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HIM
Vital Signs
By Sarah Cheney Hall
Ask yourself
these questions. When was the last time you visualized what your
department would look like in 2007? Does your current department
work in a way that is in harmony with how you visualize the future
of Health Information Management (HIM)? How are you planning your
future today? Or, will your future be planned for you? I want to
be in control of my own destiny and the destiny of my department.
I want to decide my department's future by being proactive rather
than reactive. Being proactive takes a lot of time and effort upfront
and gives you time to focus on what is important for a long time.
Being reactive takes little time and effort upfront and takes a
lot of effort and work to maintain for a long time.
Proactive
Instead of Reactive
How do we become proactive instead of reactive? It boils down to
the HIM "Vital Signs" and other critical information.
When you are a patient in a hospital or physician's office, what
do the providers always check first? The answer is your vital signs,
or, heart rate, pulse and respirations. If my vital signs are at
normal levels, my physician can concentrate on my specific problems
at hand. Being proactive is like following a preventative maintenance
program. Being reactive is waiting until there is a problem to fix.
HIM Vital
Signs
What are the vital signs in HIM? The vital signs are bill hold,
employee job performance and record completion. These three vital
signs will tell if anything major is going on in the department.
Answer the following three questions. Is your bill hold, employee
job performance, and record completion meeting your boss' expectations?
Meeting regulatory requirements? Meeting industry standards? If
you answered "no" to any of these questions, you need
to work on your vital signs. (See
sample Vital Sign Benchmark Worksheet, Attachment 1.)
Here are some
good examples of reactive versus proactive responses to HIM vital
signs.
- Example #1:
Reactive - If the physicians would only come in a complete their
records, our record completion rate would be 10% lower. Proactive
- I noticed that the charts are not getting into the physician
completion area for almost a week after discharge. I wonder why
it is taking so long for the records to get to the physician's
completion area?
- Example #2:
Reactive - The floor never has the discharged records ready for
pick up when I retrieve them each day. Proactive - I should meet
with the unit manager to see why the floor has trouble having
the records ready for my staff daily. We can come up with a solution
that will benefit both of us.
- Example #3:
Reactive - The corporate coder productivity standards are impossible.
Those corporate people need to work in the real world. Proactive
- The corporate office says I'm overstaffed on coders; I should
measure the coders' productivity to validate staffing levels.
- Example #4:
Reactive - Corporate doesn't understand that our facility is different,
and there is no way we can make that bill hold goal. Proactive
- Let's break up the bill hold to see why we can't make the goal
and work at each reason one at a time until the goal is met. (See
Sample Reason Code Report, Attachment 2.)
Which category
do your own responses fit-under the proactive or reactive responses?
A proactive person fixes the problem before a complaint is made
and attempts to keep the situation under control to prevent the
problem from recurring. A reactive person waits until someone tells
him/her there is a problem and then tries to fix it. Trust me on
this one point: Taking a proactive approach to solving problems
saves a lot of work and money on the backend. Most of all, you are
in control of your destiny.
The Facts
Being proactive is similar to the Crime Scene Investigation shows
on television. A person is murdered. The investigators look for
evidence. They talk to witnesses and suspects. Sometimes the statements
of the witnesses/suspects conflict with the evidence. The facts
are the statements that tell the story. The story from each witness
or suspect could be different. The investigators follow the evidence
based on facts and determine if the stories from the witnesses or
suspects corroborates with the evidence. As we watch the story unfold,
we must concentrate on the facts and follow the story, which leads
to the root cause of the problem. Let's relate this analogy to HIM.
Do you determine how your department is running based on what your
staff tells you, or on the facts in your department? If you picked
your staff, you are reactive. If you picked the facts, you are proactive.
These facts are the HIM Vital Signs. These vital signs are critical
whether you are in long term, rehab, acute care or other healthcare
areas. It doesn't matter if you have a paper record or an electronic
record. The time frames and examples may change, but the facts are
still the facts. Evaluate one vital sign at a time. The facts should
be benchmarked as well. Compare last year and last month on areas
under control. Compare last year, last month and last week on the
one area on which you are working to get under control.
Definition
of Vital Signs
Lets define these three vital signs in order of importance below.
You need to work on your processes before working on job performance
with your employees.
The bill hold
is the time it takes from receiving the record to the time it takes
HIM to finalize the record for billing.
Employee Job
Performance is broken up into two areas, quality and productivity.
Employee Quality is comparing the accuracy of an employee's task
against a standard or threshold. Employee Productivity is the time
it takes an employee to complete a task based upon a standard or
threshold. (See
sample Productivity Summary and Worksheet, Attachment 3. Also,
see
sample Quality Worksheet, Attachment 4.)
Chart completion
is the time it takes to process a record in a given period of time.
The Bill
Hold
In any kind of healthcare business or any business I know of, it
is important to get paid for what you are doing. If you want to
work for a stable, healthy and profitable company, we should treat
the company's bill hold process like we would our own checking account.
In healthcare,
there are many steps in the billing process, and HIM is usually
in the middle. In simple terms, the record starts with admitting,
and then goes to a clinical area, then HIM, then billing, and then
storing. In HIM, our process involves receiving, assembly, coding,
analysis, and completion areas. (Your process may be slightly different
or in a different order, so adapt examples below to your process).
Basically, you need to review your HIM process from start to finish.
Let's use our
previous Example #1 to illustrate. The reactive person said, "If
the physicians would just come in and do their charts, our record
completion rate would be 10% lower." Is the physician at the
beginning or the end of the HIM process? Two things are wrong with
this example. First, the physician is at the end of the process.
Second, we don't have control over what others do. You have control
of yourself and what your staff does. Change needs to start with
ourselves and then with others. You need to start with the first
area in HIM, which is receiving. Are you receiving all complete
records timely based on industry standards? If you answered "yes",
go to the next area until all processes are fixed. When all the
HIM areas are meeting standards, you can begin working with the
areas before and after HIM in the process, until all the needs of
the other areas and HIM are met. When a process is agreeable to
all parties, you monitor the process, ensuring continued compliance.
When problems occur, follow the chain of command in other departments
to address them. I am confident that your financial team will support
you if you do your part first.
Employee
Job Performance
You should always work on quality first. It is essential to obtain
a standard in quality. If the task temporarily slows down due to
focusing on accuracy, the discrepancy is usually short lived. When
confidence is built, productivity usually increases in the long
run. Measuring quality and productivity of employees is the best
proactive measure you can take. Make the measure of job performance
a positive solution and not negative one.
Base employee
quality and productivity on good simple written procedures with
guidelines. These procedures should be developed with input from
your staff and other management personnel from all areas within
your department. One area of HIM usually affects another area in
HIM. (See
sample procedure, Attachment 5 on page 10.) Your grandmother
should be able to come to your department and perform the basic
task based on your instructions.
Run preliminary
data of the facts to see where your staff quality and productivity
rates are. Do not expect perfection, drastic changes, or meeting
industry standards if your preliminary findings are far below industry
standards. Each year that you measure quality, improvement should
increase 10 - 20%. Write a job performance policy before you implement
job performance. (See
sample Job Performance Policy, Attachment 6 on page 12.)
Perform the
task you are measuring yourself by following the written procedure.
This is a good time to review the employees' processes. It is easy
for managers to forget the job functions or fail to appreciate staff
if we don't do their jobs periodically. Based on your findings of
performing the task, you need to add a little time to the productivity
for interruptions and worse case scenarios.
For quality,
it is not easy to measure on the computer except to tabulate results.
For productivity, most software programs contain reports on how
many tasks each employee performs in a certain time frames, which
is compared against the same time frame on productive hours. If
you can't get this information from your software or the task is
not computerized, you should randomly pick the completed task in
a month's time frame from a list or stack of completed tasks. Any
employee can have a bad day or week. But a bad month is pushing
it. Pick the completed task randomly by picking one day of the week
from each week in the month, or every so many of the task on the
list.
(For example, you have a 120 tasks listed on the report. Pick a
percentage that you want to review between 5 - 15%, depending on
level of compliance. Lets pick 10%. Ten percent of 120 tasks is
12 tasks. Divide 120 by 12, which equals 10. This means that you
will start on the first record the first quarter, the second record
the second quarter, etc. If you pick every 10 tasks on the list
you will randomly pick 12 tasks.) You will have four or five days
of charts to review. Use a work sheet and base criteria on written
procedure and current complaints. The criteria should be yes, no
or not applicable (NA). You have a total of all tasks reviewed,
excluding those marked "NA". You total all the "yes"
answers and all the "no" answers. You divide the number
of "yes" answers into the total of all tasks reviewed.
This percent will give the positive compliance rate.
Example: You reviewed 50 completed tasks out of a total of 500 tasks
performed last month. Thirty-seven of the completed tasks were done
correctly. Ten of the completed tasks were not done correctly. Three
of the completed tasks were "NA". Your positive compliance
rate is 79% (37 compliant tasks out of a possible 47).
Share your results
on a weekly or monthly basis with employees who are not meeting
your threshold with an action plan based on your job performance
policy. Share the results with your employees monthly or quarterly
if they are meeting the threshold. You should also share the results
with all the employees with a comparison of the peers (without names).
(See
sample Productivity Employee Worksheet, Attachment 7. Also,
see
sample Employee Comparison Chart, Attachment 8.)
Include the
results of quality and productivity on the employee's yearly evaluation
whether good or bad. I can't tell you how much most your employees
appreciate this. It lets the employee know exactly where he/she
stands, where they need to improve, and where they exceed. It lets
management measure the employee in a fair and consistent manner
based on facts not on appearances. It lets you put the problem back
on the employee and leaves it up to the employee to meet the standard
or not (make sure it is a reachable goal). Its lets you be fair
by treating everyone under the threshold the same way and not whether
you like the employee or not.
Chart Completion
If you have the bill hold and job performance areas under control,
your chart completion areas should be under control to the extent
to which you can fix it within your department. You have now addressed
most of the areas within your department over which you have control.
Critical
Areas
After the vital signs are under control, the next areas to work
on are "critical areas". For some examples of critical
areas, see Attachment 1. When critical areas are under control,
work on the future of HIM. Also, you should never stop benchmarking
the results of fact finding; just change how often you verify them.
As you benchmark, you will prevent areas from becoming out of control.
As you can see, HIM has a lot of work to do now and in the future.
Be in control of your destiny. Become proactive in all you do.
Sarah Cheney
Hall is the Director of Health Information Management Services and
Facility Privacy Officer for Methodist Healthcare System, a five
facility system in San Antonio, Texas. She is also a mom with two
small boys.
Please note:
All the attachments for this article can be found on www.txhima.org
in PDF format.
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