Process mapping the revenue cycle

Healthcare Financial Management, Feb, 2006

At first blush, process mapping would seem to be nothing more than flowcharting. Actually, it is flowcharting--but with double the operational power: With process mapping, organizations create not only an "is" map, which is a flowchart that tells you where you are, but also develop a "should" map that tells where you want to go. Together, these two process maps can lead healthcare organizations to major improvements in the revenue cycle.

What makes process mapping so valuable? John "JT" Trusten, of Colorado-based organizational improvement company The Knowledge Webb, puts it this way: "Processes are the engine of your business. To achieve sustainable growth, you must be able to improve your processes, and that means understanding how they work.

"Process mapping allows you to identify productivity opportunities, best practices, and root causes of problems, create workflow consistency, and determine who owns an action item within the process and who's accountable for it."

Perhaps the best part is that process mapping can be applied to almost any process, big or small. "We typically use it for any high-volume, rules-based procedure," says Eric Burton, CFO of Hudson Headwaters Health Network in Glen Falls, N.Y. "One example in the billing cycle is copay collection; the process map lays out the detailed steps the receptionist is supposed to follow when a patient comes in with a self-pay balance."

At the other end of the spectrum, Rita Bowen, director of health information management at Erlanger Health System in Chattanooga, Tenn., is implementing one map for the entire revenue cycle, from scheduling through billing, to standardize processes in accord with their new information system. "Printed on engineering paper and taped to the wall, it practically goes around the room," she says.

Step by Step

Here, in a nutshell, are the basic steps in process mapping:

1. Identify the critical business opportunity. "If you're going to put 10 key people in a room all day long, which is what it will take for most mapping exercises, there better be a darn good business reason for doing so--improving your ROI, for example," says Trusten. This step should be taken by the organization's financial leaders.

2. Identify key processes with the greatest influence on that opportunity. This will be either all or some of the key areas of revenue cycle management, such as patient access or charge capture.

3. Create a project team. Trusten recommends that you start by identifying the executive sponsor for the project, often the CFO, who will establish expectations and priorities, coach the team, break down any organizational barriers, and assume overall accountability.

4. Do the "is" map prework. Prework includes developing the business purpose or value proposition for the mapping project, defining the scope of the project, identifying subject matter experts who actually perform the steps in the process on a daily basis, and pinning down meeting logistics.

5. Develop "is" map. Once everyone meets and goals are communicated, the actual process of identifying process steps may begin. "You might say to the team of subject matter experts, 'OK, walk me through what occurs in the revenue cycle management process when someone has a lab test,'" says Trusten. "Start with admitting. Write each step on a Post-it[R] note and put it under the appropriate function on a large sheet of paper on the wall."

6. Look for disconnects and opportunities. This is where you put on your Sherlock Holmes hat. Areas with greatest potential for improvement typically include those with too many go/no-go decision points, too many feedback loops, duplication, non-value-added steps, role or authority ambiguity, bottlenecks, and places where you are misusing or, more likely, underusing the available technology. Why are we doing Step C? How is it different from Step J? Is there a different technology we could purchase to make that step easier or faster? These are the types of questions that typically arise at this stage. Make sure everyone involved with the process in any way has a chance to review and discuss the map that develops.

7. Create the "should" map. Validate your original value proposition: Are the purpose and outcome the same? All of the opportunities that you identified in the "is" mapping should be business requirements in the development of the "should" map. The map should also identify functional managers and best practices. In fact, many organizations prefer to start this step with a best-practice map and customize as they go along.

8. Review, finalize, and distribute the "should" process map. This should never be a cut-and-dried process, cautions Trusten. "You need to communicate the new vision and expectations, set new goals, and arrange for training. Have a plan for informing people about progress during implementation."

What if you can't get from here to there in one fell swoop? That's what "could" maps are for. For example, says Trusten, "If you don't yet have the technology to send reports automatically to patient access management each month, then set up a manual process for doing this--running the report and faxing it, for example--and map that."