Collaboration key in decentralization effort

Nurses, registrars worked closely

When BryanLGH Medical Center in Lincoln, NE, built the Bryan Medical Plaza in 1993 to better serve its outpatients, the emphasis was on customer satisfaction, with a goal of having the patient encounter as few faces as possible during the course of a visit.

That effort, says Marilyn Klem, admissions manager, was fueled by a true collaboration between clinical and admissions staff, with an outcome that could not have been achieved by either side alone.

In the past, explains Shelly Seher, registration manager, outpatients were registered in a central admitting area and escorted by a hospital volunteer to the appropriate ancillary department, where they checked in with a receptionist and waited for a technician to call for them.

Now patients directly report to the point of service, with registrars on duty in eight outpatient areas, she notes. Those include cardiovascular and radiology services, the hospital’s specialty clinics (where such services as preadmission testing, physician consultation, and patient education are offered), outpatient surgery, and off-site locations such as the mammography center, Seher says.

After looking at patient volumes in the various departments and determining the staffing needs, Klem adds, she and Seher rewrote job descriptions to include the new duties the registrars would be assuming. (Both Klem and Seher report to the director of patient financial services.) As registrars were dispatched to the ancillary areas, she notes, there was a corresponding drop in those working in the main admissions area.

Registrars’ responsibilities in the outpatient areas include tasks that are not clinical per se, but rather "clerical duties within a clinical [setting]," Seher says. "They’re answering the telephone, stamping patients’ charts, taking charts back to nurses, and in some areas, entering physician orders. In some cases, they stock the fridge with patient preps, order medical records, and call patients [regarding] clinical appointments."

"These are things not typically done in the admission area," she adds. "On the inpatient side, [registrars] handle orders, but not the handling and stamping of charts."

Other tasks taken on by registrars include taking patients who are having magnetic resonance imaging back to the treatment area and helping them get undressed, Klem says.

"In radiology," Seher adds, "they check and see if certain [required] lab tests have been done before a procedure and, if not, call to make sure they are done so there is no delay."

Five years ago, Seher added four "flotation" staff members, to fill in for registrars in the various areas, she notes. They cover in the case of vacations, maternity or educational leaves, or illness. In all, there are 16.1 full-time equivalents designated for registration in the medical plaza, she adds.

There are some areas where it was not appropriate to place registrars, Seher says, primarily because all of the patients are recurring. "We went with existing staff because there are very few new patients, and the bulk of the work is truly administrative — not registrar work."

In the case of another area, the volume was so low — 10-12 patients a day — that a radiology tech was trained to perform the few necessary registrations, she says.

In most of these areas — which include health enhancement services, physical therapy, and sports medicine — administrative secretaries are cross-trained to do registrations, Seher says. They report to their respective clinical managers.

These employees receive a focused one- or two-day training session with competency validation, she adds. "We look up [the source of] any errors and send them back to that employee."

Monthly meetings held

Seher, who oversees outpatient registration, and the registration supervisor for the medical plaza meet with the outpatient registrars on a bimonthly basis, she says. "They give us input, and we do team-building exercises."

The registration supervisor and the registrars in the different clinical areas also meet — quarterly or as needed — with the supervisors and managers in the areas they serve, she notes. This meeting offers an opportunity to go over staff responsibilities, resolve problems, and talk about any new services that might be planned, Seher adds.

At both meetings, she says, registrars "take an active role in bringing up issues and brainstorming solutions. Unless the concerns are urgent, we ask them to table their concerns until the meeting and submit agenda items five days in advance."

Topics of discussion in the area meetings might include physicians in the pain clinic changing their schedules, a new procedure for making reminder calls to patients, or a change in the way charts are stamped, Seher says.

Although the move to decentralization has coincided with an increase in admissions/registration staff, Klem says, some of that jump is due to an increase in the number of outpatients treated. "Shelly tracks the numbers on a monthly basis to make sure the staffing is where it needs to be."

In line with the focus on customer service, the medical plaza is designed so that patients can easily and directly walk to the point of service, Seher points out. "It’s designed like a mall, with an awning for each area so they can see at a glance where they need to go. The entrances are in a U-shape, but the departments go deep to the back. Patients aren’t going down corridors looking for the right area."

One of the "learning points" for hospitals considering a similar move — and one her staff will keep in mind as they work on the spring 2003 expansion of the medical plaza at the hospital’s west site — is to begin the departmental collaboration right away, Seher says.

"It’s important for nursing to get registration people involved early on," she explains, "so they’re not at the end trying to find a space for registrars." An understanding of the flow of the clinical operation is critical, she adds, to determine the best place to put the registrars and the kind of space they need."

Patient confidentiality, for example, is a big concern, Seher says, as is easy accessibility, proper signage, and space for printers and other equipment.

"You need to understand the entire clinical piece," she adds. "If you’re going to be stamping charts, you want a different kind of work area, a path to walk in. A design for a clinic is different than one for radiology."

The continuing focus, Seher points out, is on facilitating the clinical processes. "We are there as frontline support. Everything we do is to support [the nurses]. The nursing documentation is stamped and ready to go, and they don’t have to work [on clerical tasks]."