
£1309
£2595
£1234
£2479
£2233
£1254
£1183
£2389
British Association of Day Surgery www.bads.co.uk
Best Practice Tariffs 2013-14 Day Case I/P
Axillary Clearance £1889 £1589
Mastectomy £2020 £1720
TVT £1126 £926
Hernia Repair £1102 £802
Subacromial decompression £2595 £2395
“Bunion” ops £832 £632
Dupuytren’s Fasciectomy £2479 £2279
Laparoscopic Cholecystectomy £1694 £1369
Tonsillectomy £1106 £806
Septoplasty £1111 £911
Mastoid Ops £2126 £1826
2012
£2053
£2206
£1222
£1136
£2613
£1257
£2735
£1694
£1035
£1183
£1949
Elective operations, without CC enhancement
British Association of Day Surgery www.bads.co.uk
Running costs for theatre?
The Productive Operating Theatre
?
?
British Association of Day Surgery www.bads.co.uk
Theatre Cost Context
An operating theatre costs between £12 and £20 per minute to run
~£4000 per operating session
• Staffing
• Environment
• Infrastructure support
• Consumables
British Association of Day Surgery www.bads.co.uk
Hernia repair BPT Payment for Day Surgery = £1102
(Inpatient care = £802)
Open Repair
‘Heavyweight’ ‘Lightweight’
GA LA
Laparoscopic Repair
TEP TAPP
‘Patch’ ‘Plug’
Mesh Type
Patient Gender, Age, Symptoms, Site, Co-morbidity
Mesh or suture Mesh Type
Size of Mesh
British Association of Day Surgery www.bads.co.uk
Hernia repair BPT Payment for Day Surgery = £1102
(Inpatient care = £802)
Patient Gender, Age, Symptoms, Site, Co-morbidity
British Association of Day Surgery www.bads.co.uk
• 10% lists cancelled
• 7.5% gap time
Theatre Utilisation (2003:Audit Commission)
British Association of Day Surgery www.bads.co.uk
Orchard et al. Journal of One Day Surgery 2011;20.1:4-6.
Theatre Utilisation
80%
British Association of Day Surgery www.bads.co.uk
Theatre Utilisation
Orchard et al. Journal of One Day Surgery 2011;20.1:4-6.
British Association of Day Surgery www.bads.co.uk
Lost Theatre Time
Unnecessary effort
Stress for crew
Delays for patients
Crew Efficiency
Long ChangeoversLate Starts
Lost Sessions
Crew scheduling
Late list changes No core crew
Staff Arrival
Prior
past experience
No sense
of urgency
Patient Readiness
Not Yet
consented
Not Decided
Anaesthetic
Late from
Ward
Not called
early
No coordination
of start
Set-up time
Many
Trays
Prep room
too small
Uncertain about
listed procedure
Equipment
issues
Clear-up time
Many trays
Only available
break time
Next Patient Readiness
Not called from Theatre
Not set-up on table
Not set-up on
table correctly
Patient Cancels
unwilling / inconvenient
Unfit – no time to recover
No substitute
patient in time
Trauma overrides elective list
Mass emergency Procedure requires
consultant
Rotation Not self managing
Still consenting
/ briefing
Instrument Delays
Recover from Error
Rep
Availability
Complex
Procedures
Scrub Nurse
Experience
Technician
Availability
Double Preparation
Rep
AvailabilityUnclear lists /
Self confidence
Confidence in
equipment
Confidence in
SSD
Incomplete Trays
Incorrectly re-packed
Wear & Tear
Tray Pillaging
Consumables
not separate
Late list
changes
Instrument
failure
Turnaround time
Chase trays work
intensive for SSD
Transport of
instruments
Basic
tracking
Many
trays
Late notice of
requirement
No warning they
need a translator
Theatre Utilisation
British Association of Day Surgery www.bads.co.uk
GP Surgical
OPD Pre-op
Assessment
Diagnostics Day Surgery Waiting List
Admission and Surgery
Inpatient Waiting List
Post-op Recovery
Day Unit
Inpatient / Short Stay Unit
Unanticipated overnight admission
Discharge
Immediate Post-
operative support
Booking
The Engine Room of Day Surgery
British Association of Day Surgery www.bads.co.uk
Best Practice Tariff: Lap Chole
HRG Operation Elective Emergency
GA10C Open Cholecystectomy without CC
£2233 £3942
GA10D Laparoscopic Cholecystectomy with length of stay 1 day or more without CC
£1369 £3099
GA10E Laparoscopic Cholecystectomy with length of stay 0 days without CC
£1694 £1290
GA10F Open or Laparoscopic Cholecystectomy with CC
£2233 £4564
British Association of Day Surgery www.bads.co.uk
What’s in it for you?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Day Case Laparoscopic Cholecystectomy
British Association of Day Surgery www.bads.co.uk
£0
£20
£40
£60
£80
£100
£120
£,0
00
Op
po
rtu
nit
y
What’s in it for you? Additional BPT payment per year
Day Case Laparoscopic Cholecystectomy
British Association of Day Surgery www.bads.co.uk
What’s in it for you? Additional BPT payment and saving
on overnight bed costs per year
Day Case Laparoscopic Cholecystectomy £0
£50
£100
£150
£200
£250
£,0
00
Op
po
rtu
nit
y
British Association of Day Surgery www.bads.co.uk
To qualify for Day Case BPT...
Planned management intent must be Day
Surgery
British Association of Day Surgery www.bads.co.uk
An example... D/C Tonsillectomy
0
10
20
30
40
50
60
70
80
90
100 Day Case Rates
Day Case + Zero Length
Of Stay Rates
Day C
ase
Rate
(%
)
British Association of Day Surgery www.bads.co.uk
Future plans for Best Practice Tariff?
PbR now administered by Monitor
Appears to be embedded in DH thinking.
Evaluation in 2011 by the PbR Team
British Association of Day Surgery www.bads.co.uk
“The NHS Institute for Innovation Improvement...They
brought in a cholecystectomy rapid improvement
programme last year and the large thrust of it was to say
that up and down the country we need to be doing more
and more of our gall bladders as day cases and that led to
me being the lead clinician on the surgical side and then a
colleague who was the anaesthetist backed up by various
managers, senior nursing people and so forth to look at
implementing day case laparoscopic cholecystectomy
which, up to then, we hadn’t really done... about thirty
percent of our gall bladders are being done as day cases
which is right up from virtually zero percent a year or two
previous to that.”
(IID22, Consultant Surgeon, Provider)
Best Practice Tariffs (BPTs) Evaluation Report June
2011
British Association of Day Surgery www.bads.co.uk
“...One is the day case rate for cholecystectomies and I
find that I’m a bit uncomfortable about that. Because that is
really interfering into the processes of medical treatment in
a way where the guys that sit in the British Association
of Daycase Surgery and all the real cranks. They have
their weird and wonderful little ideas but whether that is
then able to be rolled out across the whole of the UK I think
is doubtful. And to push people to adopt that before they
feel clinically comfortable is, I’m not so sure about it.
Having seen a few people who cholecystectomy actually
they feel like a horse hit them the day of surgery we are ….
kicking patients out rather than letting them sleep...I
don’t think it necessarily enhances their quality of care”
(IID54, Medical Director, Provider)
Best Practice Tariffs (BPTs) Evaluation Report June
2011
British Association of Day Surgery www.bads.co.uk
0
10
20
30
40
50
60
70
80
0
10
20
30
40
50
60
70
80
1998
2012
English hospitals
%
Day case Laparoscopic Cholecystectomy
British Association of Day Surgery www.bads.co.uk
Day Case Mastectomy
0
10
20
30
40
50
60
70
80
%
English hospitals
2012
British Association of Day Surgery www.bads.co.uk
Optimising BPT income
• Ensure that the ‘Day Case Management intent’ box is ticked
• Ensure that co-morbidities are recorded and coded appropriately
• Maximise the use of your theatre sessions