Executive Summary

Registration staff at Nyack Hospital are trained to cover any area on a moment’s notice, resulting in a 50-hour reduction in annual overtime hours. The following steps can help prevent overstaffing.

  • Give competency assessments to ensure staff understand processes.
  • Schedule a “floater” during peak volumes.
  • Rotate floaters to keep them updated on changes.

If registration areas are understaffed during peak volumes, two bad things happen very quickly: Wait times surge, and patients are unhappy.

“Patient safety and traffic flow are immediately impacted when there is inadequate staffing in a registration area,” warns Jason Guardado, manager of patient access at Nyack (NY) Hospital.

Patient care, registration quality, and customer service all suffer. When short-staffed, says Guardado, “staff is solely focused on getting through the registration process, rather than providing service excellence to each patient.”

Tough Decisions

The emergency department (ED) is the biggest staffing challenge for many patient access departments. One reason is the need to provide coverage 24 hours a day, seven days a week. Unexpected call-outs can wreak havoc on ED registration processes.

“This puts a strain on management, who have to make decisions on mandating staff to stay past their scheduled shifts,” says Guardado. For unionized institutions, this is particularly difficult. “Management and non-union staff members are unable to cover the area until another staff person can provide the coverage,” Guardado explains. Here are some strategies to prevent understaffing in registration areas:

  • Ensure that all registration staff are able to cover any area on a moment’s notice.

In January 2017, Nyack Hospital began cross-training all registrars — even those who work weekends or nights. If necessary, patient access managers step in to do the training themselves. “Competency assessments ensure staff comprehend processes,” says Guardado. Registrars answer five to 10 questions on key points of the particular registration process. “The questions also identify some form of compliance or quality assurance component that must be followed,” says Guardado.

Once the test is scored, employees meet briefly with management. “We discuss the score and provide clarification on any questions that were answered incorrectly,” says Guardado.

If staff have difficulty understanding a process, the trainer or an experienced employee does some one-on-one review. “If staff continue to struggle, management schedules a ‘performance counseling,’” says Guardado.

Some registrars find it difficult to scan the correct documents into the patient record when working in the fast-paced ED setting. “Although quality measures and best practice methodology has been implemented, staff still must be vigilant,” says
Guardado. Registrars contact management immediately about any scanned document errors, so they can remove the document from the wrong patient record and place it into the correct one. “This has to be done no later than midnight of the day of the infraction to ensure it does not get identified by Health Information Systems’ medical records division,” Guardado explains.

Employee turnover has decreased slightly since cross-training was implemented. However, a change in morale has been much more noticeable. “There has been an obvious reduction in employee burnout and employee dissatisfaction,” says Guardado.

Another plus: Overtime costs have plummeted. “From July 2016 to July 2017, we saw a reduction of over 50 hours in OT,” reports Guardado.

  • Schedule a “floater” during peak volumes.

“This alleviates some of the stresses that come with unanticipated surges in patient volume or shortage of staffing resources,” says Guardado.

The department’s floaters are well-versed in all registration areas. These highly skilled employees cover the ED, the admitting department, outpatient centers, inpatient admissions, bed control, and radiology.

“They are called upon at any given moment to assist with registration duties when needed,” says Guardado.

The floater is the go-to solution if a registration area is in dire straits. During off-hours, though, a Plan B is needed. “Having someone available 24 hours a day is impossible, unless you are able to staff more than one on a consistent basis around the clock,” says Guardado. If no floater is available, the solutions become tougher: Registrars may need to work mandatory overtime, or patient access managers step in to cover.

Floaters frequently rotate to all areas. This keeps them up-to-date on changes and new processes.

“This staff person will receive the best training and information to succeed in their role — but usually will have the most inconsistent work schedule and shifts handed to them,” says Guardado.

  • Create a registration pool.

Registration areas have consistent, steady staffing despite absences and medical leaves at Abington-Jefferson Health/Aria-Jefferson Health in Philads. “We then hire permanent slots from this pool and backfill the pool with new hires,” says Kim Roberts, MBA, RHIA, CRCS-I, vice president of the revenue cycle.

The department is looking to create a similar pool for the central scheduling department. “A different skill set is required,” notes Roberts. “But again, we would look at it as an ongoing resource for coverage in the event of call-outs and vacancies.”


  • Jason Guardado, Manager, Patient Access, Nyack (NY) Hospital. Phone: (845) 348-2316. Email: guardadoj@nyackhospital.org.
  • Kim Roberts, MBA, RHIA, CRCS-I, Vice-President, Revenue Cycle, Abington-Jefferson Health/Aria-Jefferson Health, Philadelphia.
    Email: Kim.Roberts@jefferson.edu.