SPICE’ up record filing and billing with QI model
Processing and updating medical records was becoming a challenge for SNI Home Care Inc. in Flourtown, PA. The independent home health care provider, which started as a relatively small operation in 1980, exploded to a patient population of more than 140,000 visits per year by 1995. The surge in business made the company’s manual process of updating and tracking patient records, particularly for insurance payer changes, a nuisance for staffers and hurt the bottom line.
To tackle the paperwork pile more efficiently, SNI implemented the SPICE model, a companywide recipe for continuous process and quality improvement. The model’s goal, which stands for select, plan, implement, check, and evaluate, is to address inefficient procedures and aggressively work to improve them.
"We realized our paperwork process for patient billing just wasn’t working anymore, especially when there was a payer change involved," says Beth Henn, RN, MS, director of quality management at SNI. "We aren’t as technologically advanced as other [companies] in that we are still manually processing [patient records], but we had to find ways to improve within our own system.
"When a patient changed insurance payers, we’d close the chart down and open up an entirely new one for the new payer [information]. This wasn’t a big deal when we weren’t handling as many patients, but it got out of control when SNI started growing [rapidly]," she adds. "It was a big waste of time and money, and it took a lot of rework from the medical records and billing staff. We decided that [targeting] the process for payer changes would make a great impact."
After SNI selected the area for improvement, Henn quickly began designing a plan for effective change. Each factor that influenced the process was evaluated, as were any obstacles that could potentially hinder the process improvement efforts. Convincing employees that change was necessary posed one of the biggest roadblocks, according to Henn.
"It’s sometimes difficult to modify [processes], especially when people have been doing the same thing for so long. It’s up to [quality management personnel] to educate them and make them see how small changes can make a big difference," she explains. "We needed to stop and ask ourselves, Why are we still doing things the same way as before, even when they aren’t working for us anymore?’ Once you take care of that, you can form a task force with everyone closest to the problem and start working toward the same goals."
The task force, which consisted of clerical support personnel, a medical records manager, a performance improvement coach and facilitator, a medical records clerk, and a billing coordinator, gathered data to identify the degree of change required and measure its incremental progress.
In this case, the group could visually assess the mounting pile of paperwork. With each payer change, the number of patient files and problems multiplied. Rather than binding new and old patient medical records together, the department filed numerous charts separately. At times, the newly changed files did not make it to the billing department quickly enough, and the old payer was billed for the service, Henn says.
"When medical records changed from Medicare to another payer, for example, it would present a problem for both medical records staff and billing. We were dealing with so many patient charts and payer changes that we couldn’t [keep up] anymore," she notes. "Each time there was an error in billing, it wasted a lot of time, and that translated into a lot of wasted money. There was also a lot of money tied up in supplies used for creating all those new charts. It was very disorganized and confusing."
Breaking communication barriers
After pinpointing the changes needed, the team entered the third stage in the SPICE model: implementation. The departments involved met weekly with a performance improvement coach and immediately began making subtle changes to the 15-year-old process.
"Communication between the departments was very helpful because there were so many subsystems going on. There were some people in each department who realized there was a problem, but they tried to solve it on their own," she recalls. "They all meant well, but if you have Mary in one department doing one thing and Joe in another doing something differently, eventually the subsystems are going to clash. When we got everyone working together it paid off big."
The medical records staff abruptly stopped creating duplicate charts for payer changes. Instead, they attached new payer information to the front of the patient’s original file, with previous payer information behind it. In addition, the files were color-coded according to the current payer.
It didn’t take long for SNI to realize the impact of subtle changes. Within one year, the departments saved $35,400 by increasing productivity, eliminating excessive supply utilization, and reducing the time it took to fix filing and billing errors. The last stage of the SPICE process evaluate, employ, or eliminate did not require a great deal of scrutiny, according to Henn.
"At the end of the SPICE [process], it’s our chance to look and see which changes were effective and which weren’t. In some areas, we may find that the changes didn’t offer any immediate results or that they didn’t improve our overall [productivity]. In that case, we’ll eliminate the changes and go back to the drawing board to come up with a new plan," she says. "But when we used SPICE [to improve the filing and billing process], it didn’t take much to figure out that most of the changes should continue. The changes were [minimal], but the payoffs were great."
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