A patient access and flow project at the University of Mississippi Medical Center has improved the medical center's margin by more than $30 million-and has resulted in improved care and service.
At a Glance
Three keys to the success of a patient access and flow initiative at the University of Mississippi Medical Center are:
- The creation of a patient placement center
- The formation of multidisciplinary teams to address issues with throughput
- The development of a rapid admissions unit
In any hospital, the ability to efficiently provide high-quality patient care is one of the most critical measures of success. However, many hospitals do not invest enough effort in improving the fundamentals of the patient care process from admission through discharge.
Recently, The University of Mississippi Medical Center (UMMC)-a 722-bed hospital located in Jackson, Miss.-began an initiative to enhance its patient care process by focusing on patient access and flow throughout the organization. The initiative was part of a larger margin improvement program for the hospital and was also designed to enhance patient care quality, increase the hospital's capacity to serve, improve patient and physician satisfaction, and strengthen the hospital's financial performance.
Since the patient access and flow project was implemented in 2008, UMMC's margin has improved by more than $30 million. The hospital also has experienced a number of other benefits related to improved care and service, reductions in cost, and increased revenue as a result of the initiative.
Pinpointing Areas for Improvement
In 2007, UMMC began its patient access and flow initiative by assessing how different areas of the hospital-including the emergency department (ED), operating rooms, inpatient nursing units, case management, resident and attending physicians, and the discharge planning department-addressed patient access and flow. Enhancing patient flow in these areas required that these departments collaborate to improve patient flow throughout the system, rather than concentrating solely on ways to enhance flow or service in their specific areas. For example, the hospital business office should be involved in patient access management, and physicians should work collaboratively with nursing and social work on discharge planning. The failure to collaborate effectively in any of these areas results in process inefficiencies, added costs, and decreased patient satisfaction.
During the assessment process for the initiative, UMMC compared its current processes with industry best practices and organized small teams of stakeholders to identify opportunities for improvement. This assessment revealed significant challenges in patient access, length of stay (LOS), and ED flow at the hospital. Based on the results of this assessment, UMMC designed a new operating model that incorporated best practices for patient access management, patient throughput, and discharge planning. The goals of the model were to reduce LOS, enhance patient throughput and discharge planning, and improve patient and physician satisfaction. The assessment enabled UMMC to identify three critical objectives for the initiative:
- To create a patient placement center
- To form multidisciplinary teams charged with identifying ways to improve throughput
- To establish a "rapid admission unit"
Creating a patient placement center. A key focus of UMMC's new operational model is on coordinating patient access. Through its assessment of patient throughput, the hospital realized that its patient registration process was being performed at multiple points in the organization, leading to inconsistent processes and access procedures that had become a major source of dissatisfaction for physicians and an ongoing planning challenge for staff. Often, access was controlled by resident physicians without any hospital involvement in acceptance or denial of patients. This practice had a severe impact on patient throughput and often resulted in payment denials due to lack of medical necessity or appropriate payer authorization.
To address this issue, UMMC developed a nursing-staffed "patient placement center" that coordinates all inpatient admissions. Akin to an air-traffic control center, this unit combines all of the hospital's bed-control functions, admitting nurse functions, and front-end utilization review nurse activities. With these functions centralized, the patient placement center can maintain accountability over bed control, place patients according to best-practice algorithms, and even cluster patients by attending physician to enable physicians to complete their rounds more efficiently.
Since its implementation, UMMC's patient placement center has dramatically improved the organization's patient placement process. As of December 2008, 99 percent of UMMC inpatient admissions and transfers are processed through the hospital's patient placement center, and 85 percent of patients now meet InterQual criteria for medical necessity and severity of illness. In addition, 70 percent of patients now have the appropriate precertification and authorization for elective procedures and transfers, which has greatly reduced payment denials for services.
"We are very pleased with this level of compliance and with the high level of collaboration that has been developed with admitting physicians, physician office personnel, and the business office," says Kimberly O'Reilly, UMMC's director of patient access. "Prior to implementation of UMMC's patient placement center, a one-month review of admissions showed that 68 patients were admitted who did not meet medical necessity and severity-of-illness criteria. These cases resulted in more than $2 million in charges that had limited to no opportunity for reimbursement."
Forming multidisciplinary teams to address issues with throughput. Another focus of UMMC's patient access and flow initiative was to better manage patients after they have accessed the hospital. The initial assessment revealed multiple reporting relationships and highly fragmented processes within the hospital's case management, discharge planning, and utilization review programs. UMMC realigned these reporting structures into a single department. Within that department, the hospital developed teams called "triads," which consisted of RN case managers, utilization review nurses, and social workers, to develop ways to optimize patient throughput.
Each triad is assigned a patient population and is responsible for all traditional case management, discharge planning, and utilization review activities for its assigned patients. Within each triad, an RN case manager serves as the team leader and is responsible for focusing on patient placement at the appropriate level of care. A social worker is responsible for managing the patient's psychosocial needs, discharge planning, and placement, while a utilization review nurse is accountable for managing the financial and payer issues for the team. Recently, UMMC added financial counselors to the triads to provide additional assistance for patients regarding the financial aspect of their hospital experiences.
UMMC's triad model has strengthened relationships among triad team members, high-volume admitters within the hospital, and the patient care delivery team assigned to each patient. Triad members also have formed collaborative relationships with other care team members throughout the hospital and serve as a resource for patient financial and discharge planning.
Developing a rapid admission unit. A third key objective of the patient access and flow initiative was to improve UMMC's ability to expedite admissions, decompress its ED, and facilitate elective admissions that arrive when beds are not yet available. To this end, UMMC established a 20-bed rapid admission unit, staffed eight hours per day, to provide a place for patients who are waiting for inpatient beds to begin admission orders and treatment, thereby creating an immediate inpatient destination for patients until the appropriate unit bed becomes available.
Since the rapid admission unit was created, boarding times in the ED, which often were as high as eight hours, have been significantly reduced. The availability of a rapid admission unit also has allowed UMMC to increase its patient care capacity and implement strategies to grow volume. Treatment start times have improved as well.
Results of the Patient Access and Flow Initiative
Just over a year after UMMC implemented its patient access and flow improvement initiative, the hospital has recorded a number of financial benefits from the initiative. For example, in the first 10 months of implementation of the hospital's triad model, denials for exceeding preauthorized days decreased 70 percent, and denials for lack of preauthorization declined 50 percent. This equates to a more than $9.7 million reduction per month in denials from payers for these two categories.
The number of avoidable days recorded by the hospital has also been reduced. Historically, avoidable days often represented uncompensated resource consumption and higher costs for the hospital. UMMC estimates that it saved $18 million during the first 10 months of the program by reducing avoidable days through this initiative, ensuring the right care setting, following best practices for discharge planning, and providing admission guidelines that were based upon current best practices.
UMMC also reduced its LOS among several different patient populations, including its long-term care, critical care, and ICU patients-and has saved more than $9 million.
The initiative also has resulted in a number of nonfinancial benefits for the hospital:
- Physician satisfaction has improved as physicians are able to get patients admitted and discharged with greater ease.
- Residents and house staff are learning to practice in a hospital that teaches them not only the medical best practices, but also the financial management of patient care. This approach will better prepare them to enter private or academic practice, thus enhancing UMMC's educational mission.
- Patient satisfaction has improved as access processes have become more efficient and wait time has decreased.
- Nurse retention and recruiting has improved due to greater process efficiency. The result has been the ability to staff an additional 60 beds.
Overall, UMMC's patient access and flow initiative has improved the hospital's margin by more than $30 million while greatly improving patient access and flow, physician satisfaction, nurse retention, and overall bed management. The program continues to undergo refinement. The use of various tracking and revision tools allows UMMC to further enhance the program and derive additional benefits for the good of the system as well as patients, physicians, and staff.
Kent Giles is a partner and senior strategy expert, CSC, Atlanta (firstname.lastname@example.org).
Louann Parker, BSN, RN, is a principal, CSC, El Segundo, Calif. (email@example.com).
Janet Harris, MSN, RN, is chief nursing executive officer, University of Mississippi Healthcare System, and chief nursing officer, University Hospital, Jackson, Miss. (firstname.lastname@example.org).
Publication Date: Tuesday, June 01, 2010