Case Study Challenge

South West London Acute Commissioning Unit (SWL ACU) found that the activity area of Unwell Babies within an NHS Foundation Trust was over-performing against plan. maxwell stanley were appointed by the ACU to further investigate this over-performance.

Case Study Approach

Our first action was to validate the Commissioner’s over-performance concern through analysis of the SUS activity dataset.

Our Payment by Results (PbR) experts applied HRG trend analysis to isolate shifts in the clinical coding of Unwell Babies activity, identifying specific procedure and diagnosis codes to be challenged.

Our qualified Clinical Coding Auditors then manually reviewed individual episodes containing the challenged codes. Accounting for all patient admission details (for example, length of stay), emerging trends were identified to offer explanations for inconsistencies in the coding of clinical activity and explain the over-performance.

Data analysis and review results were extrapolated and interpreted to propose recommendations for corrections or resolutions to the issues resulting in the over-performance and potential activity and financial implications for the contract baseline were calculated.

Case Study Outcome

A succinct Challenge Rationale Report was produced containing:

  • Data analysis
  • Auditor review results
  • Supported hypotheses
  • In-year financial and activity implications for contract baseline

Our findings and hypotheses supported the negotiation of an in-year financial settlement as well as an agreement to revise the application of the Trust’s clinical coding in this particular activity area.