Registration Academy Improves Performance
St. Joseph Health started its curriculum design by asking patient access leaders what a perfect training program would cover.
In late 2014, St. Joseph Health revenue cycle educator Lee Ann Zambrano asked patient access leaders at the health system’s Southern California Region’s four hospitals what they needed most from the education team to succeed. One consistent answer was a new hire training program for patient access specialists, says Zambrano, system director of training and development for revenue cycle services at the Irvine, Calif., health system headquarters.
Less than a year later, that’s exactly what the patient access leaders got. In July 2015, St. Joseph Health launched its registration academy, a formal training program for patient access specialists that focuses on roles and responsibilities, revenue cycle information systems, and patient experience.
St. Joseph Health comprises 14 acute care hospitals in three regions: Northern California, Southern California, and West Texas.
In addition to getting new hires up to speed on patient access tasks more quickly and thoroughly, the academy also has generated several positive impacts on registrar performance, training costs, and employee engagement, Zambrano says.
Creating the Academy
The four hospitals had some measure of training, but there was no standard program or curriculum. Training generally was provided by staff, such as experienced registrars, managers, and quality analysts, who had to take time away from their regular duties, Zambrano says. There also was no clear way of measuring the competency of new hires.
Before designing a curriculum, Zambrano assembled a design team of three, including herself, one educator, and a technical writer who also served as the project manager. First, they generated a needs analysis, which was used to develop an outline for the academy’s curriculum. The analysis asked patient access leaders what a perfect training program would cover. The following answers from patient access leaders formed the beginnings of the curriculum. The training would cover the following areas, among others:
- How the actions of patient access staff affect the revenue cycle downstream
- How to select the correct insurance plan code
- How patient access staff can discuss bill payment with patients while maintaining patient satisfaction
“We just sort of threw everything in the pot and organized it into a logical order, and then came up with a high-level plan,” Zambrano says.
Zambrano oversees revenue cycle education and training for St. Joseph’s Southern California and Western Texas regions. The academy was rolled out at the four Southern California hospitals.
After determining specific curriculum topics, the design team developed learning objectives for each topic area, called modules. The team established the appropriate learning methods and then determined an estimated timeframe for teaching each module.
To build new hires’ confidence level through training, Zambrano says her team used a building-block approach to develop the curriculum, with foundational principles taught first, followed by easier and then more complex tasks. “It had to be suitable for people who had no healthcare experience,” she says.
For example, students are first taught what insurance is, and then move on to basic terminology and an overview of health plan types. They are then instructed on easy tasks, such as determining whether patients are covered under certain plans. Next, students are taught more complex tasks, such as selecting correct insurance plan codes, which identify payers and products and are important for accurate billing and prompt payments.
What Students Learn
The two-week academy is taught by educators in St. Joseph’s revenue cycle training and development department who have been registrars or patient access specialists. Instruction comprises several learning methods, such as lectures, demonstrations, electronic-learning, teachback—in which students teach a lesson—and games, such as scavenger hunts and competitions. Students also are provided instruction on the various revenue cycle tools—such as for registering patients and checking eligibility—through hands-on practice. Student performance is gauged through quizzes, tests, and observation.
Instruction covers about 30 modules. One of the longest modules covers the main patient registration system, Zambrano says. Another module provides an overview of Medicare, including eligibility and entitlements, and how Medicare coordinates benefits with other payers.
Zambrano says the coursework prepares new hires for about 70 percent of their work, while the remaining 30 percent comes from on-the-job training.
For three of St. Joseph’s four hospitals in the Southern California region that are located within close proximity to each other, students are taught at the system headquarters in Irvine, Calif. The fourth hospital in the region has its own educator who teaches the academy on-site at the hospital.
The number of students in the academy at any one time ranges from as low as two to as high as 12, depending upon hiring needs, Zambrano says. The four hospitals have a total of 245 registration staff.
If students perform poorly on tests, they are provided with additional training. If the extra training does not improve performance, Zambrano says it is up to the hiring manager on how to proceed with the new hire, but she hasn’t encountered that situation yet.
Figuring in Success
One of the critical success factors of the academy is its foundation of standardized patient accounting and registration information systems and policies and procedures across the four hospitals. The policies and procedures were developed by Zambrano’s team of technical writers in collaboration with patient access leaders and include such directives as the proper way to complete a registration. “The fact that those directives were standardized set the stage for what we had to do,” she says.
Another key to the program was engagement of patient access managers, directors, and quality analysts. These leaders reviewed the initial curriculum plan and provided feedback on whether it was headed in the right direction, Zambrano says.
For example, one area that patient access leaders believed required a lot of instruction was the insurance plan code, including its purpose and how it impacts the revenue cycle. Students are provided with examples of easy, moderate, and complex cases in selecting the appropriate code. “That was a huge area where the input from our patient access leaders really helped to drive the curriculum,” Zambrano says.
Another success factor was the ability to rely upon in-depth expertise, provided by an educator who brought significant institutional knowledge and patient access experience to the project, Zambrano says. “Karina Cervantes, an educator in the training and development department for revenue cycle services, was really the lynchpin of the project in terms of drawing upon her expertise and making sure it got into the curriculum. It was really, really important to have somebody who was not only an educator, but also a subject matter expert who could help make sure the curriculum was accurate and up to date.”
Use of a documented plan with official due dates and expected milestones also drove accountability, as did a project manager who oversaw the work. “When we got off track, she would bring it to everyone’s attention,” Zambrano says.
Zambrano says one of the greatest challenges she and her team faced in developing the academy was determining the frequency of the academy and trying to align that with recruiting and hiring schedules. Initially staffed by one educator, the academy was offered once a month. But that limitation posed problems. “That can be difficult for patient access leaders because if they don’t get that new hire into the academy on that date, they have to wait a month,” Zambrano says. Consequently, not every new hire attended the academy.
St. Joseph Health is now considering ways to offer its registration academy more frequently. One area the health system is exploring is to convert some of the lecture-based curriculum into online learning to free up the educator and provide more flexibility.
After more than a year in operation, the registration academy has resulted in improvements in several areas.
Performance. Over a five-month period beginning in June 2016, registrars who attended the academy had an average 1 percent better accuracy over nongraduates in getting demographic and insurance information correct.
Registrar Accuracy Increases After Training
Training. From 2015 to 2016, the average number of hours invested in training per trainee dropped from 240 without the academy to 180 with the academy. Average training costs per trainee decreased from $7,200 to $5,800 for the same time period.
Training Academy Reduces Average Hours of Instruction
Training Costs Decrease as Instruction Improves
Employee engagement. Zambrano says anecdotal reports show that new hires that have gone through the academy are very confident and often train existing staff on areas where staff were not fully trained or where information has changed.
“The students are feeling pretty confident about their abilities to perform their tasks on the job.” Zambrano says.
Zambrano says the results of the academy have highlighted the importance of formal training. About 15 of the modules have been modified to be used as refresher courses for existing staff. “We’ve been able to leverage the curriculum and tweak it slightly so that we can help people who maybe never had formalized training in some of these functions and help them to be more successful on the job,” she says.
At 1.5 hours long, these mini courses are shorter than those for new hires, which can run as long as six hours.
The health system has also begun developing a “registration academy light,” a shorter academy of two or three days. “We’re experimenting with how we can make the existing curriculum useful for existing staff, and we’re starting to get some good results from that,” Zambrano says.
A full registration academy also will be rolled out at hospitals in the system’s West Texas region.
In an environment of lower reimbursement, Zambrano says the academy’s underlying function is to help ensure that front-end revenue cycle staff understand how their work has downstream impact.
“We need to make sure we’re tightening the front end and getting it right the first time so we’re not spending time at the back end to fix problems that could have been avoided in the first place,” she says.
Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill., and a member of HFMA’s First Illinois Chapter.
Interviewed for this article:
Lee Ann Zambrano, system director of training and development, revenue cycle services, St. Joseph Health, Irvine, Calif..