Special Report: Focusing on Performance

Rehab hospital revamps its admissions process

Admissions time dropped by two hours

It only took one patient’s complaint about the inpatient admissions process for a rehab hospital to make changes that have cut the admissions process by two hours per patient and resulted in a net savings. "We were saddened to hear the news initially that we weren’t doing as well on the admissions process," says Lynae S. Nielsen, MS, CCC, CPCRT, special projects coordinator of Idaho Elks Rehabilitation Hospital in Boise. "It came from a patient who was disgruntled enough to speak up and tell us what was happening wrong," she says. "Then we studied the process and totally changed the process."

Administrators quickly learned that patients were overwhelmed by how complicated it was to become admitted, Nielsen adds. "They felt it was too disorganized, that there were too many staff in the room, that they were asked too many questions; there were problems with not getting pain medications on time; and the food arrived cold," she says.

Rehab administrators quickly realized that the problem was that the one-time small rehab hospital’s staff had become accustomed to doing everything the same way it always had been done, despite the hospital’s growth over the years, Nielsen notes. "The old ways don’t meet new demands," she says. "So the process needs to be renovated."

As a result, the hospital’s patient admissions process was reduced from 3.5 hours per patient to 1.5 hours per patient, and the improvements have saved the hospital a net $1,700 in the past year plus an estimated pharmacy division savings of $32,500 a year, Nielsen explains. The gross savings of $107,000 was offset by $105,000 in new expenses related to the development of the process improvement.

Changing the workflow process

Here’s how Idaho Elk Rehabilitation Hospital revamped its admissions process:

1. The hospital hired a process improvement consultant.

The rehab facility hired Ben Graham Corp. of Tipp City, OH, to provide process improvement consultants to teach the management staff and certain other employees a process for studying workflow, Nielsen says. "They taught us how to create a flowchart and word processes to track documents and steps in a process," she says. "That’s what we used as a basis of studying our admissions process."

Using the Ben Graham process, administrators identified 17 departments that were involved in the process of admitting patients, and each of these departments’ roles was assessed and charted as they related to each other and the admissions process. "The administrator, the managers of departments, and I studied the charts and came up with recommendations of processes or portions of processes that we could eliminate," Nielsen explains.

The charts made it clear which areas had too much work and which were underutilized or unnecessary, she notes. "We could see that our nursing and unit secretaries were work-heavy, and there was a poor distribution of labor," Nielsen says. "So we spread it out among shifts and had admissions packets prepared in the evening shifts."

A second chart that showed how things could be changed highlighted the differences between the current practice and a potentially more efficient admissions process, she says. "The process was great for studying work, but it missed teamwork and attitudes and didn’t capture all that," Nielsen adds. "So we also looked at the admissions process more holistically than just using the charts."

Input from all departments

2. The hospital formed a process improvement team.

The team included frontline workers from each department, who were asked to come up with recommendations for improving the intake process, making it smoother and more comfortable for patients, Nielsen says. "Then we assembled these recommendations by department onto a project completion table," she says. "The administrator and I sat down with each department and went over the recommendations for their department and determined if it was realistic and something they’d go along with changing."

If the managers agreed with the change, then they would determine a date for implementing it, Nielsen adds. "If the managers approved of the recommendations, then we asked them to assign someone to implement them," she says. "Of 14 pages of recommendations, we had only three recommendations that were rejected, so we had a good buy-in, and we had responsible people to carry them out."

The people selected for implementing the changes were the employees who appeared to be good leaders and who had initiative, Nielsen adds. For example, the hospital’s unit secretaries fall under the nursing department, so the nursing supervisor might ask the supervisor of nursing secretaries to carry through with the recommendations for that group, she explains.

3. Committee members provided follow-up services.

The process improvement team assigned a committee member to follow up each of the recommendations. "I was given 15 things to follow up on," adds Nielsen. "Then we’d meet once a month and update the project table."

Follow-up process examines results

The team recorded whether a particular process change had been completed, not initiated, or was on time for the target date of completion, she says. "We looked at whether the change was done to the satisfaction of the committee," Nielsen says. "There were some items the managers said we were done with, but the committee said, That’s not exactly what we’re looking for, and it won’t give us the outcome we want, so we’re sending you back to the drawing board.’"

Part of the follow-up process included the development of a new patient satisfaction tool in which satisfaction with regard to the admissions process is measured, she says. "We’re currently at 97% satisfaction, and the departments are much happier," Nielsen says.

4. Complete short-term goals and move toward long-term objectives.

Some of the processes that needed to be changed could not be completed all at once, so some short-term goals have merged into longer term goals, she notes. For example, one of the recommendations was that the night shift unit secretaries assemble five charts and admit kits for each station, Nielsen says. "So that would expedite the process of chart preparation for a new admit because all the essentials would be in there," she says. "The charts would have tabs for all the paperwork that needs to be signed and blank physician orders, intake and out-take sheets, pain management scales, safety assessments, and other forms," Nielsen points out.

In the past, when charts were needed, the day-shift staff would have to pull each form from a different place and this would be time-consuming, she continues. "If we had three or four admits at the same time, you can imagine the stress it would cause," Nielsen adds. Now that the short-term goal of having the charts assembled each night and ready for the day shift has been achieved, the long-term goal is to build up a stockpile of the kits so there always will be a ready supply, and that process is under way, she says.

Cost benefits

5. Administrators conducted a cost and benefit analysis.

One category on the project completion table is the cost and benefit analysis. "We did a cost and benefit analysis for each recommendation, and it ended up that we had some expenses, but more savings than expenses," Nielsen adds. "The bottom line is we came out in the black during the process."

Basically, the hospital spent about $105,000 to complete the process improvement, and the outcome has saved the hospital nearly $107,000 — a net savings of $1,700, she explains. "We found that one of our big expenses was that we had registered nurses do everything, including the intake paperwork," Nielsen says. "We eliminated that process and instead hired another staff member, a patient admission liaison who welcomes patients."

The new liaison costs about one-third the hourly rate of registered nurses and also improves public relations by working to make patients feel comfortable, she continues. "We also made some changes in the pharmacy division, saving the division about [30 minutes] per patient per year times 1,300 admits per year — although we now have 1,500 admits per year," Nielsen points out. The savings last year with the 1,300 admits translated into a $32,500 annual savings.

6. Administrators continue to monitor the process.

One year after the process was implemented, it appears to be working effectively, Nielsen says. "If there are problems people let me know, and we troubleshoot those," she notes. "Our new patient admission liaison developed a tool, a monthly quality assurance report that lets me know a few different things."

The liaison will time the admit process and will see if everything is happening in a sequential manner, or if there’s a hold-up because someone is waiting for a therapist’s or physician’s evaluation, Nielsen points out. "We make sure the process is going the way we set it up to flow," she says.