November 2017

HIM Consolidation on the Upswing
By Selena Chavis
For The Record
Vol. 29 No. 11 P. 12

Centralizing departments is becoming more pervasive as health systems strive to streamline operations.

In today's health care environment, integrated delivery networks are growing rapidly—for good reason. These models are providing the framework for the creation of operational synergies and increasing scale for improved bottom lines.

In line with these trends, hospital financial and clinical leaders continue to identify opportunities to consolidate various clinical and operational functions into centralized service centers. HIM is not immune to these movements, and many organizations have either completed a consolidation project or have one in the works.

The financial benefits of such a move often speak loudly. For example, Sharon Boggio, RHIA, enterprise director of HIM with Bon Secours Hospitals in Virginia, says the consolidation of the HIM departments at hospitals in Richmond and Hampton Roads led to nearly $2.4 million in savings from 2013 to 2014.

In addition to a more robust bottom line, Debi Primeau, MA, RHIA, FAHIMA, president of Primeau Consulting Group, says other HIM consolidation benefits include standardization, the implementation of best practices, and improved communication between functional areas.

On the flip side, Primeau notes that centralization will likely produce less interaction between team members at the local hospital level, specifically physicians and clinical areas. Jane Schulze, RHIA, HIM leader with Sutter Shared Services, part of Sutter Health in California, experienced this drawback firsthand. "When you are not at the hospital and not directly interfacing face to face with hospital administration and physicians, there can be a little disconnect. It can become less personal," she says, adding that her team works hard to keep those relationships intact.

Despite potential downsides to HIM centralization, industry professionals agree that the trend is not likely to slow down, although they caution that these complex initiatives are not for the faint of heart and require well-thought-out planning. "Consolidating HIM departments from individual facilities into a centralized corporate HIM department clearly impacts people, processes, and technology, but there can be significant benefits," says Brooks Tingey, senior marketing manager of revenue cycle solutions at 3M Health Information Systems. "Success is achieved when centralization efforts are founded on the principles of transparency, communication, and change management."

Benefits of Consolidation: A Deeper Look
Tingey places the primary benefits of centralized HIM into three buckets: economies of scale, shared goals and reporting, and consistent education and employee career development.

In terms of economies of scale, he explains that centralization creates a deeper bench of coding and clinical documentation improvement professionals. "As an HIM director, for example, you may have an unanticipated large census in one facility which requires adding coding resources, or you may temporarily reassign your team to cover for a colleague on family or medical leave," Tingey notes. "A centralized HIM department gives you the flexibility to assign resources where they're needed most."

Additional economies of scale are gained by consolidating the number of vendors in a centralized structure. For example, Boggio says Bon Secours gained notable savings by reducing office supply costs, purchased services, and offsite storage fees.

Shared goals and reporting are another benefit, Tingey says. "Centralization ensures that each facility in the organization is held to the same standard and measured using the same methodology," he explains. "The nuances of reporting productivity; discharged, not final billed; case mix index; and quality can differ across facilities that use disparate technologies and processes."

Boggio agrees, pointing out that centralization helps ensure that each Bon Secours hospital is doing the same thing. "Consolidation standardized our workflows and processes, and we are able to implement best practices," she points out. "It has been such a positive journey for us. After we did the Virginia consolidation, we conducted a Gallup satisfaction poll with employees and hit the 90th percentile in both markets. For the first time, I had several employees say I now know what is expected of me, and we have targeted goals."

Tingey adds that centralization allows consistent staff training and creates career progression opportunities for the team. Staff members can more readily learn new specialties and departments, advance to midlevel management positions, and eventually lead a much larger coordinated department.

Project Preparation: Overcoming Hurdles
Although a complex undertaking, HIM centralization has more pros than cons, industry experts say. However, HIM directors and hospital administrators must tackle the project with well-honed change management strategies. The reality is that consolidation delivers dramatic impacts to staff both inside and outside of HIM.

In the case of existing HIM staff, Primeau says positions are usually eliminated and existing staff are often required to "reinterview" for positions. "Some staff may have worked at a facility that was close to home and may only have an option of relocating to a centralized office in a different city," she notes. "They may need additional training and/or certifications. This is the time when everyone must understand the future and make decisions that will best suit their future career and family goals."

Boggio acknowledges that staff reductions comprised the largest percentage of savings associated with Bon Secours' centralization efforts. For the first consolidation project (Richmond), she says human resources (HR) posted positions and all staff interested in staying with the organization were required to interview, a process that took approximately nine months to complete.

"HR was very supportive," she says. "We had staff who didn't have a résumé. HR did rounding with the employees, helped them prepare, and even did mock interviews with them."

For its Hampton Roads consolidation, Bon Secours used a different tactic. HR approached the project from the standpoint of a reorganization, which required no interviews and allowed a more efficient process lasting three to four months.

According to Schulze, Sutter Health took a similar reorganization approach to its consolidation. A survey requested employee feedback regarding preferences, flexibility, and requirements. For instance, it was noted whether an employee could commute to the new shared services location. Staff were then chosen based on survey responses, seniority, current skills, and performance.

"That was hard for people," Schulze says, adding that there is no easy way to approach a consolidation of staff roles. "Maybe someone worked for the same hospital for 20 years and now they work in a corporate office. They might feel they had lost their connection."

Because the HIM consolidation was done in conjunction with a larger shared services project for Sutter Health, Schulze notes that there were some disconnects regarding the needs of HIM as compared with other functions that would operate in the same facility. "If you get outside the HIM world, not everyone knows what HIM does," she says, pointing out that the original building chosen for shared services was closed from 7 PM to 7 AM and on weekends. "We said that's not going to work for HIM. Some of our areas were working 24/7."

Schulze says that when the building first opened, everyone was in a learning mode, and both approval and change procedures had not been ironed out. "You take someone who has done release of information for Hospital A and now they have to release records for Hospitals A through D … they don't know physicians at those hospitals. They also are not familiar with the forms used at each hospital or the patients they treat. There was a big learning curve for a lot of people," she says.

Today, most of Sutter Health's HIM staff work from home, and systems are established for getting documents scanned or printed at the shared service center and attending to HIM employee requests and needs. Schulze cautions that it's difficult to identify and address all hurdles ahead of a project of this magnitude, but the more that can be accomplished on the front end, the smoother the process will be.

Technology is another common hurdle that must be overcome. For HIM consolidation to work well, all areas of a health system need to be on the same EHR, Tingey says. "Individual facilities within a health system may operate different EHRs, coding systems, or release of information systems," he says. "These differences are reconciled over time, and technology is eventually standardized, but in the meantime, staff must be trained on multiple systems, which may lead to reduced productivity in the short term."

Best Practice Considerations
Having the executive support for a consolidation project should be the top priority, Boggio says. "The CEO of Richmond and the CEO of Hampton Roads were the ones who said they wanted this to happen. I received all the support I needed," she says. "You definitely need senior leadership support before you even start a journey like this—and HR because HR became intimately involved in this journey."

Primeau suggests that staff buy-in isn't a necessity for HIM consolidation, but it goes a long way toward achieving a smooth transition. "The change is going to happen, and in any change process communication is key for a smooth transition," she says. "There will be those who are willing to accept the change and those who will not, for various reasons. If the communication plan and implementation of the plan are effective, then staff buy-in is more likely."

The team at Bon Secours met on numerous occasions to discuss plans, brainstorm, and hash out ideas. "I think a leader has to be a very good listener and process what's being said before the decision is made," Boggio says. "The decision needs to be made collectively. You need buy-in from management and frontline employees. We did a lot of rounding with employees as we were going through this journey. We let them ask questions and would give them the best answer we had at the time."

Primeau says communication strategies extend from physicians to support clinical staff and HIM. "The end goal must be well communicated and understood," she says. "Don't rush the process, and have a very strong project management plan that includes the current workflow processes and the future workflow processes so you know what changes will be needed for success."

Over the past five years, many health systems have successfully centralized their HIM departments, Tingey says, adding that the industry is beginning to see the next phase of centralization take shape as organizations bring together their facility and professional services coding. Much like the first phase of centralization, this emerging trend has benefits and potential hurdles that must be carefully considered.

"First, there are coding efficiencies to be gained when coding is done in a single path," Tingey says, referring to facility and pro fee coding being performed by a single coder in a single workflow. "Second, providing consistent education and employee development to both pro fee and facility coders opens up career development opportunities across coding specialties. Third, centralized reconciliation of pro fee and facility claims reduces the potential for poor performance on audits."

He cautions that most HIM professionals aren't up to speed with pro fee coding rules, guidelines, and billing activities, while the same can be said of professional services coders and their knowledge of facility coding. Therefore, he believes it's essential to standardize training, processes, and procedures. "If your organization chooses to centralize facility and professional coding organizations, do so knowing there will be obstacles to overcome but the benefits can be significant," Tingey says.

HIM's Changing Role
As consolidations continue, HIM professionals must change with the times and adapt their skill sets accordingly. Boggio underscores the importance of critical thinking skills and being technologically savvy going forward. "Now that we are in an EMR world, critical thinking is at the top of my list. I look for employees who can think outside of the box and have those critical thinking skills," she says. "When they see something, they can question it."

Boggio says an emphasis on patient matching and charting errors has changed the landscape in terms of the skills being sought after in HIM professionals. "When it comes to my [master patient index] team, those people have to be very good critical thinkers and very good with technology," she says. "We found several people who realized they didn't have the skill set, and they elected to retire. It's where we are with technology. [HIM professionals] have to be very technology driven and critical thinkers."

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.