Every manager has a responsibility to review those functions supervised to determine if the workflows, staffing, and policies need to be revised to deliver more efficient services. This can be a daunting effort, especially when we consider all the other competing priorities we’re juggling these days.
Managers may initiate an assessment on their own or request an external firm to conduct it on their behalf. Both approaches have advantages. A manager knows the history of the function, is closer to the issues and challenges that the staff handle on a daily basis, understands the relationships between the function and its customers, and knows the personalities of the staff working in the team. An assessment is an opportunity for a manager to see and understand the coding team’s challenges and build a stronger rapport.
Choosing the Consultant Route
On the other hand, the manager may be too close to the function and unable to recognize its deficiencies. An external consultant may “see” those deficiencies more clearly. Staff may be willing to share with a consultant their ideas and concerns about their work environment.
Many managers and directors today have full plates. Finding the time to do the assessment may be challenging. The consultant will be able to devote uninterrupted time with each staff member during a condensed period, while the manager may need to carve out one or two half days a week – for as many weeks as necessary – to complete the assessment.
Finally, the consultant can draw upon prior consulting experiences and action items from other operational assessments to develop recommendations that will have a greater impact in enhancing the team’s performance.
Regardless of the approach, the goal to create the most efficient function remains the same. Any assessment requires to analysis of data. Capturing the following data for your coding function is the first step:
• annual number of encounters to be coded by type
• number of work hours available for the staff assigned to the function
• productivity of each staff member (ideally by record type)
• results of coding quality audits
• DNFC (discharged not final coded) balance for the last business day of each month for the last 12 months.
Number of Encounters to be Coded by Type
Most healthcare organizations publish statistics that account for the total number of inpatient discharges, ambulatory surgeries, emergency encounters, etc. Determine which of the record types are coded by the coding team. Monitoring encounter volumes from month-to-month and year-to-year may identify seasonal trends that need to be accommodated. Monitoring this data may indicate that a part-time, PRN, or contracted staff member may be needed at certain times of the year to ensure coding can be accomplished in a timely fashion.
Number of Work Hours Available for the Assigned Staff
This data element attempts to determine how many hours are available for coding. This is not the same as the total number of paid hours. It’s important to differentiate between the hours that an employee is productive and working versus the hours they are paid, which may include non-productive paid time such as vacation, holidays, educational conferences, etc.
Productivity of Each Staff Member
The assessment should focus on the staff’s productivity. This includes comparing productivity of team members who are coding the same types of records while achieving department quality expectations, and understanding what each employee does on a day-to-day basis. Spending time with each team member to observe the workflow throughout the day is an important facet of the assessment. These one-on-one interview sessions are opportunities to identify distractions, redundancies, lack of tools, and non-coding related activities that interfere with the individual achieving optimum productivity. It may be necessary to time activities to account for variations in production.
Segregate the activities that are directly coding-related versus those activities (regardless of the amount of time involved) that are not coding related. For example, if one of the coder’s duties is to pick up the ED records from the ED on a daily basis, or if a duty is to print out the census lists for other staff members, these are tasks that are “stealing” time from the primary function of coding.
Flowcharting the workflow may help visualize redundant activities that can be eliminated or streamlined; however, in today’s environment when many coders are working remotely, one-on-one observation sessions may not be possible. The manager or consultant still must seek input from the team members to understand their daily routine. Regardless, these interview sessions should be used to seek input from the team members and gather suggestions for improving their work environment.
Results of Coding Quality Audits
Conducting coding quality reviews is important for the organization to meet its compliance initiatives. More importantly, the results should serve as the basis for educational programs for the coding team and future monitoring of the educations’ impact on coding results. The quality audits should be compared to determine if mentoring and education has resulted in improved coding performance for those coders who were found to have coding errors.
Some audits will identify documentation deficiencies of certain physicians. Many physicians are attending educational sessions that are encouraging them to be less committal with their diagnoses to avoid litigation exposure. This issue creates challenges for coders to assign the most accurate code(s) when flip-flopping or when many “possibles” are noted in the documentation. When external auditors identify these situations, the manager should promptly address the findings with the physician, medical staff leadership, or other designated administrators. Documentation challenges are time stealers. Time stealers impact productivity as well as quality. Future audit results should be compared to prior audits to determine if there has been any improvement in physician documentation practices.
Monitoring Discharged Not Final Coded
DNFC from month-to-month and year-to-year may identify the impact of seasonal workload trends due to variations in encounter volume. Demonstrating the impact of the seasonal trends while maintaining the same labor hours pay-period to pay-period could support the need for seasonal staffing allocations. If DNFC is increasing at the same time that there is a decline in patient volumes, this is a red flag for the manager to investigate the cause. Causes may include a change in case mix, the loss of productive hours due to a team member on vacation or extended leave, a delay in record availability for coding, productive time being used for non-coding related activities, or so forth.
Other Assessment Actions
Managers should use the assessment to refine productivity and quality expectations. Productivity standards may need revision if the prior productivity standards were established when the records were totally paper-based and staff were working on-site, but now, the records are on-line and staff are working remotely.
Capturing worked hours and production data for several pay periods will provide the basis of comparison. Compare results between coders who code the same types of records. Compare the results to published productivity standards, and determine if your team is significantly different than those published benchmarks. If so, your analysis of the coders’ daily work routine may surface reasons for the variation. For example, if your coders are using a computer-assisted coding application, it should be expected that their production will be higher than the published benchmarks.
Conversely, if the coders perform coding and core measure abstraction, the manager should expect that coding production will be less than benchmarks. In these situations, the timings that were taken during the interview sessions will be beneficial to help adjust the benchmarks accordingly.
For example, if the AHIMA standards stated that 20 inpatient records should be coded per day, that equates to 22.5 minutes per record in a 7.5 working hour day. Let’s assume your observation of core measure abstraction reveals an average of 24.5 minutes to abstract core measures. If your data indicates that each staff member averages two core measure abstractions per day, then the 20 record benchmark will be reduced to approximately 17.5 records per day.
During the assessment, educational opportunities may be identified including opportunities to cross train certain members who have become proficient in coding certain work types and desire to learn other record types. The manager or consultant would then create a cross training program and predict the labor impact. When cross training occurs, the DNFC cannot slide. A proposal may need to be prepared to justify some temporary staffing while the cross-training occurs or require the coding manager to fill in the production void while the individual is learning the new record type. Cross training always has a payback for the team. When the team has more individuals who know how to code multiple record types, the easier it is to flex staff assignments to address patient volume peaks and valleys.
The assessment may identify tasks that the staff is doing that may no longer be required or that staff is not following the coding guidelines established. This is the ideal time to reinforce the department procedures and policies in a more personalized setting. Finally, this is an opportunity for the employee and manager to have a chance to communicate at a time that is not associated with a performance evaluation.
Remember that assessments take time. If it’s impossible for managers and directors to fit a coding team assessment into the schedule, then a consultant can dedicate a concentrated period to conduct the assessment in a timely manner. It’s important for management to follow any recommendations after the consultant leaves. Otherwise, the team members may feel slighted, which could be detrimental to morale.
Rose T. Dunn is chief operating officer of St. Louis-based First Class Solutions, a national healthcare consulting firm specializing in HIM coding and operational services and ICD-10 readiness preparation. She is a former AHIMA president and active in AHIMA, ACHE, HFMA, and AICPA.