County council of Region Värmland

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The County Council of Värmland had an old-fashioned system to manage registrations, free passes and payments. For the patients, this meant that they had to wait a long time to be registered. As a consequence, the long queues could sometimes result in the patients missing their appointment. Patients had to arrive in good time before their appointment to make sure they had enough time to register beforehand. The clinics even advised patients to arrive way ahead of their appointment. If not, chances were they would miss it. The queues at the hospital entrance were long and to register took time. It was not unusual for the registration and payment process to take over 10 minutes. Only 18% of the patients got to register within 2.5 minutes (from when the patient received his/her queue number to when the registration procedure was completed). This despite the fact that all receptionists were doing their best to keep up. When the patient got to see the receptionist, a slow and complicated procedure followed. Payment had to be in line with a comprehensive and detailed price list. If the patient did not have cash or a credit card, they had to ask for an invoice. This could be perceived by the patient as suggesting they had poor finances. Besides registration and payment, high-cost protection and free passes also had to be administered. The patient had to keep track of his/her physical high-cost pass, which also had to be signed by the receptionist. Once the patient had reached the level of a free pass (SEK 1,100), the receptionist would inform the patient about the free pass and then administer and print the pass. This was both a resource-draining and risky administrative task. The staff would spend a lot of time administrating cash and payment card transactions and free passes. In addition, the cash management posed a risk of robbery and presented a big cost for the County Council to ensure secure collections. The entire registration, payment and administration process felt outdated! (313 words)

B. Strategic Approach

 2. What was the solution?
The agenda was laid down by the County Council Board, led by the Chief Financial Manager at the time, where the problems/framework of the project were outlined. The County Council of Värmland conducted a survey of patient fees payments in 2009. The pre-study identified three overall problems with the current payment flows: • Lack of alternative, modern payment methods for the citizens. • Resource-draining manual cash management. • Handling of cash posing security threats. A project was set up in the autumn of 2010, based on the intentions of the pre-study. As the project progressed, more light was shed on the current system and the project team saw ways of improving the process and thus making the administration more efficient and cutting costs at the same time as the patients would be offered better service. The direction changed when the team realised that the project ought to carry out a bigger change in terms of payment methods than was originally planned. The new direction meant that: • Cash and card payments would be replaced by invoices • High-cost and free passes would be managed digitally • Registrations would be made in self-service kiosks The project team presented the new idea to the County Council Board. Following a number of discussions, the board decided on the new direction. In the spring of 2012, a new free pass system was implemented as well as a system to invoice all patient fees (based on the patient’s account balance). As a result, we saw considerable improvements in the registration process within a relatively short period of time. As a result, patients no longer had to face long queues to register for an appointment. A few months later, a number of self-service kiosks were also put in place at Karlstad Central Hospital. This presented a completely new way for the patient to get registered, as an alternative to the manual service carried out by a receptionist. Shortly after the kiosks had been introduced, patients felt familiar with the new registration system. Staffed receptions were still in place to help patients with special needs or who wanted manual service for other reasons. The registration was now running efficiently. (More than 90% of the patients could go through the registration process under the target level of 2.5 minutes.) Patients could forget about queuing up to register altogether. This also meant that the system with queue numbers became redundant. (326 words)

 3. How did the initiative solve the problem and improve people’s lives?
The concept, which was largely put in place during 2012, means that the patients and staff do not have to worry about making payments at the time of the appointment nor keep track of high-cost or free passes. Instead, the patients can now use self-service kiosks, leaving more time for the receptionists to help patients in need of personal service. Payment fees are later paid via monthly invoices. Invoices can be set up for automatic payment which means that the only thing the patient has to administer is the registration prior to an appointment. Once a patient reaches the high-cost level, a free pass will automatically be sent out to the address where the patient is registered. All appointments are registered in a free pass database (“FRISK”). This is a completely unique and innovative solution within the Swedish health care system on how to manage registrations, free passes and payments. You can forget about the time-consuming and complicated registration process – something that will benefit both the patient and the organisation. This leaves room to focus on the more value-adding processes of the patient journey. Looking at the whole picture from a patient perspective has been crucial to the successful implementation of our new system. That is why we arrived at interconnected systems for self-service, free passes and payments. (183 words)

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The project began in October 2010 with a survey of the current situation. We then proceeded by looking at how other county councils and organisations/businesses dealt with the registration and payment process. One of the county councils that we visited had implemented an invoicing system with successful results. In order to put a system in place within a reasonable timeframe, we chose to change from card payments to invoices. Because we were going to invoice all patient fees, we would also be able to keep track of our patients’ high-cost and free passes. As we had solved the issue of payments and high-cost and free pass management using a digital solution, we were also able to implement a self-service registration system. In order to prove that the system would work, we conducted a Proof of Concept (POC). This was then used as the basis for the final decision and further development. Once the decision for further development had been made, the project was divided into three parts: invoicing, free pass system and self-service. The development of the project began in September 2011 and the implementation of the invoicing system of all patient fees and the free pass system took place on 1 April 2012 throughout the entire County Council of Värmland. The self-service kiosks were put in place in November 2012. (171 words)

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initial project team consisted of co-workers from all units involved in the process: the finance department, customer service, IT, purchasing unit and the primary and institutional care units. Progress was reported with regular intervals to the project steering group, which consisted of County Council officials and politicians. We had an ongoing dialogue with the pensioner and handicap organisations throughout the project. These meetings provided us with a lot of useful input. One of the first tasks of the project was to investigate whether there were other county councils who had done something similar. We found a few county councils that had removed cash payments and implemented a free pass database. We went to visit them and made valuable connections. Relatively early on, we were able to establish that no county council had changed the entire process from initial appointment letter and registration to payment and management of high-cost passes. We were up for a challenge! (130 words)
 6. How was the strategy implemented and what resources were mobilized?
The project has been financed by the County Council of Värmland. The initial budget was roughly SEK 3 million. This was to cover the development of the systems and hardware with the help of external suppliers. The final cost was more or less in line with the budget. However, the main investment was the time that the staff spent on the project. Participating staff included the IT department, the finance department, receptionists and a number of other units. (68 words)

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
We can now forget all about the hassle of physical high-cost passes, cash and long queues. Patients can register their appointment in a self-service kiosk, all appointments are invoiced on a monthly basis and we keep track of the patient’s high-cost pass. This means a more efficient registration process for the patient at the same time as the staff can focus more on providing good service. Throughout the project, we have focused on the patient’s experience. We can conclude that the new system has had a very positive impact on the patients. In fact, the outcome has exceeded our expectations. Here are the biggest advantages from a patient perspective: • The use of invoices has meant that more time can be spent on helping the patient with other queries • The implementation of a free pass system and a system free of cash and payment cards have led to faster registration and therefore shorter queues • All patients are treated equally from a payment point of view, which makes for a more just system • Patients do not have to keep track of receipts to obtain a free pass • The patient has access credit From an organisational perspective, we have been able to cut a lot of costs and administration time. More time can now be spent on patient care and conducting a more detailed administration, such as writing chart notes to increase patient safety. (179 words)

 8. What were the most successful outputs and why was the initiative effective?
In order to achieve the targets set up for the project, the project leaders met regularly to synchronise the different parts of the project. In addition, the project reported back to a steering group on a regular basis. A time plan with tasks was used to organise the operative work of the project. (42 words)

 9. What were the main obstacles encountered and how were they overcome?
Process modelling – current situation In order to establish the current situation, we used process modelling. To do this, we gathered people who had knowledge of the separate processes in one way or another. After a few days of workshops it was concluded that the process was very complicated, for example in terms of complex payment flows. We identified a lot of problems; however we also saw great possibilities to improve the current process. Process modelling – future situation Using a highly creative process with the project team, “no stone was left unturned” – nothing was sacred! For some, this was a somewhat overwhelming experience. The result was that invoicing would be the only payment method, a free pass system was to be implemented and self-service kiosks were to be used as an alternative registration option. This meant that we would diverge significantly from the project directive laid down by the steering group. We therefore had to swiftly revise the project directive. And we had to make a convincing case! Proof of concept (POC) In order to test/prove that the concept was viable, we conducted a so-called POC. As the project progressed, more light was shed on the current system and the project team saw ways of improving the process and thus making the administration more efficient and cutting costs. The direction changed when the team realised that the project ought to carry out a bigger change in terms of payment methods than was originally planned. The result of the POC showed that it would be possible to develop and implement the concept. Thus, a decision to implement the new systems would be well-founded. Communication plan We realised early on the value of identifying important parties for a successful implementation of the project: Both those who would be active in the project, as well as other parties such as user organisations (pensioner or handicap councils), politicians, senior civil servants of the County Council, union representatives and the media. We therefore outlined a communication plan at the start of the project with the purpose and aim. Further, we added the different tasks and assigned responsibilities. (288 words)

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
A number of concrete goals were defined in the project directive. The goals have to a great extent been achieved. Impact goals (answering the question why) Impact goal 1: At least 50% of all patients should be attended to within 2.5 minutes (waiting and registration time). The goal was reached even before the implementation of the self-service kiosks. Today, 95% of the patients at Karlstad Central Hospital are attended to within the target time. Impact goal 2: Cutting the total costs of registration and patient fee payments by 25% by 30 April 2013. Eliminated costs: pass fees, cash collection fees, payment card terminals. Added costs: postage, kiosks, certain operational costs for FRISK, self-service and invoicing. The total net costs have met the target. Impact goal 3: Cutting costs by 90% (regarding the patient registration process) by 30 June 2013. Costs for the handling of cash and balancing the numbers. The goal has been reached. No costs. Impact goal 4: Costs for the collection and counting of cash. The goal has been reached. No costs. Impact goal 5: Costs of payment card terminals. The goal has been reached. No costs. Impact goal 6: Administration revolving the balancing of cash deposits and card payments. The goal has been reached. No costs. The aim of the project has been to implement a new system which would make it easier for patients to pay their patient fees. The goal was also to improve the administrative routines to eliminate unnecessary extra work. This has been achieved! When 80% of the patients register by using a self-service kiosk, 35 full-time positions are freed up which can then be used for tasks other than unnecessary administration. Transferring to a system with monthly invoices also has a number of advantages from an administrative and staff perspective: • Less administration and lower costs throughout the whole process • Lower external costs for payment cards and handling of cash • An easier and clearer process with one payment option • No manual bookkeeping of daily balancing of cash and card payments • No corrections of daily balancing of patient fee payments • A better working environment for the staff working with patient invoices. Staff who have previously been in charge of patient invoices have had a problematic work situation answering phone calls throughout the day and therefore having difficulties keeping up with and concentrating on their other work tasks. (299 words)

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
In this respect, the County Council of Värmland has been a role model in Sweden regarding how the administrative process of registration and payment can be changed to the advantage of both patients and organisation. We have received a lot of attention from other county councils around Sweden. All of the county councils (20 in total) have been in contact with us. It is clear to everyone that changing this process has great advantages. And a majority of them will be following our example within the near future. The concept and the system for free passes and self-service can be used and transferred to other county councils in a relatively easy way. With good project management, any county council can implement the concept in 6-12 months. Assuming that all county councils would manage the registration process using self-service in the same way as the County Council of Värmland, we could free up to 1,500 full-time positions for other tasks instead of wasting them on unnecessary administration. (136 words)

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
It takes courage to make a change! Question the original directives. If the project directive presents a solution proposal, make sure to find out whether “all stones” have been turned! Some of the key people in charge of the project development were under an unreasonable amount of pressure for large parts of the project. The ordinary work tasks usually had a higher priority. This meant a risk of falling behind and losing speed! The choice of suppliers is important. You need to involve individuals with an innovative approach and who can contribute to the success of the project in a positive way. Unexpected events (external debt collection, external operation of FRISK). Resistance within the organisation (“why change”). Communication with other parties. Involving other parties from an early stage. Having an open agenda. Using iterative work processes. Daring to conduct tests early on in the project. We have tackled a neglected, but important part of the patient’s contact with the health care service and found a smart and automated solution with self-service kiosks that manage appointment registrations, payments and high-cost protection. A big step towards making the everyday easier for both patients and staff. The organisation has firmly stated that they are very pleased with the final result; it lives up to the requirements of the specification far and beyond. The patients are very satisfied with the new system! (200 words)

Contact Information

Institution Name:   County council of Region Värmland
Institution Type:   Public Agency  
Contact Person:   Staffan Flodin
Title:   Project Manager  
Telephone/ Fax:   +46 70-662 94 10
Institution's / Project's Website:  
Address:   Rosenborgsgatan 50
Postal Code:   65182
City:   Karlstad
State/Province:   Värmland

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