Centralization doesn't mean sacrificing quality

Consistency in standards, measures was goal

When Providence Health System began regionalizing many of its departments - including access services - a couple of years ago, centralizing the quality and training functions was near the top of the agenda for regional access director Barbara Wegner, CHAM.

The idea was to combine and standardize operations at the three Portland, OR-area Providence hospitals, each of which had its own quality measures and training programs, into one department.

Her goal was to monitor the quality of employees' work and have a sophisticated training program from the beginning, she says. "I wanted [employees] to know our objectives, which are to make a strong positive impression on the patients and families and to get high-quality demographic information the first time around, so we have a billable account and the bill can go electronically."

A year after the department's inception, Wegner describes the results as "excellent. We're getting high-quality work, the business office is happy, and the employees feel good about the training and the quality."

Located in Providence Office Park near Providence Portland Medical Center, the department is staffed by five quality and training analysts, with plans to add a sixth in the near future, says Jeanne Hughes, regional manager of quality and training for access services.

"I felt strongly that I wanted training to be off-site and out of the department," Hughes says. "The previous experience had been that when there were staffing problems, the trainer was pulled in to help out. I wanted to be sure the trainers were dedicated to training and not day-to-day operations."

The department trainers often were highly skilled access services employees who could work in other areas, she explains, and when a last-minute sick day was called in, that employee was pulled out of training for the day or for several hours. "It was important that we had dedicated training space and a classroom that is not shared," she adds. "In the past, we often had trouble [booking space] for the amount of time we needed."

To create the new department, the quality and training employee at each of the two larger Portland-area facilities was brought in (the smaller hospital had no full-time trainer), and three more full-time equivalent positions were added, for a total of five quality and training analysts, she says. A sixth position, to focus on Medicare compliance, is budgeted for next year.

Hughes says the five existing staff members specialize in these areas: training, quality management, technical writing and documentation, liaison with the information systems (IS) department, and combination quality assurance and training.

The analysts were hired in October 1997 and had to start training employees almost immediately. For that reason, the department's biggest mission - building "modules" for each training topic - has been an ongoing challenge, she explains. Analysts are in the midst of writing these training modules for each of about 45 topics, including collecting copayments, advance directives, basic interviewing skills, and insurance, among many others.

Some modules are written by the analyst with the most expertise in that area, while others are a group effort, Hughes says. For example, the IS liaison drafted the module on log-ins and computer security, but everyone worked on the customer service module.

"The agreement is that we review the modules as a group, so if anyone has to go in and train [in another specialty] because someone's out, we'll do it in the same way," she adds. "This includes not only the topic and the key points, but the handouts or video we might use, the follow-up questions, and different modalities like Power Point presentations or using games to break up dry material."

This standardization also makes it easier to take a training module "on the road" to departmental meetings or to a specific facility, Hughes points out. "We know what we need to cover and how long it takes to teach it."

In March, for example, one of the analysts was off-site for a good part of the month, training on the health system's regional data set. The data set - which Providence personnel spent about two years drafting - includes about 180 elements that have been standardized across the health system, she explains.

For example, it specifies such details as whether a hyphen is used in certain word combinations, or whether there is a space between the two parts of a name like "St. George," Hughes says. "It clearly defines each piece of data, its format, how it's collected and entered into the computer system, so as the health system moves toward an electronic medical record, we're using the same data standards."

Other projects the quality and training department is involved in include the following:

· Creating regional policies and procedures.

"We have a Joint Commission visit in October at one of the facilities, so we decided to seize the opportunity to go to regional policies and procedures," she says. "The [access] managers and I are meeting weekly to go over the policies for half a day and at least once a month for a full day."

The group has come up with the structure for how it will develop new policies, Hughes says, and as the policies roll out, how it will implement them at each facility. For example, they're working on reports to monitor the collecting of advance directives information. The idea is to make sure staff in all the appropriate locations are asking for and documenting the information in the same way in the computer system.

· Focusing reports on known problem areas.

"We have about 15 different reports that we work on on a daily basis," Hughes says. "We're working on a new report that looks at any time a primary care physician [is not collected] for a managed care plan that requires one."

Other reports look at multiple accounts opened on the same day, failed bills, duplicate medical record numbers, and exception reports regarding, for example, preadmits with charges on them. The latter situation, she explains, means the registrar either didn't change the status of the patient or put charges on the wrong account.

"We're trying to be proactive on reports, not just writing a report every time we see a problem, but identifying areas we want to watch," Hughes says. "We're still doing trending and trying to establish baselines."

· Providing feedback on individual training needs.

The analysts do a limited amount of face-sheet monitoring because it's so labor-intensive to monitor new employees for a short period of time, in addition to the other employees whom they have a concern about, she adds.

· Working with information systems.

The quality and training department's IS liaison coordinates all of the log-ins and passwords for access services personnel, as well as working with IS on software upgrades and installation, Hughes says. That analyst is involved at present in a Windows 95 upgrade that includes 140 personal computers distributed among access areas in four locations.

"[The IS liaison] is scheduling the work so as not to take hardware out of service during peak periods and addressing problems as people find them," she says. A big piece of her job, Hughes notes, is evaluating new products on the market that might be of help to managers. "She translates IS technical talk into language managers can understand so they can make a good decision about their computer needs."

· Producing The Accessor newsletter.

Every two weeks, the quality and training department produces a one- or two-page access services newsletter with a regional focus, she says. It covers major changes, perhaps a new policy that's highlighted and reviewed, and insurance additions and updates. "We work closely with the regional business offices," Hughes adds. "They often send things to be included, such as trends and Medicare compliance."

There's a "Customer Service Is . . ." column and occasionally a profile on an individual employee, she notes. Although the department's technical writing specialist takes the leadership role with the newsletter, if another analyst has a topic that needs to be covered, he or she is responsible for writing that article and getting it in by the deadline, Hughes adds.

· Developing a database for all employees.

This project, which is still in the design phase, aims to develop a database of all access services employees that will enable managers to track both their errors and their progress in different areas, she says. "We're hoping to begin building it by the end of summer. We need a better way to trend and watch things over a period of time."