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By Ruth Finkelstein
Director, Admitting Services
University of Texas Medical Branch at Galveston
A successful attribute of progressive-thinking access managers is their ability to initiate and implement change. But because it is disturbing and people naturally resist it, change should not occur just for its own sake.
If the outcome is recognized and explained before change is initiated, anxiety can be minimized, implementation can be made easier, and instead of undermining or subliminally sabotaging new processes and operations, personnel will accept them and participate.
As the saying goes, "The most effective way to cope with change is to help create it." Fortunately, access managers are well-versed in recognizing changes required to improve operations, respond to new demands and processes, adhere to third-party payer requirements, and facilitate nursing reorganization.
In fact, admitting departments already have experienced dramatic change. At one time, their primary responsibilities were hospital registration, room assignment, and giving directions in the lobby. Now their roles and responsibilities have increased in response to requirements from federal and local agencies, administration, insurance companies, physicians, nursing, and patients. (See redesign chart, inserted in this issue.)
Customer relations formerly was based on the individual qualities of staff. Now customer relations is a core value throughout the health care system. Registration has moved from centrali-zation to decentralizaton; combined to include outpatient, emergency, and inpatient access, or any combination thereof; and switched its reporting responsibilities from hospital operations to finance.
Change will remain a part of the equation. It is no longer sufficient simply to substitute one methodology for another change must be substantial. For example, the admitting process has been renamed "access" in many institutions, reflecting the fact that access opens and combines many venues, including coordinating ambulatory appointments or arrival in the emergency department, the decision to hospitalize a patient, and assignment to the respective nursing unit.
This process in turn drives the creation of the medical record and initiates not only billing, but collections as well. It also funnels information into ancillary departments and must be coordinated with other functions.
Automation has created efficiencies and reduced redundancies in many access procedures, and it has shepherded in the opportunity to explore further changes that can improve old processes. To be at the forefront of innovation and take advantage of the changes that automation makes possible, management must have strategic vision and not ignore any possibilities.
John F. Kennedy once said, "change is the law of life, and those who look only to the past or present are certain to miss the future." But even as changes revolutionize the registration process, they may be difficult to embrace if people are timid about taking risks or eliminating familiar processes.
Risks must be taken, and new processes must be sought out. For example, the access process can be integrated into the ambulatory process and the billing process. This means that the access department can begin to focus on patient assignment and follow-up with patients whose hospital registration is incomplete.
In fact, the need for a separate access department may even cease to exist. Instead, the billing office could coordinate benefits; the utilization review process could obtain authorization and even assign beds.
Regardless of how the access process is redefined, to be successful, mutually agreed upon objectives and collaboration are required. Planning for change must include discussion among all stakeholders regarding current system weaknesses, how new processes will address these weaknesses, distribution of responsibilities, where the potential for future weaknesses lies, how to manage problems, and what quality assurance indicators will be used to measure success.
To make new processes successful, there must be data integrity, trust and data entry reliability. But data integrity is only part of the equation. We must not lose sight of the overriding goals of change improved patient satisfaction and maximized reimbursement. Customer service must be another commitment. The success of the change process must include customer service values such as compassion and consideration. Through it all, the patient must feel appreciated and embraced by the process.
But we must assist staff through reengineering as well. Such obstacles as ego needs, territoriality, and loss of "professional worth" also must be addressed as part of the redesign process. Negative feelings caused by change can be minimized if there is something for everyone at the end.
This is not always easy to achieve because reengineering often turns into a game of musical chairs in which someone is left standing when the music stops. Helping staff cope with restructuring must be part of the change process and may require participation from the human resources department and employee assistance programs.
To avoid change is to be an ostrich with its head in the sand. The inevitable is around the corner: Smart cards and on-line registration via the Internet will alter the face of access management. The most certain way of overcoming fear of change is to be an active force in bringing it about not its victim.
Knowing when to let go of old ways and embrace change as an evolution or in this case a revolution of the registration process holds the key to future success.
(Ruth Finkelstein is the former admitting director for the University of Texas Medical Branch at Galveston. She is currently working with the chief financial officer and medical director for that facility, coordinating process improvement initiatives.)