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June 2014

Hooked on PEDs: Performance-Enhanced Departments
By Selena Chavis
For The Record
Vol. 26 No. 6 P. 24

As HIM professionals look to raise the bar on quality, process-improvement initiatives take on added weight.

The broader goals of any national health care movement essentially come down to two outcomes: higher quality and lower costs. As a result, health care professionals across the board are looking for ways to make the best use of resources.

Like most hospital departments, HIM is faced with the challenge of not just doing more with less but also exacting better results from fewer resources. “It comes down to resource constraints in HIM,” says Jim Garvin, national practice leader of revenue cycle for Genpact, who points out how a slew of recent regulatory audits has placed greater expectations on HIM. “When health care organizations started to dig into all those potential revenue takebacks, it was the professionals in HIM who were asked to step up.”

As the regulatory landscape continues to evolve into a risk-bearing system in which quality underpins all operations, the concept of process improvement increasingly will become paramount to success, according to industry experts. “Everyone is convinced that there is not going to be more money in the system; there is going to be less,” says Fletcher Lance, national health care leader for North Highland Company, adding that providers and payers are faced with an enormous amount of change from both a process and workflow standpoint. “That’s a harsh reality. Process improvement will become the norm across the board.”

Current State of Affairs
While regulatory initiatives such as meaningful use and ICD-10 serve as the impetus for better workflow designs and resource allocation in HIM departments, Lance notes that the need to incorporate solid process-improvement strategies has existed for some time. Pressure to get ready for the ICD-10 transition has put HIM departments under the microscope, but he suggests that many already were behind the power curve. “As we work with clients on clinical documentation improvement, we find a lot of errors in ICD-9,” he explains. “We were a little surprised when we got into it. HIM has not been keeping up in terms of processes.”

Kim Wheeler, vice president of HIM services for Yes HIM Consulting and a former HIM director at several Florida hospitals, notes that the HIT movement has sparked a greater need for more streamlined processes and quality control. Pointing out that automation has created a climate where fewer staff resources are available, she suggests that despite a spike in electronic documentation, the need for quality review actually has grown. “Lack of controls in EHRs creates concerns that doctors may not be inputting orders appropriately or accurately,” she says. “There is a lot of room for error, a lot of cutting and pasting by doctors. When you get into the legal arena, that’s when it is going to become a problem.”

Acknowledging that past process-improvement efforts within HIM primarily have been reactive, Garvin says the industry is beginning to wake up and become interested in addressing issues before they become problems. “I would say that the top 30% of performers are having proactive conversations in some form,” he says.

Recognizing the Need for Process Improvement
Health care experts agree that virtually all hospital departments are in the midst of undergoing massive workflow changes as the industry shifts to a new business model and technology projects take center stage. As such, many indicators within HIM suggest that operations and workflows must be analyzed and sharpened.

As automation takes hold in more departments, Lance suggests that those using paper in any form should seriously consider process change. While not all manual processes may necessitate a workflow change or require new technology, they should be reviewed and research should be conducted to determine whether technology can pave a path toward improved quality and lower costs.

Denials are an obvious indicator that processes are not up to par, according to Wheeler, who says inappropriate orders and unnecessary deficiencies such as dictated content not making it into the electronic chart are ongoing problems across the industry. Physician complaints also are a sign that process change needs to occur.

Also, as more HIT projects come to fruition within the organization, process assessments should be routine to help staffs that already are being challenged by workflow changes. “When staff members begin saying, ‘I thought it was going to go this way,’ or the right and left aren’t aware of what the other is doing, processes need to be analyzed,” Wheeler says. “Automation is causing us to have to rethink how we do the daily work. Plus, you have quality metrics to consider. You have to make sure all staff [members are] conducting work in the same way.”

Although not always welcomed, employee turnover can offer unique opportunities to analyze the need for process improvement. Wheeler points out that staff members who have been in one position for many years may become stuck in a rut, unwilling to consider better workflows. When any of those employees moves on, it could be the ideal time to gain creative input from others on how to improve workflows and processes.

Multidisciplinary Approach
Wheeler says any person or department affected by a particular process must be involved in an improvement analysis and the broader initiative to reach a particular metric. Because many departments are affected by coding, a multidisciplinary effort is essential to any successful HIM process-improvement initiative.

In the past, Lance says such efforts often have started with the department itself, including staff members, supervisors, and executives overseeing operations. In today’s health care climate, he recommends integrating the complete clinical team, focusing on cross-functionality that includes HIM, operations, clinical, IT, and the executive leader who will govern the process. “In the future, [process improvement] won’t be as siloed as it has been in the past,” he explains.

The entire process often begins with identifying a project champion, according to Garvin, who adds that the ability to pull in a nurse or a physician champion often is the key ingredient to a successful campaign. Wheeler points to having the right people on board from the start, otherwise plans can veer off course. “That often means going to the frontline people to learn how involved each person is in the bigger picture,” she says.

Strategy Options
When developing a process-improvement initiative, HIM leaders have several plans of attack at their disposal. Lance points to Six Sigma, a widely accepted management method, as an example of techniques and tools that can be leveraged. Developed by Motorola in the mid-1980s, Six Sigma’s foundational concept is to identify causes of errors or problems and remove them from workflows.

Once a method is identified, Lance says the next step is to keep process improvement from becoming a siloed effort. “It comes back to how this is all working together,” he says, suggesting that an effective approach is to collect external benchmarks, identify more granular internal benchmarks, and then consider core processes that need to change. “Every organization is a little different.”

Garvin believes a top-down approach that begins with industry best practices to be the most effective approach. “Here are agreed-upon best practices in the industry. If we are not achieving best practices, then let’s have a frank conversation about why,” he says.

Using a problem-solving method known as root cause analysis, HIM departments can identify a problem’s origins and make the appropriate adjustments either to eliminate or prevent its root cause. For example, take a health care organization that’s struggling with its discharged not final billed statistics. If national benchmarks for discharged not final billed are three days, but the hospital can’t get below five days, the question becomes, what’s the root cause of this problem? Is it due to resource constraints, the need for more expertise, or another factor?

Garvin says identifying a problem’s root cause can’t be limited to a particular department or viewed as being in a silo. For example, when it comes to revenue cycle management, many organizations focus more on patient access or the business office when “HIM is the No. 1 interlink between the front and back end.”

The coding process essentially begins with registration staff understanding medical necessity and how to bill. It then moves to physicians providing appropriate and timely documentation along with accurately capturing ancillary data. All these steps affect HIM’s role in revenue cycle management. “Instead of HIM being viewed in the middle, they should be involved from the start,” Wheeler says.

Process review must consider the larger view of how data flowing through an entire organization impact HIM. If data aren’t captured accurately at registration or clinical documentation lacks the granularity needed to code at the highest level, HIM processes are hindered. “It comes down to being able to break up that value chain of all the different steps,” Garvin says. “What should all those different pieces look like?”

While many best practice metrics exist on a national level for HIM departments to use as benchmarks, Garvin says there may not be guidance for every step. In these cases, he suggests looking to peer groups, cataloguing data, and building an internal metric. Leveraging third-party expertise also can prove beneficial for resource-strapped departments that may not have the time or expertise.

Wheeler cautions that while industry best practices are an excellent starting point, they may not apply to every HIM setting. “There is some trial and error involved,” she says. “Sometimes you can’t fit a square peg in a round hole. You have to tweak it to work in your operation and create your own best practice.”

Best Practice Tips
Experts agree that because process-improvement initiatives always will interfere with day-to-day operations, there’s never a perfect time to tackle such projects. Garvin says the key is to prioritize important areas of improvement, obtain buy-in from management, and then secure the necessary resources. Lance says having an identified project manager in place is critical whether that’s someone internally or an external source.

Once the right leader is in place, Wheeler says a reasonable completion date must be negotiated if the effort has any chance of succeeding. She says health care organizations must be realistic about their deadline expectations in order to provide enough advance notice to all essential personnel who must prepare and schedule time for assessment and analysis meetings. “If you pull a frontline person, you have to have a plan for how that work will get done,” she says. “If you don’t pull them out, you are never going to get there. Process improvement is not an easy thing to do.”

It’s not easy, but it’s critical, according to Lance. “You’re going to see more and more process improvement,” he says. “You’ll see more aggressive measurement.”

In the long run, this sort of approach will help HIM departments—and organizations as a whole—stay in step with health care’s changing landscape.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to health care and travel.


Process Improvement vs. Performance Improvement
Throughout the health care industry, there appears to be confusion about the differences between process improvement and performance improvement. While there’s some overlap, industry experts suggest that performance improvement rings truer because many facilities have dedicated resources to that particular terminology.

The Centers for Medicare & Medicaid Services defines performance improvement as “a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems.” Meanwhile, SearchCIO describes business-process improvement as “a strategic planning methodology aimed at identifying the operations or employee skills that could be improved to encourage smoother procedures, more efficient workflow, and overall business growth.”

In a sense, because outcomes are the result of processes, performance improvement depends on process improvement. According to “Leveraging Information Technology to Drive Performance Improvement,” a white paper made available through HIMSS, for processes to lay a foundation that drives performance improvement, the following three key ingredients must exist:

• Both clinical and administrative data must be timely and relevant, providing for high-quality information that can be analyzed, interpreted, and acted on.

• Available skill sets must include the analytical capability to interpret data and identify, prioritize, and implement operational improvements.

• Planning and incentive alignment must exist to bring together performance improvement targets and clear management accountability that are integrated into operating plans, performance objectives, and incentive programs.

— SC