Optimizing Workflow

Workflow is one of those "religious" issues within the world of IT. Everyone has strongly held opinions on what it means and how to do it best. Even the name is a point of contention. Which term is preferred, "workflow" or "business process management" (BPM)?

By either name, we have managed to unify a number of disparate processes over the past several years, and successfully implement a series of workflow projects at CHS. In the process, we have reduced our operating costs, enhanced customer service, facilitated staff responsiveness, and improved our ability to produce better audits and respond to federal and state requirements.

Carolinas HealthCare System is the third largest public healthcare system in the United States, with some 29,000 employees; 75 physician practice groups in 150 locations; and 19 hospital campuses across the Carolinas. The Information Services department has approximately 450 employees supporting a highly complex technology environment deployed across the entire enterprise. Applications range from department-specific to enterprise-level. Our IT budget varies from year to year and is dependent upon capital projects.

We began the RFI process in 2001 — 2002 and implemented our first procedure in 2003. As such, we began using TIBCO BPM software almost four years ago, in order to move away from various manual and paper-intensive processes, such as denials management, information requests between billing office and ambulatory Care practices, and routing of customer service requests. In the past, it could take two weeks or more to transmit and receive back requests for various kinds of information from our expansive base of physician offices. This information included requests for explanation of benefit, date of service verification, copy of insurance card, worker's comp notes, and medical records to name a few.

Now that workflow is a part of our established way of doing business, our requests to physician offices take only a day or two to be returned. (See the table below.)

How did we do it?

First, we marshaled the support of upper management.

Getting started with workflow is a major endeavor. It is an exploratory process that will quickly highlight any problems with the status quo, while also stirring up possible territorial issues. In order to take on a project with these types of flashpoints, it is imperative to have the support of upper-level management. This ensures a mandate to address and solve these problems as they arise. Without this support, it will inevitably take longer to achieve workflow goals.

One of our initial goals at CHS was to automate denial processing at the billing office. Because of the complexity of denial processing, though, we started with the less complex system of manual customer service procedures. We then progressed to denials, a sequence which allowed us to walk before running.

Second and of utmost importance, we spent significant time understanding our own business processes.

If those people who serve as subject matter experts aren't familiar with their workflow procedures, it is hard to use software to automate those procedures. In order to ensure that our automated processes were effective and reflected best practices, we worked very closely with our subject matter experts on system design. We made sure that the inputs and outputs were clear and the relationships between them understandable. Without this partnership, it's unlikely we would have been as successful. The point was to position this initiative so that it was not perceived as an "IT project." We wanted its scope to extend from IT all the way to both internal users and external customers.

We decided that our first workflow implementations should focus on the most manually intensive procedures, such as denials management. We then moved on to a more complex process that involved a fuller integration of the entire physician practice management system. Eliminating excessive manual work seemed like a good way to speed payback.

For example, our clerical staff members were using manual, paper-based methods to keep track of more than a dozen different billing processes. These methods were cumbersome and prone to error. It was difficult to route information to the right person in a timely fashion. Our workflow system now keeps track of all routing and logging, and frees staff to focus on more important activities, such as working cases rather than documenting productivity on tick sheets, concentrating on customer service. We estimate that our savings in facilitating requests between the business office and physician practices will total some $300,000 annually.

Third, we had a formal program to ensure that our end user staff was fully engaged with the new workflow applications.

We train our staff constantly. Every time we build a process or develop a new workflow procedure, we initiate a new round of training. We try to schedule the training sessions close to the time when we are going live, so people don't forget what they've learned. We develop all of our own training materials. We also work directly with our customers, so they can conduct training at the same time we are demonstrating the advantages of workflow in automating previously manual procedures.

One of the reasons that training sessions are so successful is that CHS business office staff members have a portion of their compensation tied to performance. This ensures a higher level of motivation during any training period. Employees must genuinely understand how new systems and processes work, if they are to do their jobs productively.

Finally, we use custom reports to get visibility into our process performance.

Reporting and process visibility provide major benefits to any workflow system. We have leveraged our TIBCO BPM software to help with all sorts of auditing requirements. A good example of this is in denials management. The department in question needed an easier way to track claims status, distribute work, and track productivity. This is because the daily case load was approximately 2,000 cases. Several different departments, including cashiers, practice management, and the denials processing team, would see each case. The situation was ideal for workflow, and we developed a series of reports (using existing reporting software from Business Objects) which provided greater visibility to the department managers.

Workflow in Action

The Denials Management procedure routes cases automatically to the right work queue every morning, improving productivity. Now we have work items based on denial type sorted by practice and group, making the routing of denials a more efficient and timely process. As a result we have seen savings of more than $130,000 annually. (This figure is not related to the $300,000 mentioned earlier, in that the $300,000 is specific to a communications procedure between our billing office and the physician practices. This $130,000 is specific to a procedure for the management of denied insurance claims.)

As another example, we had a process in place to identify potential missing charges and outsourced the work effort associated with researching and billing. By bringing this process in-house using TIBCO software, we were able to save about half a million dollars in annual fees. Also, in 2006 we collected more than $500,000 in net missing charges.

But this solution is not limited to automating denials management and revenue cycle issues. Other areas we plan to use the BPM software include:

Routing billing errors for resolution
Correspondence between billing office and physician practices
Request for addition/modification of inventory items to profiles for supply ordering
OR application change management