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Keeping Registries Staffed in Tough Times
By Ellen R. Kolender, RHIA, CTR

Just as cancer registries were beginning to move out of the basement or the medical records department to find homes in the cancer center, the outlook has changed, and their mere existence is now in jeopardy. Staff numbers are being reexamined, as healthcare leaders have focused much of their attention on the budget.

Each day, registry staff find it more difficult to keep up with their workload, while hospitals fight to stay financially afloat. The economy’s current state has impacted hospitals’ payer mix, as patients have less insurance coverage or none at all. Cancer patients are especially vulnerable because insurance companies determine procedure approval, as well as medication or chemotherapy coverage. At the same time, elective procedures are being placed on hold.

Administration Paints a Picture
To compensate for pay reductions from insurance companies, hospitals are getting creative. Some are cutting back on employee benefits, some have mandated furloughs, and still others are handing out pink slips. Meanwhile, departments such as cancer registries that are historically understaffed must find ways to keep pace with increasing workloads. In the case of the cancer registry department, the quality and timeliness of work are imperative to maintaining status as an American College of Surgeons (ACoS) Commission on Cancer (CoC)-accredited cancer center.

Chronicling Work Hours
How many registrars work off the clock to catch up when their department has insufficient staff to do the necessary work? Do they come in on weekends to finish a study that needs to be presented to the cancer committee the following week? Have they performed quality checks on cases that are going to be reviewed by physicians, thereby doing the work for them, only to have them turn around and complain? Does the registry have volunteers or students chipping in on a regular basis?

All the hours that are worked and not paid need to be tracked and used as evidence when building a case for hiring more employees or for maintaining current staff. Cancer registry departments are being taxed further as hospitals pull back on budgets, employees, and salaries. All of this is compounded by a general shortage of qualified registrars.

Add Your Own Strokes
Experienced managers must do their homework. Have discussions with administration when building a case for keeping or increasing your full-time staff. To maintain status as an accredited cancer center, you must be able to justify the need for the number of full-time employees required to run the department. Be sure to present an accurate report that provides a complete picture of the number of staff hours needed to run the department effectively.

Thoroughly review the efficiency of the department’s workflow and include employees in discussions and brainstorming sessions. Allowing employees to take part in improving efficiency can have surprisingly positive results. Check to make sure no duplicate processes are being performed. Time-and-motion studies, while satisfactory, take time and could be subjective due to manual calculations. Depending on which job needs attention, determine the time it takes to perform that task and how many cases can be done within that time frame.

How It Could Look
For example, in the case of abstracting cases, we determined that, on average, five cases could be completed within an eight-hour workday. To determine this average, examine the workload of all cases, not just the analytic ones. Every case must be processed, no matter its class. When averaging the number performed per day, be sure to include all classes. Once the number of cases per year is determined, divide that total by the number of days worked per year. (Be sure when counting the days an employee works per year to consider those not worked due to vacation and sick leave.)

The result is the number of abstracts that need to be completed per eight-hour shift. In our case, it was determined that 11 abstracts must be completed per day to meet ACoS CoC standards. As a result of these findings, each abstractor (the department had 1.2 full-time employees [FTEs]) would need to complete nine abstracts per eight hours; however, on average, they were capable of completing only five per day. With an external benchmark of five abstracts per day, we concluded that our volume required 2.2 FTEs to perform the entire workload within the required time frame.

1. Estimated annual case load = 2,228
2. 2228 / 216 = 11 abstracts per day
3. (11 abstracts per day) / 1.2 FTEs = 9 abstracts per day / FTE
4. External benchmark = 5 abstracts per day / FTE

Presenting Your Perspective
Having all the facts in hand, we submitted our request to the administration, along with the all-important question, “Do we want to maintain an accredited cancer center?” The cancer registry is responsible for approximately 90% of the work mandated by the ACoS CoC for accreditation, and the hospital must maintain its accreditation to continue attracting cancer patients. Internet-savvy cancer patients visit physicians equipped with the latest research news and questions based on this knowledge. Consumers are more aware of the services provided by different treatment centers and are dutifully doing their homework to find out which facilities are accredited and which treat the most cancers with their condition. If administrators want their cancer centers to survive, they must maintain accreditation status.

Outsourcing the work is often only a temporary solution for eliminating backlogs. If the department is not sufficiently staffed, the backlog will reemerge as soon as the outsourcing company’s service ends. In addition, outsourcing is typically twice as expensive as adding a full-time staff member and requires payment for services plus room and board. While vendors can guarantee their work, whether all quality checks have been performed often remains unknown. In addition, the time it takes to train outsourcing staff to work for a temporary period of time could be used to train a permanent employee.

Showing Off Your Results
In conclusion, adequate staff must be supported for the cancer registry department to maintain its accreditation, and managers must keep administration apprised of what it takes to keep pace with the number of abstracts and the amount of staff needed to produce quality outcomes.

— Ellen R. Kolender, RHIA, CTR, is the cancer registry department manager at
Roper Saint Francis Healthcare in Charleston, S.C.