Errors drop dramatically with new QI program

Peer pressure aids quality improvement

An error report that sorts mistakes by registration area and a healthy dose of peer pressure have helped reduce her departmental error rate from 15% to about 1%, says Marne Bonomo, RN, MHA, director of patient registration at Alexian Brothers Medical Center in Elk Grove Village, IL.

The hospital has an electronic billing system, so if the various fields in a registration form are not completed correctly, the bill "falls out" and shows up on a failed bill report, Bonomo explains. Using Excel software, she further refined the raw data to generate an error report, which she calls the "failed bill quality indicator." The failed bill quality indicator shows a breakdown of the types of errors by registration area and displays the initials of the registrar who made the mistake.

The registration categories for which mistakes are tracked include inpatient, outpatient, mental health, newborn, ambulatory care, cardiac care, observation, rehabilitation, hospice, and emergency department (ED). (See example of error report, p. 126.) The information also is broken down by patient type.

With a registration system that is becoming increasingly decentralized, fewer registrars report to her, Bonomo says. She directly oversees inpatient, outpatient, and ED registration, for example, but registration for day surgery and radiation patients is handled separately. Still, she is ultimately responsible for the quality of data, even for areas not directly under her control.

The new quality control process has proven invaluable in creating peer pressure that prompts registrars to clean up their acts, so to speak. "We have a shared data base, and I put information from the failed bill summary out on the office network," Bonomo says. "It’s updated every two weeks. All the managers have e-mail and can go into a particular drive and look at it."

In addition, she says, "We have a monthly meeting of everyone responsible for registration. Medical records, the business office, and information services are also represented, because if records are not complete, it’s a problem for them all."

Each of those departments is responsible for the accuracy of the hospital’s master patient index, another data base that is monitored to ensure the quality of data entry, she notes.

Having the failed bill quality indicator and communicating it to employees have been key to the dramatic improvement in accuracy, Bonomo says. "When I first came here, the failed bill report was 300 pages long. Nobody ever [looked at] the report."

With the new Excel program, Bonomo simply keys in the total number of errors and the total number of registrations shown on the failed bill report and receives data that let everyone know "exactly where they stand," she says. The failed bill quality indicator might reveal, for example, that inpatient registrations are 97.15% accurate, while those in the ED are 99.3% accurate. Meanwhile, the failed bill report is down to "just a few pages."

Improvements came almost immediately after the system was put in place three years ago, Bonomo adds. "It’s a customer service issue," she says. "If we don’t get the correct information [during registration], people call because the bill went to collections or someone called them for information after the fact. It has an effect on days in accounts receivable, because if the bill goes out, it has a chance to get paid. If not, it doesn’t."

Follow-up on the errors reported on the failed bill quality indicator is handled in several different ways, Bonomo says. Sometimes one-on-one training is used, and sometimes the whole department receives instruction. "Sometimes the business office comes over and trains on a particular insurance, or if an insurance is changed on the master," she adds. "We have a couple of departmental trainers, so [business office personnel] can also ‘train the trainers.’"

Staff can practice on-line in trailers, which are equipped with computers and set up behind the hospital, Bonomo says. Material also is covered at staff meetings or with a few employees who are gathered together during the work day.

Employee response to the new process has been good, she notes, with a positive effect on self-esteem as accuracy increases. And the relationship between registration and the business office, which used to be a "war zone," also has improved. Bonomo says. "Before, they had the feeling we didn’t try," she adds. "By tracking this [report], they know where to put their efforts, and it’s all seen in a better light at this point. The relationship is not adversarial anymore. Registrars can call someone in the business office for help."

[For more information, contact Marne Bonomo, patient registration director, at Alexian Brothers Medical Center, 800 Biesterfield Road, Elk Grove Village, IL 60007. Telephone: (847) 437-550, ext. 4777.]