Several years ago, turnover of ED registrars was almost 50% at Lakeland (FL) Regional Health. Morale was at an all-time low, both for registration staff and their supervisors.

“Lots of staff were very disgruntled. They didn’t understand why some things were being imposed on them,” says ED Registration Manager Nancy Jessee.

To push back against plummeting retention rates, the department made some simple but important changes. “There are not lots of dollars to bolster the department. It’s been small things that don’t take any money at all, or very little money,” says Jason Driskell, associate vice president of revenue cycle.

First, Jessee invited registrars to tell her what they wanted fixed. She held multiple meetings to give all shifts the chance to be heard. Many really wanted to know the “why” behind various tasks. They did not realize some things had to be completed because of federal regulations, or because putting information in a certain format means the claim is paid. “It’s not just ‘Do this because I said so,’” Jessee says.

More than anything else, registrars wanted accountability for the entire department. “They wanted the same standards for everyone, regardless of their shift,” Jessee says.

It was obvious that the team of about 70 ED registrars felt overworked and undervalued. QA revealed there also were problems with registration accuracy. For the ED, accuracy rates were only at about 83%.

Patient access leaders could not offer more compensation, other than the standard cost of living pay increases given to all hospital employees. They also did not lighten the workload; in fact, they did the opposite. “We asked them to do more,” Driskell says.

Jessee set out to make ED registration fun — or at least as enjoyable as humanly possible. Here are some ways she does it:

Before every shift, staff enjoy some pleasant conversation, jokes, or small talk during staff huddles. “Instead of dreading going on to the floor, they now have started their day off with a smile,” Jessee says.

Supervisors always ask team members to thank one of their colleagues. “This builds camaraderie and support,” Jessee observes.

The huddles also serve a practical purpose. Jessee may comment, “Collections were awful yesterday. What happened?” This gives staff a chance to explain why. Sometimes, she notices an employee appears ill. If so, she takes the opportunity to assess whether they should go home or report to employee health.

Team members asked for, and received, a standard uniform of a colored polo shirt and black slacks.

Small rewards are doled out occasionally. Recently, there was a sudden surge of patients in the ED due to an accident involving a busload of disabled students. “The registration team did a great job getting the patients registered in a timely manner,” Jessee recalls.

Many played with the children during the troubling time. All registrars who worked that day earned a gold coin (these are worth $5 toward lunch in the cafeteria or an extra 15 minutes for lunch breaks).

Scavenger hunts send employees to various hospital areas to pick up clues, with a prize at each station. At the end of a recent hunt, the last prize was a card with personal comments signed by all the supervisors and director. “Staff seemed to appreciate that the most,” Jessee says.

Staff have come to expect birthday cards. If staff are out sick for more than a day or two, they receive a card. If they tell Jessee about an upcoming hospital stay, she visits that employee.

Supervisors ask staff to work in group community service projects. Some recent initiatives include collecting items for people displaced by Hurricane Dorian in the Bahamas, a vocational training program, and adopting a family for the holidays. “We have team members who are willing to volunteer and take the lead on these initiatives,” Jessee notes.

Supervisors go around the department and ask each registrar, “How are you today?” Sometimes, they do not even need to ask; they can clearly see a registrar is overwhelmed. If so, the supervisor grabs a registration cart and goes right to work.

Sometimes, it takes only 15 minutes to catch up. Other times, it takes two hours or longer, but the supervisor stays until things are manageable. “The fact that they are willing to help out when we are slammed has really helped morale,” Jessee says.

Today, staff brighten at the sight of supervisors since they view them as people who offer help. “They no longer see leaders as people who are just going around looking for what’s wrong,” Driskell observes.

With more than 200,000 visits per year, Lakeland Regional is the busiest single-site ED in the country. “The goal is to get people in and out in three hours, from the time they hit the ‘Quick Reg,’” Jessee explains.

Collections used to be minimal, about $30,000 a month. Now, collections average $70,000 a month, with a high of $100,000. Staff were reluctant to ask patients for money, so they rarely did. Previously, new registrars felt ill-prepared. Now, a preceptor works alongside them for a few days or even weeks. They are not left alone until they are fully competent. “When the preceptor believes they are ready to fly on their own, the supervisor monitors that the quality is really as we expect it to be,” Driskell notes.

ED registrars are held accountable for high-quality work. Some left the department; the ones who did not like the accountability. “If you don’t hold people accountable, the hardest workers will still work hard. But they will leave,” Jessee cautions.

Flexible schedules are offered whenever possible. Some employees want to change from working eight-hour shifts five days a week to working 12-hour shifts three days a week. Certain college students want to work only weekends. Other staff want to try working in different registration areas or even billing. Jessee not only encourages them, she introduces them to her counterparts in those areas so they can try it.

All team leads and supervisors encourage staff to call them anytime with any questions. If frontline staff ask for a promotion, Jessee hands over the phone for a day to see how they like serving as leaders. Some love the faster pace and the chance to be a leader. One registrar admitted, “This is not for me after all.”

“It’s a litmus test right there as to whether they can handle it,” Jessee notes.

Better morale is mirrored in higher departmental metrics. For almost a year, accuracy rates have been at 99%. “What that means is that what we are saying people have as insurance, we’ve gotten it right,” Driskell explains. Employee engagement scores for ED registration rose from 3.09 (on a 5-point scale) in 2017 to 3.98.

For many years, the ED was seen as just a stepping stone to another job, but that is not true today. “Staff are no longer always seeking to leave the department,” Driskell reports. “We have people in other departments who are wanting to come to the ED.”