Executive Summary
A new Institute of Medicine report on wait times, scheduling, and access to healthcare services puts a spotlight on registration and scheduling processes. Patient access leaders can do the following:
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promptly obtain required precertifications;
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offer patients same-day and next-day access;
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register surgical patients in a separate area during peak volumes;
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assign more patient access staff to pre-registration.
Patient access is “critically important” to achieving the recommendations in a new Institute of Medicine (IOM) report, according to Gary S. Kaplan, MD, chair of the committee that produced the report.1 Kaplan is chairman and CEO of Virginia Mason Health System in Seattle.
Improving access to care “has to start at the foundation,” adds Kaplan. “The people at the first points of contact — the scheduler, the reception desk, or call center — are all critical,” he says.
The June 2015 IOM report, Transforming Health Care Scheduling and Access: Getting to Now, recommends that hospitals do the following:
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continuously assess changing circumstances to match supply and demand;
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put surge contingencies in place to ensure timely accommodation of patients’ needs.
“When those systems exist, it’s a beautiful thing,” says Kaplan. “When they don’t exist, inefficiency is manifested by prolonged waits.” This leads to not only poor patient satisfaction, he warns, but also suboptimal clinical outcomes. (See related story on same-day access in this issue.)
Kaplan recommends mapping out each step that occurs from the moment a patient attempts to make an appointment. “Waits and delays can occur at every step in that process,” he says.
Long waits at registration are one underlying cause of delayed care. Katherine H. Murphy, CHAM, vice president of revenue cycle consulting in the Oakbrook Terrace, IL, office of Experian Health, says, “There is no guarantee the patient can or will wait and no guarantee they will actually reschedule and make another trip to the provider.” Experian Health provides technology for hospitals and healthcare providers.
Pre-registration and pre-service financial clearance are “an absolute must,” says Murphy. “This requires proper automated tools and a commitment by patient access to reverse some traditional processes.”
Collaboration between patient access and clinical areas is necessary to stop inefficient processes that result in delays. “I have heard many times that the ancillary clinical departments do not want to band the patients or obtain the required signatures,” says Murphy. “There must be executive-level support for process change.”
Here is how patient access departments can implement the IOM report’s recommendations:
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Avoid delays stemming from failure to obtain precertification.
Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle operations at Emory Hospitals in Atlanta, says, “If the physician’s office hasn’t received the pre-cert, there may be delays with insurance carriers, beyond the hospital’s control. This can result in delayed or deferred services.”
This potential problem underscores the importance of patient access leaders allocating sufficient staff to obtain prompt pre-certifications. “When pre-cert is not forthcoming, ask the patient to assist by contacting the insurance carrier to resolve the delay,” suggests Kraus.
A greater portion of patient access staff should be assigned to the “pre-encounter” process, advises Murphy. “Upon entry, only exceptions should be routed to registration,” she says. “The change in process must include as many self-service solutions as possible.” (For more information on this topic, see “Patients will soon self-everything — Apps to revolutionize registration,” Hospital Access Management, January 2015.)
At Lucille Packard Children’s Hospital Stanford in Palo Alto, CA, “We have worked on improving the training of our team on communication skills when scheduling and taking away complexity of scheduling,” says Christine Cunningham, director of the Office of Patient Experience.
Most of the health system’s clinics now schedule through the Patient Access Scheduling Center. “A central scheduling model is key for our operations,” explains Cunningham. “Many of our patients have complex medical needs and require multiple appointments across several specialty service centers.”
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Avoid rescheduling when patients present to the wrong area.
Miguel Vigo IV, revenue cycle system director at Edward–Elmhurst Healthcare in Naperville, IL, says, “Sometimes when this occurs, patients sit in a department and wait to be called, not knowing that they are in the wrong area.”
Patient access employees constantly check in with all patients who are waiting to make sure they are in the right location, instead of waiting for patients to approach them. “Some of the patients are not too far away from the correct location. Most of the time, it is a mix-up from one side of campus to another,” explains Vigo.
Patient access staff members contact the clinical areas on the patient’s behalf. “We alert them that the patient is here on campus, but will need a few minutes to make their way over to the correct area for registration and their scheduled service,” says Vigo.
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Avoid problems with physician orders.
Is the physician order signed, dated, with the diagnosis and test clearly stated? Eston Allison, MBA, MHSA, CHAM, an access management analyst at Ferrell Duncan Clinic in Springfield, MO, says that if not, “this is a patient flow stopper.”
“Just the physician order alone can put up roadblocks for the patient,” Allison says.
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Register patients in a separate area during high-volume times.
At Edward-Elmhurst, many surgical patients arrive at the same time to register because multiple procedures are scheduled for 6 a.m. “It’s really hard to register 10 patients that all start at the same time,” says Vigo.
OR and endoscopy patients register in a central patient access location.
“In order to pull them out of a single, general line for all procedures and outpatient testing, we are working with clinical leaders to develop signage to direct these patients to register in a separate area,” says Vigo.
This change will prevent delays that interfere with OR/endoscopy procedure start times.
“Since these registrations take a little longer due to their complexity, it helps to move the outpatient registrations along more timely as well,” says Vigo.
ID waste in workflow
Having a “problem statement” keeps the patient access team focused on delay reduction, says Allison.
“The goal should be to increase the speed from the first contact to the patient care service beginning,” he says.
Allison gives this example: “Identify the current scheduling process, and redesign the work flow to increase efficiency,” he says. “The current time to schedule a new patient is 12 minutes, leading to patient and staff dissatisfaction.”
Allison recommends having someone play the role of a patient and following them through the entire process from pre-registration to billing. “Identify the boulders in your patient flow stream,” he urges. “Look for waste items.”
Here are some examples of inefficiencies in patient access:
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The hospital’s admission/discharge/transfer software doesn’t “talk to” the system used by referring physicians’ offices.
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Pre-certification staff members work with multiple software programs to do their jobs.
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The hospital lacks a patient portal for patients to pre-register themselves, complete paperwork, and pay online.
“This adds time and unnecessary work for registration staff,” says Allison. “Many patients would prefer to do as much as they can at their convenience.”
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Work flow procedures aren’t electronically available for easy access.
“When employees do not have good tools to use, they create their own workflow,” says Allison. “This can lead to wasted steps and duplication of effort.”
1. Institute of Medicine. Transforming Health Care Scheduling and Access: Getting to Now. Washington, DC: National Academies Press; 2015.
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Eston Allison, MBA, MHSA, CHAM, Access Management Analyst, Ferrell Duncan Clinic, Springfield, MO. Phone: (417) 875-3876. Fax: (417) 875-3820. Email: [email protected].
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Pete Kraus, CHAM, CPAR, FHAM, Business Analyst, Revenue Cycle Operations, Emory Hospitals, Atlanta. Phone: (404) 712-4399. Fax: (404) 712-1316. Email: [email protected].
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Katherine H. Murphy, CHAM, Vice President, Revenue Cycle Consulting, Experian Health, Oakbrook Terrace, IL. Phone: (630) 812-2559. Fax: (630) 620-9328. Email: [email protected].
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Miguel Vigo IV, Revenue Cycle System Director, Patient Access & Pre-Service Center, Edward–Elmhurst Healthcare, Naperville, IL. Phone: (331) 221-3413. Email: [email protected].
