Invest in patient access team with career ladders

A career ladder has helped the patient access department at Palmetto Health Richland in Columbia, SC, to "build our own leaders," says Charlene B. Cathcart, CHAM, director of admissions and registration.

"We like to promote to higher positions from our career ladder graduates. We recently had a Patient Access Rep I promoted into a Financial Counselor position," she says.

All team members start out at the "Patient Access Rep I" level, and can move into the "Patient Access Rep II" level through the career ladder. They are then encouraged to take the Certified Healthcare Access Associate (CHAA) exam through the National Association of Healthcare Access Management. As part of the career ladder, staff are also given tests on registration, billing, and insurance.

The CHAA component was added recently, with two employees taking and passing the test.

"Employees that pass are given a pay increase and are moved up to the next pay grade level," says Cathcart. "Our quality increased from 92% to 97% since implementation. I think that it is an excellent way to invest in your team!"

About three years ago, the patient access department at Children's National Medical Center in Washington, DC, developed a career ladder to improve retention, reports Fairon F. Fitzhugh, senior practice operations manager. "We wanted to give our best employees an incentive to stay within our workgroup, and make opportunities available to them for growth and development," she says.

Fitzhugh says that patient access staff are now more interested in learning and more knowledgeable about what it takes to be promoted. "Our retention rates have improved within our workgroup," she says. "Staff are more likely to stay within the institution, even if they decide to leave the outpatient clinical arena."

Fitzhugh says that baseline data were difficult to establish because there was more than one workgroup with the same job titles. "But, I would estimate that retention rates have improved by 10% to 15%," she says. "Staff in search of growth, development, and promotion are now more likely to transfer to other positions than to leave the hospital's workforce altogether."

To develop the career ladder, these steps were taken:

• Existing job descriptions were reviewed, revised, and updated.

• Tasks were prioritized, so that they reflected increasing job knowledge and accountability. "This process allowed us to see natural 'steps' for our ladder," says Fitzhugh.

• Roles were inserted that were missing from the existing structure.

"Our job descriptions reflect that the knowledge necessary for each step in our ladder builds upon the know-how of the step beneath it," says Fitzhugh. "This makes it easy for our staff to rotate when we're short-staffed."

When using a career ladder, it is important to: establish appropriate levels/steps within the ladder program, determine appropriate salary ranges, evaluate all staff and assignment to a correct level and salary range, identify outliers, and calculate the cost increase, advises Anna Dapelo-Garcia, director of patient admitting services at Stanford (CA) Hospital & Clinics.

"Staff quickly adapted to the new process and now feel that there is an opportunity for advancement," says Dapelo-Garcia. "Staff no longer feel it necessary to leave the department in order to advance within the organization."

To get the most out of career ladders in your department, use these tips from patient access professionals:

• Be sure to clearly define the required steps.

For example, state clearly that the employee is required to take Registration 201 before he or she can take Billing and Insurance 204, says Cathcart.

"One pitfall is using longevity — years of service — as a primary trigger for advancement to the next level," says Dapelo-Garcia.

• Have a competency test for each level.

"Establish your expectation for competition, such as a score of 95% or better passes the class," says Cathcart.

• Include a cross training component.

State what additional duties the employee must be able to perform in order to move up the ladder, says Cathcart.

• Think through the issues that will inevitably come up.

For example, what would you do if an employee wants to advance but can't pass a competency test? "When employees can't pass a competency test, we give them the opportunity to review the material again and then retake the test," says Cathcart. "If they still can't pass, we have them go through the training again. I don't remember anyone that did not pass the third time."

You also need to decide whether it counts if an employee has worked in the cross training area, but it was several years ago. "My rule about cross training in an area they previously worked in is that all cross training has to be within one year of the career ladder application," says Cathcart.

• Have a clear vision of what you're trying to accomplish.

"You need a good understanding of where your current structure falls short of that vision," says Fitzhugh.

• Think about the type of employees you want to attract, in addition to your existing staff.

For example, over the last few years, the number of Hispanic patients treated in the hospital has increased, says Fitzhugh. She says that it is helpful to have staff who can greet the families in their own language, interpret basic demographic and insurance questions, and relay information about appointments and directions.

"We are careful about staff translating, however, due to obvious liability concerns. We created a position for a bilingual registrar, which requires the employee to be certified in basic translation through a community college," says Fitzhugh. "This created an opportunity for a few members of our Spanish-speaking staff to be promoted after receiving the requisite training."

• Get input from human resources (HR).

"They may be very helpful when you're ready to implement your new structure, so it's best to include them in the early planning stages," says Fitzhugh. She says that the hospital's HR department was instrumental in the roll-out of the career ladder in clinic operations.

"They were generally supportive to our team in many ways," she says. "They were with us when we met with union representatives about our plans, and helped us draft the informational materials for the staff. HR became another resource to the staff. They were able to field questions and provide our handouts."

• Create a cross-walk.

This is a visual reference of positions similar in grade and qualifications across your institution. "This helps staff learn about a variety of job opportunities available to them within your organization," says Fitzhugh.

• Be practical.

"Don't create more steps in the ladder than you need," says Fitzhugh.

[For more information, contact:

  • Charlene B. Cathcart, CHAM, director, admissions and registration, Palmetto Health Richland, 5 Richland Medical Park Drive, Columbia, SC 29203. Phone: (803) 434-6990. E-mail:
  • Fairon F. Fitzhugh, senior practice operations manager, Children's National Medical Center, 111 Michigan Ave. NW, Washington, DC 20010. E-mail:]