Spring 2019  
Rigorous Process Improvement to Improve Access, Productivity and Provider Morale
By Dr. Nancy Gagliano, MBA
Increasing regulatory and administrative burdens have added significant complexity to practices. While practice managers do their best to manage, these complexities often lead to inefficiency, confusing processes, duplication of efforts, and add to provider administrative tasks. Providers, in turn, compound the situation by expecting individualized processes to manage their patient flow.
Common Findings:
Role confusion: In an effort to take care of patients needs, the entire staff “does what it takes”, resulting in staff working below license and confusion of ultimate responsibilities.
Lack of Protocols: Most practices frequently care for certain common conditions. Without clear protocols, variability exists, and staff are challenged by each provider expecting something different.
RNs working below their license: When RNs are not given the authority or clear expectations, messages flow ineffectively to and from providers to RNs rather than RN’s teeing up issues so they only require provider approval or signature.
Governance: Insufficient governance, either at the practice physician leader and manager, or at the organizational level, leads to inadequate communication, vision, and accountability resulting in practices left to their own devises.
Previous unsuccessful projects: While many organizations have done process improvement projects, without a rigorous organizational approach, there is not lasting cultural change and improvements may be short lived.
Core principles of successful process improvement:
  • Incorporate robust governance
  • Incorporate communication, change management, and measurement
  • Focus on the process not the people
  • Engage all members of care team to identify current and design future state
  • Use Lean foundational elements focused on removal of waste
  • Break down work into discreet components which are Value-Added or Waste
  • Develop standard “best” practice based on consensus of those who do the work
Multistep process
  1. Governance: Development of an effective governance structure which is tasked to set vision, hold the project team accountable, set boundaries and expectations. It should approve all standards agreed upon and be responsible for a robust communication approach. Membership must include providers and other stakeholders.
  2. Process Improvement: Lean concepts focus on process rather than people, removing waste and bottlenecks, clear workflow and clear roles. In order to develop a streamlined process, it is essential to understand current processes. This is accomplished through cross functional design sessions engaging all role groups from front desk through the provider. The process of outlining current processes, highlighting variability and unclear ownership is usually extremely enlightening. Getting to the “ah-ah” moment when the entire group understands that the process is inefficient and there is clearly opportunity to streamline is critical for engagement and change. This step is foundational for creating a culture of continuous improvement.
    The next step is designing future state, once again by those that do the work. Often multiple new processes are identified. The group is encouraged to vote on prioritizing which new workflows will be deployed first.
    Pilot: We find that piloting the new workflows is another important step. It continues to require active engagement, as well as appease any naysayers. During this phase, formal protocols and refined job descriptions are often developed.
    Measurement: Through the pilot phase pre and post measurement is critical to demonstrate improvement. It is used to gain buy-in for the spread phase and critical to maintain ongoing accountability and long lasting change.
    Spread: Finally, after the pilot phase the organization is ready for spread. While the governance body has been engaged throughout the process, this is the critical time for the group to take the leadership role in communicating the new process and hold the organization accountable for adopting new standards and processes.
Case Example:
Organization faced low productivity and high provider turnover due to low morale. There was no organized representative governance and practice managers often had minimal interaction with physician leaders. The formal process highlighted above was deployed, inclusive of a new central dyad governance structure including practice manager and physician leader. While, staff resistance dissolved through process redesign sessions, physician buy-in was slow. However, once active pilots demonstrated both measurable and qualitative improvements their acceptance increased improving cohesion and morale.
It is common for organizations to attempt to improve processes and become frustrated by lack of “stickiness”. It is often tempting to skip steps and jump to implementing obvious solutions. However, that will not create the cultural change and buy-in needed for long lasting improvement. It is essential to follow rigorous process improvement techniques including governance, change management, and broad-based engagement, if your ultimate goal is to create permanent change and an organizational culture of continuous improvement.
How Robotic Process Automation Can Improve Revenue Cycle Operations in Healthcare
By Kamet Smith
Robotic process automation (RPA) has become a popular approach to drive key business objectives within the revenue cycle for healthcare organizations. Healthcare organizations utilize RPA to enhance workflow processes, operational efficiencies, cost effectiveness and resource productivity.
RPA is the use of software with artificial intelligence (AI) and machine learning capabilities to automate, complex rule-based work. Essentially, when an RPA robot is at work, it will perform repeatable tasks that previously required humans to complete: logging in, operating applications, entering data, performing complex calculations and logging out. RPA provides the opportunity to split work between humans and robots optimizing efficiency in such a way that both are able to excel.
Benefits for utilizing RPA would consist of, but not be limited to:
  • A higher quality service, resulting in fewer mistakes and errors, driving better patient experience and satisfaction.
  • Processes can be completed at unprecedented speeds due to the reduction in the handling time of robots. Additionally, robots can operate 24 hours a day, 7 days a week only alerting an employee when something goes wrong.
  • Reduced overhead and the ability to accommodate new or changing process rules in a timelier manner.
  • Improved efficiency by digitizing and auditing process data.
  • More interesting and less mundane manual work improves employee engagement resulting in increased staff productivity.
For healthcare revenue cycle operations, some of the workflows that would benefit from RPA include checking coverage eligibility and initiating, submitting and confirming status of prior authorizations. RPA can also be utilized during patient check-in workflows to determine patient financial responsibility. Lastly, healthcare organizations can automate insurance claim follow-up and work denials prior to the receipt of remittances by retrieving claim status data from payor websites and EDI. RPA provides reduced power usage and waste as more and more work is done digitally resulting in a reduction in paper usage, transportation and logistical work. After implementing RPA, foundational processes that are complex, unintuitive, outdated and disjointed are found to be more simplified, standardized and streamlined.
Key goals to successfully implement RPA:
  • Identify the right process – select processes that have some level of standardization, repetitiveness, high volume and low complexities.
  • Gradual implementation – complete small things first and scale up gradually. Select a small subset of processes, specific to one area and introduce RPA to this subset first before rolling out RPA to other processes or departments.
  • Manage cultural issues through employee engagement and education – Employees can feel uncomfortable or threatened until the full implementation and understanding of RPA is adopted. Educating employees on RPA and developing new career avenues by expanding employee specialties will help alleviate some of the stress and tension that will be felt during the implementation process.
  • Vendor Selection - Any organization looking for RPA implementation should work with a partner who will guide them throughout the implementation process from beginning to end. Work with a vendor that understands your organizations needs and workflows.
  • Be realistic and pragmatic in your approach – have a clear vision with realistic expectations and ensure due diligence is place.
Robotic Process Automation is set to grow exponentially in the coming years. We will continue to see RPA develop and will soon become an industry standard with the continued growth.
Chicken or the Egg - Improve Access or Expand Clinical Capacity
By Paulette DiCesare & Deborah Kilbane
Improving patient access is a top priority of every healthcare organization we work with. While this goal is very common, there is often a high degree of variance in how organizations define patient access, as well as the root cause of the underlining problems they are trying to solve. Often times, the expansion of patient access capacity is a direct challenge to another major priority of most organizations which is mitigating physician burnout. Ultimately, any patient access strategy must be inextricably linked with an organization’s capacity to satisfy patient demand. As such, the ability to execute on patient access improvement opportunities is dependent on a holistic plan including clinical resourcing and clinical workflows.
The following case study highlights how an organization’s attempt to improve provider productivity through workflow enhancement uncovered a significant barrier increasing volume. Their current approach to scheduling and template management also impeded patient access
Case Example:
A midsized community health system was challenged with low provider productivity and low morale. They had recently implemented a patient access center to support scheduling and registration and had recently transitioned into a different EHR. Our evaluation revealed workflow inefficiencies which resulted in significant administrative burden falling on the providers shoulders. Minimal support for medication refills, clinical questions, inadequate patient prep for rooming, and poor EHR setup were all factors contributing to this burden. It was impossible to meet their productivity expectations given the amount of administrative work. As we looked to improve their workflow and shift these basic tasks to their clinical support staff, we quickly realized that clinical staff were equally burdened performing tasks well outside their scope of practice and job responsibilities. What was everyone doing? They were rescheduling patients. Complex scheduling rules and frequent provider schedule changes resulted in the need to reschedule a tremendous number of patients on a daily basis. Patients in referral queues had long delays. Errors in scheduling often were not caught until the patient arrived in the clinic requiring significant service recovery. As a result of all these inefficiencies, providers were not meeting their productivity expectations, due to schedule slots not being filled effectively, coupled with a long list of patients waiting to be seen.
Consequently, the solution was twofold. We needed to simplify the scheduling protocols, reset provider expectations of their schedules and create clear policies that would ensure minimal changes to scheduled appointments. In addition, we needed to set up templates in a predictable manner with some flexibility to facilitate the ease of scheduling patients. This will ultimately drastically reduce last-minute schedule blocking. This in turn would free up clinical and front-end support staff to promote the patient experience toppled with excellent quality care and excellent customer service. Shouldn’t this be the ultimate goal for all healthcare organizations?
With consistent and simplified scheduling rules and guardrails, the slots could be correctly utilized and rework was minimal. As a result, clinical and front-end support staff could re-focus on their work. Completing our process improvement workflow design approach would now support patient flow and reduce provider administrative time.
Another common obstacle is whether the new simplified schedules are realistic. Creating simpler cleaner schedules may create the appearance of increased capacity and access. However, the patient flow within the practice may not actually be able to handle the increased patient volume and before you know it, the providers are complaining and placing blocks in their schedule. Therefore, simplifying schedules does not automatically translate into increased capacity despite the appearance of increased access. It is important to consider the practice workflow and capacity. It may be extremely beneficial to focus on process flow and administrative tasks falling onto the providers in order to free up time to see those additional patients.
While many organizations implement patient access centers to streamline the scheduling process for patients and improve registration accuracy, the hard work of simplifying schedules and setting provider expectations is often incompletely accomplished. The result may be tremendous rework within the practices and ultimately impeding patient throughput. Those organizations that do simplify the scheduling process and set clear provider rules, often overlook the process improvement redesign to closely look at any process inefficiencies that might exist in order to increase capacity and patient flow. Therefore, it is definitely a chicken or the egg dilemma. Organizations need to focus both on access through scheduling simplification and process redesign to increase capacity.
The Changing Role of the CIO: The Patient Experience
By Wayne Thompson
Over the past decade, Healthcare providers have moved to a point where their internal operations have transitioned to a platform of systems and automation. Finance has been systems-based for a long time, and areas such as HR, Supply Chain, and the rest of the Revenue Cycle have followed. With the ARRA push, clinical areas completed the major areas of most Provider organizations. This transformation of the clinical areas resulted in some patient-facing interaction through patient portals and health information exchanges. Outside of patient billing and payer interactions, this represented a significant shift, and a new front along which to engage patients. However, many provider organizations were concentrating on doing the minimum necessary to meet regulatory compliance or incentives. Parallel to this, the rise of social media and the beginnings of the Internet of Things, allowed marketing and outreach efforts to engage patients in new ways. In an important third parallel stream, consumerism has been on the rise fueled by intuitive and valuable personal technology.
While the CIO has been contending with all of these streams and more individually, there has not been a concerted effort to look at the complete experience that is emerging. I would draw parallels to the Facilities environment at most Health Systems. For years, we have worked to create as friendly an experience as possible around parking, signage, wayfinding, look and feel, vertical and horizontal transport, etc. In other words, we have taken a complex and often fragmented physical plant, and invested time, effort, and dollars in making it friendly to patients. We even created patient transport departments. It is fairly common to float bonds and reserve the majority of capital budgets for facilities improvements. It helps that the Patient Satisfaction scores contain this element, but I foresee this including the virtual environment to a greater degree going forward. Today, the first impression, and the first engagement of patients is often virtual. What do your public-facing scorecards look like? What does your virtual campus (or separate clinical locations) look like? Can you perform common patient functions (reg, sched, education, refills, payment, e-visits, etc) virtually and seamlessly? Do patients have to repeatedly provide the same information at various sites in your system? Most importantly, is there a plan for how to move to a more seamless and patient-friendly experience?
While patient portals, reminder systems, billing systems, and various other patient-facing elements are increasingly present, they often do not represent the kind of experience that your organization has probably spent millions to create on a physical level. A significant portion of your patient population, and probably the majority in most cases, have growing expectations that healthcare will close the gap to fairly common virtual capabilities in other industries. The CIO, knowing the existing systems, industry capabilities, integration opportunities, and the gaps, is once again uniquely positioned to lead or to play a leading role in this critical transformation.
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