Discussion Post- Health Information Management.

Tackling Tough Management Issues: Advice From the Top

by Jessica Squazzo, assistant editor

Wondering how your peers across the country are managing the myriad challenges that confront HIM professionals? We assembled a panel of experts to address common problems and concerns.

With changing technology on the horizon, HIPAA deadlines fast approaching, and staff shortages at all skill levels, HIM professionals have more than a few reasons to toss and turn at night. How are your peers handling these challenges? We asked a group of management-level professionals to address some common problems confronting HIM leaders.

The panelists are:

Richard Adams, MPH, RHIA, director, HIM, University Medical Center, Tucson, AZ Lynne Thomas Gordon, RHIA, MBA, CHE, director of operations, Shands at AGH, Gainesville, FL Pamela Haines, RHIA, administrator of medical records, Operation Par, St. Petersburg, FL Kimberley Hazelton, RHIA, file services manager, Nebraska Health System, Omaha, NE Deborah Neville, RHIA, CCS-P, CPC, analyst, Mayo Clinic, Rochester, MN Joy Rose, RHIA, CCS, coding manager, health information services, St. Luke's Hospital, New Bedford, MA Karen Rosendale, RHIA, corporate director, HIM, South Jersey Health System, Bridgeton, NJ Peggi Ann Rufener, MBA, CCS-P, senior manager, Moss Adams Advisory Services, Seattle, WA Gerri Smothers, RHIA, president and CEO, Professional Dynamic Network, Olympia Fields, IL Starla Stavely, RHIA, corporate director, HIM, Baptist Healthcare, Pensacola, FL

Case no. 1: Short Handed

I am the sole manager in charge of medical records staff in all 15 of my healthcare organization's facilities. Currently, there is only one supervisor available to help me. I'm beginning to feel stretched too thin and productivity is beginning to suffer. What can I do to improve this situation?

Rose: It is an unrealistic expectation for one person to have management responsibilities over 15 facilities with no support teams in place. Begin with a report to your immediate supervisor stating the hours needed to adequately address all issues confronted by a manager at 15 different facilities and address it from a number standpoint. If there is only 2.6 hours devoted each week to each facility, it should be quite obvious that little will be accomplished in an effective manner.

Next, create a project plan of all pending items that are currently addressed on a daily or ongoing basis and the hours that will be needed to address these projects. Also create a project plan for all future considerations and the anticipated time involved to implement them. If you don't voice your concerns with a plan in mind, you won't ever see a change.

Smothers: List and evaluate your priorities. Eliminate every task that can be delegated. Create three team leaders and give each five facilities. Increase the responsibilities for the manager position and the team leader position.

Gordon: Identify one staff member in each facility who could become a team leader. This person would become the point of contact for the HIM staff and you. Then work with the team leader and HIM employees in each facility to list the tasks and results that are the most important to accomplish.

Next, mutually set productivity and workload standards for each of these tasks and establish a tool to chart these standards against target goals. Each team leader would submit this information weekly along with any concerns or problems. The end product would be a weekly snapshot to determine how well each facility is meeting its goals and to help set priorities for intervention.

Case no. 2: A Sensitive Issue

Jeff has been working at our facility for 25 years. He is a talented coder and a model employee. In the past few months, however, I have noticed that Jeff's work is not being completed at the same pace it used to be and that it is occasionally incomplete. He is often late to work and is missing meetings quite frequently, often without realizing it. I think that Jeff's symptoms are the early signs of Alzheimer's disease, but I am afraid to bring it up with him. How should I handle this?

Gordon: First, gather objective data to show Jeff's drop in productivity, how often he has been tardy, and the number of meetings he has missed. Review this information with Jeff and explain how his actions are affecting the department and his coworkers. Offer helpful ideas for improvement and listen to his response. Summarize by reviewing expectations, showing your support, and planning a follow-up meeting to review his progress.

If Jeff feels comfortable providing an explanation for his change in behavior, refer him to appropriate resources such as a physician or an employee assistance program.

Neville: You may want to start by meeting with Jeff to get his opinion about how work is going for him lately. There may be many reasons that his work has been affected. Making assumptions before knowing the background can have devastating results.

Encourage him to evaluate his job performance from both a productivity and a quality standpoint. After getting Jeff's input, avenues may open up for discussion about specific issues that have arisen over the past few months. If a reason for the change in behavior has not been identified or he is unwilling or unable to accept the fact that his performance has not been what is expected, work with the human resources department to determine additional steps that should be followed.

Rosendale: Call Jeff into your office for a private yet gentle conversation about his recent change in work habits. Rather than starting out with a differential diagnosis like Alzheimer's, ask him if everything is okay at work, or if there are any difficulties that he is experiencing lately. Tell him you are concerned and point out examples of missed meetings and work.

He may give you insight about what is causing him to be less efficient. If he needs time off or other help and you can provide it, you should assist him however you can. If you can do nothing, refer him to human resources who can refer him to a program or agency.

Adams: With this change in Jeff's performance taking place within the past few months, I'd be more inclined to think he may be preoccupied with personal matters and that this preoccupation is interfering with his job. Call him into your office for a friendly counseling session, citing the recent changes in his work patterns, and ask if he has any explanation. If he is hesitant or states he is going through personal problems, refer him to your organization's employee assistance program. If he refuses and his performance does not improve, you have no alternative but to follow the human resource policies regarding verbal or written warnings.

Case no. 3: Workload Inequality

One of my night shift transcriptionists has made several complaints that a daytime transcriptionist appears to be leaving more difficult dictation for her and the other night shift employees. How should I address this with the daytime employee?

Rose: Gather your documentation. Today's dictation systems should include the ability to assign work in a queue as well as a report function to determine the accuracy of the night shift transcriptionist's complaint. Determine if the day transcriptionist is indeed leaving more difficult dictation and, if so, approach that person. Let this person know that all transcribers will be responsible for equal amounts of work on all report types and that this will be monitored and assessed. Address the issue in a way that does not point fingers, but rather supports the equal distribution or performance of work types.

Rosendale: Do not make it look like either shift is doing less or insinuate that they are complaining about each other. Tell the transcriptionists that you are keenly aware of how difficult it is to select the next dictation and that you want to personally prioritize their work for several weeks so they can get insight into how you want them to select their work.

Each day, assign them an even amount of report types, carefully including all levels of difficulty into both of their assignments. Watch their productivity and attitude over time and then meet with them again to see if they understand the manner in which you make your assignments and what you expect of both of them.

Neville: First, it is important to have standard expectations that are known to all. If expectations are known, the next step is to determine the cause of the difference of opinion in type of work performed. One thought would be to make sure a fair and impartial system is in place to assign dictation. Also, determine whether other factors, such as education, may be causing someone to pick and choose the type of dictation they transcribe.

Case no. 4: Money Matters

Many coders in my facility work both day and night hours. Pay is substantially higher for the night employees. It has been brought to my attention that a number of the coders have been "saving" work so that it can be done in the evenings so they will get paid more. What can I do to stop this from happening?

Adams: Review how records are distributed for coding, along with coder productivity reports. Monitor coder productivity--if your benchmark is four inpatient records per hour, then each of your inpatient coders should complete an average of 28 records per shift. Also, consider having regular evening positions along with day positions and no crossover in shifts by staff unless approved by the director.

Smothers: Talk with the staff and let them know that this behavior is inappropriate and unacceptable. Establish hourly standards and hold individuals accountable.

Case no. 5: A Question of Authority

I recently started a job as the manager of an HIM department. I've learned that the current assistant manager had also applied for my job and is very unhappy about not winning the position. She has been undermining my authority in the department and often goes behind my back to do things her way. How can I resolve this problem?

Rosendale: Call her into the office and have a frank talk with her. Tell her very calmly and politely how you perceive her actions and reactions to you being the newly appointed director. Do not make it sound like an attack, but more of a peace offering that you hope she is willing to work through. Usually when confronted about their actions, employees will feel better because they were able to vent and they know that you noticed they were disgruntled. They also appreciate that you care enough about them and their happiness to broach this conversation with them.

Sometimes asking them for their input and showing how much you really respect them will also make them feel less threatened or offended by your power. If neither of these work, the employee will need counseling for insubordination and disruptive behavior.

Stavely: Discuss with her the implications of insubordination--both to the morale of the department and to her career. Clearly communicate your goals for the department to her and your expectation that she will work to attain them. Write an "agreement" that you both sign stating your expectations and her understanding. Set a target date for improvements and begin disciplinary actions if goals are not met.

Case no. 6: Piles of Paperwork

The stack of loose filing grows by several inches in my HIM department each day. I can't hire any more staff to get this filing under control. What should I do?

Stavely: Take the time to "sort" about a week's worth of loose filing by department or nursing unit. Meet with the leaders of those departments and bring your "samples." Include the hours and salaries that are needed to handle this volume and let them know that it's getting worse. Often, loose work can be reduced by departments taking more ownership in the record. Most department managers aren't aware of the volume they send each day to the medical records department, nor the staff hours required to handle it.

Rose: What worked for me was assigning terminal digit numbers to each employee. The employee was then scheduled on a daily or bi-weekly basis for one to two hours at the beginning of his or her shift to file loose filing. This worked very well. They were responsible for reporting back at the end of their scheduled file time with the number of inches they had accomplished.

The employees did not like having to disrupt co-workers in the file room or take time away from their regular duties, so they became much more proactive about finding charts and filing loose filing on a daily basis as it arrived from the floor. Loose filing was decreased by 90 percent with this implementation.

Case no. 7: Delinquent Doctors

When physicians in my hospital fail to complete their records, we place them on a delinquent chart list, send them a letter, and track and process their delinquent records. The occasional offenders usually complete their charts right away, but the chronic offenders never get any better and we have very little time left to deal with them. How can we make this process more effective?

Rufener: Incorporate medical record completion standards into the medical staff privileging process and enforce the standards. Administrative leadership is the key, and non-compliant physicians need to be "visited" by the chief of staff. Physicians tend to respond better to discipline from their peers. Where I have seen the best results is in facilities that follow through their progressive steps and suspend the offender until records are brought up to date.

Rose: Administrative support is needed, both on the hospital side and the chief of staff side. Educate the chief of staff and the offenders on the chart flow process and the delinquent process using flow charts. Demonstrate to the chief of staff how many records are being held up, the potential for patient care concerns, and also the bottom line accounts receivable amount for the facility.

On a weekly basis, inform the offending physicians and administration with the amount of money that has been delayed in billing, if applicable. Administrative support is necessary in suspending all privileges of this physician, including the current inpatients for whom they will need to find coverage.

Case no. 8: Plummeting Productivity

Several months ago we hired Joanne, a very experienced transcriptionist who originally worked at twice the productivity of the other transcriptionists. After a few months, Joanne's productivity dropped to the level of her coworkers--half of what she had originally been producing--but still meeting the minimum standard. She could provide no plausible explanation for this drop in productivity. Is she obligated to transcribe at the rate she is capable of, or is her current level good enough?

Adams: Unless there is an incentive program for transcription, an individual who meets the minimum productivity standards as set by the job description, regardless of his or her capabilities, is fulfilling his or her obligations to an employer. Consider adopting an incentive program. Either pay transcriptionists by the line or a bonus amount after a certain productivity level has been reached. Paid by the line, each transcriptionist is reimbursed at his or her own pace. As an alternative, if your standard is 1,200 lines per an eight-hour shift, offer a bonus amount for those who produce 1,300 lines, 1,400 lines, etc.

Rose: Incentive programs usually address this. It appears that some dissatisfaction with her pay may have led to this. If coworkers get paid the same for half of what she produces, she doesn't have the incentive to produce more. Establish an incentive program to encourage her to set an example. Also, let her know that deliberately failing to perform to a certain standard is unacceptable performance and will be addressed on her evaluation if necessary.

Case no. 9: Breach of Confidentiality

Sarah, one of my best coders, came across the medical record of a woman she knew from college and learned that this woman had presented at the ER due to complications from cosmetic surgery. Sarah told her roommate about this woman, and her roommate then told several other people. The woman who had been to the ER called the hospital to complain and threatened a lawsuit. When confronted, Sarah admitted the breach of confidentiality. She hasn't made any other mistakes, though, and I really depend on her. How should I handle this situation?

Smothers: A breach of confidentiality is a serious matter and should not be taken lightly regardless of her dependability. You must send a message that violations of confidentiality will not be tolerated. I recommend termination.

Stavely: If you or the organization did not provide education about confidentiality to Sarah upon hire nor sign a confidentiality agreement, you have failed. If these things were done and Sarah made a "slip," she has failed and you have no recourse but to follow precisely what your HR policies dictate--typically, immediate termination.

Rose: She needs to be counseled and a written warning issued. If hospital policy supports termination if an employee breaches patient confidentiality, then this employee should be immediately terminated. She has violated the coder's ethics as well as patients' rights.

What Keeps You Up at Night?

Are you and your peers confronting similar problems? We asked our panelists to share the types of management challenges they frequently face.

Retaining talented employees. The market is very competitive and keeping your employees happy while working within your budget is a fine line.

--Peggi Ann Rufener, MBA, CCS-P

Overwork. Many of us are managing the equivalent of two full-time jobs in one. Our departments also tend to be understaffed and backlogged.

--Pamela Haines, RHIA

Challenges include doing more with less, retention of qualified staff, planning strategically while handling the day-to-day workload, balancing cost, quality, and service, resistance to change, and maintaining open, honest, two-way communication.

--Lynne Thomas Gordon, RHIA, MBA, CHE

It is a constant challenge to hire, and more importantly, maintain, motivated and conscientious employees. Every day I must attempt to strike the proper balance between handling personnel issues, meeting the day-to-day needs of both the staff and our customers, and planning for the future.

--Kimberley Hazelton, RHIA

The hardest things to deal with are the personnel issues. The day-to-day operations are not nearly as exhausting as the petty squabbles that staff try to drag you into.

--Karen Rosendale, RHIA

Getting people of different backgrounds, ages, and cultures to work together as a team.

--Gerri Smothers, RHIA

The challenges include increasing workloads without adding positions, managing time for coder continuing education versus coding production, and working with other departments to eliminate bottlenecks as information gets passed from one department to another.

--Richard Adams, MPH, RHIA

Top Priorities

Our panelists revealed what they consider the most pressing problems facing HIM leaders today.

Appropriately balancing departmental resources to meet both the fiscal and clinical concerns of the hospital.

--Richard Adams, MPH, RHIA

Talent shortage combined with failure of CFOs to understand the need for competitive salaries in a non-revenue-generating department.

--Starla Stavely, RHIA

Changing the perception, outside and maybe inside the HIM field, that as the paper medical record goes away, the need for the HIM department will go away.

--Pamela Haines, RHIA

Conflicting regulatory standards. Staying on top of regulations is in itself a full-time job. Keeping staff abreast of regulations is a necessary but time-consuming task and often frustrates staff.

--Peggi Ann Rufener, MBA, CCS-P

The continued expectation to do more with less. There are more challenges, regulatory and financial, that increase a manager's responsibilities, yet there are no resources to address them.

--Joy Rose, RHIA, CCS

Finding balance with limited resources to meet ever-changing regulatory requirements, staff educational needs, and integration of new technology. Unless a manager is willing to keep abreast of industry and regulatory changes that will affect HIM staff, they will find difficulty in recruiting and keeping skilled HIM professionals.

--Deborah Neville, RHIA, CCS-P, CPC

HIPAA implementation, staff shortages, and staying current on healthcare trends, new technology, and regulations.

--Lynne Thomas Gordon, RHIA, MBA, CHE

Managers are being asked to accomplish more with less as the healthcare industry deals with difficult financial situations. Trying to meet the needs of the customer, the requirements of regulatory agencies, and the expectations of staff while staying within the budget takes hard work and creativity.

--Kimberley Hazelton, RHIA

Managing cost, problems, and risk; doing more with less; education and training of staff; and resistance to change--getting people to adapt.

--Gerri Smothers, RHIA

Doing more with less is the state of healthcare now and for the foreseeable future. It is getting increasingly more difficult to make ends meet, perform the job to the level of quality that you know is required, and do it all on a shoestring budget.

--Karen Rosendale, RHIA

Jessica Squazzo ( [email protected] ) is assistant editor of the Journal of AHIMA.

Article citation: Squazzo, Jessica. "Tackling Tough Management Issues: Advice From the Top." Journal of AHIMA 73, no.9 (2002): 72ff.

Copyright ©2002 American Health Information Management Association. All rights reserved. All contents, including images and graphics, on this Web site are copyrighted by AHIMA unless otherwise noted. Reprinted by permission of AHIMA at [email protected] .