Health Information Management

How one HIM director turned his department around-and saved big bucks in the process

JustCoding News: Inpatient, January 4, 2012

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by Jim Brown, FHFMA, RHIA, CCS

Jefferson Regional Medical Center (JRMC), a 471-bed nonprofit hospital located in Pine Bluff, AR, is the fourth largest medical center in the state and serves 11 counties in south Arkansas. When I started working there in early November 2010, I quickly realized we had a number of opportunities to improve our health information management (HIM) operations and efficiencies.

Many of our issues were operational; some were just matters of perception. Operational issues included dysfunctional processes and work flows, problems with productivity measurements and tracking, and customer service issues, just to name a few. Perception issues included lack of confidence in staff qualifications and quality assurance (QA) processes.

Luckily, I also had two extremely knowledgeable managers in the department with many years of in-house experience. Eventually I ended up promoting both of them. We could not have achieved the results to date without a team effort.

The issues

Our top 10 issues to resolve were as follows:

  • Overstaffing and excessive overtime hours
  • Not having the right mix of skilled workers
  • High turnover of skilled coders
  • Release of information (ROI) complaints
  • High discharge not final billed (DNFB), averaging more than $4.5 million at the end of each week
  • Excessive purchased services, including outsourced contract coding
  • Inefficient and outdated work flows
  • Outdated department policies and procedures
  • Non-timely responses to business office inquiries (Staff members often took more than two weeks to respond.)
  • Inadequate physician documentation and high incompletion of delinquent records

The solutions

I quickly learned that we had more than enough staff; we simply didn't have the right kind of skilled mix. I also found that a number of medical record QA functions were redundant.

To address these problems, I began to rewrite job descriptions and meet individually with most of the staff members. As I did, I asked them to step up their game—improve their productivity. These meetings were structured as discussions to allow both parties to give feedback. I felt that if I accepted and implemented staff members' suggestions as well, they would hold up their end of the bargain without needing to be forced.

For the most part, this approach worked very well. In the process, though, we identified some lower performers that were not going to make it. I believe in working with folks and letting them know my expectations; however, if they still don't get it, it's time to let them go. Fortunately, I had great support from my boss. In my experience, many managers will simply accept poor performance—especially if they walk into a new position when the employee has been there for several years—because it's easier to tolerate the problems than to retrain and hold folks accountable. However, my past for-profit experience has taught me that this is neither feasible nor acceptable. Plus, hard workers may start to develop a negative attitude if they see others underperforming.

Other key aspects of our department turnaround included:

  • Tracking and reporting productivity standards. For example, we created a war board for scanning personnel to track their daily status. We also tracked daily productivity for coders and used this information to eliminate barriers to meeting goals.
  • Cross-training staff. For instance, we cross-trained medical transcriptionists to help with coding. Since they already had knowledge of medical terminology, anatomy, and physiology, this was a relatively easy transition. We also cross-trained discharge analysts to help out with incomplete records—another easy crossover since they were the ones entering the deficiencies. In addition, prep and assembly area staff members were cross-trained to perform clerical work such as distributing physician copies, covering the front desk and ROI, as well as pulling lists in the Incomplete area.
  • Creating a career ladder. This was done to prevent staff members feeling like they were in a dead-end job. The career ladder offered opportunities for selected clerical staff to dip their toe into coding through further education in medical terminology and side-by-side training with more experienced coders. So far this has produced huge productivity benefits as well as improved morale and loyalty.

The results

Our work had excellent results. Consider the following:

  • We reduced staffing by 7.5 full-time equivalents and reduced overtime hours from more than 150 hours per month to less than 15.
  • The establishment of career ladders allowed several folks to shift from their previous clerical positions (eliminated as a result of improved work flows) into coding. This included a clear path to achieve coding certification within 12–18 months while being productive and gaining actual coding experience. This move will also help us prepare for the coming of ICD-10-CM/PCS.
  • We eliminated coder turnover. I continue to spend a lot of time making sure coders are happy and that they get the recognition they deserve as well as appropriate compensation for a job well done.
  • We reduced ROI turnaround times from 25 days to less than seven. This was done by eliminating unnecessary calls from physicians' offices and improving methods for locating paper records. Phone calls from physicians' offices have dropped by 70% because the offices have been educated on how to independently access the information they need via our EMR.
  • Our DNFB has gone from more than $4.5 million at the end of the week to less than $1 million. The number of accounts uncoded after four days has dropped by 350%.
  • We reduced purchased services by $75K through elimination of coding outsourcing.
  • We addressed and improved work flows in ROI, scanning, coding, chart deficiency, and incomplete charts, allowing us to reduce and realign staff.
  • We reviewed and updated our policies with an eye toward adapting to an EMR environment vs. a paper world. The policies are undergoing final critique and will then be posted on our intranet.
  • We now respond to business office (i.e., patient account) requests within three business days. Seventy-five percent are handled within one business day.
  • We worked with the quality department to improve our documentation. We also worked with the medical staff office to push for consistent suspension of physicians who do not complete documentation in a timely manner.

Overall we were able to reduce department expenses and come in 9.5% ($149K) under budget for the end of fiscal year (FY) 2011. Meanwhile, we greatly improved our services to all of our customers, both internal and external. Currently we are on track to reduce expenses by 29% ($400K) since FY 2010.

Editor’s note: Brown is JRMC's director of medical records. This article was originally published in the December issue of Medical Records Briefing. E-mail your questions to Senior Managing Editor Andrea Kraynak, CPC, at akraynak@hcpro.com.



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