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Effort dispels preconceived notions’
Using a dual-faceted continuous quality improvement (CQI) process, the patient access services department at Lafayette (LA) General Medical Center (LGMC) boosted its percentage of preregistered patients and increased registration accuracy, says Jeri Pack, director of access services.
The department is 18 months into a CQI effort that began with training by the Wilton, CT-based Juran Institute and culminated with consulting initiatives from Ernst & Young, Pack adds. "Two major purposes of these initiatives were to revise internal processes and eliminate equipment or support barriers that hinder productivity.
As of February 1999, the preregistration rate was 84%, up from 42.6% when the process began in October 1997, and registration accuracy was 87%, up from 70%, she says. The department continues to work toward a benchmark of 100% for preregistration and 95% for registration accuracy.
The quality initiative began after selected LGMC staff received two to three days of in-depth training on Juran’s CQI process and LGMC’s management decided to establish an official project, Pack says. The first areas chosen to be redesigned were access services, escort services, and medical records. (See list, p. 58.)
"We completed that process in February 1998, and then in April 1998 revised some of the remedy design features,’ as Juran calls them, that we had developed," Pack explains. "Simultaneously, Ernst & Young came on campus and did similar quality processes, using a different method."
The Ernst & Young initiatives were put in place throughout the institution, not just in the areas targeted by Juran, and tended to be broader in focus, she says. "When Ernst & Young came in, we rolled over our information to them, and in July 1998, they completed their value propositions,’ which were the same as Juran’s remedy design features."
The experience with Ernst & Young, she notes, "not only validated that what we had begun was good, but also gave us more firm direction in how to get there." The mission statement developed for access services was, "LGMC scheduling/preregistration process does not meet expectations as demonstrated by responses from our customers." (The box on p. 60 shows how the mission statement fits into the Juran process.)
Among the tools used to identify parts of the process that needed to be corrected or improved was a fishbone diagram, Pack says. The diagram specified problem areas under various headings. (See diagram, p. 59.) For example, under the heading "Dr.’s Office," the contributing factors include such items as "no written orders" and "no lead time to schedule."
The team completed surveys to gain input from the access department’s customers, including patients, physicians’ offices, and the resource areas for which scheduling is being done, she says. The resource areas, for example, were asked these "yes" or "no" questions, with room for comments:
These are the objectives specified under the mission statement:
One of the major quality improvement goals was to modify registration processes to increase the percentage of preregistered scheduled patients to 100%, Pack says. (Ernst & Young consultants changed the revised goal of 98% back to 100%, she notes.) This goal was to be accomplished by establishing flexible staffing schedules for preregistration personnel, with some moving to an earlier schedule and others working later hours.
As a result, the department averaged seven additional preregistrations for those who worked later, and 10 more per day for staff who moved to the earlier shift, Pack says.
"You always have preconceived notions of what the problem might be, and sometimes you go stampeding off to correct it, and you’re on the wrong track," she points out. "The value of organized QI processes is that it forces you to gather data objectively, put it in an objective format, and review it with a team."
The schedule changes were a case in point, Pack says. "We all were determined that to accomplish more preregistrations, we needed to shift more people into the late shift," she adds. "But what we discovered is that people don’t want to be disturbed at that time. We were more successful in shifting staff to earlier in the day, calling people at 7 in the morning."
Because of the high number of calls that must be made to accomplish a preregistration — maybe 55 calls to schedule 40 CT patients, for example — it will be difficult to reach the goal of preregistering 100% of scheduled patients, Pack points out. For that reason, the CQI team decided to work toward a quick outpatient registration through new software from Atlanta-based McKesson-HBOC, she says.
"The main reason to preregister is so that on the day of service, we don’t have to go through a lengthy process involving 14 to 17 computer screens," she explains. "In December 1998, we installed OPRR [Outpatient Registration Rapid], an upgrade that reduced that to seven screens. It’s now not as critical that [patients] are preregistered because we can rapidly register them when they come in."
However, she adds, "we still want to preregister and to monitor to make sure insurers that require precert before service are called and the precert is started."
LGMC has a scheduling system, One Call Combined, from Atlanta-based Per Se, that it has been implementing over the past two years, Pack says, with an interface for surgical patients and outpatients. "That interface downloads basic scheduling information — name, procedure, date, insurance. Preregistration [staff] pull from that listing priority patients, including [those scheduled for] surgeries, magnetic resonance imaging, and other big-ticket items, and put those at the top of the list. They also pull out mammograms, for which we know precert is required."