A health system has improved the patient experience with a variety of new processes and protocols, including the introduction of a new patient access center and tutoring by physician coaches.
As value-based healthcare models take hold, the walls between clinical and revenue cycle operations are breaking down. Clinical and revenue cycle staff are jettisoning the siloed approach and instead working together to change processes and procedures to provide a better patient experience.
“As our payments are becoming a lot more quality- and outcomes-focused, it’s necessary that the providers and the hospital are aligned together and headed in the same direction in providing the most optimal experience possible for the patient—not only from a clinical perspective, but from a revenue cycle perspective, so that we can have the optimal outcomes needed and receive the highest payment possible to be able to reinvest in our organization and continue to provide the best possible care for our patients,” says Leah Dixon (pictured at right), administrative director of patient access services for CHRISTUS Trinity Mother Frances (TMF)/Northeast Texas Health System.
Tyler, Texas-based CHRISTUS TMF, part of Irving, Texas-based CHRISTUS Health, is a 14-hospital system with facilities in northeastern Texas. A few years ago, revenue cycle leaders began working with clinical leaders to develop a new patient access center and processes that would improve the overall experience for patients. Key performance indicators (KPIs) show that these efforts are having positive results.
Part of improving the patient experience at CHRISTUS TMF has involved removing some of the frustrations that are seemingly inherent in many clinical processes, such as scheduling visits and tests.
For example, scheduling an appointment for a specialist from a physician referral can be a frustrating experience for patients. To remove some of the hassle, a new process was created for patient access staff. A staff member automatically receives the physician order for a referral and then sets up the referral appointment based on the patient’s preference, obtaining approval from the payer if necessary. Any tests ordered by the specialist, such as an MRI, are automatically sent to the work queue of a patient-access diagnostic team member, who works on insurance verification and authorization for the test. Patient access staff also provide estimated out-of-pocket costs and schedule any additional services that are necessary.
“We try to be proactive in identifying opportunities where we can maybe provide a better service to our patients,” says Dixon, who co-presented at HFMA’s Revenue Cycle Conference in October on ways to engage clinical operations in improving the patient financial experience.
Two years ago, the health system began its Saving Lives initiative, in which call center staff support the organization’s population health management focus on preventive care. When a patient calls to schedule a visit, the scheduling staff reviews the patient’s health maintenance record to let the patient know if he or she is due for a screening or exam. The initiative focuses on six areas: mammograms, pap smears, retinal eye exams, Medicare initial physicals, Medical annual wellness physicals, and well-child exams.
Patients often appreciate the reminder, and 50 to 75 appointments per day are scheduled through the review, Dixon says. Staff also like knowing they are part of providing better care and possibly making an impact on a patient’s life, should a screening, for example, show the need for further testing.
Together with other population health management initiatives, Saving Lives has helped garner strong quality indicators, Dixon says. For example, the share of patients who require screenings for risk of falling and actually receive those screenings rose from 73 percent in the third quarter of 2016 to 100 percent in the third quarter of 2017. The proportion of diabetes patients receiving an eye exam rose from 56 percent to 71 percent over the same period.
“That’s what it takes,” Dixon says. “To partner with our physicians, partner with our clinical staff. That’s why the revenue cycle is an important component, so that we can work together to bring about the quality needed for our patients.”
Dixon and Drew von Eschenbach (pictured at right), regional vice president and chief information officer for CHRISTUS TMF, created a patient experience dashboard that measures the performance of front, middle, and back-end revenue cycle staff.
Many of the dashboard’s 45 KPIs are patient-facing, including such measures as the average length of time that callers to the call center wait on the phone before a call is answered; length of time to register a patient; and accuracy of out-of-pocket cost estimates.
“We wanted an objective way to measure our patient experience versus just hearing anecdotally about a patient experience,” von Eschenbach says.
One KPI that has improved considerably since the dashboard was implemented is the percent of online payments, which increased from 8 percent of total patient payments in April 2017 to 15 percent in February 2018, Dixon says. If more patients are paying online, that means they had a positive experience and trust that their statements for the care they received are accurate, she says.
Dixon and von Eschenbach chose which metrics to use based on areas within the revenue cycle that have the greatest impact on the patient experience. Creating such a dashboard should begin with a few metrics that represent major “pain points” and that can be tracked and monitored, von Eschenbach says. “In some cases, it’s as easy as pulling an indicator off a report,” he says. “And in other cases, you’re going to have to devote man-hours and resources to tracking information or doing audits in order to track and monitor what you feel is important.”
For example, von Eschenbach says “hold time” is a simple metric that at CHRISTUS TMF is tracked automatically via the phone system. “The good news is there is an industry standard to be less than 30 seconds, so we can strive to be responsive to our customers,” he says.
A more complicated metric is “time to process refunds,” which measures how long it takes to refund a patient credit balance or overpayment if the patient overpaid at the point of service. “There is no benchmark for this,” von Eschenbach says. “So, we have our own internal tracking. It is a report we generate out of our patient accounting system.”
Getting Clinicians Involved
A key part of improving the patient experience involves changing clinicians’ practices and behaviors. For example, clinical and office staff at CHRISTUS TMF ambulatory clinics have been trained to greet patients by welcoming them to the office or walking up to meet them in the waiting room, rather than calling out names from a doorway, says Andrea Anderson (pictured at right), administrative director for population health and ambulatory quality for CHRISTUS TMF/Northeast Texas. Scores and comments from the health system’s patient satisfaction surveys show that patients appreciate the more personalized attention, she says.
“Overwhelmingly, we found our patients noticed when it was happening and when it wasn’t,” Anderson says.
CHRISTUS TMF physicians especially have an impact on the patient experience and are held accountable for improving their behaviors.
For example, physicians who receive low scores on patient satisfaction surveys as benchmarked against national standards are coached by their physician colleagues on how to be more engaging with patients, Anderson says. Physician coaches, who have received high scores on the surveys, spend a few hours in exam rooms observing how their colleagues interact with patients. The coaches then provide real-time feedback on how physicians could improve their behaviors.
For instance, according to survey results, patients prefer that physicians sit rather than stand during an office visit because it feels like the physician is spending more time with them, Anderson says. Patients also appreciate when physicians look directly at them rather than at a computer screen during discussions. Physician coaches may also remind their colleagues to always ask whether patients have any questions about the care visit.
“We had some very focused initiatives to improve our performance in all areas of delivery regarding patient experience,” Anderson says.
The efforts are paying off. Patients share their positive experience with CHRISTUS TMF with family, friends, and coworkers, and that word-of-mouth has helped to attract more community members to the health system, Anderson says.
“We can spend a million dollars on a marketing campaign, but there’s nothing better than Suzy recommending her doctor to her neighbor or to her coworker,” Anderson says. “Having that support and validation from one of your patients is so much better than any commercial we can do.”
Anderson says the keys to gaining physician buy-in on improving the patient experience have been transparency and accountability. Physicians are shown their patient satisfaction scores, along with the comments from patients. High scores and positive comments are posted on billboards in break rooms, while low scores and negative comments are discussed one-on-one with physicians and at staff meetings.
Competitive by nature, physicians naturally want to perform as well as or better than their colleagues, Anderson says. “Nobody wants to be at the bottom, especially providers who are very competitive,” she says. “We found with providers, data is key.”
Fundamentally, Anderson says, reinforcement has enabled sustainable improvement. There is periodic training on appropriate ways to treat patients, and staff are held accountable for their behavior. “And that has made such an overwhelming difference,” she says. “Because patients feel that they are getting a better experience.”
Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill.
Interviewed for this article: Andrea Anderson, administrative director, population health and ambulatory quality, CHRISTUS Trinity Mother Frances Health System/Northeast Texas, Tyler, Texas; Leah Dixon, administrative director, patient access services, CHRISTUS Trinity Mother Frances Health System/Northeast Texas; Drew von Eschenbach, regional vice president, revenue cycle, chief information officer, CHRISTUS Trinity Mother Frances Health System/Northeast Texas.
This article is based in part on a presentation at HFMA’s 2017 Revenue Cycle Conference.