Rural hospitals have to do more with less

In situations of tight staffing and limited resources, the concepts of Lean can play a huge role.

By Sue Kozlowski

There are no small hospitals in the eyes of the patients who come to them for care. People who need healthcare don’t care what your designation is, how many beds you have, or what the trauma level is in your emergency department. They expect the best care and communication no matter what the size.

From the hospital’s perspective, financial challenges are present in both of the major categories, expense and revenue. Labor may cost more for recruitment and retention, and supplies may cost more because of limited vendor availability and transportation expense. Automation and EMRs can be very helpful, but come with a significant price tag that many smaller hospitals can’t afford. On the revenue side, payments may be collected more slowly, or not at all. Even though there are multiple rural payment programs, they are attached to a significant regulatory burden. What’s a rural hospital to do?

In situations of tight staffing and limited resources, the concepts of Lean can play a huge role in simplifying work so that it is easier to perform, and easier to train new people to the job. By looking at the process flow, and collected data to identify bottlenecks or barriers, rural hospital departments can identify areas to reduce costs and improve the quality of the process outcome.

Revenue Cycle

One rural hospital had a system for billing in the emergency department that was based on correcting documentation on the chart. The chart would be received with multiple errors, and the billing and coding team would spend one to two weeks trying to get back with the doctors and nurses to correct errors and fill in gaps. This was especially a challenge with locum tenens doctors who only worked 1 – 2 days a month. The billing department was receiving significant criticism for failing to submit clean bills on a timely basis. When the delays reached the 12-week mark, from discharge to submission of the clean bill, the proposed solution was to hire more members of the coding team.

Instead, the team asked to charter a Lean project. When they mapped the process, they quickly realized that the coders had a huge backlog of charts waiting for correction and clarification. The root cause was incomplete charts. A six-week Lean team was formed to address the issue with the ED staff, and to fix disconnects between how the data was entered into the EMR and how the coding staff was able to view it.

The result of the initial project was a reduction in delays from 14 weeks at the time of the project start, to two-weeks at the conclusion. (Dictation challenges still remained.) The ED providers and nurses were initially skeptical of the improvements suggested, but their payoff was big – a stop to the endless phone calls and emails that were generated as the coders tried to get information over many weeks.

The team was so encouraged that they chartered another project – increased efficiency in the billing process – that resulted in one team member being re-deployed to help with IDC-10 implementation, and two team members enabled to work from home instead of in the office – something they had requested previously but the old process required them to be present to help solve problems.

Spin-off projects included the dictation process flow, and the updating of the Charge Master for recently-added CPT codes.

With fewer staff needed to produce clean bills faster, this ED billing process saw significant improvements, an increase in ED provider engagement, higher staff morale, and fewer denials.

The best part of this improvement was that the employees themselves came up with the ideas that resulted in better process performance. The Lean facilitator is there to coach through the process – but the improvements belong to the employees, who then take ownership to make sure the changes are sustained.


If you’re not sure this method would work for you, neither were the team members in the billing department! In fact, they tried to map the process seven – yes, seven – times previously and had never even gotten to a complete process map. By using the approach of Plan-Do-Check-Act, which is the foundation of Lean, the team was able to accomplish the impossible.

-Sue Kozlowski is senior director at TechSolve Inc. in Cincinnati, Ohio.



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