on-line charging=increased revenue
TRANSCRIPT
Zimmermann/JOURNAL OF EMERGENCY NURSING
t ed for a trial period; a m in imum of 6 months is r ecommended . In the ini t ial phases of the pro- gram, it is impor tan t tha t the manage r refrain from in te rven ing in conflict resolut ion or allow- ing the staff m e m b e r s to abd ica t e decis ion mak- ing to m a n a g e m e n t when problems arise. Changes in staff a t t i t udes to a s sume responsibi l - ity for unit coverage emerge, in part, as a result of observing the consequences when it is not done.
2. At least 1 year, and often almost 2 years, are required to achieve smooth-flowing systems.
3. Time is needed for the staff members to become proficient in negotiation. The key to mutual coop- eration is that everyone eventual ly experiences a need for a change in his or her particular schedule. The staff may need assis tance in learning how to perceive possible changes or how to approach oth- ers.
4. Problems are usually resolved by staff-suggested rule addi t ions or modifications. Rules can be used to help enforce consideration and fairness, but a noncompliant person may need individual atten- tion.
The cons is ten t t hemes tha t emerge in discus- s ions about se l f -schedul ing are tha t it is a continu- al ly evolving process, but one tha t both staff and m a n a g e m e n t u l t ima te ly prefer.
Many thanks to Belinda Mertz, RN, BSN (FHP Hospital); Tammy Koslenko, RN, BS (St. Joseph's Hospital); Chris- tine Doner, RN, BA (The Hospital for Sick Children); Judy Sharstrom, RN, BSN, CEN (Rice Memorial Hospital); Theresa Larsen, RN, BSN (Hoffman Estates Medical Cen- ter); and Shirley Wolford, RN, MSN, CEN (CGH Medical Center), for their assistance with this column.
References
1. Griesmer H. Sel f -schedul ing turned us into a winn ing team. RN 1993;56:21-3. 2. Alexander C, Pal ladino M, Evans B, Harp K, Marable K, Whi tmer K. The art of the deal. Am J Nurs 1993;93:70-4. 3. Hens inger B, Harkins D, Bruce T. Self-scheduling: two success stories. Am J Nurs 1993;93:66-7. 4. Bischof J. Sel f -schedul ing in critical care. Crit Care Nurse 1993;12:50-5. 5. Belanger D, Snell C, Fortier W. Self -schedul ing on trial. Can Nurse 1992;87:17-9.
A s hea l th care becomes increas ing ly cost con- scious, it is essen t ia l tha t charg ing of resources
ut i l ized be accura te and t imely. To mee t this objec- tive, on Ju ly 1, 1993, we i m p l e m e n t e d computer iza- t ion of ED charges as par t of our ED computer- t rack- ing project. Overall the process was very successful. It dec reased work load for clerks, da ta process ing employees , and nurses, and resu l ted in inc reased revenues for the depar tment .
Old charge system Previously a one-page charge shee t was inc luded in each char t pack (Table 1). The reg i s t e red nurse who
d i spos i t ioned the pa t i en t checked the appropr ia te ED level and other charges as n e e d e d and re turned this form to the clerk. Clerical staff ba t ched these forms dai ly and took them to da ta process ing for da ta entry. The nurse a s s igned a level charge b a s e d on the amount of nurs ing care del ivered. The major- i ty of the supply charges were cap tu red with a sup- ply labe l system. The supply process is still used
J EMERG NURS 1995;21:61-4 Copyright �9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 4- 0 18/82/80848
February 1995 61
JOURNAL OF EMERGENCY NURSING/Bradley
UNIVERSITY OF KENTUCKY HOSPITAL CHANDLER MEDICAL CENTER LEXINGTON, KENTUCKY
EMERGENCY DEPARTMENT CHARGES
INSTRUCTIONS: Use this form dur ing computer downt ime only . Clerical wi l l enter the correct charges once the computer is back on- l ine. Do not batch th is form. File this charge sheet with the ye l low copies o f char t fo rms after charge is entered. Do not use th is fo rm for direct admits or Aeromedical d irect admits who do not receive care in the Emergency Department. These pat ients do no t require an ED charge.
53120 _ _ Level 1, 10-20 minutes Nursing Care
53130 Level 2, 20-50 minutes Nursing Care
53135 Level 3, 50~ minutes Nursing Care
53140 Level 4, 90-150 minutes Nursing Care
53150 Level 5, 150-240 minutes Nursing Care
53101 Clink: Visit (KENPAC denials, LWBS, wound check)
53184 _ _ UK Suture Removal
53185 UK Physician call bask
53181 Decon I: Urgent
5 3 1 8 2 Decon Ih Emergent
53186 Fast Track Level 1
53187 Fast Track Lever 2
53188 Fast Track Level 3
53189 Fast Track Suture Removal
ADDITIONAL CHARGES
53165 _ _ Observation Level 3 per hour
53170 _ _ Observation Level 4 per hour
53180 _ _ Observation Level 5 per hour
58201 Oxygen per hour
53998 _ _ Glucose monitoring
53155 Trauma Alert
t 53402 Cast, Long Arm
5 3 4 1 3 _ _ Cast, Sho~ Arm
53404 Cast, Long Leg
5340J Cast, Short Leg
53406 Cast, Shoulder Spice
53442 _ _ Splint, Long Arm
53450 Splim Arm (Piaster)
53441 Splint, Cock Up Wrist
53476 5p
Bradley/JOURNAL OF EMERGENCY NUI~SING
UNIVERSITY HOSPITAL 09120194 15:57
CAT. KITTY I 020402021148 CURR
EO TRACKING PATIENT CHARGING SELECT CRARGE(S)ISELECT ENTER . . . . . . * ~ 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6
DEPARTMENTAL CHARGES LEVEL ! - 10-20 MIN NURSING CARE LEVEL 2 - 20-50 MIN NURSING CARE LEVEL 3 - 50-90 MIN NURSING CARE LEVEL 4 - 90-150 MIN NURSING CARE LEVEL 5 - 190-240 MIN NURSING CARE CLINIC VISIT (KENPAC DENIAL. LNBS, WOUND CHECK) UK SUTURE REMOVAL UK PHYSICIAN CALL BACK DECON I: URGENT DECON IT: EMERGENT FAST TRACK LEVEL I FAST TRACK LEVEL IT FAST TRACK LEVEL I l l FAST TRACK SUTURE REMOVAL
DEFER PATIENT CHARGES ENTER DEPARTMENT CHARGE
RETURN MASTER CSQGI2A CLINIPAC USERi VICKY BRADLEY TERMINAL IO: D783
4B/ Aa O0--SESSION3 R i C I 15:53 9120194
Figure 2 First charge screen. DECON, Decontamination; LWBS, left without being seen; UK, University of Kentucky.
UNIVERSITY HOSPITAL 09/20194 15:55 CAT, KITTY E-R 02040202-1148 ED TRACKING PATIENT CHARGE REVIEW ENTER OR CORRECT/PRESS ENTER . . . . . . . . , , ~ 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 1 7 6 . . . . . ~
DEPARTMENTAL CHARGE ? L2
STAFF INITIALS : VB :
OTHER CHARGES : : OXYGEN (PER HOUR} : : BLOOD GLUCOSE (#) : : TRAUMA ALERT (Y)
OBSERVATION CHARGES (ENTER NUMBER OF HOURG)
: :LEVEL 3 : :LEVEL 4 : :LEVEL 5
ORTHOPEDIC SUPPLIES (ENTER I OR 2) : : CAST. LONG ARM : : CAST. SHORT ARM : : CAST, LONG LEG : : CAST, SHORT LEG
: : CAST. SHOULDER SPICA : : SPLINT, LONG ARM : : SPLINT, ARM (PLASTER)
: : SPLINT. COCK UP WRIST : : SPLINT, POSTERIOR KNEE
: : SUGAR TONGS : : THUMB SPICA
Please review thi~ data before Eonts ACCEPT
CSOGI2B CLINIPAC USER: VICKY BRAOLEY 4DC Aa DO--SESSION3 R 7 C 21
Figure 3 Second charge screen. L2, Level 2.
MASTER
TERNtNAL ID: DZG3 [5:51 q/20/94
February 1995 63
JOURNAL OF EMERGENCY NURSING/Bradley
�9 T h e r e w a s no s i m p l e m e t h o d to a u d i t t h e a c c u r a c y of t h e c h a r g e leve l a s s i g n e d b y the n u r s e b e c a u s e t h e r e w a s no r eco rd of t h e p a t i e n t c h a r g e leve l on t h e ED record.
�9 T h e r e w e r e no r epo r t s t h a t i d e n t i f i e d p a t i e n t s w h o h a d no t r e c e i v e d a c h a r g e or i n s t a n c e s w h e n pa- t i e n t c h a r g e s w e r e incorrec t .
On-line computerized charge process A s of J u l y 1993, w e c o n v e r t e d t h e p a p e r form to a c o m p u t e r i z e d form, a n d l i n k e d the c h a r g e p r o c e s s to p a t i e n t d i s p o s i t i o n from t h e ED t r a c k i n g sys - t em. Now, as t h e r e g i s t e r e d n u r s e s e l ec t s p a t i e n t d i s p o s i t i o n (e.g., d i s c h a r g e , admi t , t ransfer ) , two c h a r g e s c r e e n s a re a u t o m a t i c a l l y d i s p l a y e d , one af te r t h e other . T h e n u r s e h a s to e n t e r t he pa - t i e n t c h a r g e s to d i s p o s i t i o n t h e p a t i e n t a n d free t r e a t m e n t b e d s in t h e t r a c k i n g sy s t em. On t h e first sc reen , d i s p l a y e d in T a b l e 2, t he n u r s e s e l ec t s one c h a r g e level . The n u r s e t h e n e n t e r s h is or he r i n i t i a l s a n d a n y o the r ED c h a r g e s (Tab l e 3). If t h e n u r s e is u n s u r e of t h e cor rec t cha rge , t h e de - f e r r ed op t ion is s e l ec t ed . Da ta for all p a t i e n t s w i t h d e f e r r e d c h a r g e s a r e s t o r e d in a " d e f e r r e d c e n s u s " c o m p u t e r file. R e c o r d s for t h e s e p a t i e n t s r e m a i n in t h i s c a t e g o r y un t i l t h e c h a r g e s a re m a d e . RNs a n d c h a r g e n u r s e s a re e n c o u r a g e d to c h e c k th i s c e n s u s d a i l y to e n s u r e t h a t al l p a t i e n t c h a r g e s a re e n t e r e d .
A d d i t i o n a l l y , a c h a r g e a u d i t r epor t is g e n e r a t e d a n d r e v i e w e d d a i l y for p o t e n t i a l errors. E x a m p l e s of a u d i t f i l ters are:
�9 A d m i t t e d p a t i e n t s c h a r g e d less t h a n a leve l 3 �9 P a t i e n t s w i t h ch ie f c o m p l a i n t of s u t u r e r e m o v a l
c h a r g e d for s e rv i ce o t h e r t h a n a s u t u r e r e m o v a l c h a r g e
�9 P a t i e n t s c h a r g e d two l eve l s h i g h e r or lower t h a n the i r in i t i a l a c u i t y leve l
�9 P a t i e n t s w i t h l e n g t h s of s t a y g r e a t e r t h a n 8 hour s w i t h o u t o b s e r v a t i o n c h a r g e s
C h a r t s of t h e p a t i e n t s l i s t e d on the a u d i t re- po r t a re r e v i e w e d a n d c h a r g e co r rec t ions a re sub - m i t t e d . The a u d i t is d e s i g n e d to c a p t u r e t h e m o s t c o m m o n c h a r g e errors. F e e d b a c k on c o m m o n errors is c o m m u n i c a t e d b y m e a n s of t h e d e p a r t m e n t n e w s l e t t e r a n d a t s taff m e e t i n g s . C h a r g e n u r s e s p r o v i d e f e e d b a c k to s taff m e m b e r s w h e n t r e n d s de - ve lop for an i n d i v i d u a l . T h e t r a u m a a le r t log a lso is c h e c k e d b i w e e k l y to e n s u r e t h a t al l t r a u m a a l e r t s a re c h a r g e d .
Evaluation of the new charge process T h e r e are m a n y p o s i t i v e m e r i t s to t h e n e w c h a r g e s y s t e m . The major b e n e f i t s a re a s fol lows:
�9 E l i m i n a t i o n of d a t a e n t r y of a p p r o x i m a t e l y 100 c h a r g e s h e e t s pe r d a y
�9 E l i m i n a t i o n of c l e r i ca l role in f i n d i n g a n d b a t c h i n g c h a r g e forms
�9 E l i m i n a t i o n of a p a p e r form for t h e n u r s i n g s taff �9 D e c r e a s e d v a r i a b i l i t y of p a t i e n t c h a r g e s a m o n g
n u r s e s �9 E n s u r e d ED c h a r g e s for all p a t i e n t s �9 I n c r e a s e d c h a r g e s c a p t u r e d from t h e pr ior yea r �9 I n c r e a s e d a v e r a g e c h a r g e pe r p a t i e n t b y 13% �9 I n c r e a s e d t i m e l i n e s s of p o s t i n g of ED c h a r g e �9 Prov is ion of a m e c h a n i s m to cor rec t e r r o n e o u s pa-
t i e n t c h a r g e s be fore b i l l ing , t h e r e b y d e c r e a s i n g p a t i e n t c o m p l a i n t s
A l t h o u g h t h e n e w p r o c e s s h a s h a d pos i t i ve re- sul ts , t h e r e is s t i l l room for i m p r o v e m e n t . P r o b l e m s w i t h t h e n e w s y s t e m i n c l u d e t h e fo l lowing:
�9 O v e r s i g h t s in r e m o v a l of p a t i e n t d a t a from the de - f e r r ed c e n s u s
�9 V a r i a b i l i t y a m o n g n u r s e s in s e l ec t i on of t h e c h a r g e level , a l t h o u g h less f r e q u e n t t h a n in t he p a s t
�9 O m i s s i o n s of s o m e o p t i o n a l c h a r g e s such as t he t r a u m a a le r t c h a r g e
�9 T i m e - c o n s u m i n g co r rec t ion p rocess , r e q u i r i n g ap- p r o x i m a t e l y 60 to 90 m i n u t e s d a i l y
Summary A l t h o u g h the n e w ED c h a r g e s y s t e m is no t perfect , i t h a s r e s u l t e d in i m p r o v e d c h a r g i n g for s e rv i ce s de l i ve r e d ; t h i s i n c r e a s e in cor rec t c h a r g e s h a s more t h a n offset t h e r e s o u r c e s to d e v e l o p t h e en t i r e t r a c k i n g s y s t e m p ro j ec t w i t h i n 1 year . Th i s is one e x a m p l e in w h i c h c o m p u t e r i z a t i o n p a i d for itself, w h i c h s h o u l d h e l p ED m a n a g e r s jus t i fy c o m p u t e r - i za t ion of the i r d e p a r t m e n t s .
It is h o p e d t h a t m o r e ef fec t ive c h a r g e s y s t e m s wi l l occur a s a c o m p o n e n t of t h e c o m p u t e r i z e d pa- t i e n t r eco rd in w h i c h t h e p a t i e n t c h a r g e is ca lcu- l a t e d on t h e b a s i s of p r e s e t f o rmu la s for t h e a m o u n t of r e s o u r c e s u t i l i zed , t h u s e l i m i n a t i n g s u b j e c t i v i t y in c h a r g i n g . Wi th t h e c a p t u r e of all s e rv i ce s ren- d e r e d , e v a l u a t i o n of p r a c t i c e p a t t e r n s a n d o u t c o m e s w o u l d a l l o w the ED s taff to i d e n t i f y ef fec t ive t r ea t - m e n t r e g i m e n s . Hopefu l ly , u n n e c e s s a r y t e s t s or t r e a t m e n t s can b e e l i m i n a t e d to p r o m o t e a d e c r e a s e in r e sou rce u t i l i z a t i on a n d cos t s w i t h o u t compro- m i s i n g q u a l i t y p a t i e n t care.
G4 Volume 21, Number 1