Can it be true? Patient-focused care and savings

Admitting comes down from the Mount’

After taking $25 million out of its budget, eliminating 540 jobs, and, among other changes, closing the central admitting department, New York City’s 1,200-bed Mount Sinai Medical Center is "a better functioning hospital," says Joel Seligman, MBA, MPH, vice president for patient services.

Registration now takes place in each of nine individual "care centers," part of a patient-focused care solution that Seligman says is kind to patients and the bottom line. "Even I underestimated how much it would mean to patients to have admission on the local level," he adds.

Because there is no physical admitting department, Mount Sinai created a function called "central listing" to oversee admitting activities between the hours of 11 p.m. and 7 a.m., Seligman says. Someone is available to assign beds, a necessity with an active emergency department that sees some 75,000 patients a year. Central listing also reports to management on length of stay and admitting and discharge information, and it arbitrates when there are no beds available.

There is no admitting director or manager. Instead, Seligman explains, each care center is run by a combination administrator/nursing executive. Those care center directors report to Seligman and the vice president of nursing, who jointly oversee all the centers, he adds.

Even before Mount Sinai began the five-year patient care re-engineering campaign in 1994, work had begun to overhaul the admitting department, notes Patricia Garcia Sullivan, RN, vice president of re-engineering initiatives. (See story, p. 39.) Mount Sinai hired a consulting firm to reengineer business processes, and admitting was the first target, she says. The result was the consolidation of several jobs — including scheduling, preadmitting, and admitting — into one position, called "admitting planner," Sullivan says.

"Six years ago," Seligman points out, "there was no admitting system out there that included a true reservation function that would work in an environment of our size." That being the case, Mount Sinai created its own admission planning module and put it on the front end of the existing admission, discharge, and transfer system, he says.

Mount Sinai is considering a move to bedside registration but doesn’t see it as a top priority, he notes. "A year or two ago, there wasn’t a neat, portable way to move from room to room and admit." Meanwhile, patients seem pleased with the current system, which amounts to nine individual admitting offices located on one of the floors of the care centers they cover. "People like it, and it solves most of the problems. If patients need to go directly to a room, they do."

The proximity of the admitting function to the patient is "nice, particularly for a large hospital like this," he adds. "When you have a central admitting office, that bed might as well be in the Philippines. They’re telling you it’s empty and clean, but maybe it’s not."

Now the business associate "has something to do with saying goodbye to the patient who left and may have been the person who called the family to pick up the patient. The business associate is doing the chart preparation, the appointment scheduling, preadmission, admission, and is like a unit clerk," explains Seligman.

Physicians praise the new arrangement, Sullivan notes, relishing the fact that they’re dealing with the same two or three people on each admission, rather than any one of 20 or 30 admitting planners.

"The biggest benefit and the lesson learned is that we took a large hospital and made it into [nine] smaller ones," she adds, "bringing leadership and authority down to a more local level. The business associate has a working knowledge of who’s coming and going and can be more specific about date, bed, and time."

Although Sullivan says she’s still unsure that the new way of doing things is "that much less expensive," she’s positive it costs no more than the old way. In an industry where "patient-focused care" and decentralization efforts routinely deteriorate into money pits, that’s a dramatic endorsement.

"It’s all a matter of how you approach it," adds Seligman. "Many, many institutions use the phrase patient-focused care’ to mean, We cut the skill mix and saved money.’ A lot of the bad connotation is that it is a fancy word for fewer nurses. Our project intended to find a savings that wouldn’t cut bedside nurses."

With that in mind, he says, Mount Sinai project leaders "talked to every [consulting] company we could find," finally selecting a firm called Patient Focused Care Associates, which has since disbanded. The result was "a very nice partnership," with one overriding theme: "Every redesign step has to have an economic target. We don’t go forward with the design otherwise. Savings requirements are built into every step of the process."

That means less management and less support staff, he points out. "I don’t want to suggest that everything is perfect. It’s a skinnier scheme. There’s a lower head count on floors than we used to have. People come to you to complain that on the night shift there is no one supervising the support associates."

Ensuring the quality of registration data is "definitely one of the challenges," Seligman says. The finance department initially double-checked every admitting packet and provided feedback to every care unit. "They still do a lot of checking and [issue] a weekly report about incomplete packets."

The registration process, Seligman explains, typically works like this:

"When the physicians, 95% of whom have a home’ care center, have a patient to be admitted, they call that center and talk to the business associate, who takes the information, calls the patients [to preadmit], and then [passes the account] to a financial screening person. It’s an easy handoff because of the computer system."

In three of the nine care centers, however, financial planning has been added to the duties of the business associates, Seligman notes. Plans are to extend that function to the other care centers as the necessary training is completed, he says. That process has been slow-moving because of the feeling that whoever does the financial piece must spend a month in training, he explains.

Despite the ongoing challenges, he says, the result of Mount Sinai’s re-engineering is "a better-functioning hospital at a lower cost." Staff are more accessible to patients, and physicians and business associates feel more a part of the care team, he adds. "Patients feel that difference."