Doing ‘what makes sense’ changes plan to decentralize administration

Health system calls halt to administrative deployment

Seven years into a program to achieve a "patient-focused hospital," Sentara Health System in Norfolk, VA, halted its plan to deploy multiskilled administrative associates to all clinical operating centers and gave precedence instead to doing "what makes sense," says Brenda Loper, CMPA, director of patient financial services.

In the midst of completely decentralizing admitting, registration, and patient financial services, the health system changed course, realizing the crucial importance of maintaining central authority over insurance and other business functions to monitor data quality accurately.

"We found that this thing that we used to call re-engineering — process design, benchmarking — is not a destination; it is a journey," Loper says. "You are continually revising it. Patient-focused care [PFC] has wonderful components, but it’s easy to lose sight that it’s about the patient, not about what you as a hospital want. If you keep saying that over and over, you can’t go wrong."

Sentara Health System comprises five hospitals, one of which has a minority interest, and a large senior division known as Life Care. Life Care includes adult living facilities and nursing homes. Using Lakeland (FL) Hospital as its role model, Sentara began designing its patient-focused hospital in 1989.

Let the designing begin

The clinical piece was planned and implemented first, and then work began on the administrative piece, says Loper, who joined the effort about four years ago. Originally director of corporate patient accounting for three hospitals, she moved to the largest, Norfolk General Hospital, to help train the administrative associates. (See related story about administrative associates’ duties, p. 98.)

"The [constant] message is that no one understood how difficult it would be to implement the administrative piece," she adds. "Outside the admitting area, there was a basic lack of understanding about the skill sets necessary, about how complex the job had become. We started recognizing in October or November that we were trying very hard to complete the deployment of the administrative associates, and we just couldn’t seem to make that final step."

The key to the decision to keep the administrative associates — with a couple of notable exceptions — in a centralized setting were serious concerns about data quality in an increasingly contentious compliance environment.

"We realized as we went along that we were organizationally naive in thinking we didn’t need central QI function," she adds. "When we moved the administrative associates to the operating centers, they reported to clinical managers, and that was unfair to [the managers]. Their experience was not in the administrative chain, and we threw a bunch of employees at them that needed a lot of hands-on supervision, where when questions come up, they needed to be answered right away. Somebody is needed to make sure all the insurance rules are being followed."

The original intent was for the deployment to be a budget-neutral change, Loper says, and her understanding is that this was adhered to for the most part. However, there were some training costs associated with both the deployment and the move back to central management, she notes.

The planned complete deployment, which took place at one of the system’s hospitals, included moving all traditional admitting office functions and more to each of five operating centers: medicine/mental health, surgical, women’s health, cardiovascular/transplant, and cancer/ambulatory. For the past two years, as part of the implementation of PFC, clinical services at Sentara have been aggregated around particular patient populations, Loper explains.

Obstetrics patients are an ideal population to receive decentralized services, Loper notes. Traditionally, OB accounts were the hardest to collect because a patient could get in and out of the hospital before all the information was gathered, insurance cards signed, etc. "When we deployed those services to the [women’s health] operating center, that turned around."

At Norfolk General, a mini medical records department was established in the women’s health operating center, she says. "It was beneficial to have the record room right outside labor and delivery."

Although the mini medical records department worked well, ultimately, physicians preferred having the records in one place, Loper notes. The satellite area now is used only for preparing current records. This more closely matches the process to the actual customer of documentation.

The original plan was "no central admitting and minimal [centralized] medical records, but you can’t make centralized files go away," Loper says. "If you have technology and electronic capability you can do it but not if you live in a paper world. We don’t have an automated medical record yet."

On May 12, Sentara officially changed its management structure, implementing what it called "administrative associate management consolidation," she says. Under the revised plan, "we’ve looked at what makes sense," Loper says. "We had to make rational decisions as to how to meet patient needs."

Now Sentara has two kinds of administrative associates — those who perform the traditional admitting/business functions and those who support the needs of the operating center’s clinical managers. For the most part, the former work in a centralized setting. However, in line with avoiding the "cookie-cutter" approach and doing "what makes sense," Loper adds, administrative associates perform business functions on-site in the women’s health operating center, at the cancer operating center, and at two physical therapy centers.

Patient convenience inspired locating on-site administrative associates at the cancer operating center, which is a considerable distance from the main admitting area, Loper says. Also, because cancer patients, who often have to make many visits as part of their treatment, are an easily identifiable population that involves a small portion of the medical staff, the hospital can better provide them with specialized service, she adds.

Although these administrative associates work at the operating centers, they report to central management. Hiring and firing are done by central managers, but the operating center managers are included in interviews. The administrative associates understand, however, that although they report to central management, they are still "part of the team" at the operating center, Loper emphasizes. "We are not ever going back to the old world where ‘it’s not my job.’"

[Editor’s note: For more information, contact Brenda Loper, director of patient financial services, Norfolk General Hospital, 600 Gresham Drive, Norfolk, VA 23507. Telephone: (757) 668-2166. Fax: (757) 668-3705.]