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[Editor’s note: The following two stories focus on health information management (HIM) and medical records directors who found themselves trying to coordinate multicampus operations in the middle of a complex and evolving environment. In the process, both directors gained a wealth of knowledge and advice for HIM professionals who may soon find themselves involved in managing a challenging transition.]
Jim Braden, MBA, had quite a directive when he began working as the director of health information management for the Detroit Medical Center (DMC) in June 1998. The medical center had undergone a corporate merger the previous year, and the eight hospitals in the system needed to be integrated.
"Upon arrival, I had essentially eight silos’ or distinct medical records departments with separate staff in each of the facilities," Braden says. "The challenge was to construct an organizational structure, develop business processes, and identify the business systems that could bring it all together."
Before he began making any changes, Braden and the management team he inherited, along with the assistance of the vice president of finance, spent time listening to the "customers" that use HIM services.
These customers included medical staff and department heads, as well as corporate staff, support staff, and clinical staff — the frontline medical records staff who would be charged with actually doing much of the work — plus users on the fringe of DMC. Braden’s team was also assisted by local representatives of the consulting company Ernst & Young.
After about six to eight weeks of this research, Braden says he had a good sense of the HIM needs. "We made a gap analysis of where we were, where we needed to be, and what it would take to get there." The team then developed an organizational structure and delineated some of the initiatives that it needed to pursue in the next few months.
Based on his research, Braden decided DMC needed a multifaceted program that involved a "fairly rapid process of re-engineering. I learned that the HIM operation at the DMC lacked some of the basic fundamentals of information system infrastructure to support business processes. For example, it lacked up-to-date automation supporting the whole deficiency chart completion operation. It lacked automation supporting chart management and tracking. It also needed a Y2K-compliant and efficient coding/abstracting system."
When Braden arrived, DMC had acquired and was installing a coding/abstracting system in the hospitals. Braden’s analysis revealed that the system could not effectively and efficiently meet DMC’s needs. His management team made the unpopular decision to acquire and install another system.
"That was a challenge because the inertia had already begun," he explains. "Resources had already been [expended]; expenses had been incurred. We had to be effective in communicating and convincing folks why the decision they made was not necessarily the best one."
Braden’s team continued the process of planning for the acquisition and implementation of the infrastructure that would support the new application systems. The team is now in the middle of aggressively implementing these products. Braden plans to train personnel in use of the applications on the front end of the implementation, however."Frankly I have found that it doesn’t do a lot of good to immerse the staff in training until after integration testing and shortly before our go-live date."
Braden immediately involved personnel in the revision of several business processes. In his research, Braden discovered that DMC hospitals had a problem with delinquent medical records and uncoded, unbilled accounts. For myriad reasons, the medical center was operating in the range of 14 days to bill for revenue in accounts receivable (A/R). That meant that the eight hospitals had about $47 million in A/R due to uncoded medical records.
Braden’s team quickly mapped new processes and decided what technology was required to address the problem. Instead of just changing policy, Braden focused on determining ways to achieve desired outcomes — such as reducing the delinquency from 14 days to two days — and then making expectations clear to staff.
For example, one step in revising the coding and A/R process was the standardization of transcription operations throughout DMC, which now provides the operative report and discharge summary in support of A/R and patient care.
"You need to determine at what point the outcomes need to be measured and what kinds of information the people need to manage," he says.
"People need to know the goal and need to know the critical path to that goal. They need to know the time frame within which they need to achieve that goal. They also need to know what is expected of them along the process — from patient discharge all the way to the dropping of the bill," notes Braden.
He says he hoped to achieve the two-day goal by June, but final data are not available. Meeting the goal would reduce the accounts receivable figure to about $12 million. In May, the HIM department had succeeded in reducing it to $13 million.
HIM also made a decision to outsource transcription services and have that department report to HIM, rather than to information services. "That provides consistency and standardization across the system so the documentation that is transcribed can consistently move up to our electronic medical record."
Between 55% and 60% of all DMC transcription is now accessible on-line within the medical center. HIM is now working on cleaning the master patient indexes across the system and developing an electronic enterprise access directory. The directory will allow staff to look up a particular patient and see the patient’s continuum of care across the medical center.
HIM could not have standardized the business processes without its partnership with patient accounting, patient management, and the medical staff, Braden says. "We spent a fair amount of time working with our rank-and-file medical staff in leadership to put in place mechanisms to communicate progress."
One of the communication tools HIM developed is a report published weekly to all DMC medical staff leadership that lists delinquent medical records and their impact on cash or A/R. The report names the physicians within each hospital who represent roughly the majority or a significant percentage [of the delinquent records].
"Fewer than 10 to 15 doctors represent the vast majority of the delinquent records of most facilities." The publication has been effective in "eating the elephant bite-by-bite rather than trying to swallow it whole," Braden says.
The medical staff also helped HIM shine during a visit from the Joint Commission on the Accreditation of Health Care Organizations, which took place at the same time as the A/R initiative. Although DMC once had a problem with delinquent medical records, the hospitals scored 96% to 98% in the survey and had no Type 1 recommendations for medical records.
The survey was not the primary distraction in the process of coordinating the different facilities of DMC. The reorganization of the entire medical center was. "I walked into an organization that was about to undergo a lot of change and significant financial difficulty," Braden says.
Soon after his arrival, the DMC board of directors decided to turn to the Hunter Group in St. Petersburg, FL, to help the center get back on its feet. Faces changed as staff left or were replaced. "That reinforces the intensity of the time lines and the intensity of change. Not only are we bringing change to the HIM organization but the world around us is also reorganizing."
The DMC organizational structure migrated from the traditional manager/supervisor/worker scenario to one that involved directors/team leader/teams. Each hospital has a director, and DMC has more than 30 teams across the eight hospitals that are led by team leaders.
DMC is now organized into three regions:
• Central region, comprised of five hospitals;
• Northwest region, comprised of two hospitals;
• Oakland region, with one hospital.
This will all soon change, because two of the hospitals in the Central region and two hospitals in the Northwest region have undergone an asset merger, eliminating the need for two of the directors.
In addition, the structure migrated from an "umbrella" model that focused on the entire system to a "four-wall" organization that focused more on the success of each individual hospital. "If each hospital is successful, and we have standardization of process and system and policy across the system, then the whole system will be successful," Braden says.
His greatest challenge and the greatest opportunity at DMC has been the management of change in a changing environment. "Fundamentally, one of the biggest challenges is building and developing a team and keeping that team informed as they go through change," he says. Change can be unnerving when it happens at such a rapid pace, particularly when you have new faces or faces go away."
DMC’s situation is becoming more common, Braden adds. "Many organizations will go through this type of change. We’re not unique," he says. "[HIM departments] are going to need to be able to come to grips with how to help organizations manage that change."
Much of HIM’s success at DMC is a result of regular communication with HIM staff and users, Braden says. This communication should take place face to face or electronically and should be regular, direct, honest, and succinct, he emphasizes.
"It’s important that managers are visible and accessible. They should facilitate the people who do the work to be progressively capable of making more day-to-day decisions, so the decision making is pushed down in the organization vs. up. That has been our focus," Braden explains. n