HFMA recently recognized CHRISTUS St. John Hospital as one of 14 organizations with a high-performing revenue cycle. When asked for keys to their success, St. John leaders enthusiastically describe a cultural change that has empowered front-line staff, increased transparency, and encouraged finance, clinicians, and other staff to collaboratively improve the organization's fiscal health-while creating a friendlier billing experience for patients.

Top-Down Inspiration

Ten years ago, leaders at the CHRISTUS St. John Hospital would have appreciated a crystal ball that allowed them a peak into their future success. At the time, the then 150-bed hospital in Nassau Bay, Texas, was hemorrhaging millions of dollars due to denials, timely filing issues, and other revenue cycle problems.

The hospital had just invested in a new hospital information system that hosted patient accounting, case management, and other major functions. Leaders had hoped to maximize gains, not increase losses.

Fortunately, this particular crisis ended up inspiring positive change-from the top of the organization. "Our hospital CEO Tom Permetti became very engaged in the situation," says Cassandra Hogans, patient financial services director for CHRISTUS Health. "Tom has created a safe environment for us all to work together and share information. He has eliminated finger pointing and encouraged us to break down silos between departments."

Corporate leaders at CHRISTUS Health have also provided instrumental guidance. For instance, corporate CFO Jay Herron encouraged staff to improve processes and reduce waste by introducing industry-based improvement tools, including Lean Manufacturing and the Toyota Production System. Kaycee Orman, corporate executive director of revenue cycle, also continually reinforces the need for collaboration and process improvement.

The Results to Date

All the focus and effort around St. John's revenue cycle has paid off. St. John Hospital is now performing well on financial measures:

  • Bill hold has dropped by more than 70 percent.
  • Denials have decreased significantly to 0.51 percent of net patient revenue.
  • Days in A/R are the lowest they have ever been.
  • Net to cash 120 days is hitting 93 percent. 
  • Cash to net patient revenue 30 days ago consistently exceed 101 percent.

Best of all: "All the clinical directors are involved in the billing process and understand our commercial contracts," says St. John CFO David Witt

Patients have also benefitted, especially from efforts to streamline registration and billing and improve customer service. "Our patient satisfaction results are stronger with the improved processes," says Hogan. For example, the admitting department continually scores in the high 90th percentile ranking on Press Ganey patient satisfaction surveys.

Data Is Transparent at St. John's

One of the most visible changes of the cultural change at St. Johns is what's missing: "In typical business offices, you'll find stacks of papers and mail shoved away in corners, in drawers, and in overhead bins. It's a treasure hunt to find anything," says Hogans.

Not so at St. Johns. All revenue cycle functions are now paperless. All staff and managers can find out exactly what is happening in the revenue cycle by checking what Hogan calls their "visual workstation." "We document progress throughout the day on our management boards," says Hogans. "As a manager, I can see where each of my billing teams is in terms of productivity, etc." 

St. John managers and staff also have access to various performance reports and tools that help them identify and address trends and problems. For instance, revenue cycle service staff and leadership receive a daily report on 15 critical indicators, including gross revenues, daily cash, and outstanding balances. Currently, the report is put together manually. Data is pulled from various sources across the hospital, and input into a spreadsheet. But the extra work is worth it, says Hogan. "Data is essential in terms of understanding where we are and where we want to go."

Eliminating Waste, Designing Quality: A Registration Example

When staff at St. John see a problem or opportunity for improvement, they now have the tools they need to resolve it. "Our staff now use Lean Manufacturing concepts established by Toyota to design and improve processes," says Hogans. "Each team has daily briefings, during which the team talks to whatever issues, opportunities, and problems they encounter during the day. Then, the team takes on the resolution of those issues, assigning various tasks to different team members."

Some of the improvement efforts have focused on making the patient's financial experience simpler and more satisfactory. One example: St. John staff have streamlined the registration process for patients. "We have turned registration into a full-service encounter," says Sandy Green, patient access director. "We now verify benefits during the registration, confirm the patient's responsibility, and explain to the patient in an easy-to-understand manner what his or her obligation will be. So, by the end of the registration, everything that needed to be handled from a registration and billing perspective has all been done in one setting."

Key to this change: Providing registration staff with extensive training and education. "In the old days, the registration process was full of hand offs," says Green. "One person did this, one person did that. Now, all our staff are competent to address everything with regard to registration, including understanding all the managed care contracts we have." 

In addition to seeing an increase in patient satisfaction, St. Johns has also witnessed an uptick in upfront payments. "At one point of time, there was belief that patients didn't want to be educated about their bills or have responsibility for payment upfront," says Hogans. "Our results show otherwise. Patients want to be educated and are willing to pay if they have an understanding of their obligations."

Getting Clinical Directors Involved in the Revenue Cycle

Transparency and process improvement goes hand in hand with collaboration at St. Johns. One of the most telling examples: Clinical directors are working with finance to help meet payment limitations and requirements under managed care contracts-without sacrificing quality care.

"Anita Fluharty, regional managed care manager, has done a great job of laying out our managed care contracts in a way that clinical directors can understand," says Witt. "We also get together with clinical directors every four months to review these contracts."

Witt and his staff explain how managed care contracts affect payment for services and supplies in their areas. For instance, they may explain to the orthopedic services director which implants are covered under which managed care contracts so the director can work with physicians to identify the most appropriate implants for patients.

"It's about ownership of your department's charges and breaking down the silos to show that we're all in this together," says Witt. "This is not just the OR show or the billing department show. Everyone at St. John's needs to understand that this is a process that we are all involved in."

Publication Date: Monday, September 21, 2009