Ohio HHA wins JCAHO quality improvement award
Efforts led to decreased AR days
An Ohio agency’s efforts to reduce its accounts receivable days in home health has earned it the Joint Commission on Accreditation of Health-care Organization’s (JCAHO’s) performance improvement honor, the Ernest A. Codman Award.
HomeReach, an agency in Worthington, was recognized for a program that included enhancing computer use, doing a better job of tracking physician orders, and reviewing end-of-the-month activities. In announcing the award, JCAHO noted that the agency had reduced its accounts receivable (AR) days from 116 to 70, during a time when it was experiencing a significant increase in business.
But the initiative, which began nearly two years ago, changed more than just billing practices at HomeReach, whose services include a Medicare-certified home health agency, an infusion pharmacy, and a home medical equipment service.
Executive director Fran Baby, MPA, says methods used in the AR initiative have found their way into subsequent HomeReach quality improvement efforts, and notes that the entire effort required no significant investments or new hires. "It was really looking at our processes and what we had in place and saying, Hey, what can we do to change it?’"
Setting the goal
HomeReach is affiliated with the OhioHealth system that serves central Ohio. The agency’s review of its accounts receivable process, which began back in July 1998, was prompted by OhioHealth’s decision to make the issue a systemwide priority, Baby says.
"We just felt throughout the continuum that the [AR] days were not what we hoped they could be," she says. "By having a good, solid process for accounts receivable, it would help our cash positioning and allow us to meet our mission, too, in terms of providing care to the indigent."
At the same time, OhioHealth was embarking on a method of identifying goals called the "balanced scorecard." Baby describes a process by which the organization identifies goals within four areas — quality, service, work life, and finances.
HomeReach, through its performance improvement committee, made recommendations to the board of trustees regarding goals in each area. "One key area was the reduction of accounts receivable days for home health," Baby says, noting that home health consumes about 50% of HomeReach’s budget.
Once the goal was approved as part of the agency’s plan, it went back to the performance improvement committee, which identified a team to lead the initiative. The team included the director of clinical services, the medical records supervisor, and the billing supervisor — a multidisciplinary approach that Baby calls the key to the agency’s success.
"Your first gut reaction if you have an AR problem is to say, Well it’s the billing department’s fault they can’t get the bills out,’" she says. "But we know that’s very superficial, and if you look at the entire process, there’s a lot that has to be done by the clinical staff.
"What we did through this team was to sit down and open up communication between the two groups [to] develop a better understanding of why information is needed, and more importantly, the role that everybody plays in successfully getting a bill out."
Baby says the lead team recognized early that it couldn’t carry out the entire initiative on its own, so it formed eight subteams, each of which was responsible for researching a particular area and coming up with recommendations.
The team, with the assistance of HomeReach’s in-house performance improvement staff, used diagrams to sketch out the billing process from start to finish. Baby says they found three major areas that they believed would be critical to improving performance in AR days:
1. Enhancing the management information system. Baby says HomeReach has been using a Delta information system for the past three years, but hadn’t used all of the functions of the system that were available.
In particular, nurses were doing all their clinical documentation on laptop computers, but were entering billing information manually through the agency’s billing department.
Baby says the addition of the Delta Charge entry system allowed nurses to verify visits electronically for the purpose of billing. Inservicing helped explain the new procedure to them.
HomeReach took other steps to allow automation to help smooth the billing path. Fund transfers and remittances now come to the agency electronically through the fiscal intermediary. And staff now have electronic signature capability instead of having to come to the office to sign their paperwork.
In fact, Baby says, the entire medical record — or as much of it as possible — now is stored electronically. "The only material that we file in the medical record now is something that needs an original signature or the patient’s signature," she says.
2. Reviewing end-of-month activities. The agency set up a schedule of what processes needed to be completed by the end of each month, as well as who was responsible for each process. "We reduced the total days it took to close the month from an average of 76 to 108 days all the way down to 58 to 82 days — by about 24%," Baby says.
Those changes didn’t just affect billing staff. The team changed the process by which unverified visits or visit errors were tracked and resolved.
"Previously, the billing supervisor was responsible for trying to figure out what happened to all those visits and what the errors were," she says. "We ended up with a backlog."
Under the new system, the billing supervisor goes to the clinical manager of the team member in question. The manager is responsible for researching the problem and reporting back to billing promptly. "By doing that, the clinical managers have become more aware of what were some of the recurring problems," Baby says. "They could stop them or work with that clinician on correcting them."
3. Developing a tracking system for physicians’ orders. HomeReach uses a Delta mechanism for tracking physicians orders, but also has devised a Microsoft Excel spreadsheet program to help with the task.
Baby says the program does a better job of identifying when the agency sends out a plan of treatment and which physicians don’t return them promptly. The medical records staff now follow up, working with the physician offices to reduce those days. The average time of receipt of signed physician orders decreased from 33.7 days to 22.4 days.
Throughout the process, the subgroups exploring various issues had the authority to make changes in the system as they saw fit. The lead team served as a coordinator of the subgroups, rather than the final authority. "We knew that the people in each of those [subgroups] were really the experts because they were the ones who were dealing with the problems and issues day to day," Baby says.
"We gave each team broad authority to make the changes that they needed, within the scope of keeping it all coordinated with the larger team," she says. "The larger team just had to make sure that a change from one recommendation wasn’t going to have a negative impact on another one or that it was doable."
If a change didn’t work, it could be rescinded. Baby says that too often in an organization, people don’t believe that their suggestions are heard or that they have the power to make a difference. "You know how that can happen," she says. "They’ll say, They told me I could change it, but I was second-guessed.’ We never really got into that. We empowered them to make the changes they saw necessary."
As a result, she says, people got excited in seeing the success of their own ideas. Baby estimates that by counting team members, trainers, and others, the initiative involved the total participation of about 160 people.
Some lessons learned from this initiative that Baby now applies to other PI efforts include:
• Early identification of communications issues. The teams were all set up with both clinical and billing staff to ensure that communication was in place from the outset. The process has led to an enhanced understanding of each department’s role in the total success of the agency.
"In the past, if somebody in the billing department went to a clinical manager to try to work out a billing problem, the clinical manager got defensive," Baby says. "Now, they all have a better understanding of each other’s role. I have a better understanding of who I’m passing information on to, what they’re doing with it, and why they want it in the format they want it in."
• Effective display of data analysis. The agency used two- by three-foot laminated storyboards to keep the staff up to date on the progress of each of the teams.
"One thing we found out is that people don’t read memos," she says. "Your visiting staff are out in the field with laptops, so they’re not in the office every day. On the other hand, you want them to feel like they’re part of the organization and you want them to participate."
When visiting the office, nurses now can glance at the storyboards and get the information they need in a few minutes. The PI department made the boards visually appealing by using color and graphics. "We use storyboards for every one of our PI initiatives now," Baby says.
Baby says HomeReach officials were pleased and surprised by the JCAHO honor. In fact, she says, they didn’t make the submission for the Codman award with any expectation of winning, but rather as a learning experience.
Now the big challenge is adapting the successful program to meet the needs of the outpatient prospective payment system (PPS). The end-of-month activities, for example, will have to be revised to work within the new episodes of care. Staff had to be taught the importance of a successful Outcome and Assessment Information Set assessment and accurate coding.
But Baby isn’t worried about the effects of PPS. "It wasn’t like we planned [this initiative] not anticipating there would be a change on Oct. 1," she says. "Our challenge now is to maintain our low days in AR through PPS. That’s our new goal."
• Fran Baby, Executive Director, HomeReach, 404 E. Wilson Bridge Road, Suite H, Worthington OH 43085. Phone: (614) 566-0850. Fax: (614) 786-7070. E-mail: [email protected].
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