How should the hospital performance distribution system with value-based healthcare as the core run?

The distribution of hospital performance affects the whole body, is very sensitive, involves balancing the interests of all aspects, and a little carelessness will take care of one or the other, causing everyone's dissatisfaction and affecting the enthusiasm of medical staff. Therefore, we need to maintain a very cautious attitude towards performance distribution, when will the performance distribution reform be carried out? What is the performance distribution method to choose? Who are the targets of the performance distribution reform? What value contributions should be highlighted in performance allocation? All of these must be carefully studied.

The purpose of performance distribution is to better guide employees to create value, maximize the value of employees, units and the people, and encourage us to create value-based medical care and establish a performance distribution system with value-based medical care as the core.

Value-based healthcare is considered by health economists to be the most cost-effective medical care, that is, to improve medical effects at the same or lower cost, which is actually the relationship between quality, safety, patient experience and cost, and its core is "two improvements, one reduction", that is, to improve medical quality and medical effects and reduce medical costs. Some Western scholars summarize value-based medical care as: the reduction of medical costs, the improvement of patient satisfaction, and the improvement of medical quality.

When we emphasize the public welfare of the hospital, it does not mean that all the work of the medical staff is of a public welfare nature, the medical staff is also a social person, they have seven emotions and six desires, need to eat, drink and Lazar, of course, they are also economic people, and need a certain economic income to support their family life, so a moderate and effective performance distribution helps to improve their enthusiasm.

However, the traditional performance distribution model of revenue, reduction and expenditure, which completely emphasizes economic interests, leads many medical personnel to look at money for everything, driving them to seek medical treatment for money, and large prescriptions, large examinations, and large treatments are more common.

In the process of reform, some hospitals began to recognize these problems, and gradually upgraded the performance allocation method, converting the project price into workload point value.

These distribution models are completely inconsistent with the requirements of the new medical reform, in line with the current policies, in line with the development law of the health industry, and in line with the expectations of the people, and the management of medical quality and cost is almost a formality.

In practice, the Hunan Provincial Hospital of Traditional Chinese Medicine under my management has explored a set of more useful distribution methods, focusing on which medical activities are valuable medical services for patients, which are of no value or too low value, how to reduce them, and how to guide the medical behavior of medical staff through performance distribution as a "baton". Combined with the concept of value-based medical care, the hospital divides the performance distribution system into three parts: the comprehensive value of the department, the value of workload, and the value of cost control.

How to evaluate the comprehensive value of the department?

48 factors!

In the process of hospital strategic management, the relative value of departments in the hospital is ranked, that is, who is the most important and who is more important, that is, the comprehensive value of the department. This is to guide all departments to pay attention to public welfare, and guide medical staff to change their medical behavior through distribution; The shift from "disease treatment" to "health management" focuses on disease prevention, health science popularization, and health management outside of medical care, so the departments that undertake this kind of work have played a very important role in the era of value-based medical care, and will naturally receive corresponding performance distribution and encouragement.

However, in the traditional performance distribution model, this kind of department does not directly create income, so the performance distribution amount is very low, most of them get the lowest bonus or average award, or rely on policy tilt to eat labor insurance.

Through the design of the management model, the hospital scientifically evaluates all the departments and posts in the hospital, determines the value of the department and the value of the post as 48 factors, assigns points to each factor at different levels, and finally obtains the relative value of each department and post through the evaluation of the judges.

I illustrate with 4 of its 48 factors:

Evaluation factor 1: work intensity.

Reflect the labor load of each department, this factor is to reflect the value of the post and department on call at any time, not necessarily there will be patients from time to time, but once there are patients working day and day, the most obvious clinical is the emergency department, ICU, pediatrics, respiratory department, etc., the administrative department is more prominent is the medical department, nursing department, hospital infection department, office, their working hours are uncontrollable, there are many night shifts, usually busy is all night.

Some departments also have night shifts, but the patient's condition is relatively stable, the workload at night is not large, and many times they sleep until dawn, so the value of the department post is naturally different, high and low.

Evaluation factor 2: degree of risk.

This factor is to reflect that the patients received by some departments have high requirements for the ability of first-time doctors, or the patients received are highly contagious and even endanger the lives of medical staff, and hospitals need to conduct different evaluations to obtain the relative value of this factor in each department.

For example, the relative value of a department that admits more severe patients and a department that admits more common patients will be completely different; The value of the infectious disease department is different from that of the non-communicable disease department.

Evaluation factor 3: human input.

This factor is intended to reflect the differences in human input, including the amount of human resources invested and the length of time invested, which will vary in degree and value in each department.

Evaluation factor 4: degree of public welfare.

Focus on evaluating the degree of influence of public welfare events. This factor is to fully reflect the strategic contribution of the department that does more public welfare and science popularization to the hospital.

There are 48 factors in the entire evaluation system, and the hospital selects 42 evaluation experts, whose members are composed of senior experts, middle-level cadres and employee representatives in proportion, and are controlled by professional teachers throughout the process. Before the evaluation, all departments send representatives to make statements about the business needs of their departments, and then the judges will score them, and the staff will count the results on the spot and announce them on the spot. Through this evaluation, the overall value of each department is derived. This part is based on the evaluation of the relative value of each department, which has nothing to do with economic income.

How is the value of the workload assessed?

Keeping patients in their own department is discouraged!

Determine the value of each work, which is an important part of the hospital from the traditional performance of the service volume driven to the value driven, the value drive and the service volume driven are fundamentally different, the traditional performance distribution is to provide more services to more income, easy to produce excessive medical treatment.

The workload value emphasized by the hospital is different from some hospitals that directly convert the price of the project into point value, let alone directly measure the workload point value with money.

Of course, the workload value of the hospital is also measured by the point value, but the workload point value is different from the price of the existing medical project, combined with the influencing factors of DRG, citing the method of evaluating the project of the National Medical Security Administration, focusing on the difficulty coefficient, manpower investment, medical leading projects, key specialties or projects, and determining more than 20 factors such as high surgical difficulty, high technical content, high risk, time-consuming, development characteristics of traditional Chinese medicine, and external treatment techniques of traditional Chinese medicine.

The workload value drive focuses on the overall medical effect of patients, rather than the number of projects and the superposition of projects, mainly to motivate how to accelerate the promotion of patient health, advocate the reduction of unnecessary interventions, and focus on the whole process of medical activities to improve the patient experience, and enhance the sense of respect, comfort and security.

The hospital has designed a set of workload point value evaluation form, which is similar to the previous evaluation process, and selects some clinical experts for evaluation and scoring, and is guided by professional teachers throughout the process, scoring all the workload, and then passing strategic correction to obtain the final workload point value.

The hospital adheres to the result-oriented, carries out a new combination and arrangement of treatment methods, and reformulates the clinical pathway, so the performance allocation of this part is to actively encourage and gradually realize the overall treatment results of patients, and it is an integrated treatment management, rather than each department fighting independently.

The hospital does not encourage every department to want to keep patients in their own department, but encourages how to get patients better as soon as possible, speed up discharge, and return to family and society. The workload with value-based healthcare as the core should reduce unnecessary medical services, improve the efficiency of resource allocation, and truly implement the concept of "patient-centered".

How to evaluate the value of cost control?

Let employees see how much others in the department are earning!

Value = Patient's health outcomes / Cost to achieve these outcomes, which is an analysis of operating costs, focusing on how to reduce medical waste, improve efficiency, and promote patients to receive the most reasonable and high-quality medical services. This is also the management focus that hospitals need to pay attention to under the DRG reform, pursuing more cost-effective medical services, that is, maximizing medical quality or medical effects at the same or lower cost.

The practice of reducing patients' waiting, improving patients' medical experience, improving medical quality, reducing patients' hospital stay, and reducing unnecessary medical costs is to focus on the diagnosis and treatment effect and take cost control as the starting point, carefully sort out the charge details and cost details of each case, do a good job of horizontal comparison between the same group of cases, find out the cost and cost differences, analyze the reasons for the differences, and optimize the clinical path in a targeted manner.

Based on the core idea of "service items consume operations, operations consume resources", based on the hospital's medical business process and financial data, the activity costing method is introduced to collect the direct costs of the project to form a value cost chain, and the cost drivers are used as the basis for the allocation of indirect expenses, and different allocation standards are adopted to track the resource consumption process, allocate and calculate the indirect costs of the project, and calculate the medical service projects carried out by the hospital, so as to improve the attributability of costs and the objectivity of cost information.

In this area, the performance of anesthesiology and operating room is particularly obvious, the operating room basically does not generate income and profits, only costs, and the guiding ideology of the reform of Hunan Provincial Hospital of Traditional Chinese Medicine is to reasonably reduce costs and win the sustainable development of the hospital.

The hospital divides the total performance with three dimensions for weight division, and finally obtains all the performance quota of each department, and after repeated calculation, through the information system developed by engineers to the hospital, the hospital's unique performance management software system is formed, so that each department and each employee can check their income at any time, clarify the value orientation of the hospital, and correctly guide the behavior of medical staff.

There will be many unprecedented problems in this process, such as: because employees did not know how the bonus was calculated, now they can clearly see their own income and the income of other people in the department through the system, which poses a severe challenge to the rationality of the department's secondary distribution plan. Of course, whether or not you can get these performance income in the end still needs to be evaluated by the hospital.

Performance distribution with value-based healthcare as the core is not a quick plan, it is a holistic process, it is a culture establishment, a comprehensive management tool, a management and control system, and a road that needs to be adhered to and invested in.

Any management mechanism is not a vacuum, it will always be subject to various internal and external environmental constraints and effects, and the implementation of the performance distribution system is the same, and even more difficult problems than the implementation of other systems.

People do not oppose the reform, but they are afraid that the reform will touch their own interests, so the effective performance distribution mechanism is inseparable from a sound hospital management system, a complete human resource management system, a sound performance evaluation system, and a sound management supervision and restraint mechanism. Performance distribution should not only focus on breaking the pattern of "doing good and doing bad" internally, but also on value creation.