Angela Blankinship, RN, BA, CASC, director of surgical services for San Luis Valley Regional Medical Center in Alamosa, Colo., shares five best practices for reducing costs and maintaining quality in your surgical department.
1. Create a robust and accurate charge capture system. Most hospitals use line-item billing to identify charges associated with the services a patient receives while at the facility. Many departments may take for granted the forms they use for recording and billing are accurate and efficient. However, Ms. Blankinship says making sure the charge master is set up properly is essential to the process. “You need to make sure items are assigned to the appropriate code, because the codes are recognized by payors for reimbursements,” she says.
Creating an accurate list requires significant time and effort, as you need to identify each supply item on the list, which will require you to sort through your entire inventory at first. Ms. Blankinship notes that, while tasking, this process will be rewarded. It can help to identify areas for standardization, as well as correct any errors or inaccuracies on the master list. “You need to verify the supplies and run the codes past your compliance office to make sure they are comfortable with the codes on the charge master. This process will come in handy as RAC audits move forward, because your department will have everything properly monitored,” she says.
The next step is to arrange the charge master so that it makes the most logical sense. Ms. Blankinship says that the form used at San Luis is laid out in the order in which the procedure is done — with surgical packs at the top to sutures at the bottom. This organization is not limited to the OR. “Each sheet has like items organized together, so OR and PACU supplies and times are together as are IVs and fluids. We tried to make categories with these related items to make it easier on our staff members,” she says.
2. Educate and inform staff members at all levels. A clear charge capture sheet is only useful if all staff members know how best to use it. Ms. Blankinship says taking the time at the beginning of the process to educate staff on what information to collect as well as the intricacies of case mix and payor mix will avoid denials on the back end. “It can take up to 42 days for Medicare to inform you of a denied claim,” she says. “You can save time if you gather the information correctly once on the front end.”
To further aid in this process, Ms. Blankinship created a spreadsheet that included the cost of each item. She printed out a copy of the list, which also contained the item number and description, and placed it in a binder that sits at the front desk. “The sheet is fully accessible to all staff so that they can understand how much each item really costs and what the impact is when items are wasted,” she says.
Through this effort, San Luis was able to increase their charge capture over their budget by 46.3 percent, meaning the department successfully charged for more than what was budgeted for the month. Ms. Blankinship also notes that supply costs dropped from $700,000 to $250,000. A large part was due to reducing redundancies and increasing standardization as part of the first major inventory. “I saw the repetition in what we were stocking during that first inventory,” she says. “For instance, we had four different types of shoe covers. I come from an ASC background, so my desire for efficiencies kicked in.”
The project was successful also because Ms. Blankinship ensured that staff members and surgeons had a voice throughout the process. “You need to talk to your surgeons [and staff] and show them respect by following through on their suggestions,” she says. “It is a lot easier to get physician cooperation through respect, and if the physicians are on board, they can usually bring the staff on board as well.”
The effort has also filtered over into other areas of the department beyond charge capture, Ms. Blankinship notes. “It really was a teamwork building exercise. We built an atmosphere where we talk about everything, and that has empowered staff suggestions in all areas including quality and safety,” she says.
3. Process claims within 24 hours. Capturing charges can only be useful if processed in an efficient way. Ms. Blankinship has instituted a policy of entering claims into the system within 24 hours of the procedure. “We have asked our coders to make sure they are receiving dictation within this period, so that they can make sure the codes are ready to be entered into the system,” she says.
Education and cross-training was also efficient at this step. At San Luis, the data entry staff member who entered the claims had little background with the medical side of the process. In order to help her understand the charge sheet and what was being billed, Ms. Blankinship took her into the OR so she could observe and understand the process. “Now, she is able to critique the reports and recognize errors before they are put into the system,” she says.
4. Double-check claims. Even with a greater understanding of the surgical process, human error is still a factor when it comes to charge capture and reimbursement, according to Ms. Blankinship. To address this issue, she asked her IT department to create a revenue report. The report includes real-time data on all unsettled accounts in the department and includes itemized charges from each area, such as anesthesia, PACU and implant costs.
“The revenue report allows me to pull up data and double-check it at any time before the claim is submitted. This allows me to identify missing information and then go to a staff member in the area to follow up on why the information is missing or to get the information to enter into the system,” she says. “Again, this shows cooperation and ownership at each level of the process.”
5. Audit quality on multiple levels. There is a high cost to poor quality, according to Ms. Blankinship. If hospitals are underperforming, it has a direct effect on the bottom line, which most facilities equate on the level of poor outcomes that could lead to lawsuits. However, a poor patient and work experience can also cause hospitals to lose patients and A-level staff members, making it difficult for the hospital to maintain its revenue.
To address quality issues quickly and effectively, Ms. Blankinship created audits for each staff member and patient so that she can assess what is really going on in the department. “Each of the audits consists of a simple list or question that can easily be checked or answered,” she says. “This way I can see what problems are there and quickly work to improve in that area.”
Ms. Blankinship says that patient satisfaction surveys are “like gold” for finding areas of improvement. “I always follow-up with patients when they identify a problem or answer that an area was less than ‘excellent.’ I always asked them if there was something we could have done differently to improve their experience,” she says.
Open communication is essential to improving both staff issues and patient concerns, and Ms. Blankinship says accessibility is the first step in addressing these problems. “If it is a staff issue, many people would be quick to overreact and throw blame around,” she says. “I try to be proactive rather than reactive. Some times I may need to stop and take a breather to gather my thoughts before coming up with a solution.”
Monthly staff meetings in the board room also provide the San Luis staff with an opportunity to bring up concerns or to discuss issues on the floor. For example, Ms. Blankinship notes that recently the department lost an employee who decided to relocate and it had a deep impact on the staff. “I distributed comment cards that staff members could write on anonymously to suggest what we needed to do to move on,” she says.
Follow-up and transparency are also important to ensuring quality. To keep staff members informed throughout the day, Ms. Blankinship makes use of white boards in the hallways where any staff member can update the daily schedule to include add-on cases and changes. She also created a communication notebook, which began as a place where she would write down what executive measures were going on, including ideas for changes, proposals and general thoughts on how things were going. “I wanted the staff to know I was working on their concerns,” she says. “Now, we have staff members writing their feedback directly into the book.”
Similarly, with patients, Ms. Blankinship includes her cell phone number on every piece of correspondence so that patients can contact her directly. “It’s not the most ideal situation, but a five-minute phone call can do a lot for a patient’s peace of mind. It also allows me to follow-up with the problem and find out answers,” she says.
Using that information, Ms. Blankinship can then bring the issue in front of the department’s quality committee where solutions can be discussed.
Learn more about San Luis Regional Valley Medical Center.
