New access career ladder adds incentive, fairness

Morale has been wonderful’

Access personnel at the University Hospital of Arkansas in Little Rock can look forward to moving up a recently established career ladder that is boosting morale as well as paychecks, says Mary Nellums, CHAM, admissions manager. As is true at many health care organizations, the access department had been plagued by employee turnover, she notes, in part because of a discrepancy in work requirements between inpatient registrars and staff performing registrations in ancillary departments.

Salaries were about the same for those working with inpatients and in the emergency department (ED) as for clinic employees, although the clinic job is much less demanding, Nellums explains. "[Inpatient registrars] have to do a lot of different types of registrations, including admitting newborns and labor and delivery patients. They have to remember how to register an observation patient and someone who is having outpatient surgery."

In addition, Nellums says, registrars in the ED — where turnover was particularly high — have to rotate taking weekend shifts and often have to work holidays. "We would train [inpatient] staff and they would end up leaving to work at the clinics."

Under a new tiered system that has been in effect since November 2003, she adds, job descriptions have been established for level one, two, and three registrars, with placement on the career ladder dependent on a combination of factors. "When we finally got approval to give this incentive to move up, we did a career ladder scoring sheet based on five criteria," Nellums says. (See scoring sheet.) "We gave 20 points for each section, based on registration accuracy, attendance, patient/registration delays, customer service, and whether [the employee] worked within the parameters of established hospital and department policies, procedures, and protocols."

Because registration audits are regularly performed by revenue integrity personnel, she notes, "it’s easy to go back and pull a certain person’s accuracy report. We started at [assigning] 20 points for 100% accuracy, and those who went below 94% got zero points." The other information needed for rating employees also was right at hand. Nellums adds. "Attendance was easy [to measure], and it was easy to see if there were patient or registration delays or customer complaints."

Access representatives who scored 0 to 33 points stayed at the existing salary level of about $22,000 a year, she says, while those who scored 34 to 67 points moved to level two, which added just under $3,000 per year. Sixty-eight points or more put an access rep at level three, with a $5,000 increase over the level-one pay.

New hires, Nellums explains, automatically fall into level one unless they have extensive experience or education. The flexibility exists to bring more experienced individuals or those with degrees in at a higher level, which is a more subjective aspect of the system, she notes. Of the 18 admissions employees, Nellums adds, three stayed at level one, 12 went to level two, and three went to the third level. "Morale has been wonderful," she says. "I explained to each person individually where they were, and the reasons why, and told them, Here are the areas in which you need to improve; and if you do, here is where you can go.’ Some are about five points away from the next level. They are so excited that they have somewhere else to go."

While it is difficult to determine the exact cause-and-effect dynamic, Nellums notes, "accuracy has gone up for several people. I’m not sure if it’s just an adrenalin rush, but we’re looking to see if it continues."

The main difference between access levels two and three is that reps who have reached the higher level are expected to serve as "leads" or preceptors, and to fill in as supervisor as needed, she says. "They’re able to use more [computer] functions," Nellums adds, "such as being able to go back into an account and do updates and corrections." In addition, she says, level-three employees "are skilled insurance/financial counselors and have more years of experience and educational background."

The score sheet, Nellums adds, helped determine where existing employees would fall. "An additional $500 for each year of actual hands- on experience — up to four years — was added to base salary." The department’s insurance representatives, she notes, already are at a higher salary range — about $29,000 a year — and as yet are not part of the career ladder. "We’re looking at a way to build in some incentive for them as well."

To ensure the successful establishment of the career ladder, Nellums points out, "we worked hand-in-hand with [the] human resources [department] to make sure we didn’t do anything wrong. We are part of a university and have a lot of rules and guidelines." To avoid any misunderstanding, she recommends letting staff know from the beginning what the new job descriptions will entail. "Once you determine you can give more money," Nellums adds, "sit down with employees and let them know more will be expected: Here’s the plan, but I need to know that you are willing to give me more.’"

(Editor’s note: Mary Nellums can be reached at