Once Banner Health really understood quality data, they uncovered a glaring story of operational challenges and practitioner frustration leading to a closing of the organization's front door. With focus on process improvement, they achieved significant growth in transfer volumes and added an additional $26.4 million in revenue.
Located primarily in Arizona and Colorado, Banner Health is one of the largest nonprofit health systems in the country. The complex system owns and operates 30 acute care hospitals. It also has Banner Health Network, an accountable care organization (ACO) of physicians, clinics, urgent cares, and other services caring for local communities. Further, it operates Banner University Medicine, academic and employed physician groups, long-term care centers, outpatient surgery centers, and an array of other services.
Banner Health manages over 70,000 patient transfer referrals per year, about 1/2 of those are incoming patients from community hospitals and competitors. However, buried in those large volumes, it was noticed that transfer volume growth since 2016 had started to decline from 13.7% to 2.4% in 2018. Noticing this decreasing referral volume, leadership set out to determine its causes and identify ways to reverse the trend.
When we uncovered the data and really got into the weeds, we discovered that transfers on average took more than three hours – 198 minutes – due to the lack of standardized processes and communication difficulties. This included multiple phone calls between our physicians until the right physician at the appropriate facility would receive the necessary information to approve the admission.
During that extended waiting period, the referring physician could have called a competitor and transferred a patient there instead, which Banner discovered often happened. Staff estimates that in 2018, Banner was losing 600 patients a month to competitors due in part to slow transfer approvals and admissions, which created a frustrating process.
We further estimated that if this trend continued, Banner would lose $40 million in annual revenue from those missed transfers. It was clear that an intervention was needed.
Identifying where delays were occurring across Banner’s large network was a challenge using our existing data. Identifying the referring physician and institution as well as the cause for a transfer delay or cancellation required free-text searches in our electronic health record. This lack of a standardized, reliable database to manage such information made raising awareness of the problem and changing behaviors among our physicians difficult. I used to joke that we were "bringing feelings to a fact fight". Whenever we brought data to leadership to promote conversation and accountability, holes were quickly and easily poked into it until it looked like a colander. If we were going to bring accountability to providers and leadership, we needed to be air-tight in our data.
The need for a simplified, standardized transfer process was further driven home after Banner Health participated in a six-hour disaster preparedness drill with the Federal Emergency Management Association (FEMA). Banner and other hospitals in the Phoenix region simulated evacuating their patients to other facilities in the wake of a natural disaster. Several hours into the drill, my team and I had not been able to agree on a patient-load balancing plan and had yet to begin any simulated transfers. We knew this was a big issue. Should there ever be a true load-leveling emergency such as a natural disaster, mass shooting, or a pandemic ... the community and competitors alike would look to Banner for guidance. We were woefully underprepared for such an event. The drill was eye-opening. Banner is the largest system in the market, and it did not know how many patients it could admit after four hours. We were far from prepared, and we knew some changes would have to be made promptly.
After exhaustive research, Banner Health Transfer Services' Chief Medical Officer Dr. Jason Brown and myself co-wrote a 45-page white paper about the importance of transfer services and the multimillion-dollar financial impact of losing hundreds of transfers from the Banner network. We were throwing up smoke signals, looking for help.
Around this time, I met with one of the network’s senior executives and cautioned her about the patient volume and potential revenue loss. Boy is that an uncomfortable conversation to be sitting across the table from the number 2 ranking leader in the entire network. "How is your book of business running?" she asked me. After a large gulp and a deep breath, I decided to go for it. "Welp, I didn't really intend to talk about this today but since you asked, it isn't. Without significant intervention, expertise, and help, we'll hemorrhage over $40 million dollars out of our virtual front door this year" (it was already August). I then looked away, afraid to make eye contact with her.
Thankfully, this executive, who had already reviewed the white paper (likely why she asked me about my book of business - she wanted to see if I had the gall to say it), quickly garnered support from the rest of our leadership staff who agreed to invest in a transfer center improvement initiative. I will say - it was inspiring and uncomfortable all at the same time to watch her tap her fingers on the table and point at other high-ranking executives and say, "This is all of our job. This will improve, this will be successful." Then she looked at me an in an oddly stern but supportive manner said, "And you - you let me know if there are any hurdles you cannot readily jump over. You're leading this, you're leading us."
A major element of the project involved upgrading Banner’s data capture processes from multiple disparate sources. Apart from the lack of reporting capabilities, the electronic medical record was difficult to extract meaningful data and was not designed to support efficient transfer center operations. We reviewed several improvement plans, but there was a dearth of solutions offering the required ease-of-operation or reporting capabilities to track transfer activity and performance that Banner Health needed. We knew this "simply" was a process improvement project on the grandest scale. Nobody could fix this but us.
Part of the reason a solution appealed to Banner Health was that it desperately needed track and enable real-time reporting on important transfer information and metrics, such as time to transfer, real-time facility capacity, real-time provider schedules, cancellation rate, consult rate, lost rate and transportation times. Not only was this information dire, but our team desired to quickly analyze trends to identify potential bottlenecks or other emerging challenges. However, rather than choosing a path based on personal preference alone, I spoke with my counterparts at numerous health systems around the country to best understand opportunities within process improvement and data quality analysis.
Every organization we spoke to said the biggest win from a project such as this is the data. Now that we are live, we are seeing that for ourselves. We can see exactly where our transfers are going, who is involved, and where the improvement opportunities are.
Due to the patient volume and revenue losses, Banner Health wanted to implement the new transfer center processes as soon as possible. Despite its implementation during the winter holiday season, and a separate EHR remote-hosting project occurring at the same time, Banner Health was able to go live in January 2019, a month sooner than average for a comparable network of Banner Health’s size and scope.
The solution is used by our two transfer center teams, one for Arizona and the other for the facilities in our Western region. We began this initiative with 75 employees and now conduct significantly more transfers with the same staff, due to the drastically increased staff productivity. With the new processes in place, Banner Health’s teams have complete oversight of transfer operations, including times, locations, and providers. Now agents are able to provide answers and insight for our referring physicians more quickly, increasing their productivity. Communication also has been streamlined. Agents have a comprehensive view of facility capacity and provider schedules so there are fewer phone calls to arrange a transfer and less uncertainty over the appropriate physician to approve an admission.
In many health systems, patients are transferred from an ED in a community hospital to the ED of the receiving hospital for triage to another facility. This inefficient process can delay care and can also overwhelm an already busy ED staff. Thanks to our enterprise-wide project, we are able to direct more transfers and admissions directly to the facility where patients will be receiving needed specialty care, instead of delegating those duties to the emergency room.
With agents having improved functionality, Banner Health plans to continue to improve balancing patient loads between its facilities. It will conduct additional outreach to patients who were referred to a competitor’s facilities to repatriate them into the Banner Health network. Through the process understanding nationwide shared strategies and best practices gleaned from work with other health systems with high performance transfer centers helped us avoid missteps as we overhauled our processes. National preferred practices and connections was key to early success, without a doubt.
Just six months after the new technology went live, Banner Health was already on an upward trajectory with referral volume. After one year, referral volume for Banner facilities grew by nearly 10% for 2019, thus adding 3,308 more patients than the previous year, during which the network lost an estimated 716 transfers to competitors. This was possible due to the increased awareness and visibility over our facility capacity and physician schedules and more efficient processes to transfer patients, which means fewer required phone calls and less waiting and frustration for our referring physicians. In total, we reduced transfer time on average by 67 minutes in year one. We want to continue these process improvements and growth trajectory and have set an ambitious target of 30 minutes for an approved transfer – and a single phone call to approve the admission and arrange transportation.
With an estimated $8,000 contribution margin per patient transferred or retained through a transfer, the additional patients increased revenue by more than $26.4 million for Banner Health in 2019.
Get your help; find an expert. Ensure the processes and operations covers the entire health system and offers accurate visibility into facility capacity and physician schedules so your transfer center can offer quicker answers to referring physicians and arrange consult calls efficiently. Also essential is accurate and reliable analytics with the ability to easily generate many different types of performance reports about patient transfers, retention and lost rate, including information about the time and locations involved.
Before implementation, Banner Health understood how the shrinking transfer volume was impacting its network’s revenue and its referring providers but could not deliver reliable reporting to senior leaders because the disparate systems producing transfer center data was not fully integrated with one another. An organization’s data needs to be rock solid to tell a story, not only about the challenges and risks, but also the opportunities for growth and repatriation – for example, facilitating the patient's return to the network.
Transfer services often are viewed as a niche service, but they really shouldn’t be. As health systems merge and grow and form these mega networks, they have to understand the value transfer services offer in supporting that growth and ensuring financial sustainability.
With the new changes made to the transfer center and processes, Banner Health made the most out of this opportunity to expand the organization’s footprint and improve care quality in the communities it serves.
Cohen, J.K. (2020, February 22). Banner uses automation to cut time for accepting patient transfers. Modern Healthcare. Retrieved from https://www.modernhealthcare.com/operations/patient-transfer-times-cut-22-automation-banner-health