Under Pressure: Mastering Financial Pain Point in the ED

In healthcare, there is no mission without margin. Here, three Huron Healthcare experts share practical advice on how to effectively address common financial pain points in the ED.

5 Ways to Boost Productivity Without a Reduction in Force

Everyone wants to avoid a reduction in force, so it's good to know there are a number of other effective strategies to dramatically improve productivity. We've used these in hospitals both large and small to great effect. For example, we realized $2 million in benefit for a Northern California health system with four EDs. We cut labor expense by 15 percent while still reducing Left Without Being Seen (LWBS) rates by 31 percent and improving admitted and discharged length of stay metrics.

In a 550-bed nonprofit hospital in central Texas, we realized $500,000 in savings while cutting LWBS rates by half, reducing boarding by a third and reducing both door to doc times and length of stay for admitted patients.

Here are my top recommendations for how to get these kinds of results: (1) Identify any mismatches between ED demand and capacity; then shift staffing patterns for better alignment with hourly and daily patient volumes. Clearly, a rural hospital with 12 percent of patients being high acuity is different than one with 30 percent being high acuity, so it's important to take all factors into consideration. This is one of the first things my team does when consulting on productivity.

(2) Consider your staffing mix of full- and part-time employees. The best mix is usually no more than 80 to 85 percent core full-time staff, with the remainder coming from part-timers and a supplemental pool. Then you can flex staffing as needing-like during flu season-without incurring overtime. I find that facilities with 90 to 99 percent full-time staffing are often utilizing travelers and agencies more than those that can flex better.

(3) Are your nurses operating at the top of their licensure? Observe them to find out. Sometimes the highest paid RNs are busy with tasks that could be handled by unlicensed personnel. Ask: Do we have enough techs, EMTs and paramedics to assist in these roles at the beside to free up nurses so they can focus on clinical care?

(4) Best practice for overtime is two to four percent of hours in a pay period. If it's higher, take a deeper dive and consider: Are there many on Family and Medical Leave Act (FMLA) or paid time off? Smart organizations brainstorm with staff and then align expectations and accountability with clear policies that explain how paid time off (PTO) will be allocated during popular times.

And finally, (5) Use a shift management tool. Don't wait until month-end to find out if productivity is lagging. Managers need a daily tool to actively manage productivity.

David Cummings, RN, MS, FACHE, Huron Manager

Best Practices for Trauma Designation and Recertification

Trauma certification takes one to two years to complete. To prepare effectively, it can be valuable for someone who's seasoned in the certification process to observe mock scenarios and recommend best practices. Data collection and performance improvement review and loop closure are important elements of a successful program.

For example, I was recently onsite at a hospital during a mock trauma where it was quickly evident that staff were being overused. We were able to address that by establishing clear roles for everyone who responded (e.g., Ask: Who will be at the head of the bed? Who will place the Foley catheter?)

Also, it's important to understand that The Joint Commission takes the policies and procedures of stroke and STEMI programs into consideration during their quality surveys. That's why many organizations ask a consultant to complete a two-week review 16 months before the survey to ensure things like records for peer review are in place, that surgeons are reviewed by peers for any deaths and to understand how any errors are handled.

When it comes to recertification, it's easy to lose certification if an organization is found to be out of compliance with anything. The top problem I typically see is a lack of follow-up, closing the loop or missing documentation. Diversion is also a big issue.

But a trauma designation is worth the work! There are so many benefits. In addition to reducing penalty-driven payments, you'll improve patient outcomes through more coordinated care and more structured processes.

Plus, trauma people are dedicated, loyal and committed to this profession for a lifetime. They build an organization's reputation. Trauma care is the oldest organized unit of the time sensitive illness (TSI) certifications and designations and offers a solid platform to provide structure for all the TSI certifications.

Holli MacDuff, RN, MSN, Huron Manager

Embrace a Holistic Approach to Optimizing Clinical Documentation

A sustainable solution for clinical documentation improvement (CDI) needs to be flexible, physician-focused and collaborative. It requires monitoring, training and continuous feedback to and from the ED physician.

A coding professional should feel confident to share coding rules and advise a physician on documentation opportunities or request clarification. And, a physician must be willing to accept this advice.

"Pattern billing" by physicians/providers is where physicians tend to bill the same level for each encounter, regardless of the documentation. While the provider may be comfortable with this practice, they can be at risk for over/under coding and not factoring in the supporting documentation for the specific encounter. One organization realized over a $2 million annual increase in revenue by improving physician documentation and increasing coding accuracy through ongoing provider education.

In Huron's experience, ED physicians often do not appreciate the value of the services they provide-perhaps because complex illnesses and serious injuries are so common-so they could be losing out by financially billing all visits at the same level. The ED is the starting point to capture the appropriate complexity of care throughout the continuum of care.

There are many red flags for an inadequate ED coding process. For starters, ask:

  • Do the physician and facility ED levels mirror each other?
  • Is there inconsistency in results depending upon who is coding the chart?
  • Do you know what the ED level of service is going to be before the patient is discharged?
  • Is it impossible for a patient to be seen and not be billed a lower level?
  • Do your distribution of ED evaluation and management (E&M) levels reflect possible "pattern billing?"
  • Are critical care services not being reported?
  • Is caveat for documentation of 99285 being applied?

Be sure to embrace a team approach to solving these challenges. The team should include all who have insight into emergency levels; physicians, compliance, ED leaders, ED billing/coders, patient financial series and staff representation.

Gerri Birg, MSN, RN, CCDS, Huron Managing Director

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