Leading from the Middle

by Mark Hagland

With one eye on strategy and one on operations, HIM managers not only have the opportunity to facilitate change, they also have the responsibility.

Awareness of senior-level strategy combined with detailed organizational knowledge can give HIM managers keen eyesight. For Mary Staub, RHIA, CHP, it helped her see potential trouble in the midst of an extensive electronic health record (EHR) implementation. It became apparent to Staub, corporate director of HIM at Intermountain Health Care, that some aspects of the 20-hospital integrated health system’s ongoing implementation were moving forward without appropriate input from HIM, risking serious problems down the line.

“We went electronic first at the point of care,” recalls Staub, “and that was fine.” But, she says, it was clear that medicolegal, risk management, and other considerations would be left unaddressed if HIM were not to make itself heard as the process unfolded. The organization has an enterprise-wide EHR, she explains, “but we still have a tremendous amount of paper. And we’ve had to push heavy-duty over the last few years to get them to understand in IT that it’s great that you have [the EHR at the point of care], but we really need a legal electronic record.”

Among other things, there were significant discrepancies between the record of the patient as it appeared on the screen when created by clinicians and the documentation required for HIM to produce patient records that would pass muster in a court case. As a result, Staub invited key IT professionals at Intermountain to tour the HIM area and sit down and talk with the organization’s HIM professionals. Most importantly, she says, “We looked at our goals and their goals, and they really were very parallel, but the goals weren’t connected. And they came to us after that and said, ‘You’re right.’”

As a result, Staub says, Intermountain’s IT leaders have been collaborating with its HIM leaders to build a record that meets everyone’s needs. HIM had struggled with “getting electronic signatures standardized throughout our enterprise and coming up with a good electronic package that fits well with our [clinical data repository],” Staub says. Now five people have been dedicated to creating the HIM application for the EHR. And equally important, the health system’s IT leaders are now taking significant HIM concerns into account.

Staub says she’s learned numerous lessons from the experience. First, she says, “It’s never as big as you think it is; you have to eat that elephant one bite at a time.” Equally important, she says, it was clear that she and her colleagues in HIM “had keys, and we hadn’t provided the keys” in a situation critical to the organization. She notes that historically HIM staff have been seen as somewhat passive—and in her view, in some cases they have acquiesced in that perception. “Sometimes we tend to hang back and say, ‘Oh well, we don’t need to be involved.’ But it is critical to step forward when the need is clear,” she says. And the results at Intermountain have been excellent, with IT and HIM working together to make the transition into a fully electronic record a success.

EHRs: Biggest Challenges, Biggest Opportunities

“Leading from the middle,” as Staub did, is never automatic, and sometimes it is daunting. But those who have stepped up to leverage their expertise and their positions to create needed change say they feel a sense of accomplishment in knowing that they’ve helped their organizations overcome specific problems and move forward. What’s more, there is a distinct awareness on the part of HIM managers that as middle managers, they have the ability to make things happen.

On the one hand, HIM managers are aware of senior management goals and initiatives, but they are also closer to the ground and able to make changes real. They are ideally positioned to lead change on a practical level, as they marry high-flying overall organizational strategies with workable tactics and match their technical and management skills with the practical needs that broad strategies require.

The current area with the biggest opportunities is in the push to implement EHRs. HIM professionals have an opportunity to help shape the form and substance of the EHR as well as the processes around it in order to optimize the privacy, security, and usefulness of patient records. HIM managers are stepping forward in privacy and security of information, utilization management, and regulatory compliance.

At NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City, Deborah Fernandez, RHIA, an operations manager and change facilitator, took advantage of her organization’s ongoing use of the Six Sigma process to help improve the organization’s compliance with the New York State Department of Health’s Annual Health Review. The review requires all healthcare facilities document that their staffs are free of medical or psychiatric impairments that could endanger patients or other staff. Fernandez cofacilitated a day-long workshop on the process, and the group she led came up with nine recommendations. At press time, Fernandez was working on a second “Work-Out,” and she relishes the opportunity to improve processes and lead change.

At Norton Healthcare in Louisville, KY, Susan Carey, RHIT, PMT, took the initiative and requested a strategic planning session for HIM. Carey, division director of HIM at the three-hospital, 22-clinic integrated health system, brought the system’s associate vice president of strategic planning as well as the HIM directors and project leaders who report to her to the HIM division and helped facilitate a discussion of goals and plans. Among the areas Carey is leading is the organization’s “e-standardization” project to standardize all forms and order sets electronically across the system. In an organization that places a premium on strategic planning, Carey says, it was an important step to bridge the high-level executive planning process and ongoing development work in the HIM area. She is about to repeat that strategic planning discussion process again this year.

At the University of Michigan Hospitals and Health Centers in Ann Arbor, Jill Buathier, MA, RHIA, CPHQ, is spearheading a major effort to analyze claims denials from health insurers and proactively avert rejections in the future. Buathier, associate director of medical information services, and her colleagues are tackling challenges centered around a weekend staffing gap in the utilization management area and the problems involving one-day inpatient stay denials that then affect HIM’s ability to optimize coding documentation for claims. “We’re taking the lead on this because certainly we can write appeal letters, but we don’t want to end it there. We’re taking it to the next level,” Buathier says. She and her HIM team work with clinicians to avert persistent weekend-related denials in a tight reimbursement environment.

Perfectly Positioned

A progressive or innovative management environment is a critical factor in the ability to lead change from the middle. Support for change from top management helps, as well. But any middle manager can initiate action given the right circumstances, motivation, and organizational need, say HIM professionals who are leading change. Great middle managers are willing to challenge their organizations in positive ways, always seeking ways to change things for the better.

That’s certainly how Deborah Thoman, RHIA, views her role. Thoman, senior assistant director for compliance, privacy, and accreditation at the University of Iowa Hospital and Clinics in Iowa City, says, “Sometimes, your role is to provoke and to disagree.” She’s been fortunate, she says, to have senior management that understands that a middle manager with technical skills and understanding can help “provoke” improvement.

Middle managers must develop good working relationships with senior management, Thoman says. By sharing information and “doing everything you can do to help them succeed,” middle managers can make themselves indispensable to senior management and in turn use their increased visibility to spearhead action in selected areas they feel passionately about. Thoman adds a major caveat. “You need to do your homework and be prepared,” she urges. “I never present things as a problem for them to solve; I come with ideas and research.”

Still, it’s clear that middle managers are perfectly positioned to push change forward in their organizations, says University of Michigan’s Buathier. “Senior management are as good at their level as they can be, but they can’t know everything,” she emphasizes. “I’m closer to the operations within the organization.” Fortunately, she says, the senior managers above her are very supportive of middle managers’ initiatives. “They know that the best ideas come from the operational level,” she says.

The Skills It Takes

All that having been said, in order to make things blossom, Buathier says, “You have to have critical thinking skills, and you have to take the initiative.” What’s more, she says, middle managers must be innovative, flexible, and have the ability to “anticipate new work processes” in order to capitalize on needs and initiate change.

Norton Healthcare’s Carey emphasizes the need for a good combination of practical management skills and knowledge of the bigger picture. “If you go out there and try to make change without a strategy, people can’t see the end result,” she says. This applies especially to marshaling one’s HIM troops, she says. “If you have a strategic planning session and get your people involved, they start to understand the value of strategic planning and what you can do in three to five years, and you start to get buy-in and get them on board.”

NewYork-Presbyterian’s Fernandez urges her peers in middle management to never forget that bigger picture and to never allow themselves to become “myopic” in their perspectives. “I think you need to always understand that you’re not an island, that your influences are coming in from a thousand different directions, and you have to be sensitive to that. The word that keeps coming to me is ‘collaborative’—that you’re in a conversation with everybody, and you need to have good listening skills.”

Middle managers in healthcare organizations need to approach situations with the listening and analytical skills of outside consultants and then apply their problem-solving and management skills and their technical knowledge to broad challenges facing their organizations. “You need to go into new meetings, encounters, and departments and be able to quickly understand what people’s areas are like and needs are; you need to be a quick study,” Fernandez urges. Having merged two huge academic medical centers and two medical schools into a combined organization, Fernandez knows whereof she speaks. Given the merger-driven activity, combined with new building and construction and program growth, she says, “It gets almost dizzying sometimes.”

“Be Counted and Be Accountable”

The opportunities calling for HIM leadership are only growing in number and in criticality to organizations. In fact, says Intermountain’s Staub, “We have to get involved in things that we might have wanted to hang back from but know we should be involved in.” At her integrated health system, that has meant intensive involvement in “development and design of health data dictionaries, understanding what HL7 means, and in general, being involved in the intricacies of interfacing” with HIM managers bridging strategic and practical activity. “We used to think of these things as IT things,” she acknowledges. “But we don’t have time to make rework; we have to really get it right as best we can the first time, and we really have to produce out-of-the-box thinking the first time. There are no sacred cows.”

In the end, she says, middle managers not only have the opportunity to facilitate change, they have the responsibility. “Because there is so much change occurring, in order to get the water to the end of the row, it couldn’t happen without middle managers. We have to stand up and be counted and be accountable,” she concludes. “And that means both taking on specific roles and sometimes just making sure to steer your staff or they will be lost. And quite frankly, someone else will do it if you don’t.”

Mark Hagland (MHagland@aol.com) is a healthcare journalist based in Chicago