UHC records project is attention grabber
Keen interest in revenue cycle benchmarking
Talk about benchmarking in general and most hospitals will probably think of clinical quality indicators or financial comparisons. But for the University HealthSystem Consortium (UHC) of Oak Brook, IL, a recently completed project has benchmarked medical records practices at 37 member facilities. For 26 of them, it was the second time in two years they had looked at the topic.
Danielle Carrier, program director for operations improvement at UHC, says there is plenty of interest among members in all revenue cycle areas, from admitting and registration to patient accounting and financial services. "We usually have some project related to that area every year," she explains. Even in a time of tight travel budgets, 35 people still attended the knowledge transfer meeting earlier this year when the project’s results were unveiled.
How do the best performers do it?
Along with providing data on cost and cycle time issues from labor and outsourcing costs to record retrieval rates, UHC conducted more in-depth interviews with the four best performing hospitals (for list of key indicators, see chart, below):
• Brigham & Women’s Hospital in Boston;
• New York University (NYU) Medical Center in New York City;
• Shands Medical Center at the University of Florida in Gainesville;
• Stanford (CA) Hospital and Clinics.
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Key Performer Indicators |
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Source: University HealthSystem Consortium, Oak Brook, IL. |
Their input resulted in an extensive list of actions that other hospitals could take to emulate their success. For more on the data collected, click here.)
D’Arcy Myjer, PhD, director of health information management at Stanford Hospital, says running a medical records department "is a service business. If that’s your business, you want to know how good a service you provide and how your service compares to others." In addition, he says, doing this kind of project gives him a chance to see some of the good points of his department. "When you sit at your desk in the director’s office you often only hear about people’s problems and where you have let the system down. It can be a lopsided view of the world," Myjer adds.
Myjer has much to be proud of: Stanford was singled out in the study as outstanding in record completion, unbilled records rates, loose filing rates, and release of information turnaround times. The four better performers all had traits in common that led to their superior performance, the study states. Among their strengths is a culture that embraces continuous quality improvement by:
• Designing processes from a customer perspective. At Shands, that means having physicians come in weekly to the department for records completion.
• Leveraging technology. At Brigham & Women’s Hospital, physicians are automatically notified when there are missing dictations.
• Letting staff lead improvement initiatives.
• Looking at the bigger picture and evaluating how processes impact and are impacted by other disciplines and departments.
The better performers also regularly monitor and report performance, integrating them into bonus programs and staff goals. Delinquency rates are reported at NYU and Stanford by service and physician, and Shands incorporates performance targets into its vendor contracts. Those vendors are penalized if they don’t meet the targets.
Accessing medical records
Better access to medical records is another shared characteristic of the four hospitals. NYU and Brigham use on-line documentation, while Stanford uses optical imaging. The cost per record when optical imaging is used is $36, compared to $41 for those who don’t use it. Their retrieval rate is 97%, compared to 90% among the facilities that don’t use such systems. But even without using those systems, there are strategies that the better performers use to make access to records easier. For instance, they restrict when paper records can leave the department or stop delivering paper records to physicians’ offices for completion.
Myjer knows that the technological edge that Stanford has by scanning is a key to its success. "The downside is that makes us less comparable to the others," he says. "But there is still value in sharing what we do so others can learn from us. In being an early adopter of scanning, we made a lot of mistakes, which four years later seem obvious. Part of why you do this is so that you can share those mistakes and keep others from making them."
Gail Hines, RHIA, MPA, director of medical information at NYU Medical Center, agrees that one of the great benefits is learning from others. "Other people have gone the electronic record retrieval and imaging route," she says. "We haven’t done that yet, but when we do, we can learn from their mistakes and do it better."
NYU was a strong performer in record completion, incomplete record rates, loose filing rates, retrieval time, and release of information turnaround times. With its three counterparts, the 850-bed facility shared a habit of expediting the coding process. Among the practices that the four facilities use to do this are:
• They use aggressive discharge control to receive records within a day of discharge. Stanford also scans those records within four to eight hours of receipt.
• The facilities make coding the first priority when a record enters the department.
• They code from electronic documents.
Making sure physicians know what is expected of them regarding record completion is another key to success. At NYU, there are sanctions for physicians who don’t meet their expectations, and facilities that have sanctions cut record completion time from 29 to 22 days. Add incentives to the mix, and completion time can go down to 19 days. Others have implemented on-line editing or shortened the definition of "delinquency." When the latter action is taken, record completion time is cut from 25 days for those with between 21 and 30 days in their delinquency definition, to 16 days for those who call greater than 14 days delinquent.
Learning from peers
Some of the discussions that were held during the knowledge transfer were as enlightening as the survey data. "The way UHC designed this was inpatient-oriented," Myjer says. "But almost half of our records are outpatient services. The statistics are still about inpatient admissions, but that’s not how hospitals run themselves anymore. We spend our time, energy, and money on our clinics. So now we are saying, Gee, maybe we aren’t measuring the right things.’ We need to engage the financial managers in a discussion, and we need to create solutions that are both outpatient- and inpatient- oriented. How you provide information is different for an admitted patient than for an outpatient who has three clinic appointments on the same day," he explains.
Hines says her facility had just finished a re-engineering project that covered medical records when the benchmarking study got started. "For us, it was a way to see if we left any weak areas as well as a way to share information with others."
Having already completed the navel gazing, there was nothing amazing in the data. "We’d had our eureka moments before," Hines says. For instance, two departments were at odds: one saying it collected information on the patient’s place of employment, and the other saying that it wasn’t in the record, so it must not have been collected.
"It was a black hole. But they were both right, because there was never a computer interface written that included that information on the patient record. It was input but had nowhere to go," she adds. Some of the more informal discussions between participants could be as helpful to Hines as the formal presentations. For instance, how to solve staffing problems was a common topic of conversation. If you have a heavy discharge day Wednesday, how do you get the staff on Thursday without having them work over the weekend? People don’t like to work 24/seven, but that’s when hospitals run. There were ideas on that, like the increased use of casual staff you can call as needed or part-time workers who are more flexible," she explains.
Talking with her peers also gave Hines insight into how many institutions were using electronic signatures for signing transcribed documents. "We hadn’t assigned a high priority to that, but in listening to some of the others talk about its convenience, we decided to move it to the front burner." NYU is doing a pilot project now.
Looking for the choke points
Myjer says hospitals that want to look at these kinds of functions would do better to identify choke points than to focus on inputs and outputs as places to improve. "For instance, when you look at when patients are discharged, you want to put the record into ICD-9 codes. That is the foundation for the bill and for the statistical data in hospital studies. The input is patients, by type, that were discharged yesterday. The output is what is the coding backlog. But if there is a process of getting the chart from the nursing unit into the department, that can be the choke point," he adds.
Looking at the backlog won’t tell you anything except that you have a problem. Solving it is completely dependent on recognizing the choke point and finding a way to fix it, Myjer says. "Maybe they are forgetting to send it or the residents haven’t finished their documentation, or there is an interesting case and they want to present it. You may discharge 90 patients, but miss out on 10 charts. Why you miss those 10 charts is the key bit of information."
[For more information, contact:
• Danielle Carrier, Program Director for Operations Improvement, University HealthSystem Consortium, 2001 Spring Road, Suite 700, Oak Brook, IL 60523-1890. Telephone: (630) 954-1700.
• Gail Hines, RHIA, MPA, Director of Medical Information, NYU Medical Center, 560 First Ave., New York, NY 10016. Telephone: (212) 263-5495.
• D’Arcy Myjer, PhD, Director of Health Information Management Services, Stanford Medical Center, 300 Pasture Drive, Room HC006, Mail Code 5200, Stanford, CA 94305. Telephone: (650) 723-7410.]
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