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Key indicators can prove worth of access
A focused approach is often lacking
(Editor's Note: This is a two-part series on use of performance indicators in patient access. This month, we cover their benefits and how to develop the most effective scorecards. Next month, we'll report on how to use these data as a tool to motivate your staff.)
Keeping a close watch on key performance indicators (KPIs) can help you do a powerful thing: namely, demonstrate your impact on the hospital's bottom line. You can do this in terms of customer satisfaction, financial outcomes, process compliance, and organizational development.
KPIs also can help you confront a common problem in health care organizations the fact that patient access may be "understaffed and over-utilized," says Jeff Roche, a manager at Accenture's Lancaster, PA, office. Roche has worked with a number of hospitals to develop KPIs for patient access.
"Many organizations have been unable to adequately monitor and measure important statistics that drive patient access results," adds Roche.
These things have not been easy to measure. This is largely due to the fact that many legacy systems do not capture the necessary data to report the KPIs, such as dollars collected by patient access vs. expected payment, error rates, or the percentage of patients who are pre-registered prior to arrival.
"Unlike billing or coding functions, the volumes for patient access can be intangible, as with walk-ins or direct admits," notes Roche. "Thus, many organizations have not pursued a focused approach to patient access KPI management."
Make informed decisions
Roche says, however, that organizations that have chosen to invest in measuring and monitoring KPIs have seen significant benefits.
Roche explains that many organizations choose to first pursue key performance indicators implementation for their dedicated revenue cycle patient access staff, in areas such as centralized financial clearance or centralized registration.
"By setting baselines and monitoring for their own staff, it becomes easier and strengthens the case when the KPIs are shared with ancillary departments performing similar functions," says Roche.
Through this approach, data quality can be monitored across the organization, and appropriate actions can be focused to the appropriate departments and/or functions.
"Further tailoring the detailed reporting to applicable sites of service or functional areas provides the tools for effective decision-making and sets expectations for communication and accountability," says Roche.
Not an easy undertaking
At the organizations Roche has worked with, increased focus on KPIs on the front end have led to increased point-of-service collections, improved data accuracy rates, reduced insurance payer rejections and avoidable write-offs, and improved patient/customer service scores.
"This is not an easy undertaking. It requires support and involvement from IT, as well as a time investment from patient access leadership," Roche acknowledges. For instance, there must be constant monitoring of your chosen indicators once baselines have been established.
Roche says that a "robust" KPI focus on the front end gives you the ability to make informed decisions, strengthened by strong data sets rather than assumptions.
For instance, by measuring data accuracy, you're able to identify strong, productive team members. By measuring point-of-service collections and reduced avoidable write-offs, you can demonstrate the improved financial performance of your department.
Frank Danza, vice president of revenue cycle management at the North Shore-Long Island Jewish Health System, says that performance indicators are used for the elements of access functions that have "the greatest impact on revenue cycle performance and cash collections."
For all scheduled visits, the following are measured at North Shore-Long Island Jewish:
the percentage of cases where patient access staff completed pre-registration activities prior to service. (This means that staff contacted the patient and confirmed demographic and insurance information);
the percentage of cases where staff completed notification activities to the patient's insurance company prior to service;
the percentage of times that an authorization is received prior to service for emergency admissions;
the percentage of times that an authorization is secured within 24 hours of admission.
The hospital is implementing a process for treat-and-release patients in the emergency department (ED), which also will be tracked. "Our goal is to meet with all patients as they exit the ED to confirm demographic info and insurance information, and to educate self-pay patients on financial assistance options," says Danza.
Link patient access to corporate goals
Danza says that the patient access indicators directly link to the organization's corporate revenue cycle goals. For instance, cash collection goals, denial goals, and write-off goals are tracked for every hospital and reported every month.
"We have identified many types of improvement opportunities," says Danza. These include:
the need to increase staffing in select functions;
the need for additional training on verification requirements and changes;
the need to counsel staff about productivity and quality;
the need to improve the interaction between the completion of these revenue-related activities with the registration process, "which very directly impacts the patient experience," says Danza.
John Woerly, RHIA, CHAM, senior manager at Accenture in Indianapolis, says that performance scorecards can link a service area, such as revenue cycle, with the organization's corporate goals. This is achieved, he says, through shared outcomes.
"The revenue cycle is a complex, interdisciplinary process that touches many parts of the organization," says Woerly. Your approach to assessing the performance of the revenue cycle and evaluating alternative solutions, says Woerly, should be three-fold: First, assess your current outcomes; next, identify where there is "financial leakage" and finally, identify the causes of the leakage.
What exactly should you measure?
Performance scorecards can and should play an important part in the development of process improvements in your patient access department. "Scorecards should be limited to those things that are most essential to showing how the department is performing," Woerly says.
These may include:
Customer satisfaction: Measure patient complaints and also positive comments made by patients about patient access staff.
Financial operations: Track point-of-service collections, patients who were discharged but not final billed, and days in accounts/receivable.
Process Compliance: Measure work volumes appointments scheduled and pre-registrations performed and also organizational development including staff productivity, promotions, and retention/recruitment.
When setting up your scorecard, Woerly says ask whether the indicator does these things:
aligns senior management team around the company's strategy;
provides a vehicle to communicate the strategy to all employees, align the team around drivers of performance, and gain accountability for desired performance;
provides a mechanism for learning and feedback;
becomes a management tool for decision-making;
provides a means for identifying and prioritizing initiatives;
promotes accountability and follow-up;
makes explicit team contributions to the strategy;
improves management development and coaching, based upon strategic performance drivers linked to the scorecard.
Address these things before you create a scorecard
John Woerly, RHIA, CHAM, senior manager at Accenture in Indianapolis, advises considering these items when developing a scorecard for your patient access department:
1. Identify all of your available data and data sources, both internal and external.
External benchmarks may be derived from the National Association of Healthcare Access Management, the Healthcare Financial Management Association, and Hospital Accounts Receivables Analysis as well as from your own professional contacts.
2. Decide on your implementation approach.
You can do either a "big-bang" approach or a pilot/phase-in. The pilot/phase-in approach could take the form of creating a scorecard for one or two functions within the department, such as pre-service/financial clearance or up-front collection activities. In contrast, the "big-bang" approach would look at creating a scorecard for the entire revenue cycle operation patient access, medical records, and patient accounting.
3. Ask for feedback from users.
Obtain input from two groups: employees who will be performing the data entry and those who will be receiving the scorecard. "Distribute a first draft. Then receive feedback on the draft scorecard and make updates," says Woerly. This will ensure that you have the input of key stakeholders, as well as obtain their support and buy-in.
It also is essential, says Woerly, that you choose performance indicators that are easily measurable and available getting feedback from your key stakeholders should assist in this.
4. Take steps to reduce the amount of manual data entry that will be required.
Identify any available automated methods to obtain data.
5. Ensure that data are retained, in the event that information has to be reproduced or re-evaluated in the future.
Keep records of the source documents you use, including system reports and internal statistics.
6. Remember that the scorecard may "evolve" and be updated over time as new indicators are added or modified.
"If formulas and content change, keep records of those changes, so that if you are comparing outcomes over years, you don't mistakenly forget changes that have been made," says Woerly.
For example, your up-front collections in 2007 may have only included co-payment collection in the ED and ambulatory surgery, whereas up-front collections in 2008 include co-payment, deductible, and co-insurance collection in all registration areas.
7. Keep it simple and keep it meaningful.
"Scorecards can be as simple or as complex as required. Sometimes, keeping it simple is the best. Don't collect data just to collect it!" says Woerly. "Use it to motivate staff and to show your administration the improvements that have been made in your operations."
8. Use data to identify areas for improvement.
"Once you report out for at least six weeks, you'll have your baseline data and can start reviewing for trends both good and bad," says Woerly. At this point, you will likely find many opportunities to make improvements, he says, in areas such as up-front collections, pre-bill holds, financial clearance compliance (pre-registration, insurance eligibility/benefit verification, pre-certification/authorizations, referrals, patient liability estimation, and upfront collections), and denial reduction.
"Information should be shared and posted to hold all staff accountable," says Woerly. "It can be utilized to track performance, as well as to make further improvements."
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