Ghosts of the ER (Clerks)

caliotter3 · Feb 12, 2020

My thoughts are that you work with some rude people. Have had occasion to be present in the ER frequently lately and did not see the rude behavior you describe (at two different hospitals no less).

JKL33 · Feb 12, 2020

Welcome, I'm glad you posted and I have a few thoughts for you.

3 hours ago, Cody1991 said:
I may be in a toxic work environment but the nursing staff in our ED are incredibly cliquey....

I started to read this paragraph and thought, meh--who cares, it sounds like they get along good together. But reading on, it just kind of sounds like they were raised by wolves maybe. They sound downright uncivilized.

But then...there are more problems with your scenario I'm sorry to say.

4 hours ago, Cody1991 said:
If I’m standing in a room with a patient holding their credit card and the patient has a clipboard and is signing consents --- is it normal or right for a nurse to push in , not even acknowledge us and start trying to do an IV or distribute medicines?

This is somewhat my personal opinion, but it's a lot of people's opinion at least where I am (supported by employer, even!): I don't think it's one bit appropriate for the employer to have registration/billing clerks initiating or dealing with their payment processes at some of the times you are talking about; not at all. Yes, the following kind of thing is a problem:

4 hours ago, Cody1991 said:
normal or right for a nurse to push in , not even acknowledge us and start trying to do an IV or distribute medicines?

...and the problem is that your employer should not be asking you to be in that room doing that when the patient's treatment is just beginning to be initiated. I am surprised if your place has cash/cards changing hands when IVs are just getting started or the patients are in the timeframe of receiving their initial treatments. The patient's treatment takes priority over everything else generally speaking.

4 hours ago, Cody1991 said:
and politely said, “I know the ER is busy and we get in each other’s way, but we have to work together.”

You are correct. Many employers have decided the best way for these two groups to work together is to develop a system where registration staff can be alerted to appropriate times to be in the room. At some big systems, registration staff is to follow this process and if they still happen to find themselves in a patient room when elements of treatment need to take place, they are to immediately excuse themselves and return later. I'm often the one telling reg. staff "no--go ahead and finish what you are doing, it looks like you're almost done." They, for their part will either say, "yep, I'll just be a few more seconds" or "eh, we're just getting started here, I'm happy to come back later."

We DO have to work together, and we absolutely should be being polite to one another and considerate of each other's roles, but this whole project revolves around the fact that the patient is there for the evaluation and treatment. This isn't a matter of your job being less important or anyone being equal or unequal.

4 hours ago, Cody1991 said:
She approached two of us (registration) and the charge nurse yelled out, “Nuring staff only.”

She is [words that would get censored]. That is definitely mean girl. Most everything you've written about them is bona fide mean girl.

PART of the problem is that your own employer has you at each others' throats and that's nothing new AT ALL. I will come back to this, but one more important thought, first.

**The reason that many big places have developed such specific registration processes is because of a federal law referred to as EMTALA (Emergency Medical Treatment and Labor Act). I'm not sure how familiar you are with it (don't mean to insult your intelligence here), but it's a big enough deal that employers don't want even the appearance of violating it in any way. One of the major provisions of EMTALA is "examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage."

This doesn't mean that registration/billing activities can never happen until treatment is complete, but it does mean that no one wants to give the appearance of delaying the treatment part of the patient's visit for anything related to payment. So hospitals generally develop specific processes about specifically when (during the patient's visit) registration staff will complete their duties. All the hospitals with which I'm familiar aren't taking any chances with interpretation, and have decided this means that at no time will the activities of their registration/billing departments delay the medical/nursing care of the patient in any way. They want it to be very clear to everyone (the other staff, the patient and the family) that collecting your money is not taking priority over this IV that you need, this medicine that you need or this test that you need.

For all these reasons, which I sincerely hope you understand are not about me or you, you simply should not be being asked to collect money and all of that while the medical/nursing staff is engaged in episodes of active patient care/treatment.

4 hours ago, Cody1991 said:
Does anyone have any thoughts or helpful advice?

If you really like the job, here's what I would do.

I would read and research the related issues so you know you're sure of what you're talking about. Then I would go to your manager and offer to help spearhead a more coordinated effort that allows you and the nursing/medical staff to all do your jobs with fewer instances of getting in each others' ways and one that, to the extent possible, does not interrupt care in order to collect payment.

It's too bad the nurses don't have the maturity to come up with a process improvement plan related to this.

The other thing I would consider with regard to these nurses specifically is letting things cool down a little and then start trying to make some inroads. Go to the charge nurse and say you aren't happy with the registration process because it seems weird to be exchanging money while they are trying to take care of the patient (which it is weird--to almost everyone; the direct care staff, the patients and the families....hospitals get plenty of complaints about this kind of thing if they aren't careful). Let the nurses know that your manager has put a lot of pressure on you and no one has really explained anyone else's role or perspective so that you can try to work together. Tell her that you're tired of getting in their way and generally having the problem you're having. Say it kindly (which honestly is more than they deserve, but keep your goal in mind!!).

This is a problem with your hospital basically pitting roles against each other (I mean, who isn't going to hip check people out of the way when your VALUE as an employee is being judged by something so stupid as how fast you do something)? I'm being a little silly here just to lighten the mood, but it SUCKS, it downright sucks the way each of us--you, me, and the doctor--are being judged these days. Our **ONLY** hope is to try to rise above and work together despite such a degrading and unpleasant situation.

Sorry for the book but I hope it helps in some way. Let me know what you think or any questions...

??

Hoosier_RN, MSN · Feb 12, 2020

8 minutes ago, JKL33 said:
Welcome, I'm glad you posted and I have a few thoughts for you.
I started to read this paragraph and thought, meh--who cares, it sounds like they get along good together. But reading on, it just kind of sounds like they were raised by wolves maybe. They sound downright uncivilized.
But then...there are more problems with your scenario I'm sorry to say.
This is somewhat my personal opinion, but it's a lot of people's opinion at least where I am (supported by employer, even!): I don't think it's one bit appropriate for the employer to have registration/billing clerks initiating or dealing with their payment processes at some of the times you are talking about; not at all. Yes, the following kind of thing is a problem:
...and the problem is that your employer should not be asking you to be in that room doing that when the patient's treatment is just beginning to be initiated. I am surprised if your place has cash/cards changing hands when IVs are just getting started or the patients are in the timeframe of receiving their initial treatments. The patient's treatment takes priority over everything else generally speaking.
You are correct. Many employers have decided the best way for these two groups to work together is to develop a system where registration staff can be alerted to appropriate times to be in the room. At some big systems, registration staff is to follow this process and if they still happen to find themselves in a patient room when elements of treatment need to take place, they are to immediately excuse themselves and return later. I'm often the one telling reg. staff "no--go ahead and finish what you are doing, it looks like you're almost done." They, for their part will either say, "yep, I'll just be a few more seconds" or "eh, we're just getting started here, I'm happy to come back later."
We DO have to work together, and we absolutely should be being polite to one another and considerate of each other's roles, but this whole project revolves around the fact that the patient is there for the evaluation and treatment. This isn't a matter of your job being less important or anyone being equal or unequal.
She is [words that would get censored]. That is definitely mean girl. Most everything you've written about them is bona fide mean girl.
PART of the problem is that your own employer has you at each others' throats and that's nothing new AT ALL. I will come back to this, but one more important thought, first.
**The reason that many big places have developed such specific registration processes is because of a federal law referred to as EMTALA (Emergency Medical Treatment and Labor Act). I'm not sure how familiar you are with it (don't mean to insult your intelligence here), but it's a big enough deal that employers don't want even the appearance of violating it in any way. One of the major provisions of EMTALA is "examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage."
This doesn't mean that registration/billing activities can never happen until treatment is complete, but it does mean that no one wants to give the appearance of delaying the treatment part of the patient's visit for anything related to payment. So hospitals generally develop specific processes about specifically when (during the patient's visit) registration staff will complete their duties. All the hospitals with which I'm familiar aren't taking any chances with interpretation, and have decided this means that at no time will the activities of their registration/billing departments delay the medical/nursing care of the patient in any way. They want it to be very clear to everyone (the other staff, the patient and the family) that collecting your money is not taking priority over this IV that you need, this medicine that you need or this test that you need.
For all these reasons, which I sincerely hope you understand are not about me or you, you simply should not be being asked to collect money and all of that while the medical/nursing staff is engaged in episodes of active patient care/treatment.
If you really like the job, here's what I would do.
I would read and research the related issues so you know you're sure of what you're talking about. Then I would go to your manager and offer to help spearhead a more coordinated effort that allows you and the nursing/medical staff to all do your jobs with fewer instances of getting in each others' ways and one that, to the extent possible, does not interrupt care in order to collect payment.
It's too bad the nurses don't have the maturity to come up with a process improvement plan related to this.
The other thing I would consider with regard to these nurses specifically is letting things cool down a little and then start trying to make some inroads. Go to the charge nurse and say you aren't happy with the registration process because it seems weird to be exchanging money while they are trying to take care of the patient (which it is weird--to almost everyone; the direct care staff, the patients and the families....hospitals get plenty of complaints about this kind of thing if they aren't careful). Let the nurses know that your manager has put a lot of pressure on you and no one has really explained anyone else's role or perspective so that you can try to work together. Tell her that you're tired of getting in their way and generally having the problem you're having. Say it kindly (which honestly is more than they deserve, but keep your goal in mind!!).
This is a problem with your hospital basically pitting roles against each other (I mean, who isn't going to hip check people out of the way when your VALUE as an employee is being judged by something so stupid as how fast you do something)? I'm being a little silly here just to lighten the mood, but it SUCKS, it downright sucks the way each of us--you, me, and the doctor--are being judged these days. Our **ONLY** hope is to try to rise above and work together despite such a degrading and unpleasant situation.
Sorry for the book but I hope it helps in some way. Let me know what you think or any questions...
??

100% all of this, but do want to add that before any IV is placed, med is given, etc, unless it is life/imminent death emergency, a consent to treat should be signed-and most facilitiesmake sure that this is done very 1st thing. Why? If anything goes wrong, it will CYA later

JKL33 · Feb 12, 2020

3 minutes ago, Hoosier_RN said:
100% all of this, but do want to add that before any IV is placed, med is given, etc, unless it is life/imminent death emergency, a consent to treat should be signed-and most facilitiesmake sure that this is done very 1st thing. Why? If anything goes wrong, it will CYA later

Yeah, I'm familiar with variations of the quick reg process which doesn't include the payment part of it at all. Quick reg is one thing; it takes like 30 seconds.

Hoosier_RN, MSN · Feb 12, 2020

1 hour ago, JKL33 said:
Yeah, I'm familiar with variations of the quick reg process which doesn't include the payment part of it at all. Quick reg is one thing; it takes like 30 seconds.

I've never heard of money changing hands like that either. Something not ringing quite true with the OP

JKL33 · Feb 12, 2020

I think their place sounds like chaos.

It truly sounds like a place where they are perfectly happy pitting people against each other. I have never heard of registration being timed with regard to how fast they collect payment. Not letting people escape without collecting payment information-yes. But not racing to collect the payment and being judged upon that.

I believe it's someone's true experience though (nothing like this shocks me one bit) and I feel sorry for the OP. They're giving their patients a real show.

ETA: Although--you kind of raise another idea: The OP should make very sure that his/her understanding of what is expected is accurate (that should always be step 1). But I absolutely believe him/her when they say they are being timed on some aspect of getting in there; that doesn't surprise me one single little bit. So toxic.

Cody1991 · Feb 12, 2020

2 hours ago, Hoosier_RN said:
I've never heard of money changing hands like that either. Something not ringing quite true with the OP

All our triage clerks do is get the NAME, DOB and SSN and Chief Complaint. We’re not allowed to take anything but a drivers license or ID at the front window.

A triage nurse calls the patient back. Once their status goes from “Waiting to be seen” to “Treatment in progress” we can update/collect pay in the back. Usually, it’s a speed thing since we’re trying to get the consents signed before real treatment begins. Ideally, we’re supposed to run the KASPER report, put a new sheet of stickers in the charts and get the consents and privacy notices signed. Then we’re supposed to verify their insurance information, run that report and collect whatever copay when we can before the patient leaves. Our management has made it to where you do everything upfront in order to collect the copay and reach goals they have set up.

I agree it’s an atrocious system and many of the longer-term clerks complain about how better it used to be when our consent forms were signed up front and payments were taken upon departure. They said it changed when the ER decided to move from clip-boards to bedside computers/registration in an effort to catch the rapidly discharged patients who were slipping out. (Keep in mind that I may do 30+ patients per shift and only 3 probably pay their copays.) Also, obviously, we're often working with a bare bones staff. We are supposed to have 12 updaters on staff at all times but the turnover is massive and we usually just have 3 or 4.

It seems to be a mess and I’m not sure how to fix it since we recently had a group meeting and our management made it out more like a McDonalds and just reinforced how important it was for the hospital to be paid. The main registration manager actually said "It's fair game" regarding collecting payment. Something like, "If a doctor has introduced themselves to the patient and their status moves to treatment in progress, it's fair game." This new manager is the one who has enlisted the 10-minutes or less rule. The computer literally times you once you select "register patient" and management will send you messages via SKYPE about how fast you are or "what's taking you so long", etc. The only time they are lenient about going over 10 minutes is if the patient was greeked.

I genuinely appreciate all the feedback.

Cody1991 · Feb 12, 2020

3 hours ago, JKL33 said:
Yeah, I'm familiar with variations of the quick reg process which doesn't include the payment part of it at all. Quick reg is one thing; it takes like 30 seconds.

Regarding the consent/privacy forms. These were originally taken when we registered the patient in front. But it was determined that all the paperwork was "overwhelming" patients who needed to be seen quickly and so this became a part of the update process in the back.

The original model is:

1) Quick reg at triage

2) Introduce yourself to the patient after their status moves to "Treatment in progress" and do an update and get Authorization, Consent and Privacy signed.

3) Run the KASPER report, put new stickers in the chart along the aforementioned signed forms. Collect any medical records requests an MD has.

4) Run insurance, verify. Go back to collect copayment before patient is departed.

But we have 10 minutes to do ALL of this. (This more or less emerged after some rotten apple clerks were spending 40-60 minutes per patient. They weren't actually updating, but just picking them up and hanging out on them so that they didn't have to do anything else.)

So it's just not working. It will probably change.

Cody1991 · Feb 12, 2020

4 hours ago, JKL33 said:
Welcome, I'm glad you posted and I have a few thoughts for you.
I started to read this paragraph and thought, meh--who cares, it sounds like they get along good together. But reading on, it just kind of sounds like they were raised by wolves maybe. They sound downright uncivilized.
But then...there are more problems with your scenario I'm sorry to say.
This is somewhat my personal opinion, but it's a lot of people's opinion at least where I am (supported by employer, even!): I don't think it's one bit appropriate for the employer to have registration/billing clerks initiating or dealing with their payment processes at some of the times you are talking about; not at all. Yes, the following kind of thing is a problem:
...and the problem is that your employer should not be asking you to be in that room doing that when the patient's treatment is just beginning to be initiated. I am surprised if your place has cash/cards changing hands when IVs are just getting started or the patients are in the timeframe of receiving their initial treatments. The patient's treatment takes priority over everything else generally speaking.
You are correct. Many employers have decided the best way for these two groups to work together is to develop a system where registration staff can be alerted to appropriate times to be in the room. At some big systems, registration staff is to follow this process and if they still happen to find themselves in a patient room when elements of treatment need to take place, they are to immediately excuse themselves and return later. I'm often the one telling reg. staff "no--go ahead and finish what you are doing, it looks like you're almost done." They, for their part will either say, "yep, I'll just be a few more seconds" or "eh, we're just getting started here, I'm happy to come back later."
We DO have to work together, and we absolutely should be being polite to one another and considerate of each other's roles, but this whole project revolves around the fact that the patient is there for the evaluation and treatment. This isn't a matter of your job being less important or anyone being equal or unequal.
She is [words that would get censored]. That is definitely mean girl. Most everything you've written about them is bona fide mean girl.
PART of the problem is that your own employer has you at each others' throats and that's nothing new AT ALL. I will come back to this, but one more important thought, first.
**The reason that many big places have developed such specific registration processes is because of a federal law referred to as EMTALA (Emergency Medical Treatment and Labor Act). I'm not sure how familiar you are with it (don't mean to insult your intelligence here), but it's a big enough deal that employers don't want even the appearance of violating it in any way. One of the major provisions of EMTALA is "examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage."
This doesn't mean that registration/billing activities can never happen until treatment is complete, but it does mean that no one wants to give the appearance of delaying the treatment part of the patient's visit for anything related to payment. So hospitals generally develop specific processes about specifically when (during the patient's visit) registration staff will complete their duties. All the hospitals with which I'm familiar aren't taking any chances with interpretation, and have decided this means that at no time will the activities of their registration/billing departments delay the medical/nursing care of the patient in any way. They want it to be very clear to everyone (the other staff, the patient and the family) that collecting your money is not taking priority over this IV that you need, this medicine that you need or this test that you need.
For all these reasons, which I sincerely hope you understand are not about me or you, you simply should not be being asked to collect money and all of that while the medical/nursing staff is engaged in episodes of active patient care/treatment.
If you really like the job, here's what I would do.
I would read and research the related issues so you know you're sure of what you're talking about. Then I would go to your manager and offer to help spearhead a more coordinated effort that allows you and the nursing/medical staff to all do your jobs with fewer instances of getting in each others' ways and one that, to the extent possible, does not interrupt care in order to collect payment.
It's too bad the nurses don't have the maturity to come up with a process improvement plan related to this.
The other thing I would consider with regard to these nurses specifically is letting things cool down a little and then start trying to make some inroads. Go to the charge nurse and say you aren't happy with the registration process because it seems weird to be exchanging money while they are trying to take care of the patient (which it is weird--to almost everyone; the direct care staff, the patients and the families....hospitals get plenty of complaints about this kind of thing if they aren't careful). Let the nurses know that your manager has put a lot of pressure on you and no one has really explained anyone else's role or perspective so that you can try to work together. Tell her that you're tired of getting in their way and generally having the problem you're having. Say it kindly (which honestly is more than they deserve, but keep your goal in mind!!).
This is a problem with your hospital basically pitting roles against each other (I mean, who isn't going to hip check people out of the way when your VALUE as an employee is being judged by something so stupid as how fast you do something)? I'm being a little silly here just to lighten the mood, but it SUCKS, it downright sucks the way each of us--you, me, and the doctor--are being judged these days. Our **ONLY** hope is to try to rise above and work together despite such a degrading and unpleasant situation.
Sorry for the book but I hope it helps in some way. Let me know what you think or any questions...
??

We’re permitted five minutes between patients to “correct errors.” So, I usually use this time to print out all the necessary documents (stickers, KASPER, privacy, consent) and verify the insurance of the next two patients I will pick up in order to get the update done in 10 minutes. I typically know what their insurance is and what their copay will be before I ever meet them. I use the next five minutes after that to do all the necessary documentation of the last twos copays, rinse and repeat for my shift.

A few of my coworkers wanted to kind of rebel against the new rules and purposefully take time to end the 10-minute rule. It seemed like a good idea until a person was verbally warned, written warned and then fired for ‘wasting time.’ Aforementioned “meeting”, we had the whole spill about ‘we’re taking this seriously.’ As I mentioned, each time a patient is discharged without an update we receive an F-rating on the computer. The only way to repair the grade is to successfully complete another. It’s very dog-eat-dog. So, the nursing stuff just kind of adds as an extra layer of agitation.

And you’re absolutely right. It is a system that pits the work of another against the other. Toxic!

But thank you for your words, I really enjoyed reading them and appreciate the time you took. I will take a lot of into consideration and work on getting a thicker skin. I’m also going to bring up some ideas to management or get HR involved if I must. The 10-minute thing is sort of producing a toxic work environment.

JKL33 · Feb 12, 2020

8 minutes ago, Cody1991 said:
Something like, "If a doctor has introduced themselves to the patient and their status moves to treatment in progress, it's fair game."

That is true; the main thing that is a clear violation of EMTALA is delaying the MSE (medical screening exam; the part where the doctor sees the patient to determine the presence and nature of any emergency medical condition) in order to check insurance statuses and collect payments and the like. This leaves a lot of leeway for things to happen exactly as they are happening at your place.

However, many places acknowledge the aspect of not wanting the appearance of delaying and interrupting active treatment in order to do those tasks.

Realistically, it doesn't make sense to say that yes, we have screened this patient and we have decided we need to provide some kind of treatment to them, but then to have some section of our staff rush in and start up with all these business items just as we have decided we need to treat the patient. (I'm not saying you're going to talk sense into anyone, but it still doesn't really make sense).

Cody1991 · Feb 12, 2020

10 minutes ago, JKL33 said:
That is true; the main thing that is a clear violation of EMTALA is delaying the MSE (medical screening exam; the part where the doctor sees the patient to determine the presence and nature of any emergency medical condition) in order to check insurance statuses and collect payments and the like. This leaves a lot of leeway for things to happen exactly as they are happening at your place.
However, many places acknowledge the aspect of not wanting the appearance of delaying and interrupting active treatment in order to do those tasks.
Realistically, it doesn't make sense to say that yes, we have screened this patient and we have decided we need to provide some kind of treatment to them, but then to have some section of our staff rush in and start up with all these business items just as we have decided we need to treat the patient. (I'm not saying you're going to talk sense into anyone, but it still doesn't really make sense).

I probably wasn’t clear.

Our doctors select patients charts electronically which moves them into “treatment in progress” from "waiting to be seen/triage" after they meet them and sign onto their chart.

We aren’t allowed to update them until then. So, we don’t see the patient for insurance or co-payment until the doctor has screened. Typically, it may just be an initial introduction by the MD/resident. So their status changes before their care is even really underway.

Problem is that once we do go into the room, the treatment is still underway so we’re constantly being interrupted. There’s rarely a period where there isn’t someone in the room and since we do have such strict time constraints, we’re often in a hurry and clashing with nurses. It's all pretty gross.