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At M.D. Anderson Cancer Center in Houston the organization’s commitment to access services is exemplified in higher-than-average salaries for admitting and registration employees, and in a director whose status is on par with some of the hospital’s top administrators.
"Admissions really is seen as a very strategic area," says Paula Shackelford, RN, MSA, director of admissions and new patient registration, whose position is at the same level as the administrative directors of the hospital’s disease-site centers.
In practical, day-to-day terms, she explains, that commitment translates to a long-term staff with good morale and a strong focus on customer service. "We want people who have good customer service skills. We can train them to use our on-line system, but we need them to be responsive and communicative."
The starting pay for admitting and new-patient registration employees is $24,800, but many of her staff have salaries in the "mid to upper 30s," she adds.
Most of the admitting employees have been with M.D. Anderson more than 10 years, Shackelford says, and the new patient registration staff is even more tenured. She credits the manager in that area, "a 25-year employee who is just fabulous." One staff member recently retired and came back to work part time, she says.
Although most of the staff have only a high school education, two have college degrees, several have some college experience, and several more presently are in school, Shackelford says.
About a year ago, some other hospital employees with similar duties were elevated to a higher pay level, and Shackelford was concerned about a possible exodus from her department, she notes. "I was able to get my staff reviewed and to get their salaries raised as well."
The hospital as a whole has a tuition reimbursement program, paying a percentage of the cost of courses successfully completed, Shackelford says, and her department helps employees pay for continuing education when possible. For example, it is covering half the cost for employees who wish to take a course on medical terminology and entry-level anatomy being offered at Houston’s Baylor University.
Admitting and new patient registration employees receive ongoing, in-house training as well, Shackelford notes, much of which is based on customer service. Topics range from practical matters such as infection control procedures to subjects such as team building, which enhance the work experience, she adds.
M.D. Anderson has a bed capacity of 468, and an average daily census of more than 370, Shackelford says, and sees about 1,000 to 2,000 outpatients a day. "Less than 5% of our patients come in as inpatients for the first time."
Treatment at the hospital is arranged around disease site centers, she explains, with a breast center that provides medical and surgical care for breast cancer patients, and so on for the other kinds of cancer. "The patient has a one-stop shop on the outpatient side," Shackelford says, "and that philosophy is carried over to the inpatient side. Units are divided up by the kind of cancer or problem that the patient has."
Patients receive a bed assignment in the primary unit for their condition, and if that is not available, to a secondary assignment, and finally to a tertiary assignment if necessary, she explains. "About 93% of the time, we place the patient in the primary or secondary service assignment," Shackelford says, "and that has held up over the past few years. We’re constantly tweaking [the bed-control process]." (See illustration, below.)
Maintaining that level of service means that bed control can be a complicated and sometimes stressful job, she points out. With occupancy at close to 85% most of the time, Shackelford says, finding the most appropriate place for the patient requires an employee who can quickly make decisions under pressure while exhibiting good customer service skills.
This triage of patients is a challenge, she explains, because it involves not only the 50 or 60 scheduled patients for that day, but those who have been in the recovery room overnight who need to be moved out so others can get in there. Then there are maybe eight to 10 patients in the intensive care unit (ICU) who need to be moved out, as well as patients from the emergency center who need to be admitted, Shackelford adds.
Bed placement, then, is a process of looking at the whole picture and determining who goes where, she says. There are guidelines — overnight recovery patients first, then ICU patients, then emergency center patients, then scheduled patients, then add-ons, Shackelford says.
The hospital uses simulation models to plug in actual numbers and patient days by unit, and then make changes, she adds. "What if we move this group of patients to this floor, or what if we increase telemetry beds by this percent? What will it do to our ability [to place patients appropriately]?"
All bed allocation work and simulation models are done with the input of admissions staff, Shackelford says, an indication of the regard in which the department is held.
Burnout is high in this area, she adds, as staff deal with pressure from physicians attempting to get optimum placement for their patients and patients upset about long wait times. "People say they’re preadmitted and they don’t understand that it’s not like a room reservation." To make those long waits more palatable, she says, the admitting department instituted a program more than a year ago called "Enhanced Waiting Through Courtesy, Comfort, and Care." (See "Admitters get grant to enhance wait time," in this issue.)
To reduce burnout, staff are periodically rotated out of bed control, Shackelford says. The 11 admissions employees and 16 new patient registration employees are cross-trained, and are called upon as needed to help out in other areas, she adds.
"We register 500 patients a week as brand-new patients to M.D. Anderson," Shackelford notes. "On Monday, there may be 130 new patients, and we may pull someone from admissions [to help in new patient registration]. The busiest time in admissions is 1 p.m. to 7 p.m., so then we might pull from registration to admissions."
Admissions and new patient registration employees work closely with the authorization department, which is under patient business services, she notes. Patient admission information is entered into the computer at the point of origin and constantly updates the admission list, Shackelford explains. The computer system also generates a notice to the authorization department — which has offices at the various disease site centers — so that the admission can be precertified, she adds. Although the business office is in the process of being fully decentralized, some of the operations are still handled in a central office, she notes.
Earlier this year, Shackelford says, there was a point of dissension between the two departments when a significant number of patients began showing up for admission or registration without their financial authorization in place.
"Someone would show up for a first appointment, which had been scheduled for three weeks, and our staff would be caught in the middle [because the authorization had not been obtained]," she says. "We can’t assign a patient number or start a chart unless the person is in approval status."
To address the problem, Shackelford adds, her staff began checking the list of scheduled patients the day before and politely notifying their counterparts in the authorization department if a precert had not been obtained. In addition, she says, they began doing an audit report every two weeks, tracking by disease site center patients who came in without financial authorization.
"When we started in the first part of the year, for the two-week reporting period we were running about 150 cases that had not been financially cleared," Shackelford says. "Now we’re down to 15 or 20."