Admitting area redesigned for hospital’s QI project

Effort targets accountability, customer service

When it came time to reinvent the admissions process at St. Helena Hospital in Deer Park, CA, admitting director Peggy O’Neill faced tasks ranging from a complete overhaul of the staffing structure to a redesign of the department’s physical space. When O’Neill came to work at St. Helena in October 2001, changes already had been initiated, she says, thanks to a hospitalwide effort by senior management to determine "what single process needed to be improved for the good of all."

With the Malcolm Baldrige National Quality Award Criteria as a guiding force, team leaders from all the hospital’s departments were broken into four groups and held roundtable discussions to determine what that process would be, O’Neill explains. "They were looking for the one thing that would improve customer service and the hospital as a whole."

When the brainstorming was over, she says, the area to be targeted was clear: "They all unanimously came up with admitting."

As part of a patient-focused care initiative, O’Neill notes, the hospital’s admission process had been completely decentralized and was taking place on the nursing units. What had drawn the censure of the team leaders, however, was not so much decentralization, she says, as it was the lack of accountability. "Training was poor at best, and the registrations were problematic," O’Neill adds. "Patients were not getting to their appointments on time, and there were inaccuracies in billing that slowed down reimbursement. Denials and write-offs were high, and the hospital was getting multiple customer complaints."

By the time O’Neill joined the team, she says, the health system’s corporate patient financial services (PFS) director — who had selected St. Helena as the hospital to establish best practice for admitting — had laid the groundwork for the departmental redesign.

"[The PFS director] was instrumental in taking the temperature of the end users of the [admitting] products, getting the state of affairs and the areas that could improve, and developing a template," O’Neill explains. Those end users included the directors of hospital departments, physicians, and even members of the facility’s board of directors, she adds. "They frequent our hospital and certainly could see that improvements were needed."

The PFS director also worked with the director of case management — who had oversight for what at that time was a very decentralized admitting process — and the chief financial officer, O’Neill adds, to determine the number of full-time equivalents (FTEs) that would be needed and to figure out the job classifications for the new staff.

At that point, in October 2001, O’Neill was hired, "and they turned it over to me to make all this happen," she says. "I wrote the last of the job descriptions, decided where the existing staff would be placed, and did the hiring, which took place over the next six months."

Designing the space

A big part of creating the new admitting department had to do with "redesigning the workstation environment from the ground up," O’Neill says. Her experience designing registration areas at three previous facilities came in handy, she notes, as she worked on the project with an outside architectural firm. After a couple of drawings in which the architect could fit only eight workstations in the main admitting area, O’Neill says, she redrew the plan and made space for 11 workstations, drawing on her knowledge of where people and equipment needed to be placed.

About 85% of the admitting process is centralized now, she notes, albeit with a physical presence in outpatient registration, which is about 100 feet down the hall, and the emergency department (ED), which is about 150 feet in the other direction.

"Some [of the process] is decentralized by location only," O’Neill adds, including in the behavioral health center, the women’s center, the hospital’s physical therapy sites, and a job care clinic. Registration staff in those areas, she says, have "dotted-line accountability" to admitting.

The next task O’Neill tackled was interviewing the existing staff members, she says, "finding out what each one really liked to do and was good at. We weren’t laying off people, but were determining who had the skill set, temperament, and demeanor for certain jobs." For example, O’Neill explains, one employee felt stressed in her job of doing bed control, which came out in her voice as she dealt with people over the telephone. That person, she says, was reassigned to an insurance verifier position, where she could determine her workflow. "That was the type of decision I made," O’Neill adds. "There was a little bit of psychology involved. We wanted to help those people who had been reporting up through other cost centers — such as the ED, outpatient surgery, or the nursing units — fit into the new state of admissions."

That left her with the knowledge of what positions remained to be filled, she notes. "I worked closely with human resources, and from November 2001 to June 2002, we were very heavy on hiring."

When she came to St. Helena, O’Neill says, there were 11.5 FTEs to cover central admission and outpatient registration, 24 hours a day, seven days a week. When the hiring process was completed, she adds, there were 22.7 FTEs.

"Some came in as a result of transfers from other cost centers, and some I had to advertise for," O’Neill explains. "We added staff in the ED and in the main admitting area, and then we had to layer in several more positions, including another financial counselor, preregistration staff, and a [designated] bed control person.

Several key positions — most notably the outpatient financial counselor and the pre-registrars — added the time and expertise needed to facilitate the hospital’s dramatic increase in over-the-counter (OTC) cash collections, she notes.

In the admitting area alone, monthly upfront collections have gone from $7,500 to $100,184. (See average upfront monthly collections chart.) St. Helena now leads the 20-hospital Adventist Health system in OTC collections.

The idea behind the admitting initiative at St. Helena, she notes, was to provide the other Adventist Health hospitals with a model not only for cash collections, but also for registration accuracy and efficiency, customer service, and reducing denials and bad debt.

In addition to using general industry standards, goals for the various registration practices are set for each facility by the system’s corporate office in conjunction with the hospital’s senior leadership, she notes. Customer service scores are not to drop below "4" on the hospital’s 1 to 5 rating system, for example. And the industry standard is that OTC collections should total at least 1.5% of total hospital collections, O’Neill adds, a goal the hospital exceeded by mid-2000. (See upfront collections chart.)

Before implementing some of the changes in the admitting process, St. Helena was preregistering between 4% and 5% of patients, she says. Now the figure is 96% of scheduled cases. Accounts receivable days have been reduced from 77.4 in January 2000 to 48.5 in June 2004, O’Neill notes.

In recognition of its improvements in the admitting process, St. Helena received Honorable Mention for the Best Practice Admission Model in 2003 from the California Council for Excellence, she adds. The support — both financial and psychological — of the hospital’s senior leadership team was a very big part of the department’s success, she points out. "The hospital leadership was very enthusiastic about taking on this role and lobbied for it," O’Neill says. "Once the decision was made, the money to fund this kind of redesign was there. They were committed to putting the department together the right way."

"It was so nice to get brand-new PCs and other equipment," she adds. "If they had said, Make do with old technology and with having staff scattered throughout the hospital, these changes wouldn’t have been possible. We made a complete 180-degree turn."

[Peggy O’Neill can be reached at (707) 967-3687 or]