Re-engineering strategies

ZLUH eases patients’ journey through the system

Complex admitting procedures streamlined

Taking a patient from pre-admission through discharge can be a complicated, expensive enterprise. The sheer number of people and departments involved, the myriad entities whose needs have to be met, the avalanche of paperwork, and the ultimate goal of a successful patient outcome can make the process a recurring nightmare for all involved.

"We are seeing the emergence of the empowered consumer," says Philip A. Newbold, CEO of Memorial Hospital and Health Systems in South Bend, IN.

"Much of the re-engineering activity within the health care field is being driven by customer service issues. Consumers are accustomed to moving through retail and financial systems with their information being gathered once and then being shared throughout the system to make their interactions run more smoothly. The health care field, on the other hand, has built in a lot of redundancy," he says.

Many health care facilities recognize their redundancy, procedural inefficiency, and the fact that their customers — patients and their referring physicians — are becoming dissatisfied. And like any other industry, dissatisfaction ultimately results in a loss in revenue.

This was the case at Zale Lipshy University Hospital (ZLUH) in Dallas, explains Dale Leach, process redesign coordinator for the 152-bed med/surg tertiary hospital. "In order for us to remain competitive, our systems and technologies for our high-quality service hospital needed to be radically redesigned," she says. "What brought the admitting and care management departments to the re-engineering table was that our physicians requested to have the capability to make one phone call to schedule an admission."

Prior to the redesign, a physician may have had to call radiology, surgery, and various other departments to schedule an admission, Leach notes. "And there were long waiting times in our admissions process. The satisfaction ratings from our patients and physicians were declining."

Taking the urgency out of discharge planning

Assessment for case management revolved around discharge planning, she says. "We had social workers performing the discharge planning and utilization management personnel securing the insurance and certifications for the medical care. Our discharge planning began the day of discharge, which resulted in an urgency mentality. This created a trickle-down effect of late planning in placement, in transfers, in patient and family communications, and in delays in equipment sourcing," Leach says.

"We were ready to totally redesign this department targeting two vital areas: admitting and care management," she adds. "But, unlike many other re-engineering efforts in health care that seek to cut costs by reducing labor costs, Zale’s promise to each employee is that there will be a job in the house for you.

"Administration requested that the re-engineering department evaluate the existing status of the two areas for the purpose of launching a redesign team and project," she recalls. The project began in July 1998, and by October 1999, it was 80% complete. "On Oct. 18, 1999, central reservations launched one-stop scheduling. We began with orthopedics as a pilot and will add one service at a time, refining the process as we go along." Other ZLUH re-engineering projects have been pharmacy, radiology, observation, and patient services.

The scheduling is performed by a licensed RN who schedules the necessary events such as the operating room, radiology, the laser center, ancillary services, and pre-admission testing. At that time, the scheduler also gathers the patient’s demographics and other information such as advance directives. Simultaneously, the patient’s insurance is electronically verified, including copay and deductibles, if available.

Then a phone call is made to the physician’s office and the patient to confirm the itinerary and to discuss any special needs — such as supplies or allergy/isolation needs — for the patient prior to arrival. "The patient’s financial and logistical education is also addressed at this phase. This reduces repetitive questioning and wait time for the patient. It is also less confusing and more informative to have one area schedule and coordinate for the patient’s convenience," says Leach.

The patient is then sent a packet of information including the itinerary and signs off on the itiner-ary. "This makes your patient better informed about his or her stay and may increase patient satisfaction," Leach states. Once at the facility, a care coordinator sees all new patients.

"The goal should be to make a patient’s health care experience as seamless, warm, and terrific as possible," says Newbold. "It shouldn’t be like going to the bureau of motor vehicles. If we remove our inefficiency and redundancy, we will be more productive and have more time to interact with our patients and to make their experience more personalized."

An enterprisewide approach

A key to attaining such a complicated objective is a facilitator whose responsibility it is to ensure that the project stays on track. "I was the facilitator for the admitting and care management project, which included the creation of central reservations," says Leach. She was the natural choice for the role as she is the hospital’s process redesign coordinator and has experience in research and development.

"The goals of the projects were to identify and eliminate activities that add no value to our customers and to capitalize on the knowledge of the redesign team to develop new and more effective processes," she says. The overall strategy was to:

• Identify gaps between the current process and an ideal system.

• Design a new delivery system to meet customer and cost target goals.

• Facilitate in redefining jobs and accountabilities, setting performance standards and productivity targets, and to define work-scheduling systems for the optimum use of the staff.

• Develop and implement work measurements and monitoring tools to allow evaluation of staff performance relative to the targets.

• Add resources such as training, technology, and space requirements to support the implementation of the re-engineered delivery systems.

• Evaluate the results of the project relative to the plan and then to revise the plan as indicated.

• Train staff members to maintain and extend the new programs throughout the organization.

Leach outlines the redesign team’s approach to the re-engineering as follows:

1. A multidisciplinary team met for four hours per week for three months. After three months, the management team began meeting for two hours weekly for a year.

2. The team initially created the vision and objectives for the project. Then it gathered data to determine the hierarchy of customers (including hospital staff and physicians), identified the core processes, and developed goals and measurements. Additionally, to validate productivity measurements as well as costs, overall target goals tied to admissions and weighted patient days were stated.

3. An evaluation of staffing levels in admitting helped the team forecast the development of the central reservations re-engineering project.

4. The team established an extensive education process about the central reservations redesign and the newly developed care coordinator positions for the outpatient offices. It also educated in-house staff and physicians about one-stop admitting and the discharge planning aspects of the project.

5. The team identified and implemented utilization management software to assist in the standardization of the care coordinator positions and the reporting of insurance.

6. The team brought in seven vendors to demonstrate their enterprisewide scheduling software. Then the team evaluated the software based on its benefits, how well it would integrate with systems, and the cost. The team chose the top three programs and recommended them to the information systems committee for budgeting, purchase, and implementation.

Has it worked? "Our productivity was increased significantly and our labor costs were reduced significantly throughout the department," Leach says. Within months of launching the project, care coordinators were retained or hired and were performing their duties.

"The continuity of care, patient education, and communication surrounding discharge procedures were well received by the physicians," says Leach. "The rapport created has established, according to the physician offices, a more personal approach. And the patients and their families were very complimentary as well."

The results of the other aspects of the re-engineering were equally positive, according to Leach. "The admitting office began to be able to predict crunch times caused by a high number of surgeries and to predict a high census as well. This advance knowledge allowed it to make suitable adjustments, thus diffusing staff tension."

Early in year two of the study, central reservations began to assume scheduling duties for the hospital including OR, radiology, laser surgery, seminars for the laser surgery department, and pre-admission testing. Also during the second year, the insurance verification and utilization management software was implemented. Once the enterprisewide scheduling software is in place — it’s in the 2000 budget — the combination should allow for the reduction of at least one full-time equivalent housewide by centralizing the schedulers from each department into one.

Buoyed by the success of its initial re-engineering efforts, ZLUH continues to launch task forces to tackle other areas and bring them into state-of-the-art proficiency.