Nurses help ED collections and customer service grow

Hospital’s Press Ganey rating soars

Cash collections in the emergency department (ED) at Wake Forest University Baptist Medical Center, in Winston-Salem, NC, have almost doubled in the past two years as staff continue to focus on enhancing customer service and gaining buy-in from clinicians. The hospital’s ED operation was highlighted in Hospital Access Management’s June 2002 issue. Keith Weatherman, CHAM, associate director of patient finance, notes that, since that time, monthly collections have increased from about $25,000 to — as of April 2004 — about $42,000. May figures were on track to surpass that, he adds, with an expected total for fiscal year 2004 of more than $350,000.

Before Baptist Medical Center began a formalized discharge process in February 2002, annual ED collections had been about $70,000, Weatherman says. "We’ve been [making some] continuous improvement over the past two years," he adds. "One of the things that has made a difference is going to a quick registration’ function. [Access staff] have miraculously been able to work with nurses to get them to agree to go into the computer system at triage, do a patient index search, and assign an account number."

That step, instituted by ED registration manager Charlynne Lynch, has virtually eliminated patient wait time and any registration bottleneck, Weatherman says. "Registration is no longer a factor in delaying patient treatment." Before, with pertinent patient information placed on a piece of paper and handed off, there often was a delay in placing treatment orders, which require a patient account number, she notes. "In the past, a bottleneck would occur between patient triage and patient treatment," Lynch explains. "Registration, which took place before a patient was assigned to a treatment room, could take up to 10 minutes. We’ve been able to eliminate that by completing a quick registration — done either by the greeter or, if a room is available right away, at bedside."

Early registration means faster treatment

Because order entry can be done at triage, treatment begins immediately in some cases, she points out. "There are some protocols that can start at triage." That might be the case, she adds, if a patient comes in with pain in the left ankle and an X-ray is called for. "They can even do urine [tests] before the patient goes back."

"What the nurses are doing is searching [the computer system] for the patient’s name," Lynch says. If the name is there, the nurse does a quick registration using the medical record number and basic identifying information, she explains. If there is no existing account, the nurse creates a medical record for the patient and then does the quick registration. Emergency Medical Treatment and Labor Act regulations are not a concern, she explains, "because we’re just asking for demographics — date of birth, reasons for the visit, attending physician. It’s really just a patient identification process."

While many registration managers would "shudder at the thought" of allowing nurses to do that computer search and assign medical record numbers — for fear they would create duplicate accounts — the process has not been a problem at Baptist, Weatherman notes. "If [nurses] can do lifesaving procedures," he adds wryly, "I think we can trust them to do this. It’s not like it can’t be fixed if they do make a mistake."

To ensure accuracy, Lynch points out, nurses received special training in the procedure, and get feedback — and additional training — if there are duplications or other errors.

Since the quick registration process was implemented, Weatherman says, the hospital’s customer service survey scores from South Bend, IN-based Press Ganey Associates — already in the 99th percentile overall — have gone up another 2.5 percentage points for the ED. For the quarter ending March 31, he adds, Wake Forest University Baptist had the highest overall ranking of any Press Ganey client in the nation.

Another plus, notes Lynch, is that the number of ED patients who leave without being seen also has been reduced significantly. That figure went from a high of 9% at the beginning of the hospital’s fiscal year, in July 2003, to 3% for April 2004, she adds. Much of the improvement has been attributed to the quick registration process and the ability to start treatment at triage, Lynch says.

ED staff focus on gathering information for the full registration during the period after the patient has gone back for treatment and family members have arrived and are in the waiting area, she says. "We also have an opportunity to bring closure at the back end," Lynch continues. "At discharge, a nurse will escort the patient back to the discharge desk, where we do a final review. We are able to look over the patient account, make sure we have all the information we need, and we schedule return visits to our downtown clinic for those who don’t have a primary care physician."

Final review aids patient care and payments

One of the most positive things about that final review, Weatherman points out, is that the first thing the employee asks patients is whether they have any clinical questions. "If they do, we call the nurse to come back and talk to them." Weatherman had successfully instituted a similar process at another hospital, he adds, in response to patient complaints. "People said things like, I was hurting, and all they wanted to know was how I’m going to pay.’ We want them to know that we really do care about their treatment."

Registrars follow a script, Lynch explains, that begins, "How was your visit?" After asking if there are questions about treatment, they offer to schedule the follow-up appointment, and then say something like, "How would you like to make your copay today?" or "I see this is personal pay. We do have a requested deposit on your account." These self-pay patients, she adds, are asked to put $275 toward hospital charges and $140 toward physician charges, which was part of the process that required "working out some logistics with the accounting department."

Collecting for physicians helped the hospital get their buy-in on such things as making sure patients are escorted to the discharge desk, says Weatherman. "They’re on our side. The team approach has been one of the big [positives]. It’s like one department down there." The formalized discharge process also ensures that, for the most part, patients do not leave without checking out, he says, noting that of some 6,100 patients who came through the ED in March, only 30 left without coming to the discharge desk.

Arrange follow-up visits

Scheduling the follow-up visits to the hospital’s primary care clinic has paid off in several ways, Weatherman notes. "We used to just give the patients a phone number and leave it to them to call. Most didn’t do that — they would just show up in the ED if there was another problem."

With the present system, he says, about 70% do make that follow-up clinic appointment, and perhaps continue to use the clinic for their nonurgent health care needs. This likely has had a direct bearing on the fact that the percentage of self-pay ED patients has gone down, Weatherman adds.

Further enhancing the operation, Lynch says, is the newly remodeled ED registration and discharge area that opened in March 2004. In addition to a separate area for "fast-track" patients, she adds, "we have a better area in which to interview people, with private booths for more confidentiality. [The remodel] has improved both customer service and patient flow."

[Editor’s note: Keith Weatherman can be reached at (336) 713-4748 or at, and Charlynne Lynch can be reached at (336) 713-4708.]