1. Paying For Performance Creating a Performance Program To Energize Your Revenue Cycle Team Michigan Alliance of Healthcare Access Professionals ∆ March 6, 2009 ∆ Mt. Pleasant, Michigan Pam Kast, CHAA Patient Services Manager Botsford Healthcare

2. Encouragement From My Boss...

3. 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

4. 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

5. 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?

6. Goals for Today 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

7. Botsford Location:Farmington, MI Hospital Beds:360 Gross Revenue:$515M Annual Visits: – Inpatient:17,000 – Emergency:60,000 – Outpatient:110,000 – Laboratory:700,000 – Therapy:18,000

8. 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:

9. 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) – Clinics Group (11 Members) – Laboratory Group (7 Members) – Ambulance Group (26 Members) – Other Groups (11 Members) SNF Kidney Center Customer Service and Bad Debt Quality Improvement Education

10. 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

11. 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

12. 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

13. 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)

14. 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…)

15. Introducing the Program to Revenue Cycle Group Members Staff Meetings: – 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) – December (January – November Report Cards) – January, 2009 (2008 Final Report Cards)

16. Administering the Program 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%

17. 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

18. 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

19. 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

20. 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

21. Paying For Performance – 2008 Results We Have Group Members’ Attention – Key Members Are Engaging – Lesser Members Are Nervous – Lower Members Are Leaving

22. Paying For Performance – 2008 Results 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 – Cross-training between Scheduling, Pre-Arrival, Admitting, and ED

23. Paying For Performance – 2008 Results Customer Service – Develop and schedule skill-building class on “Service Attitudes – Service Actions – Service Excellence” – 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 – Take responsibility from billing and collection groups for credit balance management – Take responsibility from customer Service supervisor for Bad Debt management – Sit, Observe, and train with Patient Access representatives from Pre-Arrival, ED, and Admitting – Implement a new system for credit-card processing

24. Paying For Performance – 2008 Results Third-Party Billing and Collections – Create an “Understanding Your Patient Statement” handout – 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

25. Paying For Performance – 2008 Results Professional Certification – 22 NAHAM- or HFMA-certified group members “Non-Worked” Time Reductions – Absence events down 42% – Tardy events down 48% Patient-to-Employee and Employee-to-Employee Recognition – 60-plus “You Made a Difference” submissions – 21 randomly-drawn “Difference winners

26. Paying For Performance – 2008 Results Per-day productivity up 6% from an very good 60-plus level Per-month quality flat at a very good 98%-plus level

27. Paying For Performance – 2008 Results Revenue Cycle Metrics (December 31, 2008) – 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%

28. A Sample Report Card

29. Building a Paying for Performance Program – Getting Started Start with your organization’s current evaluation and “factors” (what you evaluate) – Keep it simple... Start with what you already use – Everything is measurable! – Everybody is measurable! Get specific about what “Exceptional”, “Average”, and “Needs Improvement” mean – Start with what you expect and need from an Exceptional performer – Will probably create “sub-factors” (multiple measures of productivity, quality, initiative, professionalism...)

30. Building a Paying For Performance Program – Getting Started Set points for each factor to draft your Report Card – Use a 100-point scale – Allocate by factor...Then allocate factor points by sub-factor Meet with Human Resources only after you’ve completed your draft Report Card: – 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

31. Building a Paying For Performance Program – Getting Started Schedule department meetings (with sign-in logs) to – Explain the program – Make sure that everybody hears the same explanations, questions, and answers Set a non-negotiable must-do “manager-to-member” Report Card review schedule – Insist in one-to-one discussions (and no “team meetings”) – Every 3 or 4 months is good, along with a mandatory end-of-year “final report card” meeting – Check for fair-and-equal grading (and its easier than it sounds) – Keep all of your “schedule of promises” or the whole Program will unravel – Get sign-offs at each meeting

32. Building a Paying For Performance Program – Getting Started Set end-of-year “final Report Card” meetings – For months after year-end – Complete them in that month – 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 – Post to a master employee – Establish forced distribution Share final results with group members – Share cut-points – Use terms like “Top 20”, “Mid 50”, “Lower 20”, and “Low 10” – Avoid using the “Exceptional”, “Successful”, “Needs Improvement” classification with employees as this was about their relative score (and they’ll do this themselves anyway)

33. Keys to Remember Avoid “The E’s” – Ego (“I need to be involved”) – Excuses (“I don’t have time”) – 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 – The Program’s credibility depends on management’s combined credibility – More meetings now prevent fewer surprises later – They also prevent “cramming”, where group members try to backload performance into the final few months – And better better one-to-one communication – And that you’ve reaffirmed to your engaged group members that there’s really a reward at the end – And that you’ve warned non-engaged group members that they’re making a decision that will affect future pay

34. 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.) – “I can’t measure what I do” (Then we can’t show that you’re exceptional, can we?) – “This is too much work” (Not everyone is an A student, are they?)

35. Questions? Thank You! Contact: Pam Kast Botsford HealthCare pkast@botsford.org 248-471-8549

36. 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)

37. 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)

38. Paying For Performance Program Detail - Performance Factors Professional Skill (20.0 Points) – 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)

39. 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)

40. 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)

41. 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)