Patients monitored on-line as they flow’ from registration to service area
Presented with the opportunity to revamp outpatient registration in conjunction with the opening of a beautiful new facility, Parrish Medical Center patient registration manager Linda Lilleboe, RN, MSN, and business office director Christine Rich MHA, faced more than the usual challenges.
Whatever process they devised to reduce wait times and streamline the flow of patients from registration to the laboratory, or to radiology, or to preadmission testing, also had to fit the architect’s vision: one large atrium — four stories high with a waterfall — where the waiting areas for registration and ancillary departments were combined.
Adding to their mission, was that the CEO of the Titusville, FL-based hospital wanted to show patients something they hadn’t seen before, says Rich. "He wanted us to be on the cutting edge. He said he didn’t want to bring an old play into a new theater.’"
Then, of course, there was the need to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) privacy standard and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).
Looking for a way to coordinate registration, locate patients when it was time for them to be seen, and keep track of who needed to go where while protecting patient confidentiality was a difficult task, Lilleboe notes. "We looked everywhere for an outpatient tracking system." What they found, she adds, is that tracking systems typically are designed for the emergency department (ED).
While talking with an independent consultant working with her on some business office projects, Rich says, she brought up the outpatient flow dilemma. "I knew he developed software, so I challenged him with this." The consultant, whose Ormond Beach, FL-based company is called Medicon Consulting, ultimately provided the technology expertise that complemented Rich and Lilleboe’s patient access knowledge.
"We walked around the construction workers, [exploring] every scenario we could think of," adds Lilleboe. Serious brainstorming began in spring 2002; the hospital moved into its new facility in November 2002; and the tracking product they developed was implemented during in around the next 30 days, she says. "We were up and running by the middle of December 2002," Lilleboe says, noting that improvements still are ongoing.
To begin the process, she explains, patients come to a common sign-in area, where they are greeted by a cashier/clerk, who, using the tracking system, can access all of the scheduled procedures for that day. If patients are scheduled, the clerk simply checks them in, Lilleboe continues. "[Patients] are listed alphabetically, also by procedure type and time." Typically, the clerk will use the patient’s name, clicking on it to get to a pop-up menu that prompts some questions: "Is the patient here for a regular outpatient visit, for preadmission testing, or as a direct admit? Does the patient have an order from a physician?"
Paging is automated
If the answer to the last question is yes, the system prompts the clerk to give the patient a pager, which has a specific number, she says. When it is that patient’s turn to be seen, the pager vibrates and lights up.
What makes the paging process different from that at most other hospitals, Rich points out, is that a registrar is being alerted that the patient with that pager number is next on her list. "A lot of hospitals use pagers, but we’ve automated the pager system to go along with the tracking system. It’s all in the computer, so there are no logs anymore, which makes us more HIPAA- and JCAHO-compliant."
Rather than the paged patient having to report back to the clerk and be directed to the next step, he or she is greeted immediately by the next available registrar and escorted to a private registration room, Lilleboe says.
With walk-in patients, the clerk takes the person’s name off the physician order and types it into the system, prompting the same series of questions, she notes.
Registrars, leads and coordinators all have views of what’s happening with the outpatient flow, Lilleboe adds. (See sample screen.) At her facility, she explains, the job of the coordinator — who works first shift — is to monitor the tracking system and move staff to areas where they are needed, as well as approving overtime and doing staff scheduling. The lead comes in at 11 a.m., takes over the tracking review, and "drives the train," Lilleboe adds. "She monitors the tracking system, takes all calls, gets direct-admit bed assignments, monitors and diverts other staff, organizes the pre-registration process for the next day’s patients, and makes sure patients move through the tracking system on a timely basis."
"The tracking system," she notes, "will show everyone who is in check-in status, their name, and what time they checked in. For scheduled patients, it shows the time they’re scheduled."
The system also indicates if a particular patient came in without a physician’s order. As soon as the clerk enters that information, "a coordinator in the back is calling the physician, looking for the [order], already ahead of the game," Lilleboe says.
The left side of the computer screen shows all of the patients who are checked in, filed by times. It also shows the actual appointment time, Lilleboe says. The right side of the screen shows all seven registration rooms and their status, she notes. "Registrars can look over and see where their next patient is. They take the mouse, click the name of the patient, highlight the name, click register,’ and the patient’s name will drop into their room."
Typically, five rooms are used for registration, while insurance verifiers work in rooms one and two, she notes, but the verifiers pitch in if needed. Because the computer recognizes each registrar’s sign-in and room number, Lilleboe adds, the highlighted patient’s buzzer begins to vibrate.
When the registrar has finished registering the patient, he or she clicks on the patient’s name again, dropping it into "registered waiting" status. At that point, the ancillary departments can see on their computer screens where the patient is and that he or she is ready for service. "That [step] resets the pager," Rich notes, "and the registrar walks the patient back to the waiting room and says, Wait until the pager goes off and then walk to the double doors.’" When someone from the ancillary department double-clicks on the patient’s name, the buzzer is activated, and a technician goes to those doors to greet the patient, she adds.
Handling difficult registrations
One of the most helpful features of the system, Lilleboe points out, is that in the case of difficult registrations. If, for example, there is no signature on the physician order, or something else is wrong, the registrar can put that patient on hold. There is a text box from which different on-hold classifications can be chosen, she explains. Some of the options are "outpatient, no diagnosis" "outpatient, no signature" "no patient name" or, in the case of direct admits, "waiting for bed."
If a patient is put on hold, the person is either kept in the registration room or taken back to the waiting area while the registration coordinator takes care of the problem, Lilleboe notes. "At the end of the month, or the end of the day, we can run a report on how many patients we had to hold and for what reason. We know how long they waited from check-in to registration and, if they were put on hold, for how many minutes. We know now long they were in the registration room, how long in ancillary waiting, and how long they waited before treatment."
Another user-friendly feature is that at the beginning of the process, patient names are highlighted in a particular color, depending on type. Red indicates a direct admit, Lilleboe says, which means, "That’s the one you take next." Registration coordinators immediately see that the patient has arrived, that a bed is available, orders are ready, and a bed number can be entered, she adds.
Physicians have responded positively to the detailed information on patient wait times that Lilleboe now can provide at regular meetings she attends with physician groups, she notes. "For the first time I’m able to tell them that, for example, the average is nine patients put on hold and I can tell them the reason they had to be put on hold."
Although she was hesitant at first to use the names of individual physicians in describing problems, Lilleboe says she quickly found that they were eager for the information. "They couldn’t believe there were orders that somebody forgot to sign."
In the past, Rich points out, "the best we could do is take the logs from the front desk and report the time signed in and the time registered [to determine wait times]." "We said the standard is 15 minutes, but we could never prove we were or weren’t doing that." Since the move to the new facility, she says, the number of patients on a big day has gone from about 125 to about 200, and wait times consistently are fewer than 15 minutes. "They usually run between nine and 10 minutes."
Lilleboe says staff training took 15 minutes at most, and the efficiency and sense of control that the new system provides has made for a staff that is much more engaged in their work. "I don’t know if empowered’ is the right word, but one registrar me a patient who said, I’ve been waiting forever.’ [The registrar] could look at the system and say, Oh, it looks like you checked in just eight minutes ago.’"
With the freedom provided by the pagers, Rich says, patients are free to walk around the hospital, browse in the gift shop, or visit the cafeteria without being concerned about being away when it’s time for their appointment. "Before [the new system], we were putting out fires right and left," she notes. "We just don’t get as many complaints anymore."
[Editor’s note: Linda Lilleboe can be reached at (321) 268-6333 or by e-mail at [email protected]. Christine Rich can be reached at (321) 268-6870 or at [email protected]. The hospital’s web site is at www.parrishmed.com.]
Presented with the opportunity to revamp outpatient registration in conjunction with the opening of a beautiful new facility, Parrish Medical Center patient registration manager Linda Lilleboe, RN, MSN, and business office director Christine Rich MHA, faced more than the usual challenges.
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