Health system changes patient-focused plan
Health system changes patient-focused plan
There’s no cookie-cutter solution’
Sentara Health System in Norfolk, VA, spent seven years working to completely decentralize its admitting, registration and patient financial services as part of a program to achieve a "patient-focused hospital." Then it abruptly changed gears, reversing its plan to deploy multi-skilled administrative associates to all clinical operating centers, and taking a modified course that emphasizes central reporting instead.
Sentara officials realized in hindsight that completely eliminating any central component was a flawed concept that prevented the successful implementation of their original patient-focused model, explains Brenda Loper, CMPA, director of patient financial services. A major factor in the decision to keep the administrative associates in a centralized setting (with a few notable exceptions) were serious concerns about maintaining data integrity in an increasingly contentious compliance environment.
"We started recognizing in October or November [1996] that we were trying very hard to complete the deployment of the administrative associates, and we just couldn’t seem to make that final step," says Loper. "We learned there is no cookie-cutter solution. To say that everything needs to be centralized is just as wrong as saying that everything needs to be deployed."
Hospitals that successfully decentralize their admitting/business functions keep a core group of experts in a central office to monitor data quality, she says. "Somebody is needed to make sure all the insurance rules are being followed.
"We realized as we went along that we were organizationally naive in thinking we didn’t need a central QI function," she says. "When we moved the administrative associates to the operating centers, they reported to clinical managers, and that was unfair to [the managers]. Their experience was not in the administrative chain, and we threw a bunch of employees at them that needed a lot of hands-on supervision, where, when questions come up, they need to be answered right away."
For the past couple of years, as part of its implementation of patient-focused care, Sentara Health System has aggregated its clinical services around particular patient populations. The plan for complete deployment, which did take place at one of the health system’s hospitals, included moving all the traditional admitting office functions to each of five operating centers: medicine/ mental health, surgical, women’s health, cardiovascular/transplant and cancer/ambulatory.
Functions included in the deployment were preregistration, admitting, assembly and analysis of charts, handling valuables, insurance verification, financial counseling and follow-up, and cashiering. In addition, it was planned that the administrative associates would perform the duties of a unit secretary, such as typing notes at meetings, providing reception services, answering the telephone, and paging nurses.
The type of patient being served often determines the best way to provide services, Loper says, noting that obstetric (OB) patients, for example, are an ideal population to serve on-site. Traditionally OB accounts are some of the hardest to collect because a patient can enter and leave the hospital before the necessary information is gathered or insurance cards signed, she points out.
"When we deployed those services to the [women’s health] operating center, that turned around." Loper says.
Some notable exceptions
At Norfolk General, the health system’s largest hospital, a mini medical records department was established in the women’s health operating center, she says. "We got a lot of benefits from doing that. [Traditionally] the charts we had the most difficulty getting completed were those of OB patients. These patients are in and out so quickly that it’s very difficult to get residents, interns, and doctors to come down to the centralized medical records department. It was beneficial to have the record room right outside labor and delivery."
Ultimately, however, physicians decided they preferred having all the records in one place, so the satellite area now is used only for gathering information for current records.
The original reengineering plan called for "no central admitting and minimal [centralized] medical records, but you can’t make centralized files go away," Loper says. "If you have technology and electronic capability you can do it, but not if you live in a paper world. We don’t have an automated medical record yet."
On May 12, Sentera did an about-face and officially changed its management structure, implementing what it calls "administrative associate management consolidation." Under the revised plan, "We’ve looked at what makes sense," Loper says. "We had to make rational decisions as to how to meet patient needs."
Another of the concerns leading to that change in structure was that administrative associates weren’t receiving enough attention. The original administrative associates those who had work experience before the deployment were very knowledgeable about the various functions. But with 200 administrative associates spread over three hospitals, it was extremely difficult to give new hires the education they needed in the different areas, Loper points out.
The experience also validated, for example, that not everybody can ask for money, she adds. "It is very difficult for some people to talk to the family about payments." For that reason, financial counseling, although still a part of the administrative associate "job family," now is one of a few skills that is performed by employees who specialize in that function.
The same is true of insurance verification. The medical records duties, meanwhile, have been completely removed from the administrative associate job description, and the employees who perform them report to the director of medical records.
Now Sentara has two kinds of administrative associates those who perform the traditional admitting/business functions, and those who support the needs of the operating center’s clinical managers. The former work in a centralized setting, except for a portion who remain on-site at the women’s health operating center and at the cancer operating center.
Location is the big reason for the on-site administrative associates being placed at the cancer operating center, which is a considerable distance from the main admitting area, Loper says. Also, because cancer patients are an easily identifiable part of the population that interact with a small portion of the medical staff, the hospital can better provide them with specialized service, she adds.
The key difference now is that even though these administrative associates work at the operating centers, they report to central management. However, they do so with the understanding that they are still "part of the team" at the operating center, Loper emphasizes. "We are not ever going back to the old world where it’s not my job.’"
Although the need for an audit/review component was a key reason for reversing the move to complete decentralization, it’s not the only one, she points out. A decentralized environment becomes more and more difficult to support, Loper says, because of such factors as high staff turnover. "You need resources and trained staff and stability in staff to gradually build up the skill set."
But when people say to her, "You’re giving up on a patient-focused hospital," she disagrees. "We’re working to do what best meets the needs of a patient, whatever’s the best way to do it, whether something is centralized or something else is not."
"I’ve found that this thing we used to call re-engineering process design, benchmarking is not a destination, it is a journey. You are continually revising it."
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