A Database Approach to Managing an Occupational Therapy Department
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Ellen L. Kolodner, MSS, OTRIL, FAOTA Judythe B. Novey, MUP
SUMMARY. Changing and often conflicting incentives in the current reimbursement environment require occupational therapy managers to develop adaptive administrative strategies. They must maximize productiwty, create budgets, and develop marketing strategies. Accurate information provides the key to success in these tasks. This paper discusses the role of management information systems in the administration of an occupational therapy department and some of the essential factors in irn lementation. Creation of a database description, establishment o a process for collecting information and report development are explored.
t"
Survival is the struggle for existence. Survival for occupational therapy departments Gll result from predicting, planning-and responding proactively to environmental demands. Infonation is a necessary prerequisite to strategic planning. The occupational therapy manager can use data to define and measure the department output. Data which are crucial to this analysis include demographic and diagnostic information, levels of patient impairment, the patients' insurer, staff productivity, and departmental costs. Using this data, a manager can compare and Ellen L. Kolodner is Assistant Professor and Fieldwork Coordinator, Department of Occupational Therapy, Thomas Jefferson University. College of Allied Health Services, Philadelphia, PA. Judythe B. Novey is Assistant District Coordinator. Medical District Four. Veterans Administration. Philadelphia. PA. This article appears jointly in The Occupational Therapy Managers' Survival Handbmk (The Haworth Press, Inc., 1988) and in Occupational ,Therapy in Health Cam. Volume 5, Number 1 (1988). O 1988 by The Hawonh Press, Inc. All rights reserved.
I75
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The & C ~ ~ I ? W Therapy M~ Mmger's Survival Handbook
contrast the characteristics of patients presently served by the department with those of patients being sewed by other departments in the hospital, in other facilities and in the community. Analysis of the resulting information forms the basis for development of measurable and attainable plans and objectives.
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
TYPES AND USES OF DATA
Management information enables growth and change by design rather than reaction. Accurate data allow a manager to develop plans which address staff deployment, service utilization, marketing, and program strengths and weaknesses. Managers are compelled to demonstrate that occupational therapy contributes to quality of care and to the improvement of health and function. Accessible data enable a manager to respond to inquiries and opportunities quickly, and with confidence. The precise impact of new policies on the department can be determined and impressions can be substantiated by comparing data concerning the department, the hospital and the external environment. Detailed data can be used as an excellent communication tool. Audiences, whether physicians, administrators or the community, are more receptive to new ideas which are substantiated with statistics which reflect their particular interests. There are hvo major types of management information external to the department: environmental and facility level. Environmental information describes the external forces which impact on the hospital and the occupational therapy department. It includes demographic, economic, technological, political and regulatory data. This information can be obtained from census data, Chamber of Commerce reports, etc. Specific examples of environmental information and sources are listed in Figure A. Facility-level data summarize the activities of the hospital such as patient demographics, costs, utilization and productivity. A demographic and diagnostic profile of the department can be used to delineate the similarities and differences between the department and hospital patient mix. Wright identifies the need for diagnostic information in cost and productivity analyses.' Differences between the department and the hospital may represent special populations
Ellen L Kolodner o d Judyhe B. Nowy
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
TXPES
OP DATA o hospital strategic plan o l o c a l demographic d a t a i n c l u d i n g a g e and income d i s t r i b u t i o n s and a g e - s p e c i f i c p o p ~ l a t l o n projections. o u t i l i z a t i o n d a t a lover time, i f p o s s i b l e ) f o r h o s p i t a l s i n t h e community. length of stay a d m i s s i o n s by t y p e home c a r e v i s i t s outpatient v i s i t s number of p h y s i c i a n s by t y p e o t y p e and l o c a t i o n o f new t e c h n o l o g y o r e g u l a t o r y and payment d i r e c t i o n s . p o l i c i e s a f f e c t i n g reimbursement of O.T. services c o s t and u t i l i z a t i o n i n c e n t i v e s i n h e r e n t i n payment s y s t e m s
--
-
o local hospital association o l o c a l p l a n n i n g commission a n d w a t e r and transportation a ut hori t i e s o census bureau o S t a t e population agency o s t a t e h e a l t h planning agency o l o c a l h e a l t h systems agency a local business c o a l i t i o n s f o r health care o A M A F e d e r a l Report o c o n s u l t a t i o n s with: o t h e r O.T. managers who h a v e i n i t i a t e d innovative program o t h e r department heads i n t h e h o s p i t a l hospital administrators s t a f f and a t t e n d i n g p h y s i c i a n s department s t a f f financial officers consumer g r o u p s
-
-
or diagnostic classes that the staff are treating; or, they may indicate that an occupational therapy program is not keeping pace with environmental changes. Clinical distinctions made when treating patients need to be incorporated into data collection so that activities can be described in terminology which is both clinically meaningful to physicians and fiscally meaningful to administrators. Workload should be represented as specific types of patients treated such as the number of patients with joint replacement, stroke, or arthritis. Each of these -
-
~
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1 78
The Occuplrtionitl Therapy Mawger's Survival Handbook
patient types will consume different resources (both staff time and supplies). If one is aware of the time and costs associated with specific department outputs (i.e., types of treatments), observed utilization trends can be used to project staffing needs by specialization and identify budget requirements. Evaluation of efficiency and external market penetration can be achieved through analysis of referral sources, elapsed time between admission and referral to occupational therapy, and the response time of staff. The manager will be able to answer such questions as: Is the department getting all possible referrals? Are they timely? Was the response time appropriate? AN EXAMPLE: USING DATA T O DETERMINE HOW A DEPARTMENT DIEFERS FROM THE HOSPITAL
Consider the following scenario. A department manager experiences a shortage of staff. Additional staff can be justified by comparing department level to facility level data. Utilization experienced or anticipated by the hospital must be disaggregated so that those activities which actually impact the occupational therapy department can be accurately identified and measured. Figure B displays part of the current workload of a theoretical hospital. Note the variation in workload across departments.' The figure shows the occupational therapy department currently attributes 11.1%of its workload to DRG 209-Major Joint Procedures (560 treatments).' Consider the effect of the addition of another oethopedic surgeon to the hospital staff. If he/she performs 280 additional major joint procedures, hospital admissions will increase 3.6%. If the 280 additional procedures result in 840 additional occupational therapy treatments (an average of 3 treatments per admission), DRG 209 will represent 24.8% of the department's treatments and an overall increase of departmental workload of 17.5% rather than the 3.6% increase that the additional procedures will have on total hospital admissions. Therefore, if the manager were to estimate the impact on the occupational therapy department based on the effect on total hospital admissions, the projected workload would be grossly underesti-
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P A R T I A L D I S T R I B U T I O N OP WOFXLOAD BY DRG
MEDICINE: p a t i e n t Days Admissions
I
I
I
1
SURGERY: P a t i e n t Daya Admissions PSYCHIATRY: Patient Days Admissions OCCUPATIONAL THERAPY: Treatments
I 4.8B0 1 2 8 0 ...............................................
5.8
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The Occupatwnal Themm Manager's Survival Handbook
mated. An increase in occupational therapy staff to provide 3.6% more treatments would only meet about one-fifth of the need generated by the additional procedures. Thus it can be seen that knowledge of the specific diagnostic mix will allow a manager to analyze the effect of a policy or program on the department. Such a report substantiates the request for additional staff.
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
IMPLEMENTING A DATA COLLECTION SYSTEM Managers must analyze their information needs as a first step in identifying data elements. Collecting accurate data requires a plan of action. A plan of action will: (1) determine the purposes for which the data will be used; (2) identify and define the data elements to be captured; (3) specij. the collection process; and (4) outline reports to be generated. There are a variety of reasons to collect data.' A number of these were described earlier. A data collection system should be designed to support the individual needs of the department. See Figure C. Database Definition A database definition is a list of the specific elements you want to collect. First, general categories of information such as patient characteristics, workload, and costs should be identified. These categories will parallel your purposes. Specific data items then follow naturally. Each item should be clearly defined. For example, if the department wants to collect information on diagnosis, the definition must indicate whether the data is to reflect the diagnosis the patient was admitted for or the diagnosis that the occupational therapist is currently treating. They may be different. The department may want or need both. The most critical elements are those which uniquely identify the unit of output. Output can be specified as a series of treatments for one admission, an episode of illness, or individual treatments. Collecting social security number, date of admission, and date of treatment for every treatment session allows one to vary the level of analysis.
Ellen L. Kolodner and J M h e B. Novey FIGURE C
F M P L E S OF DATA
POR
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DEPARTREWl%L PLANNING AND RANAGEMENT
Patient Name
ADL Score
Zip code
Type of Treatment
Date of Birth
Treatment Minutes
Social Security Number
Test Scores
Date of Admission
Expected Discharge
Date of Referral Referring Individual Diagnosis
Date Referral to Home Care
Tenative DRG
Inpatient
Date Of Treatment
Outpatient
Cognitive Level
Supplies Used
The list of services developed by the AOTA as pan of the Product Output Reporting System (PORS) is one method of classification for department products.' However, in evaluating the PORS for departmental use, it is necessary to consider whether the definition of services is sufficiently precise to identify departmental outputs. The treatments provided within each class must represent similar levels of resource use (staff time and supplies). For example, teaching activities of daily living to physically disabled patients with psychiatric problems will require more staff time than teaching ADL skills to patients who have similar physical disabilities but no psychiatric problems. Data should be collected over successive periods of time. Profiling the casemix for the current year aids in understanding current workload; the same information collected over three years will be-
182
The Occuparional Therapy Managerk Survival Handbook
gin to indicate emerging trends. An illustration of the importance of time series data is provided in the Reports section of this article.
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Collection Methods A common misconception is that "anyone can collect data." Information which does not accurately reflect reality is frequently worse than no information as it causes one to believe that facts are known which really are not. Specific responsibilities and guidelines must be provided for the individuals who will capture the data. Individuals must also be trained in the definitions of data items in order to ensure the quality of the data. Despite the expense, periodic retraining is necessary. Where possible, the quality of the data should be verified by having a second individual collect previously collected items for a small number of records. By comparing the two sets of data the collection methods and definitions can be validated. The time and cost of data collection cannot be underestimated. Important information may be produced; but that information is not free. A clear process must identify the exact source of each item and assign responsibility for the recording of each data element. For example, should the patient be asked for the name of the referring physician, or should this information be obtained from a referral slip or the chart? It is worthwhile to determine whether any of the data needed by the department are already collected by the hospital. It may be possible to access and merge it with additional items collected by the department.' Managers may find, however, that the information collected by hospital management information systems is not adequate for departmental analysis. Data required for department management is often not collected or the data is not disaggregated to the department level.
Tools Management information of the 80s is most easily collected by computer. The capacity of the computer will be determined by the software selected and the size of the department. Software often controls the size and brand of computer as well as the format in
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Ellen L Kolodner and Judyhe B. Novey
183
which the data is collected.'s8 Wamboldt reviews a variety of software which may be applicable to administrative functions in an occupational therapy de~artment.~ A database management program will provide the greatest flexibility in generating reports. A spreadsheet program is useful for budgeting and foreca~ting.'~ Before making any decision on hardware, select software that will allow information to be collected in the needed format.'' Seeing is believing; set up a small database after deciding on the items to be collected. Ask the vendor to enter the data and write a sample report. Spend the time to watch the salespersons as she enters the data and generates the report. If she has difficulty, so will department personnel. If the vendor does not take the time to demonstrate the capabilities of the hardware and software, the system might not perform as represented. This attitude may also reflect the level of support that will be provided after purchasing the system. Crist and Davis suggest that local user groups can provide an alternative source of support.
Reports
'
The data must be organized to allow the manager to accurately describe the work the department produces. The computer allows one to search out like entries and look for additional similarities or explanations for differences. Figure D is a portion of a sample database with a few variables of interest. This structure represents the simplest relationship for data. There are more complex relationships; however, this structure is likely to meet the needs of most departments. Figure E is a sample report generated from this type of database. It shows the average number of days that each referring physician takes to make a referral. As shown, these data indicate that one physician takes a longer time to make referrals than other physicians. When the data are collected on a patient-specific basis it is possible to further explore differences. The report in Figure F shows that physician MD4 does not refer all patients later than his/ her colleagues. Rather, he/she specifically takes longer to refer cardiac patients. Armed with this information, it is possible to approach the physician to determine whether there is an administrative
184
The Occupatwml Therapy Manager's Survival Handbook PIGORE D
SAMPLE DATABASE
LlMB
PAYSICIAN
DATE OP
DATE OP
COPE
MIMISSIQtl
BEPBPM!L
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
SMITH JONES BROWN ROBERTS PETERS 0 0
problem in obtaining referrals for these patients, or whether the physician is unaware of the types of treatment occupational therapy can offer in the early stages of illness. Also, the data allow a manager to effectively demonstrate the variation in behavior between this physician and hisher colleagues. Reports can also be generated which formally identify hidden staff specializations. Many small occupational therapy departments in community hospitals do not segregate staff workloads according to specialization. Identification of emerging specializations developed through on-the-job experience can increase efficiency and quality of care. After determining the time and skill levels necessary to treat each diagnostic class of patients, staff can be redeployed to ensure maximum productivity. Figure G displays a report organized according to the types of patients each therapist is treating. It indicates that Therapist 1 appears to be developing a specialty in cardiac care while Therapist 3 may be developing expertise in arthritis. This knowledge can assist the department manager in determining patient assignment policies and procedures as well as allocation of continuing education funds. As a final example consider the following problem. Over a pe-
Ellen L.
Kolodner and Judythe B. Nowy
AVERAGE DAYS POR REFERRAL BY PBYSICIAN
TO OCCUPATIONAL THERAPY DEPARTMENT
AVERAGE NUMBER OF DAYS
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PBPSICIAN CODE
AVERAGE DAYS TO aPERRAL BY PRYSICIAN AND BY DIAGNOSIS
DIAGNOSIS
R.A.
--------PEYS-CODE
MD1
1.2
MD2
1.9
MD3
2.1
MD4
2.1
ND5
1.7
0
0
0
0
0
0
CVA
CARDIAC
...
186
The Occrcpatb~lThempy Mamger's Survivol Handbook FIGURE G
PERCEUT OF DIAGNOSES TREATED BY EACH TBERPAIST
TEERAPIW 1
TEERAPIST 2
TEERAPIST 3
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
DIAGNOSIS
R.A.
3%
40%
CVA
10%
36%
CARDIAC
75%
12%
57%
riod of time, a manager may find that the number of treatments for the department is static but a waiting list has developed. Each therapist is fully occupied. An initial interpretation might be that staff have become less efficient in their use of time. However, if the diagnostic or functional mix has changed to a more intense case mix, staff therapists may indeed be spending more time per treatment. Without the data reflecting this change, a manager might identify an erroneous cause for the problem (declining productivity) and implement the wrong solution. Data describing the diagnoses and functional levels of patients collected over time would allow the manager to identify the actual cause of the problem ( a more intense case mix) and factually demonstrate the need for additional staff. Some examples of data needed for departmental planning and management are displayed in Figure C.
SUMMARY The changing health care environment demands hard decisions concerning the use of both human and nonhuman resources. The validity of occupational therapy services are being challenged.
Ellen L Kolodner and J+he
B. Novq
187
Quantifiable data are essential for objective evaluation of the current status of a department. Subjective impressions often do not survive rigorous analysis. Successful managers will use data to forecast, plan, and initiate changes.
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REFERENCES 1. Wright M: A data management tool for reporting produaivity. Con J Occup %r, 50(3): 73-76, 1983 2. Butler PW: Medicam payment: Per case management-budgeting. specinl report 8. Chicago, American Hospital Association. 1983 Diognosir-Related Groups-Second Revirion: Dejinirions Mon3. ual, New Haven: Health Systems International, 1985 4. Smith RO: Computers and the occupational therapy administrator- 1985. Occup 7ker Heolth Core, 3(3/4): 99-113, 1986 5. : AOTA Product Output Reporting System, w e r e m e M o W l of the official Documents of AOTA. Inc.. Rockville. Maryland: AOTA. 1986 6. Smith. 1986 7. Crist. PAH.Davis, CG: Evaluation of software and hardware for rehabilitation and manag&nent: Beyond salesmen's bluff. Occup Ther Heolfh Core.
.
3(3/4): . . .29-32, 1986 8. Kaplan SH: Microcomputers; an introduction for occupational therapists. Occup Ther Heolth Core, 3(3/4): 11-26 1986 9. Wamboldt J: Using the Apple Ile computer as an administrative tool in and occupational therapy department. Occup 7her Heolth Core. 3(3/4): 117-132, 1986 10. Smith. 1986 11. Kaplan. 1986 12. Crist and Davis, 1986
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Ellen L. Kolodner, MSS, OTRIL, FAOTA Judythe B. Novey, MUP
SUMMARY. Changing and often conflicting incentives in the current reimbursement environment require occupational therapy managers to develop adaptive administrative strategies. They must maximize productiwty, create budgets, and develop marketing strategies. Accurate information provides the key to success in these tasks. This paper discusses the role of management information systems in the administration of an occupational therapy department and some of the essential factors in irn lementation. Creation of a database description, establishment o a process for collecting information and report development are explored.
t"
Survival is the struggle for existence. Survival for occupational therapy departments Gll result from predicting, planning-and responding proactively to environmental demands. Infonation is a necessary prerequisite to strategic planning. The occupational therapy manager can use data to define and measure the department output. Data which are crucial to this analysis include demographic and diagnostic information, levels of patient impairment, the patients' insurer, staff productivity, and departmental costs. Using this data, a manager can compare and Ellen L. Kolodner is Assistant Professor and Fieldwork Coordinator, Department of Occupational Therapy, Thomas Jefferson University. College of Allied Health Services, Philadelphia, PA. Judythe B. Novey is Assistant District Coordinator. Medical District Four. Veterans Administration. Philadelphia. PA. This article appears jointly in The Occupational Therapy Managers' Survival Handbmk (The Haworth Press, Inc., 1988) and in Occupational ,Therapy in Health Cam. Volume 5, Number 1 (1988). O 1988 by The Hawonh Press, Inc. All rights reserved.
I75
176
The & C ~ ~ I ? W Therapy M~ Mmger's Survival Handbook
contrast the characteristics of patients presently served by the department with those of patients being sewed by other departments in the hospital, in other facilities and in the community. Analysis of the resulting information forms the basis for development of measurable and attainable plans and objectives.
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
TYPES AND USES OF DATA
Management information enables growth and change by design rather than reaction. Accurate data allow a manager to develop plans which address staff deployment, service utilization, marketing, and program strengths and weaknesses. Managers are compelled to demonstrate that occupational therapy contributes to quality of care and to the improvement of health and function. Accessible data enable a manager to respond to inquiries and opportunities quickly, and with confidence. The precise impact of new policies on the department can be determined and impressions can be substantiated by comparing data concerning the department, the hospital and the external environment. Detailed data can be used as an excellent communication tool. Audiences, whether physicians, administrators or the community, are more receptive to new ideas which are substantiated with statistics which reflect their particular interests. There are hvo major types of management information external to the department: environmental and facility level. Environmental information describes the external forces which impact on the hospital and the occupational therapy department. It includes demographic, economic, technological, political and regulatory data. This information can be obtained from census data, Chamber of Commerce reports, etc. Specific examples of environmental information and sources are listed in Figure A. Facility-level data summarize the activities of the hospital such as patient demographics, costs, utilization and productivity. A demographic and diagnostic profile of the department can be used to delineate the similarities and differences between the department and hospital patient mix. Wright identifies the need for diagnostic information in cost and productivity analyses.' Differences between the department and the hospital may represent special populations
Ellen L Kolodner o d Judyhe B. Nowy
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
TXPES
OP DATA o hospital strategic plan o l o c a l demographic d a t a i n c l u d i n g a g e and income d i s t r i b u t i o n s and a g e - s p e c i f i c p o p ~ l a t l o n projections. o u t i l i z a t i o n d a t a lover time, i f p o s s i b l e ) f o r h o s p i t a l s i n t h e community. length of stay a d m i s s i o n s by t y p e home c a r e v i s i t s outpatient v i s i t s number of p h y s i c i a n s by t y p e o t y p e and l o c a t i o n o f new t e c h n o l o g y o r e g u l a t o r y and payment d i r e c t i o n s . p o l i c i e s a f f e c t i n g reimbursement of O.T. services c o s t and u t i l i z a t i o n i n c e n t i v e s i n h e r e n t i n payment s y s t e m s
--
-
o local hospital association o l o c a l p l a n n i n g commission a n d w a t e r and transportation a ut hori t i e s o census bureau o S t a t e population agency o s t a t e h e a l t h planning agency o l o c a l h e a l t h systems agency a local business c o a l i t i o n s f o r health care o A M A F e d e r a l Report o c o n s u l t a t i o n s with: o t h e r O.T. managers who h a v e i n i t i a t e d innovative program o t h e r department heads i n t h e h o s p i t a l hospital administrators s t a f f and a t t e n d i n g p h y s i c i a n s department s t a f f financial officers consumer g r o u p s
-
-
or diagnostic classes that the staff are treating; or, they may indicate that an occupational therapy program is not keeping pace with environmental changes. Clinical distinctions made when treating patients need to be incorporated into data collection so that activities can be described in terminology which is both clinically meaningful to physicians and fiscally meaningful to administrators. Workload should be represented as specific types of patients treated such as the number of patients with joint replacement, stroke, or arthritis. Each of these -
-
~
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
1 78
The Occuplrtionitl Therapy Mawger's Survival Handbook
patient types will consume different resources (both staff time and supplies). If one is aware of the time and costs associated with specific department outputs (i.e., types of treatments), observed utilization trends can be used to project staffing needs by specialization and identify budget requirements. Evaluation of efficiency and external market penetration can be achieved through analysis of referral sources, elapsed time between admission and referral to occupational therapy, and the response time of staff. The manager will be able to answer such questions as: Is the department getting all possible referrals? Are they timely? Was the response time appropriate? AN EXAMPLE: USING DATA T O DETERMINE HOW A DEPARTMENT DIEFERS FROM THE HOSPITAL
Consider the following scenario. A department manager experiences a shortage of staff. Additional staff can be justified by comparing department level to facility level data. Utilization experienced or anticipated by the hospital must be disaggregated so that those activities which actually impact the occupational therapy department can be accurately identified and measured. Figure B displays part of the current workload of a theoretical hospital. Note the variation in workload across departments.' The figure shows the occupational therapy department currently attributes 11.1%of its workload to DRG 209-Major Joint Procedures (560 treatments).' Consider the effect of the addition of another oethopedic surgeon to the hospital staff. If he/she performs 280 additional major joint procedures, hospital admissions will increase 3.6%. If the 280 additional procedures result in 840 additional occupational therapy treatments (an average of 3 treatments per admission), DRG 209 will represent 24.8% of the department's treatments and an overall increase of departmental workload of 17.5% rather than the 3.6% increase that the additional procedures will have on total hospital admissions. Therefore, if the manager were to estimate the impact on the occupational therapy department based on the effect on total hospital admissions, the projected workload would be grossly underesti-
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
P A R T I A L D I S T R I B U T I O N OP WOFXLOAD BY DRG
MEDICINE: p a t i e n t Days Admissions
I
I
I
1
SURGERY: P a t i e n t Daya Admissions PSYCHIATRY: Patient Days Admissions OCCUPATIONAL THERAPY: Treatments
I 4.8B0 1 2 8 0 ...............................................
5.8
180
The Occupatwnal Themm Manager's Survival Handbook
mated. An increase in occupational therapy staff to provide 3.6% more treatments would only meet about one-fifth of the need generated by the additional procedures. Thus it can be seen that knowledge of the specific diagnostic mix will allow a manager to analyze the effect of a policy or program on the department. Such a report substantiates the request for additional staff.
Occup Ther Health Downloaded from informahealthcare.com by UB Kiel on 12/24/14 For personal use only.
IMPLEMENTING A DATA COLLECTION SYSTEM Managers must analyze their information needs as a first step in identifying data elements. Collecting accurate data requires a plan of action. A plan of action will: (1) determine the purposes for which the data will be used; (2) identify and define the data elements to be captured; (3) specij. the collection process; and (4) outline reports to be generated. There are a variety of reasons to collect data.' A number of these were described earlier. A data collection system should be designed to support the individual needs of the department. See Figure C. Database Definition A database definition is a list of the specific elements you want to collect. First, general categories of information such as patient characteristics, workload, and costs should be identified. These categories will parallel your purposes. Specific data items then follow naturally. Each item should be clearly defined. For example, if the department wants to collect information on diagnosis, the definition must indicate whether the data is to reflect the diagnosis the patient was admitted for or the diagnosis that the occupational therapist is currently treating. They may be different. The department may want or need both. The most critical elements are those which uniquely identify the unit of output. Output can be specified as a series of treatments for one admission, an episode of illness, or individual treatments. Collecting social security number, date of admission, and date of treatment for every treatment session allows one to vary the level of analysis.
Ellen L. Kolodner and J M h e B. Novey FIGURE C
F M P L E S OF DATA
POR
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DEPARTREWl%L PLANNING AND RANAGEMENT
Patient Name
ADL Score
Zip code
Type of Treatment
Date of Birth
Treatment Minutes
Social Security Number
Test Scores
Date of Admission
Expected Discharge
Date of Referral Referring Individual Diagnosis
Date Referral to Home Care
Tenative DRG
Inpatient
Date Of Treatment
Outpatient
Cognitive Level
Supplies Used
The list of services developed by the AOTA as pan of the Product Output Reporting System (PORS) is one method of classification for department products.' However, in evaluating the PORS for departmental use, it is necessary to consider whether the definition of services is sufficiently precise to identify departmental outputs. The treatments provided within each class must represent similar levels of resource use (staff time and supplies). For example, teaching activities of daily living to physically disabled patients with psychiatric problems will require more staff time than teaching ADL skills to patients who have similar physical disabilities but no psychiatric problems. Data should be collected over successive periods of time. Profiling the casemix for the current year aids in understanding current workload; the same information collected over three years will be-
182
The Occuparional Therapy Managerk Survival Handbook
gin to indicate emerging trends. An illustration of the importance of time series data is provided in the Reports section of this article.
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Collection Methods A common misconception is that "anyone can collect data." Information which does not accurately reflect reality is frequently worse than no information as it causes one to believe that facts are known which really are not. Specific responsibilities and guidelines must be provided for the individuals who will capture the data. Individuals must also be trained in the definitions of data items in order to ensure the quality of the data. Despite the expense, periodic retraining is necessary. Where possible, the quality of the data should be verified by having a second individual collect previously collected items for a small number of records. By comparing the two sets of data the collection methods and definitions can be validated. The time and cost of data collection cannot be underestimated. Important information may be produced; but that information is not free. A clear process must identify the exact source of each item and assign responsibility for the recording of each data element. For example, should the patient be asked for the name of the referring physician, or should this information be obtained from a referral slip or the chart? It is worthwhile to determine whether any of the data needed by the department are already collected by the hospital. It may be possible to access and merge it with additional items collected by the department.' Managers may find, however, that the information collected by hospital management information systems is not adequate for departmental analysis. Data required for department management is often not collected or the data is not disaggregated to the department level.
Tools Management information of the 80s is most easily collected by computer. The capacity of the computer will be determined by the software selected and the size of the department. Software often controls the size and brand of computer as well as the format in
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which the data is collected.'s8 Wamboldt reviews a variety of software which may be applicable to administrative functions in an occupational therapy de~artment.~ A database management program will provide the greatest flexibility in generating reports. A spreadsheet program is useful for budgeting and foreca~ting.'~ Before making any decision on hardware, select software that will allow information to be collected in the needed format.'' Seeing is believing; set up a small database after deciding on the items to be collected. Ask the vendor to enter the data and write a sample report. Spend the time to watch the salespersons as she enters the data and generates the report. If she has difficulty, so will department personnel. If the vendor does not take the time to demonstrate the capabilities of the hardware and software, the system might not perform as represented. This attitude may also reflect the level of support that will be provided after purchasing the system. Crist and Davis suggest that local user groups can provide an alternative source of support.
Reports
'
The data must be organized to allow the manager to accurately describe the work the department produces. The computer allows one to search out like entries and look for additional similarities or explanations for differences. Figure D is a portion of a sample database with a few variables of interest. This structure represents the simplest relationship for data. There are more complex relationships; however, this structure is likely to meet the needs of most departments. Figure E is a sample report generated from this type of database. It shows the average number of days that each referring physician takes to make a referral. As shown, these data indicate that one physician takes a longer time to make referrals than other physicians. When the data are collected on a patient-specific basis it is possible to further explore differences. The report in Figure F shows that physician MD4 does not refer all patients later than his/ her colleagues. Rather, he/she specifically takes longer to refer cardiac patients. Armed with this information, it is possible to approach the physician to determine whether there is an administrative
184
The Occupatwml Therapy Manager's Survival Handbook PIGORE D
SAMPLE DATABASE
LlMB
PAYSICIAN
DATE OP
DATE OP
COPE
MIMISSIQtl
BEPBPM!L
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SMITH JONES BROWN ROBERTS PETERS 0 0
problem in obtaining referrals for these patients, or whether the physician is unaware of the types of treatment occupational therapy can offer in the early stages of illness. Also, the data allow a manager to effectively demonstrate the variation in behavior between this physician and hisher colleagues. Reports can also be generated which formally identify hidden staff specializations. Many small occupational therapy departments in community hospitals do not segregate staff workloads according to specialization. Identification of emerging specializations developed through on-the-job experience can increase efficiency and quality of care. After determining the time and skill levels necessary to treat each diagnostic class of patients, staff can be redeployed to ensure maximum productivity. Figure G displays a report organized according to the types of patients each therapist is treating. It indicates that Therapist 1 appears to be developing a specialty in cardiac care while Therapist 3 may be developing expertise in arthritis. This knowledge can assist the department manager in determining patient assignment policies and procedures as well as allocation of continuing education funds. As a final example consider the following problem. Over a pe-
Ellen L.
Kolodner and Judythe B. Nowy
AVERAGE DAYS POR REFERRAL BY PBYSICIAN
TO OCCUPATIONAL THERAPY DEPARTMENT
AVERAGE NUMBER OF DAYS
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PBPSICIAN CODE
AVERAGE DAYS TO aPERRAL BY PRYSICIAN AND BY DIAGNOSIS
DIAGNOSIS
R.A.
--------PEYS-CODE
MD1
1.2
MD2
1.9
MD3
2.1
MD4
2.1
ND5
1.7
0
0
0
0
0
0
CVA
CARDIAC
...
186
The Occrcpatb~lThempy Mamger's Survivol Handbook FIGURE G
PERCEUT OF DIAGNOSES TREATED BY EACH TBERPAIST
TEERAPIW 1
TEERAPIST 2
TEERAPIST 3
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DIAGNOSIS
R.A.
3%
40%
CVA
10%
36%
CARDIAC
75%
12%
57%
riod of time, a manager may find that the number of treatments for the department is static but a waiting list has developed. Each therapist is fully occupied. An initial interpretation might be that staff have become less efficient in their use of time. However, if the diagnostic or functional mix has changed to a more intense case mix, staff therapists may indeed be spending more time per treatment. Without the data reflecting this change, a manager might identify an erroneous cause for the problem (declining productivity) and implement the wrong solution. Data describing the diagnoses and functional levels of patients collected over time would allow the manager to identify the actual cause of the problem ( a more intense case mix) and factually demonstrate the need for additional staff. Some examples of data needed for departmental planning and management are displayed in Figure C.
SUMMARY The changing health care environment demands hard decisions concerning the use of both human and nonhuman resources. The validity of occupational therapy services are being challenged.
Ellen L Kolodner and J+he
B. Novq
187
Quantifiable data are essential for objective evaluation of the current status of a department. Subjective impressions often do not survive rigorous analysis. Successful managers will use data to forecast, plan, and initiate changes.
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REFERENCES 1. Wright M: A data management tool for reporting produaivity. Con J Occup %r, 50(3): 73-76, 1983 2. Butler PW: Medicam payment: Per case management-budgeting. specinl report 8. Chicago, American Hospital Association. 1983 Diognosir-Related Groups-Second Revirion: Dejinirions Mon3. ual, New Haven: Health Systems International, 1985 4. Smith RO: Computers and the occupational therapy administrator- 1985. Occup 7ker Heolth Core, 3(3/4): 99-113, 1986 5. : AOTA Product Output Reporting System, w e r e m e M o W l of the official Documents of AOTA. Inc.. Rockville. Maryland: AOTA. 1986 6. Smith. 1986 7. Crist. PAH.Davis, CG: Evaluation of software and hardware for rehabilitation and manag&nent: Beyond salesmen's bluff. Occup Ther Heolfh Core.
.
3(3/4): . . .29-32, 1986 8. Kaplan SH: Microcomputers; an introduction for occupational therapists. Occup Ther Heolth Core, 3(3/4): 11-26 1986 9. Wamboldt J: Using the Apple Ile computer as an administrative tool in and occupational therapy department. Occup 7her Heolth Core. 3(3/4): 117-132, 1986 10. Smith. 1986 11. Kaplan. 1986 12. Crist and Davis, 1986
