Reducing HIM Processing Time from 10+ Days to less than 24 hours

The performance of HIM departments has a largely underestimated impact on overall hospital performance. Aside from presenting compliance risks if not properly run with respect to deficiencies, HIM departments impact the quality of clinical care by providing records in a timely fashion, help or hinder physician relations by making the deficiency process more or less pleasant, and lastly impact re-imbursement through correct and timely coding. This case study outlines how several hospitals have used Extreme Makeover Events using techniques from automotive manufacturing to establish world class HIM departments.

Walking through the entrance to the HIM department of this 400+ bed hospital presented a scenario found in most HIM departments across the country. Paper stacks could be seen all over the department, some “spilling” from desks onto the floor. While some stacks were labeled, many were not, leading to a “search mission” several times per day when a specific chart was needed. In the department associates were working in cubicles often with an ergonomic situation less than optimal given the physical layout and work in process in the area. Due to the time delay in analyzing, preparing and finally scanning charts, most coding was performed prior to ‘cleaning’ up the chart to keep the unbilled amounts within a reasonable range. Physicians were less than pleased with the overall process and time frames to address deficiencies were in excess of 30 days for many charts, in part due to the long process times to assign deficiencies. The leadership team had long recognized the area as in need of improvement work, but other priorities had historically prevailed. With a pending JACHO audit, it was time to address the issue, and the use of an Extreme Makeover event seemed very much in order.

As with any Extreme Makeover event, a team of local associates was selected and subsequently trained in Lean methods on Monday morning. The team began assessing the area by Monday afternoon and completed the observations, using tools such as process mapping, spaghetti charts and the 7 types of waste filters. On Tuesday, intensive data analysis using extracted data representing 12 months of activity was conducted while simultaneously a sub-team conducted detailed time studies. By the end of Tuesday, a comprehensive baseline had been completed and assimilated. By Wednesday morning the team engaged, after some additional training on the topics of process design to Lean principles, in designing the to-be process. The team had set an initial goal of reducing the process time of records from the current 10+ days to 24 hours. In addition to historically spending over 10 days to complete a chart once started, the department had a severe backlog of unprocessed charts, which also needed to be completed in order to catch up, therefore requiring the new process with process capability that well exceeded the average work arrivals from the hospital to create the capacity needed to process backlog. While most team members did not believe that a processing time of 24 hours was achievable by Friday, everyone agreed that in light of the increasing outsourcing pressure, a 24 hours turn around time should be the department’s goal to provide a service level not easily achievable by any outside resources. On Wednesday, the area was completely dis-assembled to create room for the new process. All cubicles, which represent an unacceptable impediment to flow based processing, needed to be disassembled and removed from the area. Temporary tables, mostly in the form of folding tables, had to be found.

As soon as the first area had been cleared, the prototype process was implemented. In order to make the test area functional, IT resources had to engage in moving equipment including the high speed scanners, telecommunications equipment needed to be placed and workstations needed to be arranged. The time studies recorded on Monday were used to arrive at flow based work splits depending on chart characteristics. This, in conjunction with volume data analyzed for the same work flow split allowed the detailed design of workstations and work assignments by station. By Wednesday, the first charts were processed to the new flow, with additional time studies being conducted. Modifications were made to the process details and several different cell layouts were tested, timed and compared to arrive at the most efficient process and process layout throughout Thursday. By Thursday night three “production cells” had been established, each of them identical to provide the opportunity to shift associates as needed and assign resources in accordance with prevailing workload. In the meantime, starting on Thursday morning, a detailed material management system was devised, utilizing methodologies such as color coded Kanban carts to make all material flow efficient and error proof.

Thursday afternoon, all process elements had to be combined into one working system and the visual workplace efforts needed to be completed. While finishing the final elements of the new process, a de-brief presentation, to be held in the department for the leadership team, was prepared. On Friday morning, the area was put back into full operation, having achieved the goal of processing all records from receipt to analysis, scanning, QR, deficiency analysis and coding within 24 hours. The overall results of the event were quite remarkable:

• Medical records are processed the day of receipt from the floor
• The backlog has been eliminated with no outsourcing within a short time frame
• Floor-space requirements were reduced by approximately 30%
• 50% productivity gain was achieved

In addition to achieving the goals mentioned previously, the department
was able to reduce the cycle time of the process to 8 hours within 30 days of
the initial project without additional external assistance.

Furthermore the Joint Commission auditor commented: “I am very impressed with the (name omitted for privacy reasons) HIM department. I believe it is the best run HIM department I have ever seen in all my years with the Joint Commission”.

HIM events are one of the best initial starting points for Extreme Makeover Events. They present an area were the application of the principles is easily apparent even to initial critics of applying automotive manufacturing techniques to the healthcare environment. HIM Extreme Makeovers have been conducted for facilities ranging from 30—450+ beds, using scanning to created electronic medical records as well as departments utilizing pure paper based processes.

The results are not only measurable in terms of financial impact due to the reduction of unbilled Dollars to as low as a 1/4 day, but can also be seen in their qualitative impact such as increased physician satisfaction by being able to address deficiencies within 24 hours of discharge. Additionally patient safety is increased by making complete records available for readmissions by the next day.

A Sample of Typical Lean Tools Taught and Used in an Extreme Makeover Event:

• Philosophy of Lean
• One Box
• Metrics Design
• 7 Types of Waste
• Process Mapping and Spaghetti Charts
• Cell Layout
• Standardization
• Standard work
• Arrival Modeling
• TAKT time
• Standard Work in Process
• Detailed Staff Modeling
• Work Management Models
• Visual Workplace
• Lean Process Design Tools

Team member in “re-arrangement action”

Material Management Job Aid

Healthcare Excellence Institute
The mission of Healthcare Excellence Institute is to help organizations create safe and efficient healthcare delivery processes by adopting proven world class strategies such as Lean and Toyota Production System to the complexi-ties of healthcare.

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