AMs take different tack at small, rural hospitals

'It takes hands-on planning every day'

At Grande Ronde Hospital in La Grande, OR — and at other small, rural facilities throughout the nation — there often is a slightly different twist to the way the access department operates.

Grande Ronde, a rural hospital in eastern Oregon that serves mostly patients who are on either Medicare or Medicaid, is part of the Critical Access Hospital (CAH) Program, created by the 1997 Balanced Budget Act as a safety net device to ensure access to health care services for Medicare beneficiaries in rural areas, notes Judy Washbond, admitting manager.

As such, the hospital is certified under Medicare Conditions of Participation, which are more flexible than those for other hospitals, and receives cost-based reimbursement from Medicare and Medicaid. The Medicare Prescription Drug Improvement and Modernization Act increased that reimbursement to cost plus 1%, and gave CAH facilities the flexibility to designate up to 25 beds as acute care inpatient beds.

"If we don't follow the rules, we lose our status," Washbond says, "so it takes hands-on planning every day."

There are a number of issues associated with operating a small, rural hospital, notes Keith Mueller, PhD, director of the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis at the University of Nebraska Medical School in Omaha. Among those, he says, is the challenge of providing adequate communication services with limited staff.

Because of the 25-bed limit on acute care admissions, Washbond has reason to keep an even closer eye on patient intake than her peers at other kinds of hospitals.

"I look at the census every day to see who was admitted the previous day," she says. "I call on those admits and check insurance eligibility, and also get the precertification requirements and pass those on to case management."

Case managers depend on her to provide this service, Washbond says, because they don't have a secretary or other administrative help.

"I work very closely with case management every day, making sure patients are placed in the right areas and that there are timely discharges," she says. "If we get a call from the [outpatient] surgery center about a patient with complications and they say, 'We need to admit,' flags go up. Do they really need to be admitted?

"You have to think creatively," Washbond adds. "If we have a person in the emergency department [ED] that needs to be admitted, we ask, 'Can this patient be on observation status?' If so, he can be based in an ED bed or in outpatient surgery — where there are heart monitors — and we can monitor his chest pain and observe his condition."

The 13 admitting employees cover inpatient and ED admissions and outpatient diagnostics and surgery, she says, as well as operating the hospital switchboard. They also perform such tasks as recovering medical records after hours, communicating with on-call physicians, and monitoring emergency calls, Washbond adds.

"We have a radio system that is on all the time to allow us to listen to 911 calls," she says. "We hear a tone that lets us know an ambulance is going out on a call. We hear the 911 operator talking to the [paramedics], so we know the address, and we have the operator call us with the name."

By the time paramedics arrive on the scene and call the hospital to make a report, Washbond says, admitting staff often have already done an ED quick admit.

If the person is an existing patient, which is usually the case, the staff have access to the necessary information, she notes. "If not, [admitting staff] are standing by to hear the medical report from the paramedics."

When that call comes, admitters immediately summon a nurse — located just a few steps away — to hear the medical report, she explains. Although admitting staff used to record the information, Washbond says she changed that process when she became manager.

"I was uncomfortable with that, as [admitters] are not [clinically trained] and often would misspell names or not be entirely accurate," she explains.

Patients sign in for service

The department handles registrations differently than most facilities, Washbond says, asking all patients — including those seeking care in the ED — to sign in upon arrival at a customer service/reception desk in the main lobby.

Patients write their name, birth date, and primary care physician on a slip that includes a list of all ancillary departments, she adds.

"They check the appropriate department, put the slip in a tray, and we take them in order," Washbond says. It's all done on paper, she notes. If one of the slips is for an ED patient, the employee who comes to collect the slips doesn't enter into a dialogue with the person, but simply calls the ED admitters and gives them the information.

A staff member in the ED admitting area, which is next to triage, opens a window, places the slip in a box, and pushes an alarm, Washbond says. "The nurse turns off the alarm, takes the slip, and goes to the waiting room to call for her patient. If there is more than one person [seeking emergency care], she sees from the slip who is the most acute.

"At that point, my admitting staff go into the computer and do an ED quick admit," she adds. "It's three pages, not 17, and doesn't go into financial issues at all."

The quick admit is done so that a chart can be created quickly — also by admitting employees — which allows the nurse to place orders, Washbond says. "Sometimes [patients] don't come back to us from triage. We make up the chart, take it back to the ED, and enter the patient in the ED log and department register. Then we put the chart in a file [holder] that is bracketed to the wall, and the nurse takes it when she is ready to call a patient."

While they are waiting…

At many hospitals — including Grande Ronde — the time patients spend in the admitting process tends to "get rolled up into the whole experience of having to wait," Washbond points out, with the general assumption on the part of other departments that admitting is to blame for any delays.

"They can't say that here," she says, noting that she recently collected statistics and tracked times to show that slowdowns in patient throughput at Grande Ronde were not tied to the admitting process, but actually occurred once the patients were in the treatment room waiting for a physician.

As part of a team focused on improving patients' experience in the ED, Washbond was instrumental in having small plasma televisions placed in all treatment rooms. "People are not just sitting in an empty room with nothing to do, so they're not as conscious of the wait."

The ED quick admit process also came out of that team's work, she says.

Grande Ronde deals primarily with repeat patients, Washbond notes. "Most patients have a history with us, but if it is a new patient, we have a laptop that we roll into the room to get the information."

If a patient isn't taken back for treatment immediately, he or she comes back to the admitting area, where an employee picks up the ED quick admit and expands upon it, she explains. Then the patient is sent to the waiting area until a bed is available.

At Memorial Hospital, a critical access facility in Seward, NE, patient volume doesn't support having access personnel in the ED 24 hours a day, says Melissa Eberspacher, business office director, "so we have trained nurses to take registration information after hours."

Because their first priority, understandably, is patient care, she notes, "that leads to a little difficulty in payment turnaround or collections. It's difficult to expect the lengthy information we try to gather — good solid phone numbers, demographic stuff — all to be filled by nursing staff."

While there can be days and days when the ED is very quiet, Eberspacher says, at other times "we could be swamped" because of the hospital's proximity to an interstate highway and to the city of Lincoln.

ED nurses traditionally have handwritten registration information that then is entered into the system the next day by access staff; but they now are being trained to use the admission software themselves, she adds. "We are in transition with that.

"Admitting in the computer had to be mandatory because [admitting software] is tied to our electronic order entry product," Eberspacher says. "They have been really good about it and very receptive because getting [the data] into the system is good for them as well."

Difficulties come when situations require a lot of "stat" orders, she says. "Where [in the past] they might have just been jotting down the date of birth and a few other pieces of information, now they have to figure out the routine for getting through the whole [registration process]."

A quality improvement team has been working to facilitate that process for the past three months, Eberspacher notes. "Right now we're in the middle of creating a competency test. It's not a scoring test, but more about walking them through [the process] until they pass.

"We'll make sure we have something in place as new staff come in," she says, "and we may do it annually as a reminder."

Advance directive focus

Another way in which Washbond at Grande Ronde Hospital differs from many of her access counterparts is her handling of the dissemination of information on patients' rights and responsibilities and advance directives, she points out. Her staff offer the information to all patients, who are asked to initial a form, of Washbond's design, that references advance directives and patient rights on the same page as the terms and conditions of admission. (See form.)

"With all the rules that are out there today, this is a huge issue," she says. "If you have a complaint by a patient regarding anything happening in a hospital setting, it may go to the [state health department], and the first thing [investigators] ask the patient is, 'Were you given [information on] patient rights and responsibilities?' They want to make sure the patient is aware of how to make a complaint."

It was her idea to have patients initial the form, Washbond says, so that it can be used later to show that the information was offered. "I particularly wanted an acknowledgement that was undeniably made by the patient and not by my staff. We keep it for Medicare patients or if the visit becomes part of the patient's medical record."

The advance directives also can be referenced by nurses, she adds, who are supposed to re-address the issue of whether patients have received that information. "This way, it can be an affirming acknowledgement, rather than a repeating of the question.

"Other facilities [offer the brochure] only to inpatients, surgery, and ED patients, but I do it for everybody," Washbond says. Widespread distribution of the advance directives information is especially important, she says, because "the greatest opportunity to capture people is with outpatients."

"Nobody is ever upset about it," she adds. "We don't get complaints, and we hand out a lot of these." Besides, Washbond notes, handing out the information on advance directives to outpatients causes less stress than if it's offered just prior to surgery or another inpatient admission.

In the latter cases, she says, "the patient's reaction to being asked about [end-of-life issues] may be, 'Do you know something I don't know?'"

Before a recent remodel, the admitting staff all worked in one big office, Washbond says, but that has changed in the wake of the Health Insurance Portability and Accountability Act (HIPAA), which requires that patients be registered in a way that protects their privacy. Now, there are two registration rooms, enclosed about two-thirds of the way down with glass, so that admitters can see what's going on in the lobby as they register patients, she adds.

Washbond, who helped redesign the space, can see the registration room and part of the lobby desk from her office. "I also have a monitor in my office that allows me to see the front door. If both [admitters] are busy and I'm available, I go out to help. We like to respond to people personally."

There are no transport employees at Grande Ronde, so when possible admitters go out front and meet certain patients with a wheelchair, Washbond says. "[Cars with incoming patients] pull up right out front, so we can see if someone is having a struggle getting in, or if there is a direct admit to the intensive care unit. We also will transport elderly patients to the ancillary departments for their appointments."

Staff schedules tweaked

Seven years ago, when Washbond became manager after 10 years as an admitting representative, she made some changes. "Shaking up things was my way of taking control of the staff," she notes. "I strongly believe in controlling what goes on and I'm aware of what's going on. People do better with clear expectations, when they know what to do in every scenario."

Staff members had tended to become attached to certain areas or duties, even though all are trained to handle the full gamut of responsibilities, Washbond says. "In the beginning, I would say, 'I want you to switch with your partner every two hours.'"

These "partners," she explains, included the ED admitter and the switchboard operator, who work within a few feet of each other, and the two people in the main admitting area. At times there may be three employees in main admitting, Washbond adds, when shifts overlap.

That directive wasn't successful though, she adds, because employees found themselves in the position of trying to persuade their co-workers to swap duties with them. "Then I made a schedule, and that seemed to work. They accepted it extremely well. Now they rotate every couple of hours."

Her intent, Washbond explains, was to boost morale and reduce tension. "It helped create a more cooperative environment. It gets tiring to sit all day and admit ED patients. You might get resentful of someone in a less busy area. Or maybe you just enjoy answering the phone, but maybe your partner does, too."

(Editor's note: Judy Washbond may be reached at Melissa Eberspacher can be reached at