MEDICAL INFORMATION SERVICES PERFORMANCE MONITORING PROJECT. By TOM HEMR JULIE IRWIN DOUG JOHNSTON

Transcription

1 MEDICAL INFORMATION SERVICES PERFORMANCE MONITORING PROJECT By TOM HEMR JULIE IRWIN DOUG JOHNSTON

2 This project would not have been possible without all of the assistance we received from and many others! *9uth *$ant% *Shir(ey * * * Carol* Carol* * Connie * Caro%n * * retcften * owen * Irma * * Juc% * Lucille * 9J awe * * 714aiJorie * 9vlarij Anne * 9cole * * 2jchart[ * Rpse gylarie * fpoy * * Stephanie * Teri * Tracy * THANKS, EVERYONE!

3 Table of Contents EXECUTIVE SUMMARY 1 INTRODUCTION 3 METHODOLOGY OF PERFORMANCE MONITORING 5 APPROACH TO MIS PERFORMANCE MONITORING PROJECT 10 PERFORMANCE MONITORING TOOLS CANCER REGISTRY 13 CORRESPONDENCE 20 DATA QUALITY 26 MEDICAL RECORD DATA QUALITY 32 MEDICAL WORD PROCESSING CENTER 38 PAYOR LIAISON 43 QUALITY MANAGEMENT 50 RECORD RETRIEVAL AND AVAILABILITY 56 RECOMMENDATIONS 69 APPENDIX 1: USER S MANUAL 71 APPENDIX 2: INFORMATION ON SPREADSHEETING WORKSHOPS 74

4 EXECUTIVE SUMMARY

5 Executive Summary Recently, Doing More with Less has been a major challenge of the Medical Information Services (MIS) Department. The department has been faced with handling increased woridoads with the same or fewer resources. In order to maintain quality service levels, a need to track productivity and quality became evident. The purpose of this project was to create a uniform set of performance monitoring tools for use by (MIS) unit supervisors in reporting on employee productivity and achievement. These tools are designed to help MIS track data necessary to handle the ongoing managerial issues and the increased workloads that it faces. The performance monitoring tool design process began with the development of a list of major activities performed by each MIS unit. Each activity was classified as variable, if the activity was core to the purpose of the department, or fixed, if the activity was intended to support the operations of the department. For the variable activities, time standards were obtained from previous studies or by supervisor estimation. These time standards are used to determine an expected amount of time for each activity. This is done by multiplying the time standard for one task by the actual quantity of tasks performed. The major output of the performance monitoring tool is a productivity indicator for each unit. It is calculated by dividing the expected time for all activities by the actual time spent by employees on all activities. Unit supervisors will have to set target ratios for their individual unit s productivity, with the primary goal being continuous improvement of the ratio. Departmental productivity can be easily calculated by performing the division described above with total departmental expected and actual hours. The project team created a performance monitoring tool for each unit using Microsoft Excel spreadsheeting software for IBM-PC compatible computers. The tools are precisely uniform for each unit, and can be used with reporting periods of any desired length. To receive the most amount of feedback, data should be reported weekly. A set of data collection tools was also developed, to assist supervisors in gathering and summarizing the information required for the monitoring tool spreadsheets. Future considerations for implementation of the performance monitoring tool include the need to revise standards as well as the addition of quality indicator tracking. Many of the time standards were subjectively estimated by supervisors, and will require additional study. The quality indicator tracking section was not included in the performance monitoring tool, but will be an important and useful addition. A trend of increasing productivity without sacrificing the customer s expected quality should be the goal. 1

6 INTRODUCTION

7 Introduction The project described in this report was conducted by three undergraduate students in the Industrial & Operations Engineering (JOE) Department at the University of Michigan, Ann Arbor, as a senior design project for JOE 481, Practicum in Hospital Systems. The project was administered by the University of Michigan Medical Center (UMMC) for the benefit of the Medical Information Services (MIS) Department. Background of Project The University of Michigan Medical Center (UMMC) Medical Information Services (MIS) Department is the section of the hospital concerned with the storage, retrieval, and upkeep of hospital patients medical records. The MIS Department is divided into four major sections: the Medical Word Processing Center, the Medical Information Retrieval area, the Quality Management area, and the Medical Record and Data Quality area which are each headed by an assistant director. The Medical Information Retrieval area is comprised of the Medical Correspondence unit, the Record Retrieval unit, the Record Availability unit and Support Services. The Quality Management area consists of the Quality Management unit, the Payor Liaison unit, and the Cancer Registry unit. The Medical Record and Data Quality area includes the Medical Record Data Quality (MRDQ) unit, and the Data Quality unit. These two units are sometimes referred to as the Inpatient Record Completion unit and the Data Management unit. The Medical Information Services Department has experienced large increases in workload in recent years. In order to justify requests for increases in budget allocations to match the workload increases, MIS must be able to track the volumes of work performed. The performance monitoring tools will assist the MIS administration in meeting this reporting need. Just like any other department, the MIS Department needs to be able to continually track the activities it performs. Activity tracking will allow the department to study possibilities for making improvements, leading to greater efficiency. Since the entire UMMC community depends upon the medical records serviced by MIS, improvements in efficiency can have effects throughout the hospital. 3

8 Purpose of Project The purpose of this project was to create a uniform set of performance monitoring tools for use by the Medical Information Services unit supervisors in reporting on employee productivity and achievement. 4

9 METHODOLOGY OF PERFORMANCE MONITORING

10 Methodology of Performance Monitoring Performance monitoring can include several different types of criteria. These include workload, utilization, budget, productivity and quality. For example, the utilization of highly used equipment can be an important measure in some departments. The main criteria focused on for this project were productivity and quality. The first step in developing a system to monitor a unit s performance is to clearly define the major activities which the unit performs. By listing the activities, this serves as an overview of the overall responsibilities of the unit. Each activity can be classified as variable or fixed. (See diagram on the following page.) Variable activities, which are core to the purpose of a unit, have an associated standard time, which can be thought of as the amount of time necessary for a qualified person, working at a pace ordinarily used under capable supervision and experiencing normal fatigue and delay, to perform a defined amount of work of specified quality, while following a prescribed procedure. (Taken from JOE 481 Coursepack.) There are two important points to remember about standards: The standard may change over time, and must be continually re-evaluated to reflect changes in the work environment. The standard represents the length of time typically required to perform one unit of an activity, and does not depend on the quantity of the activity performed in any single time period. By multiplying the standard time by the number of activities performed within a time period, an expected time is calculated. By dividing this number by the actual time spent on the activity, the productivity indicator is calculated. The actual time needs to represent the amount of time spent on the job (regular and overtime hours), and not the amount of hours for which employees are paid. The latter may include non-working time such as vacations or sick leave. Including such factors in the actual time would inaccurately lower productivity. Fixed activities are necessary to support the operations of the department. They do not have associated standard times as it is difficult to capture data to determine an appropriate standard time. They represent tasks for which performance is measured by the amount of actual time spent, instead of a comparison of actual and expected times. Fixed activities may be combined with variable activities to determine an overall productivity if it is assumed that the expected time for fixed activities is equal to the actual time. This equality assumption for fixed activities is determined by a professional assessment. 6

11 Definition and Calculation of Productivity. LIST OF ACTIVITIES / VARIABLE ACTIVITI ES FIXED ACTIVITIES PROFESSIONAL ASSESSMENT EXPEC I IzD TIME Ni EXPEC I IzD T1ME EXPECTED TIME ACTUAL TIME PRODUCTIVITY

12 Because all of the activities in the department have not been exhaustively identified, the target figure for productivity should not necessarily be a ratio of 1. The standard times have not been engineered precisely enough to obtain a balanced productivity ratio of 1. Each unit must set its own target ratio based upon how well the activities listed for each unit match the activities actually performed by the unit. Hours spent performing other activities, which are not part of the defined responsibilities of the unit, will lower the productivity ratio. Thus, supervisors must consider whether the tasks performed by unit employees do constitute a portion of the unit s responsibilities, and whether the tasks should be included in the performance monitoring tool. Another useful component of a performance monitoring system is quality indicator reporting. Criteria for reporting on quality may involve the percentage of work which is being performed at an acceptable level, or the amount of work which is performed in an acceptable amount of time. It is important to track quality indicators along with productivity ratios. Continuous improvement of both productivity and quality should be the goal. 8

13 APPROACH TO MIS PERFORMANCE MONITORING PROJECT

14 Approach to MIS Performance Monitoring Project For this project, the project team developed a uniform set of tools to monitor performance in each unit of MIS. For simplicity and ease of use, the performance monitoring system was designed as a collection of computer spreadsheets using Microsoft Excel 4.0 software. The information regarding unit activities and responsibilities was obtained through interviews of unit supervisors and department assistant directors. The system was designed with a managerial focus in mind, so that each tool reports on total unit accomplishments, and not on individual worker achievements. The reporting portion of the tools for each unit, and the defmitions of the activities performed within each unit, are shown in the following sections of this report. The complete details of spreadsheet setup are given in the appendix. The maj or sections of the spreadsheet include a listing of variable activities and fixed activities, and a sununary segment, which details the calculation of expected hours, actual hours, and productivity. Each unit s tool was designed with precisely the same spreadsheet format, so that department summary information may be easily computed. For example, the overall departmental productivity could be calculated by summing the total expected hours from each unit s individual spreadsheet and dividing by the sum of the total actual hours from each spreadsheet. The spreadsheet can be used with reporting periods of any desired length. The recommended usage is weekly, but biweekly or four-week reporting periods are also possible. The portion of the spreadsheet that will be printed after each reporting period, as shown in the following sections of this report, includes both a summary of year-to-date performance and the performance data for the current period. Other sections of the spreadsheet, which would not normally be printed out, are used for the entering of the periodical data and the calculation of expected time for variable activities. Because the tools report summaries of each unit s information, supervisors are presented with a problem in gathering the data needed for the spreadsheets. To facilitate data collection, a set of data collection worksheets has been developed. These worksheets include the same list of activities for each unit, as well as space for listing each worker. This enables supervisors to record the achievements of each worker, and then to summarize these into the totals needed for completion of the performance monitoring spreadsheet. Several MIS supervisors already use various types of data collection tools. The data collection worksheets presented here are solely for the benefit of any supervisors who may wish to use them. The performance monitoring spreadsheets do not require use of these data collection worksheets. 10

15 For the development of this performance monitoring tool, many of the standards for variable activities were obtained by subjective supervisor estimates. As the tool is implemented and used, the data collected by the supervisors will assist them in recognizing which standards require refinement. As the standards become more precise, the level of accuracy of productivity measures will be increased. The following eight sections of this report include a description of the activities of each unit, the unit s data collection tool, the unit s performance monitoring tool, and definitions for each activity performed by each unit. 11

16 CANCER REGISTRY

17 Cancer Registry The Cancer Registry unit consists of 6 Senior Health Record Analysts (SHRA). Four of these SHRAs are responsible for abstracting records, a process which takes about 45 to 60 minutes per record. Each SHRA produces between 6 to 8 record abstractions per day. In addition to abstracting, each SHRA attends tumor boards in which they meet with physicians to discuss new treatments. These sessions last approximately 1 to 2 hours. Each SHRA also places follow-up phone calls to the doctors. Three weeks out of each month, the SHRA concentrates on abstracting. The fourth week of each month is devoted to patient follow-up. The follow-up procedure is a very time consuming process, primarily due to the unit s outdated data system. Following-up is done in order to keep in touch with the cancer patient and determine their current address. Over 800 to 1000 follow-up letters are sent out every month. Tracking the location of a patient is a process which can be time consuming. If after 15 months the Cancer Registry unit is unable to determine a the location of a patient, the patient is then classified as lost to follow-up. The follow-up letter are classified into three categories. Batch letters are standard letters sent to most patients. A second type of letter is manually composed and sent to a guardian or relative for patients under 19, mentally handicapped patients, incarcerated patients, and so on. Letters to referring physicians are also composed manually. One part time employee (20 hours/week) is devoted to casefinding, patient care evaluation, and cancer workgroup indicators. One part time employee (15 hours/week) is devoted to clerical work consisting of data entry, chart control, and letter review for any notes regarding deaths or treatment from patients. Finally, one receptionist (10 hours/week) primarily folds and malls letters and keeps track of when patient letters were sent out. Currently, the Cancer Registry unit abstracts approximately 300 new cases a month. They also handle outside requests from other tumor registries and phone calls from the public. These outside requests totaled 45 for September 1994 and 59 for August Previously, the Cancer Registry unit did not send out any patient follow-up letters during the holidays (November and December) as a courtesy to not upset any patients. This created a large shift in the workload during the months following this period. In addition, there is no possibility of hiring temporary employees to help during periods of large workloads, due to the advanced training required for SHRAs. 13

18 . Patient - Hours Worked Charts Abstracted Patient Letter #1 Letter #2 Referral Letter C D CD Ci) 0 - CD 00 - C: Patient Letter Sent > CC Form (_) AccessionofNewCose Change 2 to 3 Outside Request C- p. H. CD(D 0 IC-) QCD 0 CDCD : Fold/Stuff for Follow-up 33 Update Medical Record 0 -I 0 D C, CD Casefinding 0 CD Ci) UpdatePt./ReferralLetter Path Updates Bill Dates I I I I I I I I I I I I I I I I I I I I I I TrackMissinlnfo p z 0 r, (I)

19 Medical Intormaton Services Cancer Registry Performance Report Current Period Number: J 1 Janl-7, 1995 SUMMARY Year To Date Current Period Expected Hours: Subtotal Variable ActMties Subtotal Fixed ActMties Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCTIVITY: 0..0 Variable Activities: Standard Year To Date Current Period Mm/Activity Chart Abstracted 60 Patient Letter #1 Patient Letter #2 Referral Letter 3 Patient Letter Sent 3 CCForm Accession of New Case Change2to3 Outside Request 4 Fold/Stuff for Followup 1.5 Update Medical Record Fixed ActivitIes: Year To Date Current Period Casefinding Telephone Calls Update Pt./Referral Letter Path. Update Bill Dates Track Missing Information Quality Indicators o o a o For future development. Quality indicators for each activity of the form (Successful Tasks) / (total Tasks).

20 Charts Abstracted: Medical records of patients who are diagnosed with cancer at UMMC, outside by referring physicians, or patients who hailed treatment and are being treated here for the first time are abstracted. This also includes second opinion and consultations. Variable Activity. Standard: 50 minutes per case, studied from past data. Patient Letter #1: This activity involves updating letters for last contact date, treatment, and referring physicians of all patients who have returned follow-up letters. Patients who are over the age of 19 years receive letters. Variable Activity. Standard: 1 minute per letter, studied from past data. Patient Letters #2: Letters are updated for last contact date, treatment and referring physician of all patients who can not receive a letter directly. This includes sending letters to patients that are terminally ill, incarcerated, mentally handicapped, or under 19. Variable Activity. Standard: To be determined. Referral Letter: This task involves sending letters that were sent directly to referring physicians or other facilities and referrals. Variable Activity. Standard: 3 minutes per letter, estimated. Patient Letter Sent: After a letters has been sent, the information concerning its departure is recorded into a data base for tracking purposes. Variable Activity. Standard: 3 minutes per form, studied from past data. CC Form: A County Clerk form is sent to the county office. This task involves searching for confirmation and cause of death. Variable Activity. Standard: 1 minute per form, studied from past data. Accession of New Case: This activity involves assigning unique numbers to the cases based on year of diagnosis and recording it into accession register. Variable Activity. Standard: 1 minute per case, estimated. Change 2 to 3: A clerk enters data base to change code from 2 to 3 to signify case has been sent to the state registry. Variable Activity. Standard: 1 minute per case, estimated. 16

21 Outside Requests: This activity involves filling out forms from other hospitals regarding cancer status and treatment of patients. Variable Activity. Standard: 4 minutes per form, studied from past data. Fold and Stuff Letters for Follow-up: Every letter which is sent out needs to be folded and inserted into an envelope, and stamped with the supervisor s name. Variable Activity. Standard: 1.5 minutes per letter, estimated. Update Medical Record: The abstractor reviews medical record to update, last contact date, treatment, referring physician of those patients who were at UMMC for a clinic visit since their last contact date. Variable Activity. Standard: To be determined. Casefinding: Review all pathology reports, tumor board minutes, autopsy reports, MCF lists, for any newly diagnosed cancer cases. This compiles the suspense list. Telephone Calls: This includes all phone calls made for the purpose of tracking or following a cancer patient to update medical record and last date of contact and to capture incomplete information for treatment. This also includes searching for death information. Updating Patient and Referral Letters: Time spent on this task depends on the information sent back from the patients. Path Updates: This activity involves updating treatments, demographic changes, checking last contact date, and referrals from medical records. Bill Dates: This task includes reviewing patient management system and clinical scheduling for a recent bill date (within 12 months of last contact date). Track Missing Information: 17

22 This task entails searching for path reports, CT scans, and other information missing from record. Telephone calls are made to gather information and retrieve the record from the medical record room. 18

23 C CORRESPONDENCE

24 Correspondence The Medical Correspondence unit is responsible for processing all requests for the release of medical information. These requests can come from patients, referring physicians, insurance companies, other hospitals, insurance companies, the courts, or many other sources. Requests come both by facsimile and by mail, and number per week. One clerk is responsible for opening and sorting the mail. The mail is sorted by type of request and entered into the on-line request tracking system, called CORR. This creates a request for the record in the Medical Record Locator system, and the record is delivered to the Correspondence unit the next morning, if available. Prepayment is required for most record requests, so requests are sometimes returned for lack of prepayment. Otherwise, the copies required are produced by the unit s in-house, contractual copy service, checked for quality, and mailed. Another clerk works exclusively on problem resolutions. These usually relate to missing records which have been requested. Another clerk is responsible for interviewing mothers of newborns, to obtain information needed for completion of birth certificates. Requests for psychiatric records are handled by yet another clerk, because those records are not on-line and require extra phone calls and manual handling. A Health Record Analyst handles all subpoena requests. Two other clerks handle chart control and requests to satellite clinics. Finally, a reception handles requests from walk-in visitors. There are several factors contributing to high stress within the unit. Visitors making requests can be difficult to deal with. Sometimes, it is complicated to find records which have been requested. Large amounts of rework sometimes occur when patients can t or don t get what they want. The copy service typically is a week or more behind schedule. These stress factors lead to a high rate of absenteeism within the unit. Although the unit is probably overstaffed, this is presently necessary to cope with the absenteeism problem. If the approach to handling requests were to change, it may even be possible to cut back on the number of positions. For example, the assistant director in charge of the unit is considering a coding system which would avoid having more than one person trying to solve the same problem. 20

25 - -4 Q. Q. Hours Worked - Birth Certificates Open Piece of Mail Matching Chart to Request Request for Microfilm Chart Request for Psychiatric Chart Proof,Sign,Certify. and Mail Birth Ce > > m > -4 C D < CD (n 0 CD 0 - CD o. 0. 0D RD O5 -Q. (DC) CD (D (DO -n3 Problem Resolution Assisting Walk-in Customers D Cj CD C) CD 0, Assisting Telephone Customers Receptionist Duties -I, >< m Q> 0-4 Medical/Legal Emergency Request Handling Legal Files Administrative z 0-4 m C,,

26 Medical Information Services Medical Correspondence Performance Report Current Period Number: 1 Janl-7, 1995 SUMMARY Year To Date Current Period Expected Hours: Subtotal Variable Activities Subtotal Fixed Activities Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCTiVITY: 0..0 Variable Activities: Standard Year To Date Current Period Mm/Activity Birth Certificate 240 Open Piece of Mail 3 Matching Chart to Request 2 Request for Microfilm Chart 5 Request for Psychiatric Chart Praof,Sign,Certify,and Mail Birth Cei Fixed Activities: Year To Date Current Period Problem Resolution Assisting Walk-In Customers Assisting Telephone Customers Recepionist Duties Medical/Legal Emergency Requesl Handling Legal Files Administrative Quality Indicators For future development. Quality indicators for each activity of the form (Successful Tasks) / (Total Tasks).

27 Birth Certificates: Includes printing out daily list of births, picking up worksheets from delivery room, abstracting patient information and interviewing mothers, collecting worksheets, dropping off birth certificates at Professional Building and CNM Station, typing and proofreading completed birth certificates, completing paternity papers, obtaining parent signatures, educating parents about Social Security Numbers, and mailing all paternity papers and birth certificates. Variable Activity. Standard: 4 hours per certificate, estimated Problem Resolution: Involves going over problem charts to determine missing or incorrect components; finding missing parts of records, including summaries, dictations, and reports; rerouting problems to other departments. Open Piece of Mail Involves opening and reading mail, determining what is being requested, and entering the request in CORR. Variable Activity. Standard: 3 minutes per request, estimated. Matching Chart to Request Involves matching record request with correct chart, found among all charts delivered upon request. Variable Activity. Standard: 2 minutes per chart, estimated. Request for Microfilm Chart Involves normal record request steps as well as additional time for manual compilation of microfilm request list. Variable Activity. Standard: 5 minutes per request, estimated. Request for Psychiatric Chart Involves normal record request steps as well as additional time to locate record manually, additional time to obtain permission of doctor for release of record, and additional time to copy record (rather than sending to copy service). Variable Activity. Standard: To be determined. Proof, Sign, Certify, and Mail Birth Certificate Includes proofreading, signing, certifying, and mailing out birth certificates. Variable Activity. Standard: To be determined. Enter Subpoena Request Involves entering request for medical record based on subpoena received; contacting requestors to deal with problems; ensuring that work is not duplicated for different subpoenas on same case. Variable Activity. Standard: To be determined. 23

28 Assisting Walk-In Customers Any activities dealing with the immediate service of walk-in customers, which are not included in other activity definitions (such as a simple record request). Assisting Telephone Customers Any activities dealing with the immediate service of telephone customers, which are not included in other activity definitions (such as a simple record request). Receptionist Duties Any duties of the receptionist which do not deal with walk-in or telephone customers. Includes fax duties, mailings, and voice mall calibacks. Handling Medicalegal Emergency Requests Involves meeting the immediate needs of doctors, attorneys, etc. for urgent medical record requests. Handling Legal Files Involves the handling of all medical records currently involved in some type of litigation. These records are housed in a separate set of cabinets within the Correspondence unit. Administrative Time spent by employees (especially medicalllegal clerk) on portions of job descriptions including assigning work, attending staff meetings, collecting monthly statistics. 24

29 DATA QUALITY

30 Data Quality The Data Quality unit consists of 27 employees, mainly coders and analysts. The coding department consists of 21 employees: 2.5 clerical, 3 data quality analysts (DQA), 13 senior health record analyst (SHRA) and 1 temporary SHRA. Each SHRA receives 5 weeks of vacation and 120 hours of sick time each year. This is a large amount of time which must accounted for when calculating the unit s productivity. Currently, each SHRA is expected to code approximately 12 records per day. When the number of uncoded records increases, the unit uses voluntary and mandatory overtime in order to decrease the backlog. When over 400 records become backlogged, voluntary overtime is requested. When over 500 records are backlogged, overtime becomes mandatory and 16 hours of overtime are required for each worker for each month. The coders work out on the hospital floor. Time, and therefore productivity, is lost when interruptions occur that prevent the coder from doing the job efficiently. In order for the hospital to send the correct billings, accurate coding is essential. The analyst department consists of 6 employees: 4 medical record clerks and 2 clinical pertinents. Analysts are responsible for dealing with chart deficiencies, such as orders not signed or physicals not completed. This information is then entered into the DMS (Deficient Monitoring System) and each physician gets a list of his or her deficiencies. 26

31 V V V 0 ;- CD Hours Worked Chart Coded - - Chart Analyzed Aftestation Statement > Maintain Chart Flow ---- C) - -4 Focus CC s ---- Cl, Recalibration Compare Report CPT Chart Coded Followup Unanalyzed Record Assist Coders I- m C D CD 0 CD 0 -Q o p. 0D C(D Q.ci C) OCD -I oc 01 0(D a - 0 Telephone Calls Problem Records > C) -4 (-I, CD 0 CD Cl, Followup Unsigned Aft. Stmts. V-S -4 rn C,, Track Missing Information MPRO and 3rd Parly Reviews Doctor Dictation Other z 0-4m (I)

32 Subtotal Variable Activities Subtotal Fixed Activities Actual Hours: Total Expected Hours Expected Hours: SUMMARY Year To Date Current Period Janl-7, 1995 Data Quality Performance Report Medical Information Services Current Period Number: 1 Regular Maintain Chart Flow Focus CCs 8 Quality IndIcators Quality indicators for each activity of the form (Successful Tasks) / (total Tasks). Assist Coders For future development. MPRO and 3rd Party Reviews Track Missing Information Followup Unan zed Records Followup Unsigned Alt. Stmts. Fixed Activities: Year To Date Current Period CPT Chart Coded 1.5 Compare Report 1.5 Chart Coded 37.5 Chart Analyzed 14.1 Telephone Calls Year To Date Current Period Mm/Activity PRODUCTIVITY: 0..0 Total Actual Hours Overtime Variable Activities: Standard Attestation Statement 2 Doctor Dictations Other Recalibration 8 Problem Records

33 Chart Coded: The coders review medical records and assign diagnosis and procedures to obtain a DRG for hospital reimbursement. Variable Activity. Standard: 37.5 minutes per record, calculated from studied standard of 12 charts in 7.5 hours. Chart Analyzed: The analysts review the medical record for deficiencies. The chart is placed in correct sequence, assigned physician numbers, and entered into DMS system. Variable Activity. Standard: 14.1 minutes per chart, calculated from studied standard of 32 charts in 7.5 hours. Attestation Statement: Once an attestation statement is returned from the attending physician, the statements are signed into the MRAS system. Variable Activity. Standard: 2 minutes per attestation, studied from past data. Maintain Chart Flow: Records are signed into the DMU office by individual coder MRL, and also signed into MRMJW for analyzing. Variable Activity. Standard: 1 minute per record, studied from past data. Focus CC s: Medical records are reviewed for focus DRG cases after coding to evaluate for further optimization. Variable Activity. Standard: 8 minutes per chart, studied from past data. Recalibrations: Patient visits are combined if readmitted within 30 days and billed as one if appropriate, or billed as one admission. Variable Activity. Standard: 8 minutes per record, studied from past data. Compare Report: A list of cases is printed out in which the physicians numbers and/or attestations do not match what is in MR compared to DMS. These cases are opened up in MR and corrected. Variable Activity. Standard: 1.5 minutes per record, studied from past data. CPT Chart Coded: CPT procedures are coded which come from billing and have an operating room or treatment room charge but no procedure is found. Variable Activity. Standard: 15 minutes per record, studied from past data. 29

34 30 This activity involves answering all incoming calls and process as needed. For This task includes reviewing and responding to all MPRO and 3rd party denials by providing documentation within the medical record and coding clinics along new employees when needed. the correct coding assignments. Data Quality Analysts assist coders with problem solving and help in determining making sure Pend s are in the MRL, contacting clinics for the record, and example, this could involve locating a chart for Data Quality s customers. MPRO and 3rd Party Reviews: with a written letter to support the reasoning for the rebuttal. Charts which need to be dictated are pulled or located by a clerk. month, sending time sheets for biweekly staff once every two weeks, and training medical record for signed attestation. A record is considered a problem if it is signed into the unit but is not there, or if it is needed by the unit but cannot be found. The unanalyzed record list is used to track unanalyzed charts. This involves The unsigned attestation report is used to track unsigned attestation statements. This activity involves reprinting the list, making phone calls, and/or checking the This category includes the following activities: ordering supplies for DMU once a Other: Follow-up on Unanalyzed Records: searching within the department. Assisting Coders: Telephone Calls: Problem Records: Follow-up on Unsigned Attestation Statements: Doctor Dictation:

35 MEDICAL RECORD DATA QUALITY

36 Medical Record Data Quality MRDQ is responsible for closing all incomplete records, and for all phases of psychiatric records. The closing of a record is a process in which any deficiency within a medical record is corrected before the record is filed away. MRDQ consists of 11 staff members and one temporary employee. The temporary employee and 6 of the 11 staff members are located at the hospital and the remaining staff are at the Taubman, Mott, and Riverview psychiatric clinics. At Riverview, one Health Record Analyst (HRA) and one clerk are responsible for adult psychiatric outpatients. They are responsible for analyzing a record for completeness, determining if the record needs to be closed, and manually establishing a record for new patients. At Mott there is one HRA and one clerk to handle inpatient child and adolescent psychiatric records. At Taubman, one HRA handles the same type of records. Every Wednesday, MRDQ sends a list to physicians notifying them of deficiencies. Every day this list is updated in an ongoing process to reduce the number of deficiencies. MRDQ is experiencing difficulty in meeting their workload, in part because the volume of discharges has increased, the volume of surgical procedures has increased, and the demand on the record has increased. A big issue concerning MRDQ is the need to manually check for the existence of a previous psychiatric record when satellite clinics prepare to close an existing psychiatric record. If a previous record exists, then they must manually combine the two records. A large amount of overtime was used to close satellite clinic records in the past, so a new 20 hour permanent position was recently created to handle the work. Finally, the MRDQ is a highly congested unit. This lack of space contributes to the number of work-related injuries sustained, which in turn lowers the productivity of the unit. 32

37 University of Michigan Medical Center - Medical Record Data Quality - Data Medical Information Services Collection Form Time Period: Worker I: I I i I I I I I VARIABLE ACTIVITIES FIXED ACTIVITIES NOTES C ) C Total / - 7r

38 Medical Information Services Medical Record Data Quality Performance Report Current Period Number: F I Janl-7, 1995 SUMMARY Year To Date Current Period Expected Hours: Subtotal Variable ActMties Subtotal Fixed Activities Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCT!VI1Y: 0..0 Variable Activities: Standard Year To Date Current Period Mm/Activity Deficient Records within MIS Deficient Records outside of MIS Discrepancy Records Assisting Record Completion Update and Reflle Processing Parts 20 Case Summaries Phone/Transfer Requests 5 Filing Priority Loose Sheets 0.85 Update Discharge List Fixed Activities: Year To Date Current Period Answering Telephones Quality Indicators For future development. Quality indicators for each activity of the form (Successful Tasks) / (rotal Tasks).

39 Deficient Records within MIS: The Deficiency Monitoring System (DMS) is used to pull records which are located within the unit for physicians to dictate C/S and Op notes in order for daily/weekly reports to reflect a true picture of incomplete records. Variable Activity. Standard: To Be Determined. Deficient Records outside of MIS: This task is similar to the one listed above with the exception that the record is located outside of the unit and must be located. Variable Activity. Standard: To Be Determined. Discrepancy Records: If a discrepancy exists between physicians and the deficiency report, then an investigation is initiated until the issue is resolved. Variable Activity. Standard: To Be Determined. Assisting Record Completion: Requests are taken from physicians who indicate they would like to dictate records. These records are then pulled for the requestor. During this activity, any questions that the physician might have are answered. Variable Activity. Standard: To Be Determined. Update and Refile: During this activity, DMS is updated to indicate that dictation is completed and the record is then refiled. Variable Activity. Standard: To Be Determined. Processing Parts: Parts are received that have been screened in by the afternoon shift from the previous day. These parts are then processed by looking in MRDQ files, the main file room, or within the coding/analyzing area. If the missing parts cannot be located, the MRL system is updated as part and the part is then filed on the parts shelf. Variable Activity. Standard: 20 minutes per record. Case Summaries: Priority loose sheets are received and updated in DMS, or are sent back to MWPC if the information does not match. Variable Activity. Standard: 1 minute per case, subjective estimation. Phone/Transfer Requests: Records are pulled for various clinics/requestors which are needed for patient care that are located in the MRDQ area. Variable Activity. Standard: 5 minutes per request (assuming no problems). 35

40 Filing Priority Loose Sheets: Records are prepared for main file by attaching the following: case summaries, attestations statements, history and physicals, and operative notes. Variable Activity. Standard: 0.85 minutes per record, obtained from a study which determined 20 records in 17 minutes. Update Discharge List: The previous day s discharge list is used to go into MRL and pend all discharge records to MIMR1. Variable Activity. Standard: To Be Determined. Answering Telephones: This activity involves answering all incoming calls and process as indicated. 36

41 MEDICAL WORD PROCESSING CENTER

42 Medical Word Processing Center The primary function of the Medical Word Processing unit is the transcription of doctor dictation. There are currently 43 transcriptionists that are classified either as a Level 1, 2, or 3. Level one transcriptionists are responsible for typing 10 units of dictation in one hour. One unit of dictation is defined as a minute of doctor dictation. Level 2 transcriptionists are responsible for 13 units of dictation in one hour. Level 3 transcriptionists are responsible for 17 units of dictation in one hour. Each transcriptionist receives incentive pay for performing above these levels. Thus, the standards shown here indicate the number of units of dictation before the incentive program begins. MWPC also include a clerical staff which consists of 4 FTE s, 1 messenger, and 2 temporary clerical employees. The clerical staff is responsible for printing documents, monitoring the system, and answering telephone calls. The one messenger is responsible for carrying documentation to all clinics located in the UMMC. 38

43 University of Michigan Medical Center - Medical Information Services Medical Word Processing Center - Data Collection Form Time Period: VARIABLE ACTIVITIES FIXED ACTIVITIES NOTES U Total C C C U U U a).! j5 0 D cy) c.w.2 U) - 1 > > > 0) Worker.5.

44 Medical Information Services Medical Word Processing Center Performance Report Current Period Number: I 1 I Janl-7, 1995 SUMMARY Year To Date Current Period Expected Hours: Subtotal Variable ActMties Subtotal Fixed ActMties Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCTIVITY: 0..0 Variable Activities: Standard Year To Date Current Period Min/Activily Level 1: Units of Dictation 6 Level 2: Units of Dictation 4.62 Level 3: Units of Dictation 3.53 Fixed Activities: Year To Date Current Period Messenger Activities Clerical Quality Indicators For Mure development. Quality indicators for each activity of the form (Successful Tasks) / (Total Tasks).

45 Level 1, 2, or 3 - Units of Dictation: Doctor dictation is transcribed at various levels depending upon the transcriptionist. Variable Activity. Standard: 17 units of dictation - Level 3 13 units of dictation - Level 2 10 units of dictation - Level 1 Messenger The messenger is responsible for transporting documents anywhere within UMMC. Clerical Clerical activities include printing documents, monitoring systems, and answering telephone calls. 41

46 PAYOR LIAISON

47 43 challenges from external sources, such as Medicaid, Blue Cross/Blue Shield, and other insurance companies which represent patients. These challenges are always made after the payor has paid UMMC s bill on behalf of the patient. They generally request information regarding whether the patient belonged in the hospital (for inpatients) or needed the procedures (for outpatients), what intensity Requests are received less often from insurance companies. These questions involve advanced medical information, and are usually posed by was provided, and whether the billings which were paid were appropriate based of service was provided, what the severity of the illness was, what quality of care One of the major responsibilities of the Payor Liaison unit is responding to billing on the DRG coding. Over 750 requests are received each month from Medicaid. doctors employed by the insurance companies. Therefore, responding to the by mailing a copy of the record to the insurance company. For outpatients, these the hospital s billing, and the process is essentially over. If the case is not is always mailed. If the case is approved, this means that the company agrees with received from the payor. The unit clerk looks up the medical record number for no response is made. requests can be a very complicated matter. The professionals within the Payor Liaison unit must look for items which may have been missed even by medical doctors directly involved in the care of a patient. The process of responding to the challenges is extremely important as the hospital automatically loses the money if The basic process involved when a case is requested is as follows: A listing is each case, and enters the request into the Challenge Tracking data base. For inpatient cases, the records are requested, and the clerk reviews each record for completeness. Any missing bills or charts are requested. The case is then reviewed, either on-site by a representative of the insurance company, or off-site, approved, an appeal is written either by Payor Liaison staff or by a physician. This is a census study for the Bureau of Public Health. The unit is asked to the requests, they must access many different computer systems to assemble the processes are performed by the Ambulatory Surgery unit, and a copy of the record The Payor Liaison unit faces many hindrances to efficient work. To respond to required information. For example, upon receiving requests, they must look up every medical record number to obtain the records. Another problem that they must deal with is incomplete records. When a required record is missing some room and outpatient records are not in a neat order, so volumes of information components, they must have MRDQ search for those missing parts. Emergency must be searched in order to respond to requests regarding those cases. Another task has recently been added to the activities of the Payor Liaison unit. Payor Liaison

48 abstract information such as operating room data and patient demographics for certain individuals whose names are provided by the Bureau. The current Payor Liaison staff includes three professionals (an RN, an ART, and an RRA) who do the research and appeal writing. There are also two clerical positions within the unit, of which 20 hours/week are currently unfilled. Because of the small staff size, absenteeism can be a serious issue. Only one person is permitted to be gone at any one time. The volumes of request have increased recently and are very high. However, the unit has been very successful at meeting challenge deadlines. Deadlines are generally not missed except when information is missing from a medical record. 44

49 Toti University of Michigan Medical Center - Medical Information Services Payor Liaison - Data Collection Form Time Period: VARIABLE ACTIVITIES FIXED ACTIVITIES Q) U) C -o E D 0 o Z 0. 0 C E I. U) (1) () ci) - C ( 4- U) s.2 0 U) P cj 2 E U.-. a.. <C o 0. 0 <C Ci c -rj (1) < 0. t) a 0) CD ci.0 o.0 V V. - i5 0 t 0 ci ( (1) - 0) - TJ. 0 i2-0 (1) 0 ci) 0) U) C 0.2 0) 0 fl (Z U.. u () D () rj <C D Worker r - () 0) C w (I) ) , NOTES

50 Medical Information Services Payor Liaison Performance Report Current Period Number: I I Janl-7, 1995 SUMMARY Year To Date Current Period Expected Hours: Subtotal Variable Activities Subtotal Fixed Activities Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCTIVITY: 0..0 Variable Activities: Standard Year To Date Current Period Min/Activily Look Up Registration Number 2.3 Tracking Worksheet 0.5 Order Record 0.5 Record Preparation & Completion 10 Review Ambulatory Record 15 Followup Call 5 Followup Record 5 Bill Audit 60 Update Challenge Tracking System 10 Write Appeal 165 Miscellaneous Appeal 15 Close Out Case 15 Census Abstract 15 Fixed Activities: Year To Date Current Period Data Entry Quarterly Report Other Qualily Indicators For future development. Quality indicators for each activity of the form (Successful Tasks) / (Total Tasks).

51 Look Up Registration Numbers: The accessing of registration numbers for each patient in a case listing, via the Patient Management System. Variable Activity. Standard: 2.3 minutes per number, estimated by average: 75% of 1 minute + 4 mm mm. = 2.3 minutes Tracking Worksheets: The filling out of paper worksheets with patient and payor identification, date of service, registration number, and outcome. Variable Activity. Standard:.5 minutes per worksheet, estimated. Data Entry: The initial entering of each case in the Challenge Tracking System. Data includes patient name, registration number, date of service, payor, reason for medical record request, and date of request. Order Records: The batch requesting of medical records using the Medical Record Locator (MRL) System. Records can be requested in groups of no more than 10 per screen. Variable Activity. Standard:.5 minutes per record, estimated. Record Preparation and Completion: The review of medical records to ensure completeness, the completion of records by requesting documentation (attestation, DC summary, op notes, laboratory updates, x-rays, etc.), and the preparation to order medical records. Variable Activity. Standard: 10 minutes per record, estimated. Review of Ambulatory Surgery, ER, and Outpatient Records: The flagging of all pertinent information in each requested medical record for the copying service, and the quality checking of copied records. Information pertinent to case request includes date, pre-procedure notes, post-procedure notes, laboratory values, and follow-up notes. Variable Activity. Standard: 15 minutes per record, estimated. Follow-up Calls: The telephoning of physicians offices, ancillaries, and third-party payors for documentation or case outcomes. Variable Activity. Standard: 5 minutes per call, estimated. Follow-Up of Records: Tasks including calling clinics, checking MRL System, retrieving medical records from patient units, and picking up records. Variable Activity. Standard: 5 minutes per record, estimated. 47

52 Bill Audits: The review of medical records and validation of billing, and the flagging, copying, and highlighting of information. Variable Activity. Standard: 60 minutes per audit, estimated. Update Challenge Tracking: The addition of data to the Challenge Tracking System including additional correspondence, physician name, diagnosis, reason for challenge, dates of correspondence, and outcomes. Variable Activity. Standard: 10 minutes per record, estimated. Write Appeals: The composing of initial and subsequent appeals. Initial appeals are sent to physician with challenge and a promptee for appealing case after a review of the medical record. Subsequent appeals are written by the unit after reviewing the medical record, requesting the record, and updating the Challenge Tracking System. All appeals are typed, checked, reviewed, corrected, and mailed. Variable Activity. Standard: 2.75 hours per appeal, estimated by average: 50% of 2 hours + 3 hours 4 hours = 2.75 hours. Miscellaneous Appeals: The composing and sending of correspondence to Data Quality Management or Hospital Financial Services, and the updating and closing out of record on Challenge Tracking System. Variable Activity. Standard: 15 minutes per appeal, estimated. Close Out Case: The sending of final correspondence to Hospital Departments, and the entering of outcomes in Challenge Tracking System. Variable Activity. Standard: 15 minutes per case, estimated. Quarterly Report: The review and submission of quarterly outcome data for Quality Management report. Census Abstract: The abstracting of a patient s ambulatory surgery data, upon request of the National Center for Health Statistics. Variable Activity. Standard: 15 minutes per abstract, estimated. 48

53 QUALITY MANAGEMENT

54 50 quality are being developed in UMMC as in many other businesses. The Quality Management unit is made up of 4 quality coordinators who are trained in facilitating discussions about quality, educating hospital personnel about quality, They are also responsible for compiling data from monthly reports completed by The Quality Management unit primarily exists as a resource for other departments and establishing programs in quality. hospital departments and clinics. It is important for the staff members to keep up and clinics throughout the hospital. Efforts towards continuous improvement of This unit publishes a quarterly newsletter, Quality Times, for the entire hospital. with the current literature regarding quality improvement issues. Quality Management

55 Reporting - 4 Hours Worked < > m Q) m > C) < - D CD Attend Internal Meetings Attend External Meetings Staffed Meetings Presentations CD a 0 D OCD CQQ CD CD DC) CD Reporting Function - Record C/ Function-Analyze Researchand Ut. Review, Newsletter Case Review 0 D CD C) CD Professional Development Data Reporting Assisted Customers Production Problems MIS Staff Support z 0 4 C )

56 Medical Information Services Quality Management Performance Report Current Period Number: 1 1 Janl-7, 1995 SUM MARY Year To Dote Current Period Expected Hours: Subtotal Variable ActMties Subtotal Fixed Activities Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCTIVITY: 0..0 Variable Activities: Standard Year To Date Current Period Mm/Activity Fixed Activities: Year To Date Current Period Attend Internal Meetings Attend External Meetings Staffed Meetings Presentations Reporting Function - Record Reporting Function - Anale Research & Uterature Review Newsletter Case Review Professional Development Data Reporting Assisted Customers Production Problems MIS Staff Support Quality Indicators For future development. Quality indicators for each activity of the form (Successful Tasks) / (Total Tasks).

57 Attend Internal Meetings: The participation in meetings within the MIS department, including meetings with supervisors, managers, or general staff meetings. Attend External Meetings: The participation in any meetings outside the department. Meetings are usually on quality issues, either in other departments or hospital-wide. Staffed Meetings: The preparation and follow-up for meetings, including minutes and handouts, for which coordinators are responsible. Presentations: The preparation for presentations, and actual presentation of quality-related topics, in either internal or external environments. Reporting Function - Record: The gathering of data for quality reports such as the AEC report, tissue committee report, etc. Reporting Function - Analyze: The summarizing and interpreting of data for further action. Research and Literature Review: The gathering of information through a literature search with a specific purpose in mind. The information is to be disseminated to assigned areas. Newsletter: The preparation, editing, and writing of articles for the Quality Times newsletter. Case Review: The review of medical record documentation to provide data for various studies as requested. 53

58 Professional Development: Activities directed at enhancing knowledge and skills. Data Reporting: The fulfilling of requests for computer-generated information. Assisting Customers: Working with internal or external customers to determine specific needs and identifying what should be done to meet those needs. Production Problems: Time spent on problem-solving and correcting unforeseen problems with programs and systems. MIS Staff Support: Time spent assisting MIS staff with general computing needs, but not on requests for reports. 54

59 RECORD RETRIEVAL AND AVAILABILITY

60 Record Retrieval and Availability The Record Retrieval unit is the largest subentity of the MIS department. Its major functions include archiving, microfilming, retaining, and delivering all medical records, including psychiatric documentation, to requesters. It operates 24 hours a day, 365 days a year. There are two supervisors and one office supervisor who oversee this unit. One supervisor is in charge of four areas including the main file area, the communications center, niicrofilming, and registration. The second supervisor is in charge of messengers, sectionalization and doctor s study. The office supervisor manages the record availability clerks and two cross-functional employees. There are currently 10 messengers who are in charge of picking up and delivering medical records in clinics throughout the Medical Center. The tasks performed by the messengers are currently being studied and are not included in this performance monitoring tool. The main problem in the aforementioned areas is that several workers are out due to injuries. These include carpal tunnel syndrome and other arm and shoulder injuries from pushing and pulling records, which are tightly packed in the shelving units. Reaching to retrieve the records also causes some strain. Due to lack of space, records are stored on top of the shelving units which makes it more difficult for the clerk to retrieve the record. Another restriction placed on the clerks is aisle space. A time constraint is imposed as each aisle is wide enough to accommodate only one clerk. 56

61 U $I 8 University of Michigan Medical Center - Medical Information Services Record Retrieval - Data Collection Form Time Period: VARIABLE ACTIVITIES FIXED ACTIVITIES NOTES 4- U) ci) :3 4- U) (3 (1) ci) (1) ci) -Ici) U - U, C (1) E - t) o.c 1) Cl) (1) 0 ci) TJ C 4- D 0 0 o ( LI. ci) o o U) c: 0 (I) -g C U) (1) C) ci) ci) 0 -Q - I - -j ci) 0 E.22 i5 i 0 (1) b 2.22 o w 0 t (1) (I) 0) o U) 8 : C/) -Th Worker Total - ci) 0 ç) 0 c E o 0 (3

62 University of Michigan Medical Center - Medical Information Services Record Availability and Support Services - Data Collection Form Time Period: VARIABLE ACTIVITIES FIXED ACTl.Vl11E$:. NOTES 0-0 o_ 0 Cl) (1) u, E I: U) 0 a G) 2 E ci a o G) 0 2 z a) 15 0 U) 0 U) c a U) U) 0 a r D C) 4- () 0 0 () (1) (1) Q C (.) C o U) (1) Cl) W (1) > U) Cl D (1) - N.c: L1 C 0 C > (I) U) 0 U) 4-. -= 0 ci) I o (I) I Worker C Li- I C ) Total U U

63 Medical Information Services Record Retrieval Performance Report Current Period Number: I 1 Janl-7, 1995 SUMMARY Year To Date Current Period Expected Hours: Subtotal Variable Activities Subtotal Fixed ActMties Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCTIVITY: 0..0 Variable Activities: Standard Year To Date Current Period Mm/Activity Main File Room File Record 0,48 Retrieve Record 5 Respond to Telephone Request 2.5 Screen Record 1.2 Process Face Sheet 3 File Loose Sheet 0.3 Registration Combination of CPls 30 Microfilm File Microfilm Retrieve Microfilm Communication Center Receive Telephone Request Sort Loose Sheets 0.2 Fixed Activities: Year To Date Current Period Communication Center Check In Ward Basket o 0 Quality Indicators For future development. Quality indicators for each activity of the form (Successful Tasks) / (Total Tasks).

64 Medical Information Services Record Availability & Support Services Performance Report Current Period Number: I 1 Janl-7, 1995 SUMMARY Year To Date Current Period Expected Hours: Subtotal Variable Activities Subtotal Fixed Activities Total Expected Hours Actual Hours: Regular Overtime Total Actual Hours PRODUCTIVI1Y: 0..0 Variable Activities: Standard Year To Date Current Period Mm/Activity Sectionalization Sectionalize Record 23.6 Doctor Study Process Charts Record Availability Locate Problem Record/Parts/PW In-Patient Floor Sweep Lost/Reconstruct Chart Retrieve Record from Sec. Storage Temporary/Confidential Name Fixed Activities: Year To Date Current Period Sectionalization File Loose Sheets Load Shelves Cover Messenger Duties Assist with Audits Doctor Study Clerical Quality Indicators For fi.iture development. Quality indicators for each activity of the form (Successful Tasks) / (Total Tasks).

65 Main File There are 20 clerks in this area who are responsible for a variety of different tasks. They include responding to telephone requests by doing file checks, and loose sheet processing; retrieving records requested via a printer; screening records including return of batch requests (for special visits); attaching tabs to new folders; following up on all pending files; making microfilm folders; pulling outguides and attaching loose sheets in folders and filing new folders. File Record: File record by area (0 s, l s 2 s etc.). Pull outguides and place loose sheets in folder. Variable Activity. Standard:.48 minutes per record, studied. Retrieve Record: Pull transfer from printer; attach loose sheets; and set out for messenger delivery. Variable Activity. Standard: 5 minutes per request, studied. Respond to Telephone Request: Check for files; and pull and process loose sheets. Variable Activity. Standard: 2.5 minutes per call, studied. Screen Record: Put records in terminal digit order; enter into computer, batch return; attach all new folders with tab sets; follow up on all pending files, and pull and attach loose sheets; make micro folders as necessary. Variable Activity. Standard: 1.2 minutes per record, studied. Process Face Sheet: Check computer to see if chart is active. If so, file face sheet with outguide; if not, place in front of chart. If it is a microfilm chart, make microfilm folder with tabs, sign in and file. Variable Activity. Standard: 3 minutes per sheet, studied. File Loose Sheet: If chart is active, place loose sheets with outguide, if not, place loose sheets in front of chart. Variable Activity. Standard:.3 minutes per sheet, studied. 61

66 Registration There is one clerk in registration whose duties include handling combinations of double identification numbers. Combination of Corporate Person Index (CPfl: Receive request via , phone call or MIS stating that they have a combination; Look at both numbers, patient name, birth date and social security number; Determine which CPI number is correct; Obtain all records and loose sheets (psychiatric and medical); Change wrong CPI number to correct number; If inpatient, go to floor and change wrong number on inpatient chart to correct number; Update MRL (Medical Record Locator) by transferring visit history from wrong CPI number to correct number; Enter appropriate data into PTMG (Patient Management) System, and review merged CPI results. Variable Activity. Standard: 30 minutes per combination, studied. Microfilm The microfilm area in record retrieval consists of 2 clerks who refile all incoming microfilms. They also are in charge of retrieving the microfilmed records requested for scheduled visits. File Microfilm: Indicate in logbook that microfilm has been received and file. Variable Activity. Standard: To be determined. Retrieve Microfilm: Receive telephone requests, and respond by checking in the CRT, history book and history file to provide information requested. If chart is needed, retrieve film, copy it, and file it. Variable Activity. Standard: To be determined. 62

67 Communications Center The communications center consists of 4 workers whose main duties include answering phones, taking record requests which cannot be requested by the printer, and sorting loose sheets. Receive Telephone Reguest: Answer phones and take requests for charts. Check to see if chart is in file. If so, transfer to file. If not, print transfer for other area. If on floor, ask floor to set it out, print transfer, and get messenger to retrieve it. Variable Activity. Standard: To be determined. Loose Sheets: Put loose sheets in first order by sorting into 0 s, l s 2 s etc. Count loose sheets. Variable Activity. Standard:.2 minutes per loose sheet, studied. Check In Ward Basket: Call clinic and ask them to send down record. Get record ready for delivery by messenger, if patient is being admitted. Support Services The sectionalization area consists of 7 workers including 2 supervisors and 5 office assistants. They are responsible for putting records in the correct order, attaching loose sheets for scheduled visits, dividing charts and removing any duplicate sheets. These workers are evaluated on both quantity and quality of their work. Within the Record Retrieval unit, there are also two cross-functional employees whose primary tasks include handling record availability problems and filling in for other clerks who might be out. Sectionalize Record: Make sure correct transfer is on correct chart; check for correct name and registration number on all forms; check for complete chart and find if needed; add Hypersensitivity and Summary Sheets under Continuity Tab if not present; attach loose sheets under correct tabs filed in prescribed order; correctly place any misfiled forms; remove and duplicate forms and place in shredding box; place any Advanced Directives under Outside Reports tab and stamp folder and tab divider; make new folder if needed (if torn or dirty); divide large charts into 2 volumes if needed; stamp record Sectionalized, date and initial; return record to correct shelving unit. 63

68 Variable Activity. Standard: 23.6 minutes per chart, estimated by historical data. 64

69 File Loose Sheets: When there are 1500 or greater scheduled visits, it is automatically a loose sheet day. Loose sheets will be attached to records first before sectionalization is started. Load Shelves: Sort charts onto shelves. Cover Messenger Duties: Perform duties normally performed by messengers, when needed. Assist with Audits: Locate problem records and parts, combine, and deliver to requestor. Special Audits: Batch request records needing audits; pull record and deliver it to requestor. Variable Activity. Standard: To be determined. Doctor Study There is one employee in the doctor s study area who is in charge of responding to record requests made by doctors for research or other purposes. This worker is responsible for finding the record requested, attaching loose sheets and pulling the parts needed from the file. Clerical: Answer phones and direct calls to correct area; receive requests for new studies; create MRL (Medical Record Locator) for new requestor; transmit and receive information from fax; use PTMG and Check Digit Systems; write up transfers for psychiatric charts; call outside hospitals for contact; call staff reminding them that request will be canceled after 6 months if not made active; keep statistics; sectionalize loose sheets if necessary; check for chart completeness; make magnetic strips to indicate location of chart and keep them updated; refile charts in correct area; train midnight personnel on and MRL. Process Chart: Pull records or parts(medical and psychiatric) from file, MRIDQ, or microfilm where necessary. Variable Activity. Standard: To be determined. 65

70 n 0

71 67 C: Go to areas A, B, C, and D of each floor; search conference rooms, cabinets, or supervisor if record is not found; lead clerk or supervisor notifies the RAU and update alias name field in computer with temporary name used. Locate Problem Records/Parts/Patient Waiting (PW) Records: computer that track sheet was received; look for chart and deliver chart to Receive tracking sheets from area who had problem finding record; enter into Variable Activity. Standard: To be determined. In-patient Floor Sweeps: dictation rooms, and nurses areas; pick up charts or parts that are 3 days past discharge; match discharge parts with unit record; make sure part is complete and Variable Activity. Standard: To be determined. bring chart to MIS and process to coding. Search for record using Problem Tracking Checklist as a guide; notify lead clerk (Record Availability Unit); RAU clerk logs problem on MRL, follows up on clinic/mis search, reconstructs record by obtaining all on-line information and data from any existing source, copies any requested information until record is found or reconstructed and indicates that record is lost in MRL after 30 days of searching. RAU supervisor is notified. Variable Activity. Standard: To be determined. List all requests and fax to secondary storage for 24 hour turnaround; call Retrieve Records from Secondary Storage: secondary storage location to verify receipt of request, and state priority status; process any incoming secondary storage requests by removing the secondary storage notation from the attention notes and print a transfer and send chart out to entered into the MRL system by the batch process and will automatically be Change patient s temporary name to patient s legal name on all record Record Availability requestor or give to messenger to deliver. Lost/Reconstructed Charts: requestor via messenger or dumbwaiter. Two and three day scheduled visits are requested by MIS afternoon and midnight shift personnel. Variable Activity. Standard: To be determined. Temporary/Confidential Name: documentation; update patient history in computer with patient s legal surname Variable Activity. Standard: To be determined.

72 SNOIJVGNEI4IIJODm

73 Recommendations One portion of the performance monitoring tool which has not yet been considered in detail is the quality indicator tracking. Many quality indicators are calculated in terms of (Number of Successful Jobs) divided by (Total Number of Jobs). Successful could mean ajob that meets a certain degree of accuracy or that is performed by a certain deadline. The precise definition of a successful job would have to be set by the unit, and would depend upon the unit s goals and the specific activity. As previously mentioned, many of the variable activities standards were estimated by the supervisors. It will be very important for the supervisors to study these estimates as the tool is implemented, and to revise them so that they more accurately reflect the times required to perform the activities. In some cases, it may be necessary to perform time studies to determine an accurate standard. The standards will definitely need to be revised whenever there is a change in the work environment. 69

74 ( APPENDIX 1. USER S MANUAL

75 User s Manual Sections of Spreadsheet and Cell Ranges: *Majn Titles: Fl and F2. *Sury Section Titles: A7 to B18. *5umi-y Section Year-to-Date Calculations: F7 to F18 *Suai.y Section Current Period Lookup: H7 to H18. *Cuffent Period Entry and Indicator: F4 to H5 All Periods Expected Time Summation: K8 to BK1 1. All Periods Actual Time Data Entry and Summation: K13 to BK16. All Periods Productivity Calculations: L18 to BK18. Listing of Period Indicators: K4 to BK5 *Variable Activities Titles: A24 to B41. *Vable Activities Year-to-Date Calculations: F25 to F41 *V.jab1e Activities Current Period Lookup: H25 to H41. *Tjme Standards for Variable Activities: J27 to 341. Variable Activities Data Entry: L27 to BK41. Listing of Period Indicators: K24 to BK25. Variable Activities Expected Time Calculations: BM27 to DL41. Listing of Period Indicators: BM24 to DL25. *Fjxed Activities Titles: A43 to B59. *Fjxed Activities Year-to-Date Calculations: F43 to F59 *Fixed Activities Current Period Lookup: H43 to H59. Fixed Activities Data Entry: L45 to BK59. Sections which are normally part of the printed report are marked with an asterisk. Spreasheet Use The tool is used as follows. Performance data is entered as number of activities performed in the Variable Activities Data Entry section, and as number of hours spent on activity in the Fixed Activities Data Entry section. For the Variable Activities, an expected time is calculated for each defined task in the Variable Activities Expected Time Calculations section by multiplying the entered number of activities by the time standards listed in the Time Standards for Variable Activities section. The expected time for both Variable and Fixed Activities is then summarized in the All Periods Expected Time Summation section. 71

76 Hourly data is entered as number of overtime and regular hours worked, total for all unit employees, in the All Periods Actual Time Data Entry section. It is summed in the All Periods Actual Time Summation section. The Summary Section is divided into Year-To-Date and Current Period columns. The Current Period is determined by the entry in the Current Period Entry box. Current Period Indicators, which list dates of the type Janl-7 are included to assist the user. The Current Period number, such as 1, is actually used by the spreadsheet formulas to detennine the column which represents the desired period, so it must be entered in the Current Period Entry box. To change the values of the Current Period Indicators, it is only necessary to change the entries in cells K5 to BL5. The other Current Period Indicators in the spreadsheet will change automatically. The Current Period column entries in the printed report are simply duplicates of the corresponding period s column in the All Periods Expected Time Summation, All Periods Actual Time Data Entry and Summation, Fixed Activities Data Entry, and Variable Activities Data Entry sections. The Year-to-Date column entries in the printed report are summations of all corresponding entries in the same sections. The Productivity calculations are made by dividing the Total Expected Hours by the Total Actual Hours in both the Year-To-Date and Current Period columns of the Summary Section. For future reference, each period s productivity is stored in the All Periods Productivity Calculation section. 72

77 APPENDIX 2. INFORMATION ON SPREADSHEETING WORKSHOPS

78 Information on Spreadsheeting Workshops For employees unfamiliar with spreadsheeting concepts or with Microsoft Excel software, the Instructional Technology Division (ITD) of the University of Michigan offers workshops each semester. More information about these workshops may be obtained from the publication Non-Credit Computing Courses on Campus, Reference R1046, which is published each semester by ltd. A current copy of this publication can be requested from ltd by calling the ltd Workshop Registration office at (313)