Should the standardization engine be slowed when hospitals merge?
Should the standardization engine be slowed when hospitals merge?
Gutting your operations isn’t always the best way, experts say
When hospital mergers occur, it seems normal to crank up the standardization engine as soon as possible. Management then works furiously to eliminate different ways of doing things at the various facilities and to achieve uniformity in everything from forms to dress codes.
"Is there another way to go?" asks Beth Ingram, CHAM, systems consultant for Superior Consultant Company in New Orleans and a former access manager. "It appears there is some evidence that standardization may not always be the most cost-effective route.
"What I see happening in some of the mergers that have occurred is that millions of dollars are spent trying to make everything the same," she explains. "They want the same information systems, the same decision-support system, the same clinical system, so they can roll it all up at the corporate level." That means changing forms, changing processes, and changing policy and procedure, she points out. "Plus, there’s the time lost while people get oriented to a new system that may not work for them in some cases."
In some large corporations, the financial impact of such a wholesale overhaul is significant enough that they haven’t been successful, Ingram says. "There’s no direct analogy, but the two things do seem to go together."An alternative, she says, is to consider reconciling disparate information coming from different places through the use of modern technology. "With all the decision support tools out there, the merger may be better served by pulling data together in a data warehouse as opposed to totally disrupting everything. You definitely want to go in and analyze, but I’m not sure ripping the guts out of an organization is the way to go."
Access managers and directors polled by Hospital Access Management about standardization expressed varying opinions based on their experience with multihospital mergers.
"Standardization is just part of the merger," says Barbara Wegner, CHAM, regional director for access services at Providence Health System in Portland, OR. "It was complete chaos, a real mess, and everybody is still trying to get it all standardized," says Wegner, who was involved in bringing together three hospitals and assorted ancillary facilities in a process that began five years ago. "We have struggled and struggled to get things standardized, but how you could function without [standardization] and be successful, I would not know."
Although she concedes that standardizing policies and procedures, consents, and releases at several facilities is an overwhelming and expensive task, she says not doing so would cost even more. "If you don’t standardize all forms across the continuum, think of all the inventory in materials management. Think of the nightmare of auditing different forms, of running into those nightmares every day."
Still, exceptions to the standardization rule have been made, she says, when standardizing would upset the way a facility does business or cause a big operations problem. She cites one example that remains unresolved at her health system: "One of our facilities had a system whereby when outpatient day-surgery patients came in for a procedure, the computer did not show those patients as being in a bed. You could see [in the computer] that they were there, but they wouldn’t be in a bed."
Another hospital’s computer system, however, did show day-surgery patients in beds, Wegner says. "It caused problems for our cost-accounting system. It was impossible to figure out what kind of business we were doing, because we weren’t counting them the same way."
Yet to make a change at either facility would cause a serious operations problem, she says, because of the accompanying nursing and documentation changes. Such a change would be particularly disruptive at the hospital where day- surgery patients were not shown to be in beds, she explains, because of the work that had to be done in putting a chart together.
"Going the other way didn’t work for the other facility — where they do put patients in bed’ — because the day-surgery, surgical prep, and ambulatory area are all in one place," she adds. "At the facility where they don’t put day-surgery patients in bed,’ those areas are in three different locations. We backed off that [problem] about three years ago, but we need to tackle it again. Our goal is to standardize as much as we possibly can."
Customers’ needs can be different
There is another way to handle a merger, contends Rita Borowski, CHAM, patient access services director for Milwaukee-based Aurora Health Care’s metro region. While some "easy hits" do exist for standardization, such as identification bracelets and service contracts resulting in immediate cost savings, Borowski says other things definitely should not be standardized.
"What you have to weigh is the cultures of the various facilities as they respond to their customer base," she says. "Even within our organization, there are rural, community, and urban settings. How facilities respond to customers and their needs can be very different."
Further, the different insurance types dominant in different settings play a role, Borowski adds. "What the major [insurance] players are may deem differences in procedures. At our urban site, we have 24-hour-a-day financial counseling coverage. At another site in the community, we have financial counseling during regular business hours. There’s no reason to change that — it’s distinctly relative to the customer base [the facility] serves."
On the other hand, standardizing dress codes at the facilities was the right thing to do for good customer service, she says. "We wanted all the customers of the Aurora organization to realize that no matter where they go, those in navy blue are the ones who can help them."
Borowski standardized job descriptions for access services personnel but rewrote them to be general enough for use among facilities. "What they perform within those job descriptions and titles varies across the sites."
Also, some departments use labels, while others use embossers for identifying items in the paper flow process, she adds. "It was working fine, so why change it? These are not things you should worry about. There’s nothing to be gained by standardizing them."
There is a huge cost involved in bringing disparate facilities together, and it’s likely to be a make-or-break factor for some organizations, notes Charlene Overfield, RN, CHAM, a consultant with Gustafson & Associates Inc. in Port Washington, WI. "It’s not always healthy that each time you merge you have to come up with a new system," the former access manager says. "It has caused facilities problems when they’ve thrown out something that worked for them and replaced it with something that’s hard to do. I’ve seen hospitals that really had to struggle."
But like Wegner, Overfield sees standardization as an inevitable part of the process. "It’s expensive to do it, but there’s no way of knowing if you’re productive if there are different reporting mechanisms for different facilities."
And it’s not just changing computer systems, she points out. Standardization also is being brought into a regional kind of philosophy: The blow can be softened, she suggests, if changes are made incrementally.
Overfield cites one hospital that, because of a merger, was slated to have its billing handled by a regional business office. "But once [management] came in, they changed the computer system but left the business office intact," she says. "They’ve taken it step by step, first looking at processes and then putting them on [the same computer system]. Down the way, they will be under a regional business office."
Similarly, that hospital’s admitting department remains, for the time being, under the patient accounting director. Eventually it will be under a regional access manager, she adds. "Maybe it’s best if you don’t just go in and immediately change things. We’ve all been a customer of a merger, and for whatever reason, we think we’ll lose the personal touch when a large system comes in and takes over a small one. That’s another reason to take it slow."
Hospitals involved in a merger have reasons for wanting to remain different, Overfield says, while struggling to see how they compare with each other. Like Ingram, she sees the feasibility of a common reporting mechanism that can make sense of disparate data. "If hospitals with different computer systems can feed raw data into [a decision-support system], they might be able to get out the same information."
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