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Revenue Cycle Employee Engagement that Drives KPIs [PODCAST]

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The Hospital Finance Podcast

In this episode, we are joined by Sheila Augustine and Stacie Adcock of Nebraska Medicine to discuss their best practices for growing and maintaining employee engagement.  

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Highlights of this episode include:

  • How Nebraska Medicine measures employee engagement as a way to drive KPIs.
  • What kinds of incentives are offered to bolster employee engagement?
  • Details behind the task force created to deal with the impact of the pandemic on employees.
  • How Nebraska Medicine approaches employee training and quality reporting.
  • What metrics are analyzed the most when monitoring the performance of their teams?
  • And more…

Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance Podcast®. At the 2020 HFMA Annual Conference, Sheila Augustine and Stacie Adcock of Nebraska Medicine spoke about employee engagement within the revenue cycle team at their hospital. They are here today to share their best practices for growing and maintaining employee engagement.

Sheila has been with Nebraska Medicine since 2005 and is currently the Director of Patient Financial Services at Nebraska Medicine, where she oversees their single billing office.

Stacie has been with Nebraska Medicine since 1989 and is currently the Revenue Cycle Administrative Services Manager, where she is responsible for training, quality, and revenue cycle-related systems. Sheila and Stacie, welcome to the show.

Sheila Augustine: Thank you.

Mike: So in your recent talk, you looked at employee engagement as a way to drive KPIs. So let’s start off by talking about how Nebraska Medicine measures engagement using an engagement index.

Sheila: Yeah. Thank you. So we currently utilize Qualtrics for our employee engagement survey that all of our staff members get on a quarterly basis. And two of the questions in particular measure the engagement index. And those questions are, “I intend to work for Nebraska Medicine for at least the next year.” And, “I feel proud to tell people I work for Nebraska Medicine.” Those are two of the questions we really, strongly believe that drive the engagement of our employees. And we know if they’re engaged and going to be staying with us long-term. The way our survey is set up, it is strongly agree, agree, neutral, disagree, and strongly disagree. And currently the way we measure the success is by the strongly agrees. The other things that we measure too, that we look at from a department level in particular, that are drivers of engagement, is, “My immediate supervisor and I regularly work together on my growth and development.” As well as, “I’m consistently recognized for doing good work.” And so each quarter we receive it. And we can compare our results at a department level, or against the organization. And we look at last quarter to see where we had opportunity. Did we fall in one area? Or did we increase in one area? And then each quarter, we do an action plan within each area to say, “Here is the one question on the survey that I want to focus on. And what can we do to get that score to be higher?” And so for example, one of the areas within PFS was, “I am consistently recognized for doing good work.” And so what we really focused on was bringing several individuals from the team in and asking them questions. “How do you want to be recognized? Is it in a staff meeting? Is it in an all-colleague meeting? Is it an email? Is it just a shout-out?” And so then once we received a little bit of feedback, we sent it out to the entire team, trying to get a more global answer from everyone else. And those different things have caused our engagement scores to really drive up. And focus solely on the things that we can control, as some of them, at times– there are some things that we don’t have as much control as we’d like to. Stacie, I don’t know if you have anything additional to add to that.

Stacie Adcock: I was just going to add, the biggest learning through this process for me was what these questions mean to different people. So I have a smaller team. And I ended up meeting with each person and finding out what those questions meant to them. So for example, the growth and development– to me, I thought that really meant – and to most people – promotions and advancement. And to one person in particular, it meant if a coworker got to learn something that she didn’t, they had an opportunity for growth that they didn’t. And that’s an every day, simple task. Or if they got to work on a project and they didn’t. And I never thought about it to that little of a level. So it was a great learning for me to understand what each thing means to each person. Because you can’t improve those scores if you don’t understand what it means to them.

Mike: That’s great. Sheila, to bolster engagement, you offer several incentives. Can you explain what those are for us?

Sheila: Yeah. This was definitely prior to COVID. We focused on the incentives that we could offer that really tied back to some of our KPIs that we looked at. So within access, HIM, PFS, and rev cycle admin, we could have different incentives that we were doing. So for example in our HIM department, if they met a specific goal for the month– our coders had always been working from home. And so they would have to come in once a month for the monthly meetings. And the goal was, if we met our goal, you didn’t have to come in for the monthly meeting. You could call in. And so that kind of gave them that incentive of, “Oh. I can still stay home and be very casual and not have to drive in.” We also did snacks with our PFS director, so myself, where we were bringing in about eight staff members once a month, and just having a very casual lunch, getting to know each other. It came out as one of our incentives that– other people didn’t feel like they knew each other within the department. So for example, we have 188 people in PFS. And people didn’t feel like they knew other people. One of the biggest ones that we did, prior again to COVID, was– we have a business casual dress code. And essentially it really means no jeans. So wearing dress pants and a nice shirt. And so we focused on, if we met goals on a monthly basis, people could wear jeans on Fridays. And I don’t think sometimes people realize how big jeans are to others, to be able to feel comfortable in jeans and come in. And there were several months where we met it, and then– so people started asking the question. It was kind of a game. “Well, so if we meet it for two months in a row, then for the third month, can we have it Thursdays and Fridays?” And so it really became something that they were all focused on asking where our numbers were on a weekly basis. Because they were pushing and asking, “What can I do to make this number better so we meet our things?” And then within some of the areas as well, we tried to start doing outings. One area did a baseball game. Another area had done a bowling event. And so it was really just trying to, as part of engagement– and then also adding incentives. It was really to bring people together and actually have them be accountable, and helping us meet our incentives, understanding how they played a role in it. And it really was amazing once we set our goals, when people didn’t know how they impacted those goals. So they quickly asked to understand, how does their role impact the AR? How does their role impact quality? And so I think just by doing that, we actually helped our employees be more successful in understanding what role they play in that.

Mike: Great ideas. You also created a task force to deal with the impact of COVID on employees. Can you tell us about that?

Sheila: We really focused initially on how many people were going to be affected, from our patient population, by COVID. And what could we do to help them in their time of need? Because it’s already scary enough what’s going on with COVID. And then people getting furloughed, losing their jobs, hours cut. We quickly put a task force together of a few financial counselors, and then people from our RC admin team, as well as PFS. So if a patient called in and said they were having difficulty paying their bill due to COVID or due to changes within their workforce, we had a task force call that patient back. And why we did that was we wanted to offer them a couple different options. So historically at Nebraska Medicine, we have always had people pay within six months on balances owed. If at that time they couldn’t commit to six months, we did have them open a line of credit with one of our partners. So we extended that to be nine months instead of six months, just so that they wouldn’t have to go and get the line of credit. Even though it doesn’t impact their credit score. We also offered payment plan forgiveness. And so if a patient was set up on a payment plan, but for the month of June or July, we’ll say, they couldn’t make it because they were still furloughed, we did offer a forgiveness for those two months. As part of the task force, we screened them right away to see if they were eligible for financial assistance, and giving them a quick answer to take that relief off of them. And then one of the big things our vice president had us do was she came up with workforce planning. And so what we did was we identified all the work that we had, and how many hours we thought it would take to get stuff caught up or current. So in healthcare, and in the revenue cycle in particular, there’s always things that we can say, “You know what? Hey. We’d like to focus on that area. But there’s competing priorities.” And so you kind of push it to the back end. And so we were able to list out all those, “This would be great if we could focus on.” List it out. And as people started running out of work– so our insurance services area was one of the first areas to run out of work. We were able to shift them and have them learn new things without furloughing anybody or cutting anybody’s hours. Our training team, which Stacie can talk more about too– our training team was instrumental in scheduling Zoom calls with these folks, getting them the quick training they needed to jump on board and do something new. And our staff was so appreciative of learning different things, and, “Wow. How the things I do in my job today– I didn’t realize I make that impact on that duty now.” Because they’ve tried something different. It was great. And we were really excited that we could offer that to our staff. Stacie, I think you probably have more to add on that too.

Stacie: Yeah. Our patients were very appreciative too. And it was great to be able to do them. And I think the biggest eye-opener for me was how many of our patients would have qualified for 100% financial assistance prior to COVID, but paid their bill every month. And we really evaluated them– if they would have qualified for 100% charity prior to COVID with their current pay and that type of thing, we went ahead and approved them and forgave their bill. And then that went away for them. So that was eye-opening to me of how many people do pay their bills even though, according to the poverty guidelines, they don’t have the ability to pay. So that was interesting to me. I had never thought about it like that. And then shifting the work duties. It was a lot of fun to get those projects that you always wanted to do cleaned up. And then just see all the lightbulb moments. And I’m curious to see how long that helps us, having staff do those different tasks. So once we get back to whatever our new normal is, I would love for us to implement something like that, so we can have those learnings and figure out how to incorporate having them do those different tasks totally outside of their comfort zone, to have those eye-opening moments and those learnings, and take that forward. And I’m excited. The things that we’ve been able to accomplish, like that special task force– when we change how we do that kind of stuff going forward, would it make sense to have somebody, if they need a financial application to do that, and have that specialized team that could approve stuff up to a certain level? And we were able to move more people home very quickly. Telehealth moved very quickly. All things that we had been wanting to do that we were able to do very quickly, and see that we can accomplish those things in short time frames.

Mike: Excellent. Stacie, it’s pretty clear your hospital takes training and quality reporting very seriously. Can you explain how your program works?

Stacie: Sure. I’d love to. So my team does training for all of the revenue cycle. That would be access, HIM, PFS. And then we have a revenue cycle admin team that does this training and several other tasks. We also train all of the schedulers and the medical receptionists, or anybody that does registration-type work, throughout the whole facility. And we send those users a training schedule. It’s very much laid out very well. We have what we call– the first week we call core training. And we really just teach them the basics. We teach them about the culture of Nebraska Medicine. We make sure they’re signed up for benefits and have done all of their first week thing. Our managers are very spoiled. Because we handle all of those onboarding pieces. We send them to their One Chart classes and make sure they have security. We have very detailed checklists that is everything that we’ve defined that they need to know to do their job. And we train them on that. We have training materials that are associated with those things that we have them read, our policies and procedures and that type of thing. So it’s very detailed. They sign off on it when they’re done with training. And then we are responsible for– we have two different types of education materials, I guess. We have something that we called flash cards. And they’re a one-page thing. So for example, we changed our enterprise statements that go to our guarantors due to COVID. We changed the dunning messages. So we had always had a single flash card that talked about the different dunning messages. So we were able to copy that and update those and get that out to everybody, so they knew what was going to our patients. Then we have very detailed things that we call scoop educations. And there we’re able to pull in what the screens look like, any scripting that you need to know, the policy and procedure steps, so that staff have a single document that they can walk through a very detailed process that has every step in it for them. And then we do quality audits on all of those people. So we perform about 1,600 audits a month. Each person gets three. And when that quality audit is done, we send them out a form that tells them, “Here’s all the things we reviewed for your quality audit.” Everything from the standard greeting. “Did you sign the patient up for One Chart Patient?” Which is our electronic medical record. All of those things are on there. And we say yes or no. If there’s something that they did not do, we call that an identified learning opportunity. And we put that on a separate word document. And we show them exactly in the system a screenshot of where that would have been. And then we give them the training documents that go with that, so that they can look at that. And we ask that they go and update that record and do that. Then we send out monthly team reports to the managers. So it tells them how they did on productivity and what their quality scores were. So imagine as a manager how cool that is at the end of the year, when you’re doing annual appraisals, and you have all of that information in black and white. Then the individual report card goes to each user each month. And it tells them their productivity and quality. And then we also have it broke down further in some areas, and will eventually in every area, of how they’re contributing to the team goals. So for access, we have point-of-service. And it tells them, “Here’s what you collected for the month. And here’s the average of what your team collected for the month.” So they can kind of see where they’re at for their team and how they’re doing. And then they know on a monthly basis for sure. Are they meeting productivity? Are they meeting quality? There’s no questions. For the first 120 days when they get their quality audits, their lead or a trained person meets with them and goes over them, so that they have that interaction, and get to build those relationships with their lead, and also learn from those items. We recently just started a new newsletter. Our financial counselors and customer service and collections– they’re on the phones a lot or in front of patients. So they don’t always have the opportunity to look at all of our documents and training materials that come out each month, as well as the top things that have been identified as learning opportunities. So we’ve created a monthly newsletter that ties all of that stuff together in a single document. And we just started that in July for financial counselors. And then we did customer service and collections in September. So we’ve gotten a lot of feedback from them that that’s very helpful, and to have a single document that has all that information.

Mike: Great insight, Stacie. My last question for both of you is, all revenue cycle teams do– you look at the performance of specific metrics to ensure your team is on track. Which metrics do you look at most closely?

Sheila: So in particular, we’re on Epic as our electronic health record for our single billing office, so. And we do have two hospitals. And then a very large physician group. So the first thing for me that I look at on Monday morning when I come in, and I think it’s kind of a race for several of us, is we look at our financial pulse. Which compares us to other facilities that are our size, as well as we can compare to everybody in Epic. So obviously the biggest thing we look at is our AR base. One of the other things that I think we’ve really been focused – and Stacie’s area is focused – on is our clean claim rate. We definitely focus on our insurance aging as well as self-pay aging, productivity for each area. And then also all of that rolls up to our vice president. So how many of our staff are meeting productivity? How many of our staff are meeting quality scores on a monthly basis? And it really kind of depends on what area in particular. So each of our areas, there’s probably different KPIs and metrics that we particularly look at. We all know how we impact the AR. But coding, for instance– so HIM really probably focuses on their coding days and pre-AR days. Where more in PFS, we’re focused on the insurance aging and how we can get that down, as well as overall aging. Stacie, what more would you add?

Stacie: I was just going to add, our vice president, at the beginning of COVID, created a spreadsheet with all different daily KPIs on, so that we could monitor what the impact was. And that’s something that we’ve kept up. So every day at 8:30 in the morning we get on a call. And we talk about a ton of different KPIs. Where our D&Bs are, where our candidates for bills are. What was the point-of-service collections yesterday? What was cashed? Claim edits, all of that stuff. I don’t know, Sheila. What do you think? There’s 70 or 80 items on there?

Sheila: Yeah. Absolutely. And you brought up a good point. Because by looking at that, we also look at certain denials that posted yesterday. So we’ll be looking at today’s on Monday. And in particular, no authorizations or timely filing. And so really that gives us an opportunity to look at root causes right away, instead of maybe if we look at it every two weeks, or once a month, so that we can provide education really quickly. For example, one of the things that we found was some of our staff members were not entering an authorization number in the correct field that would allow it to populate to the claim. Which then it would go and deny. And so we were able to quickly turn something around like that, and just give education, and quickly go on our merry way. So it’s been a huge eye-opener. One of the things that we looked at too was our cash. As part of COVID, it was– we make comments when the numbers are low. You hear everyone go, “Ugh.” But we’re able to now look at it and say, “Why is cash low? Okay. Well, volume is low.” So I think this has been a huge eye-opener for all of us.

Mike: Those are some great insights. Sheila and Stacie, thank you so much for coming on the podcast and sharing some of the best practices you employ at Nebraska Medicine.

Sheila and Stacie: Thank you.

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