Improving outpatient registration with TQM.

ADMINISTRATION/MANAGEMENT

Quality improvement techniques have long been used in clinical departments to improve the quality of patient care. More recently, however, continuous quality improvement and total quality management techniques have been applied in nonclinical hospital departments

Each time customers come into contact with a hospital, they develop an impression of its quality. Whether that impression is favorable or not depends on how committed the hospital is to providing quality service to its customers--both its internal customers (physicians and staff) and its external customers (patients, their families, and vendors).

Until recently, quality improvement efforts centered on a hospital's clinical services. Today, however, the quality initiative is gathering momentum in nonclinical areas. By adopting total quality management (TQM) techniques in outpatient registration, hospitals can achieve improved performance and service. These improvements can translate into increased customer satisfaction, enhanced hospital-physician relationships, and higher outpatient revenues.

The team approach

TQM is not a "top-down" management technique. Rather, its foundation is teamwork, with cross-functional employee teams accepting responsibility for improving operations and services. A quality improvement team charged with improving outpatient registration typically would include staff from all areas that are affected by outpatient registration or that interact with the registration process. Physicians and staff from the preadmission testing area, the laboratory and radiology departments, the ambulatory surgery department, and the information systems department would be on the team. Other points of view that might be represented on the team could include those of staff from the patient accounting, admitting, and marketing departments.

This multidisciplinary team approach offers a broader perspective than can be gained from a team representing only the registration department or finance staff. And, as an added benefit, when changes are necessary to achieve improvement, a broad base of support is already in place.

The multidisciplinary approach also recognizes that the registration process has multiple "owners," each of whom has contributed key elements to the registration process. For example, staff in the patient accounting department may have designed the insurance screens, and laboratory staff may have created the test scheduling procedure. But to be successful, all owners of the process need to be identified and included on the quality improvement team. Then, and only then, can effective solutions to registration problems be developed--solutions that will satisfy all key players.

But while teamwork and shared ownership can push the quality initiative a great distance, they cannot do it alone. Without executive sponsorship, even the most ardent TQM team can falter. The support of a hospital leader is vital to creating a positive climate for the solutions the team proposes and a belief that change can occur. If the team does not believe that its recommendations are considered important, or if it is not empowered to effect changes within the institution, its efforts may be unsuccessful.

Understanding the process

To improve quality in outpatient registration, the team must first scrutinize the current registration process. To clarify the existing process, questions should be asked. What activities occur daily in the total outpatient registration experience? What roles do physicians, nurses, administrators, and ancillary support staff play? Failure to consider the different functions of those involved can result in incomplete identification of problems. An incomplete understanding of the process may lead to inappropriate or ineffective solutions that will only frustrate other departments and undermine the quality effort.

For example, the quality improvement team at one large Midwestern hospital looked at how patients were referred to the facility. They found that outpatient registration began much further away from the waiting room than they originally thought. Patients could phone the outpatient registration department for an appointment, or they could call an ancillary department directly. Patients often arrived unscheduled with a note from their physician. Finally, some appointments were made for patients by the physician's office staff.

Having a thorough understanding of the many ways patients can enter the outpatient registration system motivated the quality improvement team to improve and formalize its referral methods. The team recommended:

* A new test-ordering form that standardized physician orders for preadmission testing and improved accuracy;

* A computer link between physicians' offices and the outpatient registration area for physician order entry; and

* An improved phone system to facilitate the handling of incoming calls from patients and physicians.

Brainstorming

Brainstorming is a dynamic process used to identify problems as well as to uncover existing attitudes and perceptions. This process is most effective when a team's facilitator creates a climate of openness. Brainstorming is not always easy; the expression of diverse ideas and opinions--often negative ones--can be very threatening to some team members, particularly if their function or department is being scrutinized. But when brainstorming rules are laid out in advance and executed equitably, the most insightful and creative ideas are sometimes born of the conflict and tension created by the process. Later, in-depth studies of perceived problem areas may prove some early perceptions to be incorrect or invalid, but initially it is important to listen to everyone and to hear all ideas if team members are to be motivated to participate.

When brainstorming is used to identify problems, all issues and comments can be laid on the table and considered. For example, brainstorming helped one multidisciplinary group verbalize its perceptions about the outpatient registration process. It uncovered the following problems:

* Difficulty in getting through to register by telephone,

* Long waiting periods,

* Lack of courtesy from registrars,

* Inadequate hours of operation, and

* Poor collection of insurance information.

Data collection and analysis

Brainstorming gets the teams' perceptions out on the table, but data collection and analysis are needed to validate or discredit those perceptions and, in the process, uncover new issues. Members of the TQM team need to agree on how they will study a specific process, by day of the week, by time elapsed, or by shift, for example. Then, for each perception and opinion to be validated, a data collection tool must be designed. In designing data collection tools, staff members should:

* Ask the right questions during the designing stage,

* Create tools that are easy to use, and

* Develop instructions that are clean and unambiguous.

The team, for example, may have identified waiting times as a crucial measurement of quality. To study waiting times, the team should design a data collection sheet on which to record observations. It is wise to first test the data collection sheet by conducting a small pilot study to determine if those responsible for collecting the data understand how to use the form. The pilot study also will reveal how much time will be required to collect the data in real patient contact situations and what any adjustments to the form are necessary.

At one hospital, the quality improvement team's study of waiting times included measuring how long patients waited before seeing a registrar as well as the total waiting time they spent in the central registration area. Analysis of the data, using histograms, showed that waiting time averages markedly increased during break and lunch hours, when registration staff was reduced. The quality improvement team recommended adjusting staff coverage during these periods to reduce the waiting time experienced by patients. Interestingly, the registration department had been certain that no patient waited longer than 10 to 15 minutes for a registrar, until the study clearly showed that during break and lunch time patients actually waited 30 minutes.

Other beneficial data collection techniques for studying outpatient registration are interviews with patients, staff, and physicians to collect data on issues of concern and telephone surveys of patients to determine satisfaction levels.

Interviews with physicians can often identify practice patterns that may have a negative impact on a hospital's outpatient revenue. If physicians are dissatisfied with outpatient services, they frequently develop their own office programs for outpatient testing thereby reducing the number of referrals to the hospital. Again, by asking the right questions, the team may identify factors that have resulted in physician dissatisfaction (e.g., the laboratory's failure to send test results to both the surgeon and the referring physician, causing last-minute postponements of ambulatory surgery). This can stimulate suggestions for improving service and ultimately bring dissatisfied physicians "back" to the hospital.

Storyboarding

The ultimate goals of the quality improvement team are to design an improved process and to deliver improved outcomes. To visualize a new process and how it will improve operations and/or services, the team may use storyboards. Storyboards are pictures, charts, or sketches that organize complex ideas and enable team members to develop a common understanding of the process.

In one hospital, storyboarding allowed a team to display a redesigned physical layout of the outpatient registration area and to visualize how patients would proceed through the new area. The redesigned registration area introduced the concept of "one-stop shopping" to outpatient testing, where patients could have basic laboratory tests and X-ray studies performed in the central registration area. This concept addressed a major complaint of patients and physicians: ancillary testing was spread out across the entire hospital campus, creating a tiring and confusing experience for many elderly and disabled patients.

Measuring progress

Measuring the improvements gained through TQM is a critical component of any successful outpatient registration project. The quality improvement team needs to agree on measurable goals and determine the methodology for tracking progress. But the monitoring progress should be kept simple. If it takes too much effort, then it probably will not be done.

Benchmarking is an integral component of TQM, and enables an organization to improve by studying how its processes compare with those of other organizations. Benchmarking also can be used internally. To measure quality improvement, outpatient registration can use quantifiable benchmarks that are already available on the hospital's information systems, such as:

* Outpatient revenue,

* Number of outpatient visits (per day or week),

* Outpatient days in accounts receivable,

* Average waiting time in registration,

* Number of patient complaints, and

* Number of rejected outpatient bills due to registration errors.

Conclusion

TQM techniques, combined with a multidisciplinary approach, can significantly improve the performance of a hospital's outpatient registration department, and in so doing, improve its bottom line. With the right team in place and executive sponsorship, the quality improvement effort can enable the hospital to develop creative solutions to outpatient registration problems, and in so doing, reap the substantial benefits that come from satisfying customers.

About the author

Gail Larsen is manager of hospital and professional affairs, Blue Cross and Blue Shield of Illinois, Chicago, Ill.