By Debra Wood, RN, contributor

February 11, 2010 --With large-scale health care reform apparently stalled for now, hospitals and other providers can take the lead in increasing efficiency and wringing waste out of the system.
 
“As hospitals continue to face increasing pressures driven by falling reimbursements and higher costs, they are looking for opportunities to improve efficiencies and save money while maintaining their clinical performance and patient satisfaction scores,” said Patricia Tyson, RN, MSA, vice president of VHA Clinical Specialty Services, which provides analytical tools and subject matter experts to help hospitals increase their margins, reduce costs, improve quality and increase productivity.
 
Many action items can be done with no capital, just by looking at things from the patients’ perspective and making a common sense evaluation of processes and eliminating anything unproductive, added Ron Wince, president and CEO of Guidon Performance Solutions of Mesa, Ariz.
 
The industry is rife with opportunities. A recent white paper published by Thomson Reuters indicated the U.S. health care system wastes between $600 billion and $850 billion annually through administrative inefficiency, unnecessary treatment, medical errors, lack of care coordination and fraud. 
 
Healthcare Briefings reached out to more than a dozen health care experts for their suggestions about what works and what providers can do in the current environment to improve efficiencies. Several themes emerged.

Employ the power of information

• Follow a data-driven approach that strives to improve efficiencies along every step in the patient encounter—from admission to discharge, said Tyson. She added, “We look at everything from implant pricing and utilization, labor efficiencies, patient throughput, physician engagement, and even revenue management.”
• Use the tools available from private accrediting bodies, state departments of health and the quality measures approved by Centers for Medicare and Medicaid Services to pinpoint problem areas, recommended Jason Ormsby, Ph.D., MBA, MHSA, senior vice president at the health care management consulting firm Atlas Research in Washington, D.C.
• Identify which processes need changing, and then choose to focus and narrow improvement efforts on a few process measures that are aligned with organizational strategy and address the heart of inefficiency for sustainable results, recommended Marti Beltz, an American Society for Quality instructor and senior consultant with the Massachusetts General Hospital Center for Performance Excellence in Boston.
• Take action each day based on the information collected, added Christine Stead, principal for planning and operations practice with consultant CSC in Falls Church, Va.
•  Develop a values statement that lets employees know how they should be making decisions all day, every day, regardless of their title or job description, advised psychologist and consultant Christopher Bauer, Ph.D., HSP, CFS of Nashville, Tenn. “Decisions can often be made more quickly because one doesn’t have to guess what is and isn’t important to the organization,” Bauer added. “Better decision making by employees means fewer mistakes, less to correct or clean up after and, as a wonderful byproduct, higher quality service.”

Don’t leave money on the table

• Capture every dollar, said Kevin Burchill, JD, director of Beacon Partners in Weymouth, Mass. From streamlining patient registration to verifying insurance and securing pre-certification, capturing charges, getting the bill out, reconciling with managed care contracts, and managing denials, “maximize the money for the care you are providing,” he added.
• Look to the revenue stream for good, quick wins, Wince suggested. Every department should present billing information in a standard manner, such as using identical templates and submitting on a daily basis. Wince found, on average, variation slows down claims submittal by 18 days, decreasing cash flow. 
• Measure productivity daily on a departmental basis, said Ross Manson, a partner with the accounting firm of Eide Bailly in Fargo, N.D. “Establish a productivity benchmark, such as nursing hours per patient day, and have the department manager held responsible for achieving the benchmark on a daily basis. Don’t let the analysis happen at month-end.”
• Work on scheduling and governance, the way in which individual departments manage capacity and resources, said Jeff Terry, managing principal for clinical excellence for GE Healthcare. While important to establish proper policies and procedures, hospitals also must monitor and measure adherence to those policies.
• Scheduling patient flow in each department is the least understood aspect of operating a hospital, Terry said. GE Healthcare research shows only 21 percent of hospitals schedule their facilities as fully as they should. That leads to places feeling congested, but schedule changes could reduce the velocity. “Optimizing the utilization of the system requires you manage each independent schedule and intersections of the schedule, and that’s inordinately complex,” he added. For instance, he suggested assessing patient volume by day of the week and shift elective admissions to less busy days to more evenly distribute patients in the intensive care units across the week.

Streamline staffing and care delivery

• With salaries and benefits representing more than half of a hospital’s budget, Burchill recommends front-line supervisors review units of service compared with paid hours daily, not at the end of the payroll cycle, to staff as efficiently as possible.
• Consider managed services. "When our clients and prospective clients come to us they are typically trying to address the following concerns:  improve quality of supplier performance, increase order fulfillment and streamline processes," explained Tanya Tesseyman, vice president of managed services for AMN Healthcare.  "By creating customized managed service programs which are supported by our program office, often utilizing VMS [vendor management services] technology, we are able to address their key concerns. Additionally we can typically help them recognize significant cost savings annually with our close program management."
• Place the right people in the right job. “Best practice talent management involves a clear understanding of the job description, a constant focus on ensuring people have the right competencies, and feedback and education to improve performance,” said Michael DiPietro, vice president of marketing for HealthcareSource in Woburn, Mass.
• Manage overtime and call pay by appropriately scheduling, using agency staff or float pools to fill in vacancies, and initiating an approval process with few people authorized to sign off on it, said Denice Soyring-Higman, RN, BSN, MSN, president of Soyrnig Consulting in St. Petersburg, Fla. She estimates a 300-bed hospital can save $2 million annually by properly managing overtime.
• Educate charge nurses and other off-hours, front-line managers in the business aspects of health care delivery to help them realize the cost consequences of the decisions they make, Soyring-Higman added.
• Staff according to expected volume, not evenly each day of the week, Soyring-Higman advised.
• Involve other members of the health care staff in care delivery, perhaps shifting patient education to someone other than a health provider, suggested Jason Hwang, M.D., MBA, executive director of Healthcare at Innosight Institute, a nonprofit think tank in Watertown, Mass.
• Leverage community resources, such as churches and schools to provide health education, added Stead.
• Create incentive pay to produce optimal performance, recommended Fred Jenkins, M.D., with Southeast Emergency Consultants in Jacksonville, Fla. His practice measures physicians’ diagnostic acumen, customer service and speed of service delivery in the emergency department. “The point is to lead to better patient care, throughput and patient satisfaction,” Jenkins said. “All three are interrelated. Better efficiency leads to better care and satisfaction.”

Control supplies

• Supplies can represent between 14 and 20 percent of a hospital’s budget, Burchill said. He advises working with a group purchasing organization to get the best pricing, using a just-in-time inventory system and turning the inventory over. He also recommended educating staff about the cost of supplies and not to waste items.
• Verify group purchasing contracts are followed and that the organization is giving you the best price for supplies, and control inventory levels within the system to cut out waste, advised Bailly. “Work with physicians to use the same supply for high cost supply items versus every physician having their own brand.”
• VHA helped Floyd Memorial Hospital and Health Services in New Albany, Ind., realize more than $3 million in annualized savings by analyzing where it spent money on supplies and involving clinicians in identifying areas for improvement—such as product standardization and better utilization—in various departments throughout the hospital. As an example, the hospital now saves $148,000 in drug-eluting stents and $35,000 on printer cartridges each year.
• Place supplies and equipment near where the clinical staff needs them and remove items from units that are rarely used. Wince reported that time wasted by walking 1,000 miles per year looking for things equates to 2.5 full-time employees’ time.

Harness technology

• The American Recovery and Reinvestment Act will offer additional Medicare funds for facilities that have adopted meaningful use electronic health records. Burchill encourages providers start preparing now, so when fiscal year 2011 arrives in October, they can earn the extra income.
• Health information technology will be an invaluable tool for improving safety and outcomes, said Ormsby, who also advised hospitals to take advantage of the federal dollars.
• Electronic records can help providers zero-in on areas needing improvement, said Alan Genicoff, M.D., JD, a specialist in emergency medicine and the overnight supervising physician at Dameron Hospital in Stockton, Calif. The hospital emergency department treats about 120 patients a day, up to 30,000 annually. In the past, five to seven people per shift would leave without being seen. But since identifying a bottleneck at triage, Genicoff or the physician assistant began triaging patients, rather than a nurse. Acutely ill patients are seen immediately, but while triaging the less acutely ill, Genicoff orders lab work or images and sends them back to the waiting room. Now patients who leave without being seen have dropped to about three per month, a dramatic decrease.
• Allow providers and patients greater access to electronic medical records, which could help the country move toward a medical home model, said Stead, adding, “Having technology and information in a digital model is very important in achieving that goal.”
• Mobile technology, such as smart phones and web applications can help staff save time, effort and expenses. Goshen General Hospital in Goshen, Ind., replaced its manual call-in process when patients presented with a segment elevation myocardial infarction requiring prompt intervention with a centralized paging system from Amcom Software. The system notifies 30 people simultaneously about the need to come in and enables two-way communication that is documented, auditable, and repeatable. The hospital credits that system and related communication improvements with decreasing its door-to-balloon time from 129 minutes to 71 minutes.
  

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