Get other departments to sing the praises of access

Other areas may lack understanding

Registration staff were too careless to get accurate insurance information. A patient access employee was mean to a patient. Wait times at registration were ridiculously long because staff are incompetent. The list goes on and on. Too often, patient access bears the brunt of negative feedback from other areas of the hospital.

"It is difficult at times when the clinical staff really don't understand the registration process and the complexities with regard to regulations, policies, and procedures that we need to follow," says Lauree Miller, director of patient access at Saint Elizabeth Hospital in Lincoln, NE.

Others don't realize that access staff must comply with regulations on patient rights, patient privacy, point-of-service cash collections, medical necessity, and advance directives, to name a few.

In Saint Elizabeth's case, the main complaint about access involved wait times for patients being registered. Other areas of the hospital felt that staff weren't getting the patient into the system soon enough for nursing to begin their process of entering orders. They also said that the registration interview with the patient was too long, causing the departments to run behind on their schedule for the day.

"What we found was that some registrars were not as productive as others," says Miller. One registrar would register 40 patients in eight hours, while another registered only 25. To address this, the department is setting productivity targets, holding access staff accountable for completing a certain number of registrations per hour.

Work with departments

Miller says she often has worked with other departments to come up with solutions to their problems when patient access was involved.

"I am currently working with the radiology department, as they want to be competitive with freestanding outpatient radiology centers. Being part of a hospital, they fall into the regulations of a hospital, so we need to be creative in how we stay competitive with these types of services," says Miller. An express registration process is being piloted, where staff have patients who are pre-registered sign papers, place armbands, and get them to the department as soon as possible.

"At the beginning of last year, we were asked to reduce our expenses in patient access. We decided to close one of our registration areas," says Miller. "Since that time, we have been struggling with wait times, but not because the staff weren't being productive. We struggled because we didn't have any registration desks to add additional staff."

The radiology department director provided data to patient access on wait times for all radiology patients. "We tried different things to help. Nothing seemed to make a big difference. We were at a crossroads to decide if we were OK with the wait times, or was there something else we could do to decrease our wait times and increase our patient satisfaction," says Miller.

That is how the express registration process got started. Three full-time registrars now use the process for all pre-registered patients. "If the patient was called over the phone to verify demographics and insurance, there was no reason why we would have needed to go over all this information again at the time of registration," says Miller. "We also had to listen to our patients say, 'I just went over all of this last time I was here,' or 'I just went over this with someone over the phone. Why do you have to go over this again?'"

Currently, pre-registration is completed for patients for surgeries, magnetic resonance imaging, computerized tomography, positron emission tomography scan, endoscopy, and the sleep lab. At the time of registration, staff review only the basics of the patient's name, date of birth, physicians, advance directives, and consents, and initiate the patient belongings sheets.

"Because we responded to the concerns with radiology in a collaborative fashion, they were supportive in helping us to identify solutions," says Miller.

Duplication of work minimized

Another area of opportunity for Saint Elizabeth's access department was the hospital's outpatient surgery center. "Here again, we need to stay competitive with our surgery centers in the community. When you go to an outpatient surgery center, you pretty much check in and don't have to go to a patient access department to get registered," says Miller. "So we are piloting a process where the patients go directly to their room, instead of waiting in the patient access department."

A team was created with the goal of improving patient satisfaction and reducing wait times. patient access leaders worked with the short-stay center leaders to work out the details.

"The clinical staff needed to understand the importance of the work that patient access was doing," says Miller. "We also needed to balance that with getting the patient in the information system timely for the clinical staff to do their work," she says.

By having the registrar in the room with clinical staff, the patient no longer has to be asked the same questions multiple times. "The clinical staff can physically see the patient in their room, so they are not wondering where the patient is, if they are waiting in patient access or if they are late," says Miller. "The clinical staff can expedite their process sooner with the patient, thus causing our OR times to be on time for our physicians."

Since the pilot program just started, the process is used for only a few patients each day. "Our goal is to expand the number of patients going through this process," says Miller. "By working together with the short-stay leaders and nurses, we were able to collectively figure out how to work as a team to improve the process for our patients and also the clinical staff. By explaining the details of the registration process to this group, they were able to have a better understanding of the complexity of registering a patient."

Compromise is needed

Previously, nursing was responsible for keeping track of patient belongings, but there was no formal process for this. Patient access worked with clinical staff to create a form initiated at the time of registration, so that the patient's name and account number are documented. The patient access team was having the patient complete the form, but this was causing an increase in the registration wait times.

"So we compromised, in that patient access would initiate the form, and the clinical staff would review and sign off on the form. This has worked well," says Miller. "Our goal was to have a patient belongings form on all inpatient, observation, and surgical day care accounts. This then becomes part of the patient's legal record."

A two-call process was recently implemented with the nursing staff. When a direct admit presents to be registered, access staff call the floor to let the nursing staff know that the patient has arrived so that they can start to prepare. Then prior to taking the patient to the floor, staff call again and let them know that they are on their way.

Another recent initiative involved a two-call process, so the nurse could verify a patient's room was ready on the first call and be ready to welcome the patient in his or her room once the second call is received.

"This was in response to our hospital being so full that our rooms were not always ready for the patient," says Miller. "We were discharging patients and admitting patients so quickly that the rooms were not cleaned. We definitely did not want to take a patient to a room to find that it wasn't clean."

Miller says there is no question that helpful, collaborative actions spread goodwill for patient access. "In my opinion, patient access is a very important part of the experience for the patient," she says. "Our staff do set the stage for the patient's entire experience. If the patient's perception is that we are working together as a team, which we strive to do, then our collaborative efforts have meaning. I think our team approach to include clinical and nonclinical representation is key to the success."

[For more information, contact:

Lauree Miller, Director, Patient Access, Catholic Health Initiatives, 245 South 84th Street, Suite 100, Lincoln, NE 68510. Phone: (402) 219-5488. Fax: (402) 219-8008. E-mail: laureemiller@catholichealth.net.]