Automated error tracking system gets the job done

Staff gain sense of responsibility, accomplishment

As Northern Hospital of Surry County moved from one manual solution for tracking registration errors to another, Terry Hancock, manager of patient access and customer service, says she "kept thinking that with so much human error and emotion going into the effort to be 100% accurate, there had to be something out there that could do this automatically."

The hospital, located in Mount Airy, NC, had gone from checking all registrations to examining a percentage, and then back to doing a 100% review, she recounts. Much staff time was spent looking at registrations and sending them back to supervisors and then to representatives to be fixed and then back again, Hancock adds, and by that time, the bills had dropped.

Later, she notes, there were weekly training classes for registrars whose accuracy average dropped below a certain percentage. "We'd go over major errors and how to avoid them, without pointing out any one person, still trying to be very sensitive.

"What we finally understood," Hancock says, "is that with the number of pieces of information to know in a busy, busy outpatient area and an unpredictable emergency department, you can't know them all.

"No one comes to work to make errors," she adds. "Everyone comes prepared to do the best they can and they still make errors. All of the encouragement and retraining in the world couldn't stop these sometimes silly errors."

Hancock, who worked in the airline industry for many years — most recently managing the customer complaint analysis area — says she knew from that experience that there must be an automated means for the hospital system to gather and process its quality assurance information.

The airline representatives, she recalls, recorded all of the customer complaints in specific coded fields in a computer system, including "what, where, when, why codes; flights; dates; and city pairs" to define the actual customer concerns.

"We then used access queries, sequel logic, and other systems to pull that information from those fields," Hancock adds. "Being able to specify captured data fields is what enabled us to analyze and drill down into massive amounts of information to create meaningful and actionable solutions."

What the hospital needed, she realized, was a system that could measure fields, take them into another system, and check for accuracy — that could scour through hundreds of registrations a week and find the errors that staff were spending so many hours on.

"You can't replace human intelligence, but with about 85% of the errors we had — tiny and big things — you could stop and at least make folks go back and look at them," she says.

Before deciding on the error tracking tool the hospital would ultimately choose, Hancock says, "we looked at four other systems that all had good points." A couple were ruled out because they didn't work in real-time, she adds, which meant that a relief employee who was on the job one day but not back again for a week couldn't correct her errors in time to make a difference.

With a real-time system, employees could fix their errors and have the benefit of immediate feedback, Hancock notes. "What I wanted wasn't a punitive grading system, but for these folks to come to work, give it their all, and feel good at the end of the day about what they had done — and for the hospital to have clean billing [upfront] rather than fixing it on the back end."

The next step — assembling all the information needed to sell hospital leadership on the idea — was the hard part, she says. The response was positive, with the revenue cycle director giving "terrific support" to the proposal, Hancock adds. "The CFO also listened and 'got it.' He understood that we were wasting the talents of at least one FTE [full-time equivalent] who could be providing excellent customer service instead of making sure all these [data] were accurate at the point of billing."

During an average month, she says, the hospital has some 3,000 "clinicals" — X-rays, laboratory tests, CT scans, and MRIs — plus another 3,300 ED registrations and about 550 day surgeries.

Ancillary physician offices use the same registration system — although their billing is handled by another group within the hospital — and account for another 2,500 transactions, Hancock notes.

"All in all, other than inpatient admits, the Meditech [registration] system does close to 10,000 registrations a month," she says, and there are between 450 and 500 inpatient admissions each month.

"That's just 'first touches,'" Hancock points out, "and that's not always where the mistakes are made. Patients can go from observation to inpatient and, after they've been here a few days, to telemetry. We also do preregistration for all scheduled clinicals and day surgeries, so to get a true idea of how much work is being done, you have to look at so much more than the number of registrations."

In the ED, for example, there is a system whereby an access representative gets basic information during triage because so many people had been leaving through the back before being registered, she adds. "So the [triage rep] 'touches' the account, but it's not done because you can't ask for payment upfront. It later goes to the 'core rep,' who is actually verifying eligibility and finding out what the copay is."

Building from the ground up

When the new automated error tracking system — a product of Miami Lakes, FL-based AHI Software called AHI QA — was finally approved and the rule-building process began, there were issues to be worked out with the back end, Hancock notes.

"We build the rules that all the different fields in Meditech hit up against, so we control what we have in our AHI system," she explains. Jessica Arrington, the access training and systems specialist, began working with a patient financial services (PFS) specialist on "what the back side thought were errors."

There were some surprises in store, Hancock notes. "They had different things they were working from that we didn't know about."

For example, when a registrar entered "Mt. Airy," the system — which compares information against a U.S. Post Office database — read it as an error because the post office uses "Mount Airy," she says. "So PFS staff were fixing that."

Linking PFS and access

"We learned so much from each other," Hancock adds. "[The process] created such synergy between patient access and PFS." While the two departments, both of which report to the director of revenue cycle performance, already had a good relationship, one didn't really understand what was going on with the other, she notes.

"Now [access and PFS] communicate on a daily basis and the rapport that has built up is a good, good working relationship."

The error tracking system was implemented in mid-September 2007, Hancock says, and within two months, the first training class for access representatives had been held. "We're going to do two classes, because the first time you're trained, you don't know what you want to ask."

'Pop-ups' signal errors

Staff began to be excited about the process and competitive with their colleagues, she adds. "They feel good because they are seeing [the mistakes] and then fixing them.

"It's so simple for the registrar," Hancock says. "There's a pop-up that tells you everything that might be an error and typically also tells you how to fix it. That is all the end user sees. It will say, 'Excuse me, you don't have insurance in here,' but if the person [touching the account] is doing preregistration, she can't get that yet."

The system fosters teamwork, she points out. It offers "options as to whether you want the person creating the account to be the only one responsible or if you want everyone who touches the account to be responsible."

At her facility, the decision was made to have staff share responsibility. "Before, if a patient came in who was preregistered, the assumption was that [the information] must be right. Now [the pop-up] says the insurance information is not correct and they know they are [also] responsible. If no one fixes it, each of those [touches] is an error."

"The bottom line for me is to get it right the first time," Hancock notes. One registrar asked, "What if I'm always fixing somebody's errors," she adds, but explains that such occurrences would be evident to management because of all the reports on the back end that front-line employees don't see.

Those reports, Hancock says, "tell us which one has the most errors, who fixed the error. It also gave [staff] the option to let us know about an error and have us look at it."

When employees are in a hurry and work on through the pop-ups that alert them to errors, she explains, there is a worksheet they can pull up at the end of the day that gives them all of the error information and a list of warnings.

For example, if the registrar enters a clinical procedure and a day surgery for the same day, the system asks, "Are you sure this is not a duplicate?"

The AHI system "is not in your face all day," she notes. "It runs in tandem with the Meditech system, but doesn't feed back. It only flows out."

There is also a "dispute feature" that allows staff to challenge a case in which something is almost always wrong, but not in this instance, Hancock says. "We live in the corner of North Carolina and Virginia, so some patients have a home phone with a Virginia prefix, but a cell phone with a North Carolina prefix."

When the system, noting a Virginia address, says the cell phone number is not correct, the registrar can click the dispute button. "That comes back to Jessica as the one who is managing those disputes. She sees it, accepts it, and lets it go through.

"If someone disputes something they believe is correct, she can deny that dispute and give feedback to the person on why it is not disputable," Hancock says. There is an additional training opportunity if, for example, the registrar says that it was another employee who told her the information was correct.

"[The system] is doing the things I really want it to do," she notes. It can report errors by representative, by department, and by hour in the ED, Hancock adds, but also gives registrars a sense of responsibility and accomplishment.

If a mistake is fixed within 32 hours — which is prior to billing — it does not become an error, she says. "If we set too short a time, it would become an error before [staff] had time to dispute.

"We are still finding [issues] with the rules we built, but we are learning how to write more," Hancock points out, as when Arrington refined a rule associated with a Blue Cross Blue Shield insurance identification number to make it more specific regarding dependents and whether the insurance is primary, secondary or tertiary.

"The [information] can be very detailed on the back end, but we can write something that is very simple for the rep," she says.

(Editor's note: Terry Hancock can be reached at thancock@nhsc.org.)