HomeMy WebLinkAboutReview of Business Practices and Bend Clinic WorkflowReport# 05/06 - 4 (Dated September 7, 2006)
Health Department -
Review of Business Practices and
Bend Clinic Workflow
Presented to the
Deschutes County Health Department
and
Audit Committee
by the
Internal Audit Program
David Givans, CPA, CIA – County Internal Auditor
Report# 05/06 - 4 Dated September 7, 2006
Deschutes County,
Oregon
Report# 05/06 - 4 (Dated September 7, 2006)
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Report# 05/06 - 4 (Dated September 7, 2006)
To: Audit Co mmittee, Dave Kanner, Daniel Peddycord,
CC: Mike Daly, Bev Clarno
From: David Givans, Count y Internal Auditor
Subject: Internal Audit Report on Health Department – Review of Business Practices
and Bend Clinic Workflow (Report #05/06 - 4)
Date: September 7, 2006
The enclosed audit report provides informat ion concerning selected business pract ices o f the
Deschutes County Healt h Department and the Bend Clinic workflow. Informat ion
contained in this reports is from interviews, observations and analyses performed.
Audit results have been discussed with Healt h Department management. Responses fro m
Health Depart ment management are included at the end of this report and address the
findings and recommendat ions.
Health Depart ment Management and staff were cooperative and responsive during the
review.
Deschutes County,
Oregon
Internal Audit Program
David Givans, CPA, CIA
County Internal Auditor
Deschutes Services Center
1300 NW Wall St., Suite 200
Bend, OR 97701
Phone: 541-330-4674
Fax: 541-385-3202
davidg@co.deschutes.or.us
Report# 05/06 - 4 (Dated September 7, 2006)
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Report# 05/06 - 4 (Dated September 7, 2006)
Health Depart ment -
Review of Business Practices and Bend Clinic Workflow
TABLE OF CONTENTS:
EXECUTIVE SUMMARY
1. INTRODUCTION
1.1. Audit purpose ………………………………………………………………….…... 1
1.2. Object ives and Scope …………………………………………………….…...…. 1-2
1.3. Methodology ………………………………………………………………..…… 2-3
2. FINDINGS
2.1. Business practices
2.1.1. Internal controls ………………………………..……………………. 3-11
2.1.2. Performance …………………………………….……………..….... 11-13
2.1.3. Laws, regulat ions and policies …..……………………………….... 13-15
2.2. Bend Clinic workflow ……………………………………………………….... 16-26
3. RESPONSE FROM MANAGEMENT
3.1. Health Depart ment management ……………………........................................ 26-28
Report# 05/06 - 4 (Dated September 7, 2006)
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Report# 05/06 - 4 (Dated September 7, 2006) i
Health Department -
Review of Business Practices and Bend Clinic Workflow
Report# 05/06 - 4 (Dated September 7, 2006)
EXECUTIVE SUMMARY
Purpose
As one of the County’s larger departments, the audit purpose included general business
practices (primarily revenue collect ion) and the department’s concern they were addressing
patient flow to provide better service delivery at its Bend clinic. This report includes Healt h
Department management responses to these recommendat ions.
Results in brief
Audit findings result from incidents of non-co mpliance with stated procedures and/or
departures from prudent operation. The findings are, by nature, subject ive. The fo llowing
highlights the significant findings presented to management for considerat ion with
associated report page reference.
The findings include:
FINDINGS
Page number(s)
BUSINESS PRACTICES – Controls
1. There are insufficient written accounting policies and procedures over the
duties of staff.
3-4
2. Certain business office funct ions lack adequate segregation of dut ies. 4
3. Collected monies are not adequately safeguarded. 4-5
4. There is a lack of coordinated collect ion effort over customer charges. 5-6
5. Customers are not required to provide support for reduced clinic charges. 6-7
6. Department accounting system activit y is not reconciled to amounts
reported to the County.
7-8
7. Usage of certain clinic inventory items is not effectively mo nitored. 8
8. Clinic reports are not distributed to and used by appropriate personnel. 9
9. Program budgets are not maintained in balance as program budgets
change.
9-10
10. Service charge entry errors were higher than expected. 10-11
11. Program accounting does not include certain administration costs. 11
BUSINESS PRACTICES – Performance
12. Some clinic service charges may be low. 11-12
13. Staff have not explored use of available electronic insurance informat ion. 12
14. Inefficient process used to develop program financial reports. 12-13
BUSINESS PRACTICES – Laws, Regulations and Policy
15. Manual receipts do not conform to County Policy. 13
16. Daily deposits are not always performed. 14
17. The Department does not have appropriate approvals for change and petty
cash funds.
14-15
18. Support services allocat ions are not consistently applied. 15
Report# 05/06 - 4 (Dated September 7, 2006) ii
FINDINGS
Page number(s)
CLINIC WORKFLOW
19. Clinic front reception staff indicate training and operation materials could
be improved.
16-17
20. The Clinic does not have a “no show” policy. 17-18
21. Clinic scheduling of walk-ins increases variabilit y o f staff utilizat ion. 18-19
22. A decline in appo int ment confirmat ion call rates influences no show and
cancellat ion rates
19-20
23. The significant number and type of clinics are not effect ively managed. 21-22
24. Some outlying clinics do not handle all o f their own paperwork. 22
25. There is a lack of effect ive coverage of front reception staff dut ies. 22-23
26. Spanish interpreter needs are affecting clinic front reception staff. 23
27. Interpreter needs are not effect ively coordinated. 24
28. Staff ident ify poor building signage as an impact to front reception duties. 24-25
29. Locating clinic staff is a significant disruption for front reception staff. 25
30. State WIC software does not allow sufficient access to data. 25-26
Report# 05/06 - 4 (Dated September 7, 2006) 1
1. INTRODUCTION
1.1 AUDIT PURPOSE
Audit Authorit y:
The Audit Co mmittee authorized the audit by its approval of the County’s internal audit
workplan for fiscal year 2005/2006.
Purpose of Audit:
As one of the County’s larger departments, the audit purpose included general business
practices (primarily revenue collect ion) and the department’s concern they were addressing
patient flow to provide better service delivery. The timing was accelerated and the scope
expanded due to recent high turnover in the Bend clinic front reception as well as departure
of the department’s business manager. This report also includes Health Depart ment
management responses to these recommendations.
1.2 OBJECTIVES and SCOPE
Audit objectives:
The object ives of the audit were:
1. Review the adequacy o f selected business practices over revenues and judgmentally
selected expense areas in the Health Depart ment.
2. Review Bend clinic recept ion/workflow
3. Review compliance with exist ing Count y policy and procedures.
Opportunities for increased efficiency and effect iveness were included in the
recommendat ions when applicable.
Scope:
The audit period covered procedures and practices in affect at December 2005. Fieldwork
was substant ially co mpleted on April 14, 2006. Data analyzed included prior periods and
the most current periods available at the time of analysis. The scope of audit work on
internal controls was limited to selected business practices and did not include all aspects of
internal controls that may be emplo yed at the Health Department. The review of business
practices emphasized cash and revenue reporting controls. The Health Department (Fund
259) was the primary focus. The Bend clinic and associated front reception was the primary
focus for workflow issues.
Internal Controls:
Government is responsible for using public assets and public funds in a prudent and
responsible manner. Public sector managers in turn are responsible for developing and
maintaining procedures to protect public assets and promote efficient and effect ive services.
These procedures and the environment promoted by management are called internal
controls. Management is ult imately responsible for implement ing appropriate internal
control systems.
Report# 05/06 - 4 (Dated September 7, 2006) 2
Effect ive internal controls minimize the potential for errors and/or irregularit ies to occur. If
they do occur, effect ive internal controls detect such errors and/or irregularit ies in a t imely
manner during the normal course of business. An effect ive system of internal controls:
· Safeguards assets fro m waste, fraud and inefficient use
· Promotes accuracy and reliabilit y in the account ing records
· Encourages and measures co mpliance wit h established practices
· Evaluates the efficiency of operations
The procedures utilized and the scope of the internal audit work was not intended to provide
a comprehensive opinio n on the internal controls of the Depart ment.
1.3 METHODOLOGY
The audit involved gaining an understanding o f the business environment and front
reception workflow as described by management and staff during interviews. This review is,
by nature, subject ive.
Audit procedures included:
· Developing an understanding of Healt h Department through review o f financial
informat ion.
· Developing an understanding of audit issues through review of internal audit reports
and associated recommendat ions issued by other local government auditors,
· Interviews with Healt h Depart ment and Finance staff to ident ify procedures and
related internal control environment,
· Interviews and observations of front reception emplo yees at all locations.
· Interviews and observations of other supporting clinic emplo yees in Bend.
· Participation in the Healt h Depart ment’s front office project during the time of the
internal audit. This included:
o Compiling customer survey data
o Compiling Bend clinic schedule
o Compiling front reception disruption survey
o Compiling interpreter survey
o Compiling training survey
· Detailed analyses of data fro m the Health Department’s account ing system (OCHIN)
· Random sampling and testing of encounter forms and related entry into OCHIN
· Reconciliat ion of Department deposits to deposits made wit h County for a month
The audit was conducted in accordance with the 2003 Revisio n of Government Audit ing
Standards, which are issued by the Co mptroller General o f the United States.
Privileged and Confidential Information
In accordance with Oregon Revised Statute - Chapter 192.501(22) & (23), certain privileged
and/or confident ial information has not been presented in this report. This informat ion, by
the nature of its content, could disclose vulnerabilities and/or reveal securit y measures at
public facilit ies. This information has been shared with management.
Report# 05/06 - 4 (Dated September 7, 2006) 3
Noteworthy Accomplishments
Health depart ment staff showed a tremendous amount of professio nalism as they undertook
the process of reviewing the front desk issues. They participated openly in discussions,
were open to new ideas, and mo ved methodically through the issues identified. There is
little doubt they will have success in these efforts if they cont inue to monitor the ident ified
issues and marshal resources behind these efforts.
2. FINDINGS
The audit disclo sed certain po licies, procedures and practices that could be improved. The
audit was neit her designed nor intended to be a detailed study of every relevant system,
procedure or transact ion. Accordingly, the opportunit ies for improvement presented in the
report many not be all-inclusive of areas where improvement may be needed.
The Health Depart ment is a complex environment. The fo llowing findings will need to be
considered in total and carefully planned to achieve the desired outcomes. In particular, it is
ant icipated some of the clinic workflow based findings carry the weight of suggest ions for
improvement and may be more difficult to implement.
These findings and the associated report were written primarily for the benefit o f Health
Department management who has an understanding of these areas and their co mplexit ies.
Readers without health clinic experience may require further informat ion to understand
some of these issues and the associated recommendations.
2.1 BUSINESS PRACTICES
2.1.1 Internal controls
There are insufficient written accounting policies and procedures over the
duties of staff.
There were no comprehensive written accounting policies and procedures over the
accounting po licies and procedures used in the Health department.
Communicat ion is an essent ial co mponent of internal controls. Written policies and
procedures are particularly effect ive for controls over account ing and financial matters. A
well-designed and maintained set of policies and procedures enhances accountabilit y and
consistency. The result ing documentation is also useful for training and cross-training
personnel.
The lack o f comprehensive written accounting procedures can lead to inadequately planned
controls, inadequate supervisio n, poor and inadequate training, and lack of adherence to
stated control procedures.
Report# 05/06 - 4 (Dated September 7, 2006) 4
The Health Department’s business office staff should document all accounting policies
and procedures. Some areas noted for additional emphasis include: receipt processing,
service ticket entry and billing, monitoring, supervision and segregation of duties. These
policies and procedures should be available to all employees and should detail the
responsibilities of each employee.
Certain business office functions lack adequate segregation of duties.
Certain business office staff in the areas of vital records and customer accounts have too
much control over their funct ions. A staff person responsible for customer accounts handles
billing accounts, collect ing monies, posting receipts, and writ ing-off account balances. A
separate staff person over vital records is responsible for calculat ing fees, receiving fees,
billing accounts, and monitoring customer accounts. Management has established controls
over routine customer receipts received at the front reception of clinics.
Staff duties should be sufficient ly segregated so no one person is responsible for receiving,
reconciling, deposit ing mo ney and posting payments. All write-off’s of customer account
balances should be reviewed by another authorized staff person. Adequate documentation
should be retained to support all activit y. An employee’s responsibilit y for more than two of
the fo llowing funct ions is considered mutually incompat ible: record keeping, authorizat ion,
and custody. The staff noted above have all o f these funct ions.
Wit hout segregation of duties and sufficient oversight, monies could be missing and they
would not be identified in a timely manner, if at all.
Management was aware of some inco mpat ibilit y of dut ies but had not completed addressing
receipt ing controls. The departure of the business manager delayed addit ional work in this
area.
It is recommended for the business office to establish adequate procedures to safeguard
received monies until deposited. This may require the business office to separate duties
currently assigned to the above staff and/or establish additional control procedures.
Separate staff could receipt monies or log payments for later reconciliation to the receipts
from these areas. One possible solution is to photocopy checks, provide check to staff
responsible for deposit, and provide photocopy for staff responsible for handling
accounting.
It is recommended that a supervisor periodically review adjustments to customer accounts.
Collected monies are not adequately safeguarded.
Clinic front reception staff co mmingle all receipts. Monies brought to the business office
are currently accessible by other staff.
Report# 05/06 - 4 (Dated September 7, 2006) 5
Management should assure that collected monies are safeguarded and segregated under the
custody of a single person until the monies can be counted and verified. There should be
adequate controls for segregating the receipt of monies help insure accountabilit y for the
mo nies unt il they are deposited intact.
Wit hout sufficient controls (accountabilit y and safeguards) over receipted monies, it would
be difficult to determine if mo nies were missing and where it happened.
For ease of deposit, monies have been co mmingled and reconciled in total. Differences
sometimes occur but they have been relat ively small.
It is recommended for each staff person responsible for receipting monies (Reception and
business office) to maintain their receipt accounting batches separately. It is
recommended for all staff to reconcile the count of their monies to the batch prior to
giving these monies to business office staff and retain a copy of the count and/or copy the
business manager so that an independent reconciliation to the deposit can occur. Clinic
front reception monies may be balanced out in total unless issues warrant maintaining
those batches separately.
It is recommended that management establish a process to allow a proper transfer of
accountability as monies change hands between staff within the department. It is
recommended that staff responsible for custody of monies restrict access to those monies
until they are deposited or transferred to another staff person.
There is a lack of coordinated collection effort over customer charges.
The Department does not currently ut ilize a collectio n policy or have established sufficient
procedures to deal wit h outstanding customer account balances. Staff responsible for billing
customer charges to insurance, grants and customers secondarily must work on collect ions.
Staff indicate they do not have sufficient time to make addit ional co llection efforts on
unpaid customer balances. Collect ion staff have been attempt ing to keep up with secondary
claims to insurance and customers when the primary payor does not pay. Figure I
summarizes the 2005 accounts receivable act ivit y.
The OCHIN system provides an array o f reports regarding collections. However, the sliding
scale adjust ments (noted in subsequent finding) are commingled with any write-offs in the
most commo nly available reports. It is, therefore, difficult to assess the extent of write-offs
versus other adjust ments. Self-pay clients represent 42% of the services provided by the
Health depart ment ($704k in 2005). However, they have paid only 32% of these charges.
Payments from other payors covered 83% of charges.
The Department should have appropriate policies regarding the collect ion of client service
billings. It takes all those with client contact to maintain and fo llow-up on client billings.
Report# 05/06 - 4 (Dated September 7, 2006) 6
FIGURE I - Health Department revenue and payment analysis -
For service dates posted Year-to-Date totals from 1/1/2005 to 12/31/2005
Payor Service
charges
Payments %
Paid
Sliding Fee
or Other
Adjustment
Reclass/
Move to
next payor
Unpaid
account
balances
Commercial Insurance 135,602$ (53,348)$ 39%(6,851)$ (66,553)$ 8,851$
OMAP 394,540 (280,334) 71%(107,327) 7,489 14,367
MEDICARE 24,613 (16,592) 67%(4,111) (2,269) 1,641
SELF PAY 703,629 (222,058) 32%(459,846) 32,283 54,008
FPEP grant *416,510 (453,045) 109%41,164 29,050 33,679
TOTAL 1,674,894$ (1,025,377)$ 61%(536,971)$ -$ 112,546$
Source: OCHIN data
* FPEP fee payment is at a higher scale than standard fee scale used to calculate servicecharge. See Other Adjustment.
It is not clear what collect ion percentage is ordinarily being obtained by other local
governments. Staff indicates they routinely fo llow-up on denied insurance claims, but do
not pursue unpaid client balances.
Management has not sufficient ly established a co llection po licy and procedures regarding all
forms of payors.
It is recommended the Department assess to what extent it can or will pursue collection of
charges and develop a collection policy and procedures in line with that assessment.
Policies and procedures should establish performance standards for effective billing and
collection of services and these should be monitored on a regular basis.
It is recommended the Department consider the cost/benefit for additional collection
efforts.
In order to improve collections the Department should be
· Considering whether a collection service should be used for some unpaid customer
balances,
· Identifying why insurance has not paid to improve collection efforts,
· Monitoring staff adherence to collection policies, and
· Providing more quality assurance testing of service inputs.
It is recommended the Department assess if additional OCHIN reports can be developed
to identify adjustments to customer balances to identify write-offs, sliding scale
adjustments, or other adjustments.
Customers are not required to provide support for reduced clinic charges.
The Health Depart ment does not generally require customers seeking reduced fees for
services to provide proof of inco me (except for the state funded WIC program and the
Healthy Start program). Clinic staff co llecting payment information are provided
informat ion by clients on their inco me and size of househo ld. Staff are not required to
obtain proof of monthly gross inco me or number of dependents. Staff only obtain written
Report# 05/06 - 4 (Dated September 7, 2006) 7
representations from clients. The Department then utilizes this client provided informat ion
to assess charges based on abilit y to pay based upon the sliding fee schedule. This primarily
comes into play when clients are not OHP clients and do not have insurance. The sliding fee
schedule is based upon Federal poverty guidelines. In review of a select ion of customer
files, there was no support for the gross inco me or number of family members indicated. In
a couple of instances, staff had overridden the sliding fee calculat ion but failed to adequately
document the reasons in the file.
Reasonable efforts should be made to make sure reduced fees for poverty are commensurate
with the poverty level of the client. Obtaining proof o f inco me would support the reduced
fees being provided.
A significant portion (65%) of self-pay client balances are written-off and adjusted for
abilit y to pay. A large share of this adjustment is attributable to the sliding fee adjustment.
The department has not requested proof of inco me because many clients may not be able to
provide proof during their init ial visit. However, this has not been a significant issue in
operating the WIC program, for which they do verify inco me. Some programs under Title X
would see requiring support as a “barrier to service” and soon tit le X will require US
cit izenship. This will cont inue to pressure the department to balance “barriers to service”
with the need to apply the sliding fee scale.
It is recommended the Department consider (for appropriate programs) requiring support
for information used to establish reduced client fees. This might include income tax
returns or pay stubs. Customers granted a reduced fee should be periodically re-evaluated
to determine if their income and family size has changed.
In situations where there are overrides to the sliding scale, these should be adequately
documented and approved by a supervisor or manager.
Department accounting system activity is not reconciled to amounts
reported to the County.
The Health Depart ment utilizes a clinic account ing system (OCHIN) that is autonomous
form the County’s financial account ing system. The clinic system is the primary
accounting system for a significant portion of customer charges. The Department’s business
office had not reconciled the clinic revenues to those reported to the County. A test
reconciliat ion performed did substant ively account for revenues co llected in the clinic
system to show they were deposited with the County.
A process should exist to ascertain that all mo nies received by the Clinic and reported in the
clinic system are actually deposited and recorded with the County.
Wit hout an oversight process, between the two systems, not all mo nies might be accounted
for.
Report# 05/06 - 4 (Dated September 7, 2006) 8
The business office staff has been busy implement ing the new clinic account ing system and
had not addressed whether the system were in alignment and how this could be performed.
It is recommended that business office periodically reconcile information from the clinic
accounting system (OCHIN) to amounts deposited and recorded with the County (in
HTE).
Usage of certain clinic inventory items is not effectively monitored.
Clinic staff performs a mo nthly inventory o f selected medicines and prescribed items
maintained for the Clinic (by locat ion). The inventory is thorough and helps clinic staff
determine when items need to be re-ordered. However, there is no reconciliat ion of the
purchases and usage to available reports. Except for tight ly controlled medicines, clinic
staff do not know how much inventory they should have. The clinic accounting system does
track the charges for many o f these medicines and inventory items. However, not all o f the
items appear on procedure reports, which indicate they may not be billed out. Medicine and
drugs were one of the larger controllable expenses of the department (budgeted at $95k for
05/06). OCHIN currently has reports ident ifying the procedure counts for drugs by locat ion.
There are no current reports that indicate estimated inventory levels.
Clinic staff may be able to utilize the current clinic system to estimate inventory levels and
determine appropriate reordering. Periodically, the clinic should compare inventory levels
and usage to the Clinic’s account ing system.
Wit hout sufficient controls over the inventory, it is difficult to know if all amounts are being
billed and if all inventory items are accounted for.
Management of clinic inventory appears to have been limit ed to the inventory and
reordering. In detailed testing of charges, it was noted that a number of the inventory items
were under charged which would overstate inventory or understate costs in a tradit ional
inventory accounting system. Business office staff indicate that they have been remo ving
charges for items that cannot be billed. If the charges are not there, the clinic cannot monitor
the services provided and not recovered and the reduction in inventory.
It is recommended for management to investigate whether they can utilize the clinic
accounting system to monitor selected medicine and prescribed item inventories.
Otherwise, management may want to consider a manual method to strengthen controls
over these inventories.
It is recommended the business staff periodically review inventory to make sure there are
appropriate billing codes and that clinic staff are using them. The use of significant items
of inventory should be compared to usage records (paper records and/or OCHIN
production reports). Staff should investigate any significant variances
Report# 05/06 - 4 (Dated September 7, 2006) 9
Clinic reports are not distributed to and used by appropriate personnel
The Health Depart ment accounting system (OCHIN) provides a significant number of
reports. Some business office and front area staff use various reports on a regular basis to
mo nitor operations. However, there are interested users (including program managers) who
are not getting appropriate reports in a timely manner. The new system allows significant
flexibilit y in report design and is highly customizable. Informat ion technology staff have the
abilit y to develop and customize reports as requested.
Responsible staff should routinely use reports from the system to monitor and supervise
operations through analysis o f service receipts, services input, billings performed and
collect ion of outstanding receivables.
Wit hout effect ive and timely distribut ion of reports, Staff may be inefficient in mo nitoring
and supervising the funct ioning of the computerized business system and operations.
The conversio n to the current computerized clinic accounting system (OCHIN) was
implemented almost 2 years ago. During implementation, there has not been enough time to
establish routine reporting to program managers. In addit ion, the departure of the Health
Department business manager (who was instrumental in bringing in the system) has resulted
in a significant reduction in oversight of the system.
It is recommended that appropriate staff be informed of currently available OCHIN
reports. Management should develop a system to provide requested reports to appropriate
staff on the basis needed.
It is recommended that management identify and develop appropriate OCHIN reports for
use in monitoring operations. These might include:
monthly key operating data
performance measures
analytical reports (trends and measures)
Details of customer account write-offs by staff person.
Program budgets are not maintained in balance as program budgets
change.
The Health depart ment accounts for many o f its operations by discreet programs. This is
done to maintain the appropriate accounting for restricted funds. Some program resources
or expenditures are revised during the course of the year. These changes are not always
made immediately to the County account ing system (as budgetary controls). Management
utilizes excel worksheets to manually mo nitor internal program accounting for interim
changes not yet reflected in the approved County budget. Most of these internal adjust ments
to program budgets are not balanced (i.e. at the program level - if revenues are reduced the
internal adjustments are not balanced with reduct ions in expenses).
Report# 05/06 - 4 (Dated September 7, 2006) 10
Program budgets when originally approved are balanced (net to zero). As changes are made
to these budgets, they should balance. This preserves the budgetary controls originally put
in place.
Current department reports (by program) may provide an inaccurate perspective of the state
of certain programs. Without accurate and balanced budget informat ion, decisio n makers
will not have appropriate reports to make decisio ns. For example – if they decrease
revenues and fail to decrease the associated expenses they may not perceive they are
overspending.
The business office has not required and program managers have not been providing
balanced budget adjust ments for programs as internal adjust ments are received. This is
because the program budgets are balanced by general fund resources and are not self-
sufficient anyway. As program resources increase this requires less general fund support
and this increase ends up in the ending working capital position for the department. As of
the beginning of May 2006, the out of balance position was $125k of revenues in excess of
expenditures.
It is recommended for management, as they receive changes in program budgets, to make
sure their budget continues to balance in total. Budgetary adjustments should be
submitted to Finance so that these can be reflected in future financial reports. Until these
budget adjustments can be reflected by the County, it is recommended for staff to continue
to utilize internal adjustments within the excel template to properly reflect the revenues
and expenses expected for monitoring purposes.
Service charge entry errors were higher than expected.
During the testing of client service charge entries for accuracy, it was noted that four of the
sixt y-four encounters reviewed had errors in quantit ies (primarily inventory item quantit ies).
In addit ion, four of the sixt y-four encounters reviewed had errors in the entry of all
applicable procedure codes. The sampling assumed an upper error limit of 10% (two
errors). The number of errors observed (four) indicates an upper error limit of 14%.
The billing of services can only be as accurate as the underlying charge-entry. Management
should have a process to ident ify if they are getting reasonably accurate data entry.
When service charges are not entered or at lower quant it ies, service charges are reduced and
associated recovery. The total unbilled services could not be reasonable est imated fro m the
sample observed.
Staff indicated that some charges had been removed fro m billed charges (prior to
submissio n) because they knew the payor would not pay for the services. This eliminated
the need to later write-off the balances. The previous business manager had authorized this
practice. This reduces management informat ion on the extent of services provided and the
extent of unco llected amounts.
Report# 05/06 - 4 (Dated September 7, 2006) 11
It is recommended for all charges to be posted for billing so an accurate indication of
services provided can be obtained.
It is also recommended that business office staff to consider reviewing types of anticipated
charges or create edit reports to identify problems in input.
Program accounting does not include certain administration costs
The department has a significant amount of administration costs that are not allocated to
specific programs. The total administration program costs not allocated to programs were
budgeted at $1.2 millio n for 05/06. Of these costs, $372k relate to budgeted County
indirects for building maintenance, informat ion techno logy, finance, and legal costs.
Total program costs can be determined when fully burdened with appropriate administrative
costs. The County can allocate indirect costs to grants so long as the calculations of costs
meet OMB A-87 requirements. DHS in 2001 requested a copy of the Count y’s cost
allocat ion plan. The Department is due for another fiscal review by DHS and it is likely that
they will bring up the cost allocat ion plan in their review.
Management of programs cannot clearly assess the total cost of programs without knowing
their share of indirect and administrative costs.
The County has been looking at developing an indirect cost plan that will meet the OMB A-
87 requirements. Without the plan, the department has been segregat ing the administrative
costs and not allocat ing them out to programs.
The department should consider an allocation plan for its internal administrative costs
that would meet OMB A-87 guidelines. This would be separate and above the Count y level
indirect cost plan. In the absence of an OMB-A87 indirect cost plan, the Department may
allocate indirect costs to programs for budgetary purposes, but may not charge (or recover)
indirect costs from so me grants. It is recommended the department continue to support the
County’s development of an indirect cost plan under OMB A-87.
It is recommended the Department develop and implement solutions to the 2001 DHS
audit letter.
2.1.2 Performance
Some clinic service charges may be low.
Recent OCHIN benchmarking of fee conversio n rates indicated that Deschutes County was
in the bottom quartile of clinics in OCHIN. Some of these clinics, however, are not county
healt h departments. The average fee per RVU (fee conversio n rate) for selected procedures
for Deschutes County was $45. The average fee conversio n rate for all OCHIN clinics was
$56. An RVU is a numeric weight to a medical encounter that provides informat ion on its
Report# 05/06 - 4 (Dated September 7, 2006) 12
relat ive resource use. A service charge is established by mult iplying the fee conversion rate
by the RVU for individual service codes. The Count y has used a number of different
methods over the years to establish current fee levels.
OCHIN is current ly recommending a minimum fee conversio n rate of $60 and believes it
may need to be $65-70 per RVU.
Wit h a conversion rate that is current ly 20% below average, the clinic may be pricing their
services too low and therefore will not collect appropriate fees from payors. Raising rates to
the average could mean significant addit ional co llected fees.
The department in their 06/07 budget process addressed so me of the fees but did not address
many of the service fees. Many o f the fees stayed at 05/06 levels and might not have been
changed in prior years. Personnel services in the 06/07 budget cycle generally increased
10% without any changes in staffing. This would indicate a need to increase fees just to
meet with increases in internal labor costs.
The Health Department should develop a strategy (one or more) to setting appropriate
fees (cost, RVU or reasonable and customary) for all services they perform.
Staff have not explored use of available electronic insurance information.
The County’s new OCHIN system has the capacit y to utilize electronic interfaces to receive
billing remittances. They are not currently ut ilizing these electronic remittances. A couple
of current payors are capable of providing electronic remittances.
The new system allows for efficiencies from electronic remittances and utilizing these new
processes can reduce input time and improve accuracy.
Staff time spent inputting remittances may be used on other aspects of the collect ion system.
The OCHIN system is relat ively new and staff has not researched and developed a process
to handle these electronic remittances.
It is recommended for the Business Office to spend time developing a process to handle
these electronic remittances. They should then implement and work in expanding the
number of payors providing electronic information.
Inefficient process used to develop program financial reports.
The Health depart ment utilizes numerous program codes to monitor restricted funds for each
program. The County financial software (HTE) does not have the flexibilit y to give
management the types of reports to oversee programs by manager. Management utilizes
excel worksheets that must be manually input from the computerized reports. Staff
manually key-in all data (some 3600 fields) each mo nth.
Report# 05/06 - 4 (Dated September 7, 2006) 13
The County financial system (HTE) provides account ing for program informat ion. Reports
should be available that meet the needs of users. Duplicat ing co mputerized informat ion by
manual entry should be discouraged.
Wit hout proper program reporting, management may not be as effect ive in overseeing their
programs. Performing manual inputs may allo w errors to enter into the reports. Staff spend
too much t ime inputting data when their t ime could be better utilized analyzing the data.
Health Depart ment Management has been provided only certain types of reports from the
County financial system. In order to develop meaningful reports they turned to manually
inputting the informat ion and adjust ing it.
In discussions with Finance and the department, a solut ion was developed whereby the
program account ing data is downloaded, thereby eliminat ing the need for manual input.
Working with staff, it was determined the reports could be developed using Excel.
It is recommended for business office staff to consider utilizing a download process to
developed reports to distribute program financial reports to management.
{The business office has been working with information technology, finance and the
internal auditor to develop a processes to automate this function or minimize the work
required to get these reports to management.}
2.1.3 Laws, Regulations and Policy
Manual receipts do not conform to County Policy
The Department utilizes manual receipts in a number of areas. The receipts provided are
generic pre-numbered receipts and do not have the Department’s name imprinted on them as
required by Count y policy. These generic receipt books are utilized at the many
immunizat ion clinics, remote clinics and the family access network clinic. The Clinics also
use printed receipts from the OCHIN account ing system that comply wit h County po licy.
County po licy #1999-075 requires all invo icing for goods and services and subsequent
collect ion shall be recorded using pre-numbered forms imprinted with the Count y’s name
and department. No departments will use “generic” receipts. Departments using such
“generic” receipts should retain the receipt books but effect ively void any unused receipt
stock.
The use of generic receipts books provides an ineffective control over monies receipted.
It is recommended the Department obtain receipt books conforming to County policy.
From discussions with staff, it appears the receipt book should be in triplicate so one can
be provided to the customer, one can be retained, and one can be provided to the business
office with the monies. The business office should track the receipt books issued and
associated numbering to assure that they have received monies for all of the receipts
issued. The generic receipt books should be collected and no longer used.
Report# 05/06 - 4 (Dated September 7, 2006) 14
Daily deposits are not always performed
Analyses and observat ions at clinics indicated that some clinics (one in particular) were not
making daily deposits. The department seems to be making daily deposits for a bulk of its
operations. On occasion, the Department somet imes lags in deposits due to wait ing on a
check distribut ion from another department.
County po licy P-1999-075 requires that monies received by departments be turned over to
Finance or the Bank within 24 hours.
Monies not deposited could be stolen or otherwise compro mised. The retention of monies
by one particular clinic also requires business office staff to more closely mo nitor the
variance created in the clinic accounting system when mo nies are not deposited as receipted.
Some clinic staff have been delaying deposits in order to better cover clinic operations and
reduce number of trips to bank, especially when amounts are small. The business office has
developed a process to monitor and reconcile deposits when amounts are not deposited the
day of receipt.
It is recommended for staff to deposit monies on a daily basis in accordance with County
policy. The business office may consider obtaining written advice from Finance to allow
clinics to hold monies below a certain threshold. In this manner, staff can be more efficient
while limit ing potential loss should there be a theft. Another implementation option would
be to share bank deposits duties wit h other County departments in the area and utilize
tamperproof bank bags to segregate and secure the monies.
It is recommended the department utilize a suspense account where there is insufficient
accounting information at the time of deposit. This approach is used in other departments,
allows monies to be deposited immediately, and provides a ho lding area for the accounting
entries unt il all o f the accounting informat ion is ident ified.
The Department does not have appropriate approvals for change and
petty cash funds.
County reso lut ions for cash were researched and found to be different from cash held (petty
and change) by the department. The Board approves all cash needs of departments by
resolut ion. No approvals were found for Department change funds. There was less petty
cash than approved. From discussio n with staff, petty cash funds are used infrequently.
Department cash posit ions should be approved by formal Count y reso lution. As mo ney
locat ions are changed, the resolut ion should be updated.
Monies not properly ident ified for oversight could be stolen or otherwise co mpromised.
The department’s use of cash has changed over the years since the original 1996 reso lut ion.
The department does not use its petty cash frequently and has shifted so me of these funds to
Report# 05/06 - 4 (Dated September 7, 2006) 15
add to change posit ions in so me of its clinics. It is not clear where all o f the extra change
funds came fro m.
It is recommended the Department obtain a formal resolution for the type, amount, and
location of the cash it uses in its operations.
It is recommended the Department consider eliminating their petty cash fund since the
petty cash fund is not used often and services and products can be purchased on County
accounts or through employee reimbursement.
Support services allocations are not consistently applied.
Personnel support service costs (i.e. front reception and medical records) allocated to the
Clinic and WIC are primarily accounted for through the HSUP program code. However,
some staff are funded direct ly by WIC or by other programs. The funding of the business
office is also inconsistent. The allocat ion methodology for HSUP is primarily by budgeted
FTE with a couple of adjust ments. These adjust ments are not adequately described and may
no longer be appropriate. Front reception staffing between WIC and the Clinic has changed
and there is no current reconciliat ion between the staffing and the funding approach.
Allocat ion methodologies should be reasonable and allocate costs based on the benefit s
provided.
Wit hout clarificat ion and reconciliat ion there might be insufficient support for the charges
by program.
The lack o f consistency in application of support service costs probably co mes fro m dealing
with the changing environment in the front reception and continual restructuring of services
to meet department needs.
It is recommended the Department consider revisiting their allocation methodology for
support services. Consideration should be given to
Use of support staff
Use of medical records
Report# 05/06 - 4 (Dated September 7, 2006) 16
2.2 BEND CLINIC WORKFLOW
Health depart ment management wanted to make sure this internal audit addressed so me of
their growing concerns with providing better service delivery and addressing patient flow.
Some of these issues were showing through in increased turnover and reduced job
satisfact ion. The Department allocated resources to allow a group of staff to address this
issue over the course of several months. The focus of the project was on the Bend Clinic.
Many o f these findings and observat ions were the result of the work of the project team
participat ing in the front office project. The front office project’s goals were to provide for
faster and more efficient services, as well as front reception staff jo b sat isfact ion. In turn,
the project team believed they would address turnover in front reception staff. Internal
audit’s participat ion in this group was focused on gathering and interpreting data collected
and developing potential reco mmendat ions for improvement.
Clinic front reception staff indicate training materials and operation
materials could be improved.
During a survey of front reception staff, it was determined that some training improvements
may be needed. The Clinic has experienced a significant amount of turnover (in recent
years) in front reception posit ions. New reception staff are feeling very overwhelmed by the
nature and degree of responsibilit ies. During the clinic front office project, management
thought that asking staff about their training experience would be an important part of
addressing perceived staff issues in the reception area. The internal auditor utilized so me
questions ident ified by management and quest ions raised during the interview process.
Areas ident ified by staff during the informal survey included
Strengthening the training manual and process,
Providing adequate time to train and in a meaningful progression,
Ident ifying a mentor for fo llow-up training and oversight, and
Assessing each individual’s knowledge of public health working environment.
Management should ident ify an appropriate process to train staff to fulfill their
responsibilit ies. Wit hout sufficient training, staff will not efficient ly carryout their duties and
this might affect other staff required to correct work.
Though management has spent time providing training, there is not always sufficient time
for staff to learn all aspects of the job prior to the commencement of work.
It is recommended that management continue to enhance the training process and
manual for front reception staff. Enhancements might include:
Assessment of staff understanding of public health and the related issues
(programs, issues, HIPPA. Etc...)
Assign a mentor/trainer to each new receptionist to lead in all aspects of training
and coordination of work. Identify a secondary mentor/trainer when their primary
mentor/trainer is not available.
Report# 05/06 - 4 (Dated September 7, 2006) 17
(Per management, this has been implemented as of the issue date of this report.)
Develop how topics of instruction should be handled and the amount of time
devoted to each. Avoid deviation from the plan.
Develop an understanding with clinicians on who is responsible for training and
that they should address any issues or questions with the trainer and not the
trainee.
Make sure trainers and trainees have un-interruptible time to spend on the
training. (Per management, this has been implemented as of the issue date of this report.)
It is recommended that management consider additional operational resources and
materials that can be quickly accessed during the day-to day operations. These might
include appropriate technical aides (flow chart, flip charts, program details, etc…).
The Clinic does not have a “no show” policy.
The front office project ident ified “no show” rates as one of the areas that should be
addressed. Staff current ly allow a significant amount of latitude before clients are
considered a no show. Clients are told to come in 15 minutes ahead of their appo intment but
the data indicates many clients are coming in at or after their appoint ment time. There is no
impact to the client for a failure to show or call before they miss an appo int ment. The
overall no-show rate for the Bend Clinic is 19% (1/05 – 2/06)(excluding walk-in
appoint ments). The recent trend (shown in Figure II) indicates the no show rate has been
increasing.
FIGURE II -
Bend Clinic - No Show% by month (w/trendline) for scheduled appointments
14%
16%
18%
20%
22%
24%
26%
Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06
N o S h o w %
Source: OCHIN data
For efficient flow of provider appoint ments, clients need to be ready for the appoint ment as
scheduled. A no-show rate and policy are only effective when there are scheduled
appoint ments.
Late appoint ments can cause delays and may delay subsequent appoint ments for on-time
clients. No show appointments lead to a reduced utilizat ion of staff. Since a significant
number of visits are to walk-in clinics, we only have no show rates for those
clinics/providers that utilize the appoint ment system.
It is recommended the Health Department develop and implement a no show policy that
meets its needs. Staff discussions have already indicated some criteria for a policy such
as:
Report# 05/06 - 4 (Dated September 7, 2006) 18
Setting appointment times to include the extra time the client needs to be there to
prepare paperwork.
Identifying clients who are ten minutes late as a no show.
Two no shows will result in a letter to the client.
Three no shows results in no scheduled appointments. Client will be seen on a
walk-in or work-in basis.
Process for notifying and transition clients to new policy.
Process to allow nurses latitude to triage severe cases and make exceptions to
policy.
(Per management, this is set to be implemented as of July 2006.)
Clinic scheduling of walk-ins increases variability of staff utilization.
Appo int ment slot analyses o f walk-in vs. appoint mented family planning clinics indicate
much more variabilit y in the walk-in clinics. The standard deviat ion was 34% higher for the
walk-in clinics. (The period reviewed was October 2005 through February 2006.) Though
this analysis was performed for family planning (for non nurse practit ioners), it indicates
that with the walk-in clinics co me larger swings in staff ut ilizat ion.
Figure III –
Productivity analysis for selected providers for Bend Clinic
(Family planning only)
Family Planning
(A)
Av g. Slot
Utilization
Rate
(B)
Av g. No
Show
Rate
(A)/(1-(B))
Calculated
Utilization
Rate%
Std Dev
on Calc.
Utilization
Rate
Nurse Practitioners Group 95%20%76%8%
Registered Nurses Group 74%8%68%23%
Comparison (NP vs. RN):29%256%13%3
higher higher higher times lower
Source: OCHIN data (1/05-2/06)
Productivit y is being est imated by slot utilizat ion adjusted for no-show rates. The inference
is that nurse practit ioners (who are using more appoint ments) have higher overall
productivit y by so me 13%, through higher slot utilizat ion, higher no-show rates, and with
less variabilit y. Most registered nurse appoint ments are made on a walk-in basis so they
have a low no-show rate.
Department management should be looking for ways to have less variable higher staff
utilizat ion clinics.
Wit hout having appo int mented clinics it will be difficult to improve the effect iveness and
efficiency o f operations. With walk-in clinics, you cannot hold providers or clients
accountable. Therefore, you are at the whim of the clients who choose to come. Some days
more clients will co me for walk-in clinics than space is available. This may lead to higher
Report# 05/06 - 4 (Dated September 7, 2006) 19
customer dissat isfact ion. The customer survey indicated an overall higher dissat isfact ion as
wait times increased.
Wit h the significant number of walk-in clinics, this creates a significant timing issue for the
front reception staff who must deal with client flo w and pulling appropriate records (See
Figure V). Medical records must pull case files on exist ing clients. Front reception staff
must also deal with the timing of numerous walk-in clients layered over disparate clinic
types.
The analyses could not address the impact that might occur if the clinics had a no-show
policy and or were comprised more of appoint mented clinics. The Family planning clinics in
particular believe the walk-in clinics offer clients more accessibilit y to care. The program
staff and clients are used to these walk-in clinics. This may make any changes challenging.
Staff reviewing other Oregon county clinics indicated that many of these clinics were
comprised 90% of appoint ments.
It is recommended the department consider implementing more appointmented clinics.
When developing clinic schedules managers may still want to keep some slots open to fill-
in clients who have walked-in on a work-in basis. This recommendation will be impacted
by the discussion of having a no-show policy.
It is recommended the department establish reasonable productivity standards. It is
unlikely the utilization of staff during walk-in clinics can be impacted greatly since staff
have very little control over when clients will come in. This recommendation may be
impacted greatly by the implementation of the no show policy.
A decline in confirmation call rates influences no show and cancellation
rates.
Analyses of appo int ment confirmat ion calls made indicate a reduction in coverage from
91% at the beginning of 2005 to 70% in February 2006. The programs with the most
appoint mented slots are the ones that receive most of the confirm call effort. Front reception
staff make confirm calls fro m appo intment lists by time. These are usually made a day or
two in advance. By pure numbers, immunizat ion appoint ments received relat ively strong
and consistent confirm call support, whereas, nurse practitioner slots, which are longer and
utilize greater personnel resources had much more inconsistent confirmat ion calls. A recent
survey of customers indicated that a majorit y o f clients liked receiving confirm calls.
An analysis o f confirm call impact indicated no show rates nearly doubled when calls were
not made (see Figure IV). The impact on no shows was even greater if appoint ments were
made further in advance (> two weeks). Cancellatio ns were four-times higher when
confirm calls were not made. The impact on cancellat ions was significant ly greater when
over appoint ments were made further than one week in advance.
Report# 05/06 - 4 (Dated September 7, 2006) 20
Figure IV - Bend Clinic-Confirm call impact on no show rate and cancellation rate
by # of days in advance appointment was made
(excludes same day appointments)
0%
10%
20%
30%
40%
50%
60%
70%
1 2 3 4 5 6 7 8-14 15-21 22-28 29-60 61+
Days appt made in advance
P e r c e n t a g e (%)
No Confirm-No Show%
Confirm-No Show%
No Confirm-Cancellation %
Confirm-Cancellation %
Source: OCHIN data
The Department should establish reasonable standards for the priorit y and percentage of
confirm call made.
Recent front reception staffing shortages have made it harder to keep up with the confirm
calls on a consistent basis. Some calls cannot be made since the appo intments are classified
as confident ial. Confident ial appo int ments were not screened fro m the analysis, but it is not
ant icipated that it would significant ly affect the results.
It is recommended that the Department establish policies and procedures for the priority
and percentage of confirm calls made. They may want to focus on appointments that
utilize greater personnel time.
If the department moves towards more appointmented clinics, the front reception might
need to secure volunteer assistance for confirmation calls or consider technological
solutions. An auto-dialer might an efficient alternative to having staff make these calls.
The WIC program uses an auto-dialer to confirm appointments for their clinic. This was
provided by the State (for WIC) so it is unclear what these may cost (at this time).
{The Clinic indicates they are now making consistent confirm calls on a daily basis. The
clinic has also started to use waiting lists and attempt to fill no show and cancelled
appointments. They will also ask clients to come back or utilize available slots at other
clinics.}
Report# 05/06 - 4 (Dated September 7, 2006) 21
The significant number and type of clinics are not effectively managed.
The fo llowing analysis (see Figure V) indicates a significant variabilit y in the number and
type of clinics that clients to during a typical week. Program managers admit they do not
review the impact to front reception staffing for the various clinics established.
Figure V –
Analyses of number of client visits (by hour of day) by type of clinic,
appointment type (walk-in vs. appointment and program) per day of week (Bend Clinic)
0
2
4
6
8
10
12
8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 8 9 1 0 1 1 1 2 1 3 1 4 1 5
Monday Tuesday Wednesday Thursday Friday
2/13/06 2/14/06 2/15/06 2/16/06 2/17/06
Feb-06
Completed
DC BEND PH
C o u n t o f v i s i t s
Walk-In - CD-PPD Plant
Walk-In - CD-PPD Read
Walk-In - FP-Women's health Long (NP)
Walk-In - FP-Womens health short (NP)
Walk-In - STD - Office visit extended
Walk-In - FP/MCH-Office visit short
Walk-In - Immmunization
Walk-In - FP-Follow-up brief
Walk-In - Office visit long
- CD-PPD Read
- CD-PPD Plant
- FP/MCH-Office visit short
- STD - Office visit extended
- FP-Follow-up brief
- Office visit long
- FP-Womens health short (NP)
- Immmunization
Certain days are generally busier than others (Wednesday and Thursday) and clients appear
to be coming in spikes at various times. The patterned co lumns (Diagonal stripes) indicate
walk-in visit s and how large spikes in vo lume occur. In addit ion, staff must be prepared for
clients coming to see a variet y of clinics.
It seems reasonable that controlling the rate of intake of client appoint ments would make the
front desk more efficient. The frequency and distribut ion of appoint ments may be better
controlled if they are established through appoint ments. Appo intmented clinics will likely
distribute the appoint ments more evenly throughout the day and among providers.
Appo int ment clinics allow for advance medical record preparation.
Clinic workflows (especially for the reception staff) under walk-in clinics cannot be
controlled and result in in-efficient processing of clients. These peaks o f client flow have
been reducing morale of front reception staff. Medical records staff are also impacted by the
need to react to records requests that could have been planned.
Discussions with managers have indicated that many clinics are established wit hout
knowing their impact on other clinics or the front reception.
Report# 05/06 - 4 (Dated September 7, 2006) 22
It is recommended the Department consider coordinating the types of clinics and the
walk-in vs. appointment status of clinics in order to distribute the workflow and make the
workloads more even at the front reception and throughout the clinic.
It is recommended that front reception staff make the process of checking in clients for
the many programs as homogeneous as possible.
Some outlying clinics do not handle all of their own paperwork.
The Health Depart ment has located a number of clinics in outlying areas for better service to
clients. Some outlying clinics rely on the Bend clinic for various levels o f support such as in
creating charts, assembling charts, and performing charge entry. Observat ions of staff in
some outlying clinics indicate they perform very little or no input into the clinic account ing
system.
The non-Bend clinics should have adequate staffing to support the efforts for the clinic.
Staff should be preparing their own charts and performing charge entry as t ime permits.
By providing centralized support to outlying clinics, the already busy Bend Clinic much
stretch already stressed front reception staff. Staff at the outlying clinics are not always
being fully ut ilized. Wit hout charge entry, it is difficult to communicate to clients how
much their visit cost was and perhaps be able to collect some of it.
The Bend Clinic has not sufficient ly trained so me staff in outlying clinics or has told
outlying clinics to send chart and charge entry work to Bend rather than train the outlying
clinic staff to perform these dut ies. In so me cases, the outlying clinic staff have sufficient
time to perform these tasks.
It is recommended the Health Department consider training outlying clinics and having
them perform more charts assembly and charge entry.
There is a lack of effective coverage of front reception staff duties.
There are approximately eleven front reception staff over all of the clinics. Vacation leave
accounts for nearly a three-quarter time person to cover for staff vacat ions. In addit ion, the
Bend and Redmo nd clinics have separate reception staff for WIC and Clinic. For the most
part, staff are not fully cross-trained (between Clinic and WIC) and do not accept clients for
each other. On occasion, certain reception staff are out and it is difficult to maintain
separate (WIC vs. Clinic) reception staffing. Staffing must be maintained at all clinic
locat ions and the Bend clinic is the resource for those needs.
Customers coming to the clinic do not care whether they see a WIC or a Clinic recept ion
person. They want to check-in and be seen by a provider. Providers want to make sure their
clients are being checked-in and the relevant paperwork prepared.
Report# 05/06 - 4 (Dated September 7, 2006) 23
Having WIC and Clinic recept ion areas separate makes it difficult to provide adequate
staffing. In addit ion, front reception staff (for WIC and Clinic) have not been helping each
other out during the day. Having all front reception staff trained in both areas will allow
better coverage of client needs.
WIC and Clinic use two disparate appointment systems. Staff have not generally been
cross-trained on these systems.
It is recommended the Department consider having one group of front reception staff to
service all clinics and not indicate WIC or Clinic. All staff can be trained to perform all
of the duties. Staff with significant experience in certain programs may continue to be a
resource. However, customer service will likely improve by having all windows available
for all clients or rotating staff across all program duties.
{Management indicates that they have started some cross training programs}.
Spanish interpreter needs are affecting front reception staff duties.
A study of interpreter needs (at the front reception) indicates that nearly a .5 FTE could be
dedicated to interpreter needs at the front reception areas at the Bend Clinic. To cover
current needs, the clinic has been ut ilizing staff in medical records, WIC and the front
reception supervisor. Clinic interpreter needs are sometimes more than can be met by their
bilingual medical assistant. Demographic information indicates 12% of clinic clients are
Spanish speaking. The Redmond clinic has limited interpreter support and a significant
unmet need. Staff have indicated that many Spanish-speaking clients are traveling to Bend
for services for that reason.
Spanish speaking clients come to many of the clinics and the Department needs to establish
sufficient means to communicate with them.
Wit hout sufficient communicat ion, it is difficult to meet the scheduling and service aspects
of all of the clinics.
The department has had so me difficult y recruit ing bilingual staff for the front reception of
clinics.
It is recommended the Department consider filling as many positions as possible with bi-
lingual staff. The Department should consider targeting Spanish support in clinics that
are more convenient to Spanish speaking clients.
{At the time this report was issued, the Clinic had hired a number of bilingual staff for front
reception duties and has seen a significant improvement in the handling of interpreter
needs.}
Report# 05/06 - 4 (Dated September 7, 2006) 24
Interpreter needs are not effectively coordinated.
The appoint ment data fro m the OCHIN system does not include as much interpreter data as
one would expect given the client profiles. Only a third of the ant icipated Spanish
appoint ments have informat ion registered as to the interpreter used. In addition, from
discussio n wit h staff, interpreters are rarely assigned when setting up a client with
interpretation needs. The interpreter survey and the disruption survey indicated disruptions
fro m clients needing translation services.
The OCHIN system can assist the clinic in identifying and scheduling interpreter needs.
Wit hout the specific entry of interpreter data, it is difficult to make the case that addit ional
interpreters are needed.
Charge entry staff do not always enter interpreter data for appointments. Most often, this
only occurs if staff supported the appoint ment.
It is recommended the department consider the benefits of improving demographic data
for clients based on language and interpreter needs.
{Prior to release of this report, the Department hired more bi-lingual front reception staff,
which should help reduce the problem.}
Staff identify poor building signage as an impact to front reception duties.
A survey o f front reception disruptions indicated that many o f the disrupt ions related to
clients not understanding the building signage. Disruptions were indicated for :
Clients looking for offices not located in the building
Clients looking for bathrooms
Clients looking for other departments
Clients or others trying to find conference rooms
Signage should be adequate to inform clients of the location of services or rooms they are
looking for.
The number of disruptions on a given day can further stress or distract front reception staff
fro m their routine dut ies.
A number of signage issues have not been addressed since the opening of the building.
It is recommended that the Health and Mental Health departments determined the
signage changes needed and convey those to appropriate management.
Interested staff from the Health and Mental Health departments have met to discuss the
signage issues and a brief list of some of the recommendations includes:
Improve external signage (colors and location) and include address number on the
outside of the building.
Report# 05/06 - 4 (Dated September 7, 2006) 25
External signage should indicate Health, Mental Health and WIC since clients do
not understand what “human services” means.
Develop a directory for the building to direct clients to appropriate services.
Develop a neighborhood map the main local area offices for which there are
requests for directions.
Lower and improve signage (color and location) within the building.
Provide more bilingual signs.
{Management has set meetings to address these issues.}
Locating clinic staff is a significant disruption for front reception staff.
During the survey o f front reception disrupt ions, front reception staff ident ified that 22% of
their disrupt ions came fro m the need to locate various clinic staff. These disruptions are
even more significant since they will often pull the staff away fro m the front reception.
Front reception staff should be able to effect ively communicate with clinic staff wit hout
leaving their posit ions at the front desk.
Wit hout an effect ive means to communicate with clinic staff, front reception staff must call
around or go looking for clinic staff. During busy times, this is very disrupt ive and can lead
to addit ional stress for the remaining front reception staff.
The department has not yet developed an effect ive communicat ion system to address
communicat ion between the front reception and clinic staff.
The Health Department should consider options to better locate and communicate with
clinics staff. This might include some form of broadcast paging system. Also discussed
was the need to have a board to indicate what clinicians are in that day.
{Management indicates (as of the date of this report) the provider board is in place and they
are gathering research on intercom systems. Some clinicians in programs, who do not have
frequent meetings, are utilizing a notebook to log incoming appointments.}
State WIC software does not allow sufficient access to data.
A number of reports on the State’s WIC system (TWIST) could not be downloaded and
analyzed. This makes many o f the reports less useful. In addit ion, the date range is limited
to twelve months. The State was able to comply wit h requests for data but the time span
was so mewhat limited and it is not clear whether this kind of support will cont inue.
State WIC software should allow for reasonable customizat ion of reports and download of
data by local WIC clinics and their management.
The system has a significant amount of data that is less useful since it cannot be accessed to
answer the questions individual clinics have.
Report# 05/06 - 4 (Dated September 7, 2006) 26
WIC system data for the clinic is accessible in the clinic reports developed as part of the
software system. State resources are limited when it comes to accessing so me o f this data.
It is recommended that WIC staff work with the state to identify other routine reports they
would like and request an option for getting the data for management analysis.
3. REPONSE FROM MANAGEMENT
3.1 HEALTH DEPARTMENT MANAGEMENT
9/07/2006
David Givans, CPA
County Internal Auditor
Re: Health Department Review of Business Practices
Dear Dave,
Thank you for completing the recent review of business practices and clinic workflow
analysis for the Deschutes County Healt h Department. I also want to thank you recognizing
the professio nalism of our staff and for extending so many gracious co mpliments as they
worked collaboratively wit h you during this review.
We found the report to be a reasonably accurate reflect ion of many o f the business practices
of the department. One caution is that, if the reader were external to the department they
would lack a context for understanding the relative significance of so me of the findings. For
example, the finding related to verificat ion of income to support the applicat ion of a sliding
fee scale is a far more complex issue than most readers would fatho m.
Many o f the findings are issues that have been known to the Department for some t ime and
have been in various stages of address and I wish to thank you for recognizing that. Internal
controls related to segregation of reporting vs. custody of assets duties are one example.
Lack of fully developed standard operating procedures for business funct ions are another.
The Department will take a systemat ic, priorit ized approach to addressing the substant ive
issues and findings made in the report; including
· Developing standard operating procedures for business related duties
· Addressing segregat ion of duties
Report# 05/06 - 4 (Dated September 7, 2006) 27
· Safeguarding and deposits of monies collected.
· Development of an inco me verificat ion policy. This Policy must balance the
assurance of inco me eligibilit y for application o f our sliding fee scale against
creating barriers to care by alienating high risk and/or low income patients as well
as clients of anonymit y.
· Reconciling our internal account ing to amounts reported to the County finance
department.
· Assuring that internal program budgets are revised to balance in a timely manner to
reflect expected changes in revenue and expenses.
· We have already addressed the issue of use of generic manual receipts and are
having the Department’s name imprinted on pre-numbered receipts.
· This issue o f daily deposits is current ly being addressed.
· We are eliminat ing the use of a petty cash fund.
Other business and data improvements are also being addressed.
· We are exploring the use of management and productivit y reports available
fro m our OCHIN clinic management software and should soon run our first
reports.
· We are re-exploring the idea of cost accounting our indirect, support services
and administrative cost direct ly to the program level. We have experienced
several different methodologies of do ing this over the past decade and believe it
increasingly important to capture the “full cost of doing business” at the
program level. We will foray wit h allo cat ing most county indirect charges and
many other commo n costs - building charges, automo biles, direct ly to programs
during the next budget cycle.
· We are current ly exploring the abilit y to use H.T.E. budget reports at the
program level vs. utilizing excel spread sheets to capture and report year-to-date
financial information.
· As the audit report ident ified, we should attempt to adopt a more uniform
methodology for establishing fees for departmental clinical services. One
challenge inherent in the Relat ive Value Unit methodology is that much the
work of the department is not captured by this methodology and as such would
need to be excluded in calculat ing the average cost “per unit” of services. This
methodology might be feasible if we achieve another one of the audit
recommendat ions, that being to assign the full administrative and indirect
charge allocat ions directly to the program/service level. Unt il we are able to
achieve that level o f cost accounting it may be most practical to utilizing a
“reasonable and customary” methodology to create uniformit y across all
departmental fees. It will be our intention to ident ify a single methodology for
establishing all fees in the next budget cycle.
Our department business team will take the lead role in addressing most of the business
related findings in the audit. They have prepared a priorit ized task list of the finding
with the abilit y to document complet ion of the task. We will gladly share this with the
county audit committee as progress is made.
Report# 05/06 - 4 (Dated September 7, 2006) 28
The internal audit also addressed a number of clinic workflow issues. Many of these
findings illustrate the challenge of operating 20+ programs serving in increasingly
mult icultural, bi-lingual pat ient population – as a single face to the public. In fact,
there in lies the challenge – to create a single work flow design that the meets a highly
variable and diverse set of programmatic needs. Another challenge is support services
and front office staffing for mult iple satellite locat ions. We could frankly use 3 more
FTE to fully staff support and interpreter services, which would immediately relieve the
impression that workflow and demand is not effectively being managed. Some of the
findings are more readily addressable, for example:
· We are current ly exploring a clinic staff and room status call system that would
communicate the ready-state of a patient room for maximizing patient flow.
· We have created a simple in-out communicat ion board for clinic staff, which
the front office team has ready access to.
· We are addressing inaccurate and inadequate building signage as it pertains to
our mult icultural clients.
· We have drafted and adopted no-show policy for missed patient appoint ments.
· We are addressing the abilit y to accurately capture clinic slot utilization during
walk-in clinic t imes as the current method under counts utilizat ion.
· We have developed a quick reference guide for front office staff that helps to
answer typical quest ions that staff faces in their attempt to keep informed across
changes affect ing our 20+ programs.
Dave, I wish to thank you again for the time you devoted to this depart mental audit and for
recognizing mult iple efforts already underway to address many of the findings.
Sincerely,
Daniel Peddycord
Public Healt h Director
Deschutes County Healt h Department
{ END OF REPORT}