Quality and Performance Management and Methods Case Study As director of a health information management (HIM) department, Linda

knew she would have occasional problems with staff performance or personalities, but it seemed that lately there was tension in the department. She was trying to decide if the problems were occurring due to staffing, processes within the department, or the recent growth of the organization. Her organization, Clearwater Orthopedics, had recently purchased another physician group and expanded its staff by 20 more orthopedic surgeons, bringing the total number of medical staff to 50. She had heard from administrators at the last managers meeting that the addition was clearly a coup for the organization because the doctors were prominent in the community for being up-to-date in surgical techniques. One of them, Dr. Haas, was known for his teaching of continuing education courses to medical staff and his work with athletes around the state. It was not unusual for injured athletes to travel hundreds of miles to have their ligament reconstructions or shoulder arthroscopies performed by Dr. Haas because his patients recovery rates after surgery were quick and successful. Coaches and parents loved him. Regardless, Linda saw stress in the HIM department increasing and expected it would continue unless she identified the issues quickly. Over the last six months, she had been having difficulty retaining entry-level staff. These were the employees who most often had never worked in a professional environment and seemed to have the most personal problems. They also received the lowest hourly wage, although the medical benefits were good. Linda would move through the recruitment and hiring process, which took valuable time, only for the employees to decide a month or two into the job that a regular eight-to-five job, five days a week, was not for them. Linda tried not to be cynical. She reminded herself that some of her best employees today started at that level and worked themselves up through the ranks or went on for education to attain credentials in HIM. She smiled to herself as she remembered her first job, answering phones in a medical office for a friend of her dads. Those were the good old daysno stress! She hardly had time to train newly hired staff due to the organizational growth and endless meetings and planning. With government regulations changing continuously, it was important that all staff members be aware of regulatory changes. After all, the physicians group depended on her department to know all the latest regulations and convey that information to the medical staff. Nearly 40% of their patient base was workmens compensation claims, and her staff needed to have knowledge of all of those regulations as well. They also needed to maintain good relationships with insurance companies, case managers, and attorneys. Linda would usually direct a new staff member to spend a week with the front desk employee, Sally, for training, to learn those responsibilities, and that method used to work. They seemed busier now up in front, and with the turnover, Linda knew staff in the back were unhappy. Often her long-time staff found themselves pulled away from their coding responsibilities to help up front with phones and patients coming in to pick up documents. She wished she could establish a policy against accepting walk-in requests for medical records, but when she had spoken a few months ago to Dr. Blumenthal, the medical director and founder of Clearwater Orthopedics, he would not hear of it. We are here to serve the patient, he said adamantly. Customer satisfaction is our focus. She liked working for him,

but felt his ideas were sometimes outdated. Did he not realize that his organization had grown to 50 physicians? The clinic was no longer composed of the three partners who started working together 20 years ago. As she walked into the HIM department at 7:45 that morning, she was met by two of her long-time employees, Marge and Tina, who jumped up from their desks. Out of the corner of her eye she saw Sally speaking on the phone, sounding professional, while standing up to help an elderly patient who was approaching the front window. Sally handles that front desk like a pro, thought Linda. What would we do without her? Marge and Tina trailed into Lindas office after her. As Linda took off her coat and set down her briefcase, she turned to them. Go on, she said. You both look like you are ready to burst. Marge jumped in at the chance, Carrie called in again sick today . That makes three times in the past two weeks. How can we get any of our work done in the back when we have to keep helping Sally up front with patients coming to pick up their records or those blasted phones that never stop ringing? Carries useless to us. I wish she would just get it over with and quit. If another lawyers office calls today saying they need a medical record for tomorrow, I will scream! I am two days behind in my coding and you know that is not like me, Linda; I am a good employee and I am never late with my work for you. Plus Dr. Garcias nurse just called and said he does not understand why I am suggesting coding adjustments on his last operative report. (I told his nurse about the new guidelines for that one surgery.) Please, you call her back. She is always so snippy with me! Marge stopped to take a breath, and before Linda could speak, Tina jumped in. Linda, you know I love it here and I love working for this practice, she said, but they are expecting us to do the same good work for more doctors and more patients with the same amount of stafftwo up front, the two of us in back, and youand I do not know how you are doing it with everything else that is on your plate. You know I appreciate how much you help with the case management problems and these insurance companies and their complaints. I swear they think we can get everything done quickly for them, but they do not understand. Poor Sally takes the bulk of their complaints, and that girl who quit last monthwhat was her name? Irene?well, it is a good thing she left because Sally had three different insurance companies call and say the medical records they asked for were incomplete, and they were pretty mad about it and are going to tell the doctors about these problems. Linda felt her heart drop. She, too, liked working for Clearwater Orthopedics and knew most of the physicians on a first-name basis. The last thing she wanted was for them to think she did not know how to run her department. Linda told Marge and Tina she appreciated them and all their hard work. We know you do, Marge said. But something has to change, Linda. My friend over in the HIM department at Trinity Health gets paid much more than I do and has been calling me every time they have an opening. Its getting pretty tempting! Linda took a breath. She could not lose her staff. Sally, Marge, and Tina worked so well together. It was just that the practice seemed to be growing faster than they could control. They needed more staff, and she needed time to train them. She needed to hire the right people who would stay with the practice. She felt a headache coming on and checked her watch: 8:15 a.m. The day had hardly started. She had an 8:30 a.m. monthly report and brainstorm session with the physician leaders. She could not be late for that. She asked Marge and Tina to excuse her until she returned in an hour. As she passed Sally at the front window, she saw three people waiting for help. Sally continued to smile and acknowledged the people in line. Linda scribbled a note for

Sally, which said, Lets meet today at lunchmy treat. Sally glanced down, read the note, and nodded yes to Linda as her hand reached for the ringing phone. Four hours later, Sally and Linda sat in a quiet corner of a nearby coffee shop. Tell me about how you are handling things these days, Linda said to Sally. And I want you to tell me what you really think. Linda knew that Sally was by nature an optimist, but she also knew that holding stress inside was not healthy. Things are OK, Sally said. It just seems that we are really busy lately, and it is hard to keep everyone happy, you know? Sally tried to smile, but her eyes became teary. I really like my job, Linda, but the last couple of months it seems like I have no help. Sometimes the people you hire are just so much more work for me that I would rather work alone. Linda found herself feeling guilty when she heard that, but knew she had to remain objective if she was going to get the problems fixed. Sally, tell me specifically what some of the problems have been. If you can give me examples of what is going wrong, that will help me to identify exactly what we need. Linda took notes in a notebook while Sally spoke. An hour and a half later, Linda sat in her office looking at the pages of handwritten notes from her lunch meeting with Sally. Her own lunch, still uneaten, sat next to her computer. Her stomach was churning as she read through the list of problems Sally had been quiet about for the past few months. When asked why she had not brought these issues to Linda, Sally replied I did not want to bother you because I know how busy you are. I thought I could handle them on my own. As much as she appreciated Sallys work ethic, Linda knew she had i mportant issues to address right now. She began to type up her notes to have a legible recording of her meeting with Sally. She knew she would use this information to support her requests to administration. Linda started with the following: Problems with release of information (ROI): ROI turnaround time: Current policy calls for a 24-hour turnaround time on requests to release information and documentation to patients or other requestors. Sally had informed Linda that the policy was not being followed. Linda, we could do this if I had good help at the front desk, and if we had some type of rule that we really stuck to , Sally had said. We get far too many requests from patients or family members who walk up to our window and say, My doctor sent me down for my records. Im going for a second opinion and I need the records now. When I explain that we have a 24-hour time window because it takes time to organize the record and make copies, they usually get mad. Sometimes they live 50 or 60 miles away and do not want to come back, or they start to question me as to why the doctor told them they could get the record right away. Then I look like I do not know what I am doing. Mistakes with released information: Linda had asked Sally about the three charts Tina had mentionedthe charts in which Irene, who had quit, did not include all the information for the requestor. Oh, that was a mess, Sally had said. It happened within about a two-week time period, and it was with three different insurance companies. Two of the three problems were with patients of Dr. Garcia. He does all those spine proceduresyou know who I am talking aboutand his nurse, well, she needs lessons in stress management or something! The bottom line is, I took care of everything, and Irene said she was sorry and forgot what she was supposed to include in the documents. I felt bad in a way because I know I should have given her a better

orientation, but we have been so busy that it is hard to have the time to explain every little thing over and over. She quit a week later, so it did not matter. Besides, she was always texting her boyfriend when I was not sitting right next to her. No loss with her leaving. Linda made a note to herself to follow up with Dr. Garcias nurse and with the three insurance companies. Unauthorized release of information: Sally had a problem with that just last week. Carrie was covering the lunch hour for Sally and went to the window to respond to a walk-up patient. The woman gave her husbands name and said she was there to pick up his medical records. Carrie checked the list of documents for pick-up that day but did not see his name. She asked the woman to wait, as the documents were not ready. The woman was pleasant about it, and Carrie made copies of his record. The woman chatted with Carrie as she made the copies and was soon on her way, after signing a sheet verifying that she had picked up the record. When Sally returned from lunch, Carrie mentioned what had happened. Did you ask her for some type of identification? Sally asked. No. She said she was his wife and she signed her name. Isnt that enough? Carrie asked. Sally explained that the woman should have provided some type of proof that she was his wife, and Carrie could have called up to the physicians office to verify the request. Usually the patient would come down or the physicians nurse would call in most of these workmens compensation cases. Sally did not have a good feeling about this, and when she called the physicians office, they said there was no reason for the patient to request a copy of his record since he was just getting started in treatment and may be having surgery. He had a case manager, and, if anything, she would have called. An hour later the case manager called and told Sally that her client phoned her and was extremely mad. He asked why someone had given his medical record to his wife. They were going through a divorce and she was looking for more money in the settlement. Knowing that he was injured while on the job, she wanted to get a share of any money he may be receiving in a lawsuit. Sally apologized to the case manager profusely but knew that Carrie had made a big mistake with that one. I was going to tell you about it, Sally had said to Linda at lunch. But the case manager called me back a couple of hours later and said they had it all straightened out. Linda started another column: Talk with Carrie About, and wrote absenteeism, verbal warning, and release of information. She also wrote HR policy as a reminder to herself. Linda added a few more notes to her list. Sally had told her about the patient who moved out of state and requested three times that his medical record be sent to his new physician. Sally said he sounded more frustrated than anything else. What kind of customer service is that? We should have had that out to his physician weeks ago. He signed all the forms before he moved. I do not know where it fell through the cracks, she said. Before their lunch had ended, Sally said to Linda, Well , at least I have one piece of good news for you. Linda asked what that might be; she really needed to hear some good news. Dr. Haas came down yesterday morning and said his wife is a new patient with Dr. Blumenthal. He asked to see her medical record because he wanted to make sure Dr. Blumenthal is being aggressive enough in his treatment. Linda stared blankly at Sally, afraid to ask what happened. What did you do? I gave him my biggest smile and told him that unless I had his wifes signature on an authorization form, I could not release any of her medical information to him. I told him I was sure he would understand. He looked a little surprised, then smiled back and said, Of course, and turned and went back to the elevator. Lucky for us, Carrie was not at the front window for that one! Linda laughed out loud. Yes, that was good news.

Coming back to the task at hand, Linda began to write lists to herself as reminders. The ROI problems were a big quality issue, but she needed physician backing to allow her to enforce existing policies. She would check with some of her colleagues at other facilities and see how they were handling the ROI process. It was such a basic task, but it seemed like, at her organization, it was out of control. Linda needed to gather some data first to make comparisons with other organizations. She wanted to have objective data to take to Dr. Blumenthal and the physician group before she made her proposals. There was also the issue of staffing. Morale was slowly dropping among her three star employees, and she did not want to lose them. Their team needed reinforcements. The department was going to need another full-time coder; 20 new physicians was a significant addition to their coding load. She needed to find some comparison data for productivity standards and also for revenues generated to show how the investment in another staff member would generate reimbursement more quickly. The other issue she wanted to address immediately was staff training. Linda could see where she as a supervisor had fallen short of her responsibilities in appropriate training. She wanted to promote a real commitment to her staff towards their professional development. Linda would check into professional development activities when she spoke with her colleagues. It was always good to see what others were doing and to make those comparisons. Linda thought about what Dr. Blumenthal had said about customer satisfaction. She thought not only about patients and their families but also about the many case managers, insurance companies, attorneys offices, and even the physician group. All of these were customers to the HIM department, and she and her staff had a responsibility to serve all of them. She had to find a balance between customer service and enforcing policy to manage the process more effectively. She also knew she needed to do some physician training on HIPAA requirements, reminding staff that HIPAA applied to everyone. With all the new physicians joining the practice, this would be a good idea.