HA499 Unit 3 Capstone Organizational Assessment Example

Nobody Owns the Days Between Booking and Arrival: A Capstone Organizational Assessment of a Composite Community Hospital's Outpatient Imaging Authorization Path, Profiling the Setting, Mapping Three Departments and Naming Who Must Agree

[Student Name]

Purdue University Global

HA499: Bachelor's Capstone in Health Care Administration

Unit 3 Organizational Assessment

[Instructor Name]

[Date]

The hospital, its reporting lines, the payer mix and every figure are composite and bracketed for the writer's own organization.

Profile

[Valley Community Hospital] is a composite [150]-bed nonprofit hospital. Its outpatient imaging department, in the medical office building next door, runs one MRI and two CT scanners from 07:00 to 19:00 on weekdays and 08:00 to 14:00 on Saturdays. About [45] percent of outpatient MRI and CT patients have commercial insurance, [20] percent Medicare Advantage, [25] percent traditional Medicare and [10] percent Medicaid or self-pay. Orders come from the hospital's employed medical group, which shares the hospital's electronic record, and from [30] independent practices, which send orders by fax or through a referral portal.

Structure

Donabedian (1988) separates the structures of care, the processes carried out and the outcomes that result; the assessment uses those three headings in turn. Reporting lines: central scheduling reports to the revenue cycle director under the vice president of finance. Imaging reports to the director of imaging under the vice president of operations. The employed medical group reports to the chief medical officer. The two vice presidents' lines meet only at the president. Staff: central scheduling has [11] schedulers who book all outpatient services. No one in the hospital is assigned to check imaging authorizations; an informal check by the imaging front desk happens on the morning of the scan. Systems: schedulers can see orders but not insurers' authorization decisions. Two large insurers send decisions only through their own portals, which the ordering office can see and the hospital cannot without a separate login. The organization chart explains the gap: the people who book the scan and the people who perform it report to different vice presidents, and authorization falls between them.

Process

A swimlane map has lanes for the ordering clinic, the insurer, central scheduling, the imaging front desk and the patient. The order goes to scheduling, which books the first open slot. The ordering clinic is responsible for requesting authorization, often after the scan is already booked. The insurer's decision goes back to the ordering clinic. Nothing sends it to the hospital. On the morning of the scan, the front desk checks the patient's record; if no authorization number appears, the scan is postponed or the patient signs a financial waiver, depending on the insurer. Process maps are most useful when they are drawn with the staff involved and used to locate where work falls between roles (Antonacci et al., 2018). Here, the map shows the gap clearly: between booking and arrival, no lane holds the task of confirming approval.

Outcome

Last quarter: [214] postponements for missing authorization; [61] scans performed without authorization later denied; median [eight] days to reschedule; front-desk complaints mentioning authorization up [40] percent over the year.

Constraints Any Change Must Respect

1. No new positions without a financial case approved by the vice president of finance.

2. Independent practices cannot be required to use the hospital's systems.

3. Insurer portals differ and some require separate logins and agreements.

4. Privacy rules limit what patient information can be shared with whom.

5. Scheduling must not slow for traditional Medicare patients, who usually need no authorization.

Who Must Agree

The vice president of finance, who owns scheduling and the revenue at risk; the vice president of operations, who owns imaging; the chief medical officer, for the employed group's ordering practices; and the compliance officer, for privacy and payer rules. Two independent practices that send the most orders should be consulted. Practices already spend considerable time on insurer interactions (Casalino et al., 2009), so any request that adds work for them is likely to meet resistance.

What Staff Said

Two schedulers said they would gladly check authorizations if they could see the insurers' decisions, but they book about [90] appointments a day each and cannot call insurers. The imaging front desk lead described the morning check as "finding out too late to do anything." A practice manager at an independent clinic said her staff request authorization within two days of the order, but the hospital often books the scan for the next day.

Strengths to Build On

The hospital already has a denial report that identifies scans performed without authorization, a reason code for postponements at check-in and a working relationship with the two largest independent practices through the hospital's referral liaison. These give any change a baseline, a way to measure it and a route to the practices.

Readiness for Change

Leaders agree the problem is real; complaints and denials have reached the finance committee. Scheduling and imaging each see the problem as the other's. Readiness is moderate: support exists, ownership does not.

Conclusion

The assessment finds a structural gap: authorization falls between departments that report to different executives, and no lane holds the task of confirming approval before the patient arrives. Any solution must assign that task and fit within the constraints above.

References

Antonacci, G., Reed, J. E., Lennox, L., & Barlow, J. (2018). The use of process mapping in healthcare quality improvement projects. Health Services Management Research, 31(2), 74-84. https://doi.org/10.1177/0951484818770411

Casalino, L. P., Nicholson, S., Gans, D. N., Hammons, T., Morra, D., Karrison, T., & Levinson, W. (2009). What does it cost physician practices to interact with health insurance plans? Health Affairs, 28(4), w533-w543. https://doi.org/10.1377/hlthaff.28.4.w533

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033