Paying For Performance
Creating a Performance Program
To Energize Your Revenue Cycle Team
Pam Kast, CHAA
Patient Services Manager
Botsford Healthcare
Michigan Alliance of Healthcare Access Professionals ∆ March 6, 2009 ∆ Mt. Pleasant, Michigan
Encouragement From My Boss . . .
What If…

In less than a year you could create the energy in your Revenue Cycle team to see your
group members . . .
–
Complete 15-plus Service Excellence projects:
 Patient Satisfaction
 Employee Satisfaction projects
–
Complete over 25-plus in-group, cross-group, or cross-department collaborative
projects:
 Productivity Improvement
 Quality Improvement
 Cost Reduction
 Support-Recognition
What If…

In less than a year you could create the energy in your Revenue Cycle team to see your
group members . . .
–
Apply, study, and pass a health-care specific certification examination and become
nationally professionally certified
–
Reduce their “non-worked” time dramatically
What If…

What if your team would achieve this independently with
–
Lots of your support?
–
Some of your direction?
–
Little of your time or participation?

What if the outcome is a Performance Feedback system
–
Without the “pain and agony” (yours)?
–
Without the surprises (theirs)?
–
That documents and rewards exceptional performance?
–
That also documents and discourages under-performance?

What if you can do this in 2009?
Goals for Today
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Hear the first-year results from our “Paying for Performance” program
Learn how our Program was developed
Learn how to build a Program
Learn how to respond to employee resistance (and other barriers) to the Program
Take home a Report Card to use as your starting point for your own Program
Talk with managers and team members who completed our Program
Botsford

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Location:
Hospital Beds:
Gross Revenue:
Annual Visits:
–
Inpatient:
–
Emergency:
–
Outpatient:
–
Laboratory:
–
Therapy:
Farmington, MI
360
$515M
17,000
60,000
110,000
700,000
18,000
Botsford

Affiliates
–
Botsford Clinics
–
Botsford Outreach Laboratory
–
Botsford Rehabilitation and Continuing Care Center (SNF)
–
Botsford Kidney Center
–
Community EMS
–
Parastar
 Joint Ventures
– Michigan
– New Jersey
– Ohio
– Texas
 Municipalities:
Revenue Cycle Group


Patient Access
–
Central Scheduling and Pre-Arrival (15 Members)
–
Emergency Department (20 Members)
–
Day-of-Service (10 Members)
System Business Office
–
Hospital Group (30 Members)
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Clinics Group (11 Members)
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Laboratory Group (7 Members)
–
Ambulance Group (26 Members)
–
Other Groups (11 Members)
 SNF
 Kidney Center
 Customer Service and Bad Debt
 Quality Improvement
 Education
Paying For Performance – Program Evolution


Two Related Programs
–
Pay-For-Performance Program
–
Continuing Education Program
Origins
–
Employee Engagement Surveys
 Juice Check 2007
 Juice Check 2008
–
Starting Belief – Engagement Employees
 Deliver Higher Results
 Create Satisfied customers
Paying For Performance – Program Evolution

Origins (Continued)
–
Key Assessments
 I Fit
 I’m Clear
 I’m Equipped
 I’m Inspired
 I’m Valued
–
Key Messages as Opportunities
 Failure to Communicate
– Top-Down
– Front-to-Back (PA to SBO)
– Across Groups (Hospital, Clinics, Lab, Ambulance…)
 Failure to Recognize
– Poor Performance
– Great Performance
 Lack of Growth Opportunities
Developing the Pay For Performance Program

Developed By The Leadership Team
–
First Meetings Reviewed Juice Scores:
 Recognition That We Can’t Do It…All or Alone
 Goal Was For A Fundamental Culture Change:
– Relentless Communication And No Surprises:
 One-to-One
 Group-on-Group
 Not Manager Controlled
– Frequent Check-In Sessions:
 One-to-One Report Card Reviews
 Group Free-for-Alls
– Encourage Employees To Step Up and Step Out
– Start Succession Planning
Developing the Pay For Performance Program

Developed by the Leadership Team
–
Next Meetings Developed Pay-For-Performance Program
 Centered Around Existing Performance Factor Targets in Existing Annual
Evaluation Program.
 Each Performance Factor Target Broken Down in Measurable “Events” And
Point Scores Allocated to Total to 100 Possible Points
– Service Excellence (10.0 Points)
– Quality (20.0 Points)
– Professional Skill (20.0 Points)
– Conflict Management (10.0 Points)
– Productivity (20.0 Points)
– Initiative (20.0 Points)
Developing the Pay For Performance Program

Developed By The Leadership Team (Continued)
–
Next Meetings Developed Pay-For-Performance Program (Continued)
 Performance Factor Targets Created And Tailored To All Position Groups
– ED Triage Registration
– ED Registration
– Day-Of-Service Registration
– Financial Counseling and Medicare Rights
– Pre-Arrival Scheduling
– Pre-Arrival Registration-Verification
– SBO Registration-Verification
– SBO Follow-Up
– SBO Remittance Posting
– SBO Customer Service
– All Others (Process Improvement, Education…)
Introducing the Program
to Revenue Cycle Group Members
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Staff Meetings:
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Multiple Large-Group Sessions in (June)
Individual Manager-Staff Meetings In (June – July)
Technical Effective Date of July 1 with Performance Factor “Look-Backs” to January 1
Periodic Performance Check-In Meetings with Manager or Supervisor
–
June (January – May Report Cards)
–
September (January – August Report Cards)
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December (January – November Report Cards)
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January, 2009 (2008 Final Report Cards)
Administering the Program
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Maximum of 100 Performance Factor Points Available To Be Earned With 92.5 Being
Entirely Controlled By The Individual Group Member
Annual Increases To Recognize Both High-End And Low-End Achievement:
–
PFPs Calculated For Every Group Member
–
All Group Members Included The PFP Pool
–
2008-2009 Merit Increase Distribution:
 Group Members Achieving “Top 20%” (In 81%-100% Range) Earn 200%
 Group Members Achieving “Mid 50%” (In 31%-80% Range) Earn 100%
 Group Members Achieving “Lower 20%” (11%-30% Range) Earn 50%
 Group Members Achieving “Lowest 10%” (In 0%-10% Range) Earn 0%
Continuing Education Program

Developed By The Leadership Team
–
First Meetings Centered Around Education Goals
 Goals were For:
– Proven Professional Competence
– Reinforcing Service Excellence Concepts of Professionalism, Respect,
Courtesy, and Personal Accountability
Continuing Education Program

Developed By the Leadership Team (Continued)
–
Next Meetings Established 2008 Curriculum
 42 Available Hours of Education
– 32 Hours of Web-Based Independent Education
 IMA Web University (6.0 Hours)
 BridgeFront Bundles (26.0 Hours)
– Classroom Education “Example Classes”
 Registering First Impressions
 Maintaining Superior Customer Service: Eight Keys to Consistent
Quality
 Wowing Your Customers: Essential Skills to Deliver Service
Excellence
 Stopping Difficult People From Sucking the Life Out of Your
Organization
 We’re In the People Business
 Getting Started With Excel and Word
Continuing Education Program

Developed By The Leadership Team (Continued)
–
Next Meetings Established 2008 Curriculum (Continued)
 42 Available Hours of Education (Continued)
– 32 Hours of Web-Based Independent Education
 IMA Web University (6.0 Hours)
- Customer Service Basics
- Customer Service Functions
- Billing Claim Preparation and Submission
- Account Posting
- Billing Functions
- Account Maintenance Functions
Continuing Education Program

Developed By The Leadership Team (Continued)
–
Next Meetings Established 2008 Curriculum (Continued)
 42 Available Hours of Education (Continued)
– 32 Hours of Web-Based Independent Education (Continued)
 BridgeFront Bundles (26.0 Hours)
- Demographics
- Health Insurance
- Verification
- “What Do I Owe?”
- Coordination of Benefits
- Anatomy of A UB04
Paying For Performance – 2008 Results

We Have Group Members’ Attention
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Key Members Are Engaging
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Lesser Members Are Nervous
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Lower Members Are Leaving
Paying For Performance – 2008 Results
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Patient Access
–
Take daily responsibility for working (and giving feedback and training to reduce)
exception report items for
 Invalid subscriber IDs
 Inactive insurance plans
 Time-of-Service collections
–
Develop manuals, reference guides, and contact lists for
 Scheduling
 Pre-Registration
 Insurance Verification
–
Networking with physician office staff
 Meet-and-greet breakfast
 Feedback on patient demographics and financial clearance
–
Implement new processes for
 Avoiding duplicate MRN creation
 Maintaining physician order storage and access
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Cross-training between Scheduling, Pre-Arrival, Admitting, and ED
Paying For Performance – 2008 Results
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Customer Service
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Develop and schedule skill-building class on “Service Attitudes – Service Actions –
Service Excellence”
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Sit, observe, and train with representatives from Hospital, Clinic, and Lab billing and
collection groups
–
Take responsibility from billing and collection groups for Self-Pay balance
management
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Take responsibility from billing and collection groups for credit balance management
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Take responsibility from customer Service supervisor for Bad Debt management
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Sit, Observe, and train with Patient Access representatives from Pre-Arrival, ED, and
Admitting
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Implement a new system for credit-card processing
Paying For Performance – 2008 Results
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Third-Party Billing and Collections
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Create an “Understanding Your Patient Statement” handout
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Develop and schedule training classes in third-party insurance handling
 Medicare Managed Care
 Blue Cross 101
 Worker Compensation
 Motor Vehicle
 Expanded number of third-party payer representative visits
–
Group projects to
 Reduce credit balances
 Organize remittance files and denials
–
Programs
 Perfect attendance program
 “You Made a Difference” program
 CPR class
Paying For Performance – 2008 Results
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Professional Certification
–
22 NAHAM- or HFMA-certified group members
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“Non-Worked” Time Reductions
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Absence events down 42%
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Tardy events down 48%

Patient-to-Employee and Employee-to-Employee Recognition
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60-plus “You Made a Difference” submissions
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21 randomly-drawn “Difference winners
Paying For Performance – 2008 Results
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Per-day productivity up 6% from an very good 60-plus level
Per-month quality flat at a very good 98%-plus level
Paying For Performance – 2008 Results
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Revenue Cycle Metrics (December 31, 2008)
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Gross AR Days:
 Hospital Group:
45
 Clinics Group:
30
 Laboratory:
42
 Ambulance Group:
54
Press-Ganey “Percentage of 5’s” Patient Satisfaction Scores
–
Hospital Group:
 Emergency:
56%
 Inpatient:
67%
A Sample Report Card
Building a Paying for Performance Program –
Getting Started
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Start with your organization’s current evaluation and “factors” (what you evaluate)
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Keep it simple . . . Start with what you already use
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Everything is measurable!
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Everybody is measurable!

Get specific about what “Exceptional”, “Average”, and “Needs Improvement” mean
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Start with what you expect and need from an Exceptional performer
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Will probably create “sub-factors” (multiple measures of productivity, quality, initiative,
professionalism . . .)
Building a Paying For Performance Program –
Getting Started

Set points for each factor to draft your Report Card
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Use a 100-point scale
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Allocate by factor . . .Then allocate factor points by sub-factor
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Meet with Human Resources only after you’ve completed your draft Report Card:
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Sell them on the:
 Detail
 Fairness
 Consistency-Predictability
 Front-End “Performance Blindness”
 Budget Neutrality
–
This may take 2,3, or 4 re-meetings
–
HR support goes a long way to getting your boss’s support
Building a Paying For Performance Program –
Getting Started
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Schedule department meetings (with sign-in logs) to
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Explain the program
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Make sure that everybody hears the same explanations, questions, and answers
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Set a non-negotiable must-do “manager-to-member” Report Card review schedule
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Insist in one-to-one discussions (and no “team meetings”)
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Every 3 or 4 months is good, along with a mandatory end-of-year “final report card”
meeting
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Check for fair-and-equal grading (and its easier than it sounds)
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Keep all of your “schedule of promises” or the whole Program will unravel
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Get sign-offs at each meeting
Building a Paying For Performance Program –
Getting Started
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Set end-of-year “final Report Card” meetings
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For months after year-end
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Complete them in that month
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Discuss overall Report Card grade and not employee increases
 You want this discussion to be on their performance
 You don’t know their increase yet
Set manager meetings to assemble final Report Card scores
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Post to a master employee
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Establish forced distribution
Share final results with group members
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Share cut-points
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Use terms like “Top 20”, “Mid 50”, “Lower 20”, and “Low 10”
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Avoid using the “Exceptional”, “Successful”, “Needs Improvement” classification with
employees as this was about their relative score (and they’ll do this themselves
anyway)
Keys to Remember
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Avoid “The E’s”
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Ego (“I need to be involved”)
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Excuses (“I don’t have time”)
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Evasion (“I don’t like giving bad news”)
Small groups will be harder, but can be built
–
Might require more team goals
Make sure that everyone fulfills every scheduled meeting
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The Program’s credibility depends on management’s combined credibility
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More meetings now prevent fewer surprises later
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They also prevent “cramming”, where group members try to backload performance
into the final few months
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And better better one-to-one communication
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And that you’ve reaffirmed to your engaged group members that there’s really a
reward at the end
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And that you’ve warned non-engaged group members that they’re making a decision
that will affect future pay
Keys to Remember

Expect some group member resistance
–
“I’ve never had to do this before” (Well, you don’t even have to do it now.)
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“I can’t measure what I do” (Then we can’t show that you’re exceptional, can we?)
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“This is too much work” (Not everyone is an A student, are they?)
Questions?
Thank You!
Contact:
Pam Kast
Botsford HealthCare
pkast@botsford.org
248-471-8549
Paying For Performance Program Detail –
Performance Factors

Service Excellence (10.0 Points)
–
Staff To Develop and Complete Measurable Projects
 2 Projects = Exceptional Performance (10.0 Points)
 1 Project = Successful Performance (5.0 Points)
Paying For Performance Program Detail Performance Factors

Quality (20.0 Points)
–
Using Existing Monthly Quality Audits (Varies By Position Group)
 98% or Better for All 12 Months = Exceptional Performance (20.0 Points)
 95% or Better for All 12 Months = Successful Performance (10.0 Points)
 95% or Better for 10 Months = Needs-Improvement-Performance (5.0 Points)
Paying For Performance Program Detail Performance Factors

Professional Skill (20.0 Points)
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Continuing Education (5.0 Points)
 42 Available Hours of Education
– 32 Hours of Web-Based Independent Education
– 10 Hours of Classroom Education
 38 Hours = Exceptional Performance (5.0 Points)
 34 Hours = Successful Performance (3.0 Points)
 30 Hours = Needs-Improvement Performance (1.0 Points)
 26 Hours = Unsatisfactory Performance (-5.0 Points)
–
Unscheduled Absences (7.5 Points)
 1 or Better = Exceptional Performance (7.5 Points)
 6 or Better = Successful Performance (2.5 Points)
–
Tardies and Out-Earlies (7.5)
 1 or Better = Exceptional Performance (7.5 Points)
 8 or Better = Successful Performance (2.5 Points)
Paying For Performance Program Detail Performance Factors

Conflict Management (10.0 Points)
–
Department Conflicts Requiring Manager (2.0 Points)
 0 = Exceptional Performance (2.0 Points)
 1 = Successful Performance (1.0 Points)
–
Department Collaboratives (3.0 Points)
 2 = Exceptional Performance (3.0 Points)
 1 = Successful Performance (1.0 Points)
–
Patient Complaints (2.0 Points)
 0 = Exceptional Performance (2.0 Points)
 1 = Successful Performance (1.0 Points)
–
Patient or Co-Worker Complements – Recognition Boxes (3.0 Points)
 2 or Better = Exceptional Performance (3.0 Points)
 1 = Successful Performance (1.0 Points)
Paying For Performance Program Detail Performance Factors

Productivity (20.0 Points)
–
Using Existing Monthly Quality Audits (Varies By Position Group)
 64 of Better Average Daily Touches All 4 Quarters = Exceptional Performance
(20.0 Points)
 59 of Better Average Daily Touches All 4 Quarters = Successful Performance
(10.0 Points)
 59 of Better Average Daily Touches = At Least 1 Quarter = Needs-Improvement
Performance (5.0 Points)
Paying For Performance Program Detail Performance Factors

Initiative (20.0 Points)
–
Overtime Worked (7.5 Points)
 75% or Better Quartile For All Employees = Exceptional Performance (7.5%
–
CHAA Certification Via NAHAM (5.0 Points)
–
Manager Discretion (7.5 Points)
 Documented Episodes Of Employee Sacrifice To Further Team Success Such
As:
– Foregoing Scheduled Time-Off
– Postponing Leaves-Of Absences
– Participation-Representation In Out-Of-Department Meetings
 Exceptional Performance (7.5 Points)
 Successful Performance (3.0 Points)