Outpatient center's multiskilled staff key to short waits, smooth flow
Registrars draw blood, perform EKGs, code bills
Walk-in patients wait no more than 10 minutes for service, and scheduled patients wait no more than eight minutes at the Burdin Riehl Ambulatory Care Center of Lafayette (LA) General Medical Center (LGMC). Staffed with multiskilled employees since its inception in 1995, the ambulatory care center has maintained low waiting times even though the average daily patient load has increased from 50 to 100, says Jeri Pack, admissions and diagnostics manager.
Cross-trained employees register patients, verify insurance information, take blood, and perform EKGs, as patients remain for the most part in one of 18 treatment rooms, leaving only if they need an X-ray or ultrasound, Pack explains. If so, they walk only 40 feet or so, escorted by the registration employee to the next phase of care, or they are met by the technician who will provide that care. (For more on how patients are tracked, see story, p. 76.)
The idea behind the ambulatory care center was to respond to the growth in outpatient business by providing services in as timely and efficient a manner as possible, she says. "As an institution, it was determined that we needed to address how to handle outpatients appropriately."
In the past, outpatients went to the waiting room of the main facility for service, where they were filtered into the inpatient population waiting for ultrasounds or X-rays. "Because [the outpatients] are not ill, emergency department and intensive care unit patients took precedence over them. That meant extended waits. That was the basic reason the [outpatient] facility was constructed," Pack says, "but the truly innovative part was the way we set it up."
Monitoring activity by patient and by day, looking at the ratio of walk-ins to scheduled patients, and achieving flexible staffing through multiskilled employees are key to achieving efficiency and short wait times, she says. Having a new facility built specifically to accommodate outpatient flow also is an advantage. (For a two-year record of patient activity, see chart, p. 75.)
About 3,000 outpatients per month who visit Burdin Riehl are served by some 20 FTEs. Pack, the facility's operational manager, reports to the director of ambulatory services, who has an administrative assistant. The rest of the employees fall into these categories:
o Registration/clinical. These employees register patients, obtain insurance verification and preauthorization, draw blood, order lab tests, collect urine samples, and perform EKGs, Pack says. Their jobs are facilitated with innovations such as portable Mac-8 machines for doing the EKGs and pass-through doors from several conveniently located restrooms to the technician counter for easy collection of urine samples. The pass-through doors also protect patient privacy.
o Registration/coder. In addition to performing registrations, these employees are considered the center's experts in insurance verification and precertification, Pack says. "If the registration/clinical employee has a patient in a treatment room, and there is a question about insurance coverage, that employee - while continuing to provide service to the patient - can ask the coder to call the insurance company."
In addition, the registrar/coders serve as patient accounting representatives, collecting deposits and payments and setting up payment plans. Finally, Pack explains, they do the coding from all patient charts, gathering lab and EKG results and loose reports and looking at on-line results from radiology. Once it's coded, the bill drops after it's held long enough to ensure compliance with the Medicare 72-hour rule.
In the past, coding was handled exclusively by the medical records department, a much slower system. Having a coder on-site means "We own these patients from the time they walk in the door until the bill drops. We are dedicated to completing everything it takes for that episode of care," Pack explains.
o Prep nurses. These employees do preoperative teaching and assessment of patients before their date of service, she says. Appointments are not required. Patients may walk in between 6 a.m. and 6 p.m. Prep nurses start the admission history, recording height, weight, blood pressure and family history on the nursing assessment form for the area that will be performing the service. Prep nurses may be registered nurses or licensed practical nurses (LPNs), but there is always an RN in charge who signs off on the admission histories. That service is performed not just for the ambulatory care center, but also for patients scheduled for inpatient and outpatient surgery in the main hospital, she adds. That includes preparation of a medical packet containing the assessment form, the face sheet, sufficient labels for surgery, and any lab results. The prep nurse reviews the lab results, alerting the physician of any abnormalities so the surgery can be canceled in advance if necessary. Because of the preparation, patients are taken directly to a holding area on the date of service to begin their process into surgery.
o Coordinating secretaries. These staff welcome patients and enter them into the in-house tracking system. Between 8:30 a.m. and 5 p.m., two secretaries work the front desk. The coordinating secretaries also do triage and, if needed, page a registration or clinical employee to escort patients to a treatment room. Because the ambulatory care center doesn't provide services without a doctor's order, the secretaries are charged with making sure there is an order for every patient, Pack says.
"We have a goal of preregistering 95% of our patients," she adds. "When the patient presents, [the secretary] looks for the preregistration packet. If the doctor's order is not there, they are instrumental in finding that order. If necessary, they request that one be faxed. We will bend over backward to get that order."
Although the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has indicated it prefers orders to be written or faxed, Burdin Riehl will accept a verbal order given to a licensed individual as a last resort - either an RN or an LPN.
One drawback to combining so many disciplines in one position, Pack concedes, is that if the trained people leave, they are difficult to replace. "If we lose one of these people, it takes time to hire, to train, to precept."
Training for the first group of employees was far more intensive than the training provided now, she says. One component that hasn't changed, however, is the week of classroom training on the facility's HBOC system for both registration/clinical and registration/coder positions, Pack says. The person who does that training is an educator in the information systems department with an extensive background in registration, she adds.
Initially, the lab provided a three-day class in blood-drawing techniques, but since then, "we have grown our own trainers," Pack says. "The best of the best do training for incoming hires."
Training for the EKG part of the job is provided by various people, all at the management or nursing level in the cardiology department. They have included a clinical nurse specialist and a telemetry manager/EKG supervisor, Pack says. "Employees get training at a high level to begin with."
A class set up for patient accounting instruction was not very successful, she notes. "We realized we could do that training on the job."
The registration educator trains employees on the insurance portion of the registration job as it relates to the computer system, Pack explains. The key component of the insurance training, however, is that new employees are "precepted," meaning they work with a mentor for four to six weeks before doing the job alone.
"[The mentor] will allow them to watch everything for at least a week," she says. "Maybe the next week, they will register, and the next week get into phlebotomy. We add [job skills] in stages. It's too much for a person to absorb at one time. We make sure they are comfortable with all the disciplines [before] they go into the treatment room alone."
Since the ambulatory care center opened, there have been only a couple of months - when it was short-staffed - in which she didn't meet her benchmarks of eight-minute waits for scheduled patients and 10-minute waits for walk-ins. (For monthly data on wait times, see chart, p. 75.)
Employees have bought into the concept, she says, resulting in a low turnover rate. "Most have been here since we started. This has been an exciting process for all of us. We didn't know what would happen when we went into it, but we're thankful that it has been successful. The true winner has been the patient. No one wants to wait - that is their biggest issue."
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