Running Out Of Time

And then the floor fell out.

I finally convinced the Director to allow me to take over the files for the new hospital.  Not because I had received training that they knew nothing about, but rather because I insisted on it.  If I am going to be responsible for something, let me be responsible for it – victories and defeats and all.

I took over the new hospital on March 1, 2014, four months after I accepted the position for the new facility.  I won’t sugar coat it – it was hard.  I had to learn how to credential new applicants in a hurry.  I was told, it’s just like doing a reappointment application – it’s not.

I kept wondering why everyone had such confidence in me – I had none in myself.  Here I was, a high-school drop-out (with my GED), with no college education determining if a physician with 10+ years of school was qualified to do his job.  I was reporting to people who had more letters behind their names than I had in my entire name.  I wasn’t even certified to do my job – I had barely started studying to become a CPCS.

It took me much longer to review a file than it took my coworker.  I didn’t have the advantage of 20+ years of experience to determine what was important and what wasn’t like she did.  I didn’t have the knowledge to know how to quickly assemble a file for department chair review.  I was attempting to come up with processes that made sense to transport files 20+ miles away for the new facility and department chairs to review.  The process coworker had started appeared incomplete and not up to Joint Commission standards.

The new facility started questioning if I was qualified to do the work.  They would point out, correctly I might add, that it was taking me 3-4 months to finalize a new application when it had only taking my coworker less than a month, two at most.  I didn’t have an answer for them, just that I was doing my best to ensure that each file was complete and thorough.

I started looking into beginning the reappointments for the new facility.  Coworker stated multiple times that I was jumping the gun on reappointments as it wasn’t necessary yet.  They weren’t due to recredential for another 14-18 months.

I looked at the time-lines – she had credentialed approximately 150 in those first few months and automatically put them on a 24 month reappointment cycle.  There was no way I would be able to recredential that many a year later without missing someone and them going over the 24 month maximum requirement by Joint Commission.  As far as I was concerned, I hadn’t started early enough at looking at the reappointments.

Thankfully, the facilities in our hospital system (18 wholly owned non-profit hospitals) have a sharing agreement across the entities for physician files.  Because of this, I was able to tack on many of my physicians as a “piggy-back” process to the primary facility’s reappointment process.  This allowed me to not have to focus on the entire reappointment file, just the items I needed specifically for my entity.  This allowed me to begin the reppointment process with a number of my practitioners with relative ease each month.

And then our Director was given a choice – retire or be fired.

At least, we weren’t told that, but reading between the lines, that’s what happens when the director of a department for 20+ years is there one day and then gone within less than a week.

I remember the CMO talking to us, but I don’t remember what she said.  I’m pretty sure she was attempting to be encouraging, but I sat there with tears streaming down my face and didn’t hear most of it. I kept attempting to will myself to stop crying, but I couldn’t.  I was at a loss for what I was to do.  The Director who was now gone was who had convinced me that I was perfect for the job.  Now whoever came in next would take one look at me and know I was a fraud.

The CMO asked me what she could do for me since I hadn’t said anything during her meeting with us.  I managed to choke out that I wanted to have a one-on-one meeting with her, she immediately agreed and scheduled the meeting for the next day.

I went home that evening and wrote down all of my questions and concerns.  I showed up to the meeting with the CMO and, based on her facial expressions, I shocked her multiple times.  I first told her that I was not upset for the Director leaving, that I viewed that as a business decision and that it was probably a good step for the department.  I admitted that I felt lost, that I hadn’t had proper training and that I thought multiple issues were going on in the department – that I wasn’t experienced enough to know what, but that the next Director would have their hands full with correcting years of issues.  She was appreciative of the honesty and asked me to give her time to get me the training I needed and the Director I and the department needed.  She just needed time.

Time was something I was fast running out of.

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It Got Harder

Every few months, just after I felt like I was knocked down and just getting my feet back under me, I would be knocked down again.

I could almost time it to every three months.

6 months in – my coworker goes out on leave of absence.

8-9 months in – I had all of the reappointment files dumped on my desk.

12 months in – exactly – this schlub was convinced to take over the credentialing position at the new facility.

My Director and coworker both came to me and asked me if I would consider being the full-time employee, responsible for all of the credentialing, for the new facility.  My first response to them was, “I am neither knowledgeable enough nor experienced enough to take on a new facility, with new challenges, and be solely responsible for it.”

I was told:
“Nonsense!  You are great at this job!”
“We’ll be right here helping you with the transition.”
“It’s no different that what you are doing now, just for a different facility.”

I talked to my husband.  I talked to my friends and family.  No one could give me solid arguments against taking the job.  They barely knew what I did – *I* barely knew what I did – they couldn’t advise me one way or the other.  They all said the same thing – you’ve always succeeded in what you set out to do – why would this be any different?

I should have listened to my initial gut reaction.

My very first day in Medical Staff was on November 6, 2012.  My official transfer date to the new facility was November 5, 2013.  One year.

Thankfully, I didn’t have to actually transfer offices – my desk just changed.  I still reported to the same office location, still had the same coworker to ask questions to – but my Director was no longer my Director – I now reported directly to the new facility’s President.

Did I mention that I had never even credentialed a new applicant before November 5, 2013?  I hadn’t touched, opened, or looked at a new applicant’s file or application.  I was not taught how to review a reappointment application – so I guess they never thought it would be important to go over new application training either.

Just because I transferred positions and entities, did not mean that any of my actual job duties transferred with me.  I switched desks, they hired a new coworker to take over my original duties, but I continued doing all of the original tasks while training the new employee and credentialing reappointment files from the first entity.  My first coworker continued doing all of the new applicant files for the new entity.

When I questioned this, I was told, “You aren’t ready to take the new files over yet.  When you’re ready, we’ll switch.”

Confusion abounded with everyone outside of the office.  They didn’t know who they should be talking to.  They thought I was their new employee, so they would call me, only for me to transfer them to Coworker – who actually knew what was going on.

In the mean time, I was gaining no momentum in my job.  I kept hitting areas that were causing me to spin my wheels and get nowhere.  I kept asking myself, “Why is this so hard?”  From all indications, we had an awesome software database that should be able to do what I wanted it to do.  From what I could tell, there were advances in many aspects of the credentialing process, so why were we still mailing out letters through snail mail?

I remember distinctly a conversation with coworker:  After I printed a request for Medical Education for a foreign country, she handed me the stack and said, “Good luck receiving the verification back.  Foreign countries almost never respond and when they do, it takes weeks, sometimes months, to hear back from them.”  I was left with the impression that I was doing the correct steps, the steps are just hard to complete.

Several months later, I found out about the ECFMG (Educational Commission for Foreign Medical Graduates) from a completely separate source.  YOU MEAN I CAN LOG INTO A WEBSITE, ENTER IN A COUPLE OF KEYSTROKES AND HAVE A FOREIGN COLLEGE VERIFICATION IN LESS THAN 5 MINUTES?!?

To say I was livid when I discovered this – that is an understatement.  What irritated me most of all was learning that my coworker knew all about this process and did not say something when she discovered I was printing letters to send to foreign countries.  I found out we had an account with the ECFMG for crying out loud!  This is something she did on a routine basis!

Around this time frame is when I finally conceded to myself that my original training had been lacking.  I began branching out of my office, asking others in the industry for advice, help and assistance.  I no longer trusted the advice I was receiving from inside my department.

You would think that things would start getting easier for me at this point.  You would be wrong.

What crazy simple solution did you learn about after you struggled with a task?

 

Can It Get Any Harder?

About eight months into my employment with the Medical Staff Office, we were hit with another HUGE challenge.

Even though my coworker and my Director both complained that our office was understaffed (which I agreed with whole-heartedly), the Director maneuvered our facility into the position to accept the challenge of credentialing providers for a brand new entity that our company opened up.  That meant we would be responsible for our providers, plus another hospital’s providers.

I will never forget how round my coworker’s eyes became when our Director relayed the information to us.  We were told at the end of June, the facility would be opening up mid-September – we would have less than three months to completely credential enough new applicants/providers to fully staff a fully functioning new hospital.  Did I mention at the time we did not have any Bylaws, no privilege forms, and Databank was not set up (or any other systems set up for that matter) for this new facilty?

When we went back to our desks, my coworker grabbed a pile of reappointment files off her desk, walked to mine, dropped them with some force onto my desk and stated, “These are now yours.  I won’t have time to do them anymore with the new hospital.”

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I sputtered, “But I don’t know what I’m doing with these!”

Her, “Nonsense.  You were working the files just fine when I was gone on leave of absence.  Just keep doing what you were doing.”

Me protesting to both the coworker and Director was met with denial that I needed more training, assurance that I was doing just fine, and the expectation from both that I would take over and complete the reappointments for that month and going forward.

I learned the hard way that I needed to ask more questions.

I didn’t ask for case lists – let alone know how to read them and interpret that there were enough cases for specific privileges.

I struggled with communicating with the doctors and their credentialing staff.  I approached them like I had in my other positions – a weak email request with a “if you wouldn’t mind” tone rather than firm statements with hard deadlines.  I didn’t know that I would need to babysit and follow up with them, sometimes multiple times, just to get them to follow through on simple requests.

I could check the items off my database checklist just fine, but I had no idea if files were considered complete or not.  I had no one suggesting that my files be audited or that I audit myself.  I had no idea what an audit was!

I learned, years after the fact, that I wasn’t even taught how to review an application to determine if it was “complete” or not.

I cobbled together most of my working credentialing knowledge from trial and error, being repremanded that I missed something major, or from overhearing something someone else was talking about at a meeting or conference.

In between learning how to credential a reappointment file, I was also learning about Stark Laws, EMTALA and ER call schedules, planning and booking multiple attendees to out-of-state Horty-Springer conferences, leadership contracts and dealing with a “hostile-take-over” of a department chair position (that was fun).

The only thing that could have made that first 9 months worse was to throw in there a lawsuit and Fair Hearing.  Thankfully, that didn’t happen, but I did learn something about it as we were contacted by the State Medical Board regarding one of our physicians being investigated.

Nevermind the fact that I also attempted to have a life outside of work.

I relay all of this information to assure you, the reader, that you aren’t the only one struggling with this job.  It’s the new millenium for crying out loud!  Why are we struggling to learn these things?

Maybe it’s because, like me, I had people who didn’t know how to train.  Maybe it’s because you have an entity or leadership that is still stuck on doing things the old ways.  Maybe it’s because you, like me, don’t know any better and just doing what you can to get through another day.

What horror stories do you have from your first year?

Thrown Into The Fire

The first serious challenge I faced after arriving in the Medical Staff Office was when my coworker went out on Medical Leave.  It was anticipated that she would be gone for between 8-12 weeks.

This happened less than 6 months after I joined the team.

Remember – I had no real database training, no foundation knowledge regarding what I was doing and why, I had barely learned my own job duties and now I would be responsible for someone else’s as well.

I was panicking inside while those around me assured me that everything would be fine.

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My specific instructions were from coworker – “I’ve already set up all of the reports for the next 3 months, all you need to do is fill in the blanks.”

There was no – “This is where the information comes from.”  I was missing the instruction of “That is why this is important to be included on the reports.”  And there was never a conversation that included “You may run into a snag with this aspect, if so, this is how you fix it.”  Nothing.  Nada.

Up until that point, it was the most stressful I had ever been at work.  Even more stressful than a previous boss volun-telling me to attend a cancer retreat, be the craft coordinator for 80+ people, with no prior experience at doing any of that – the weekend before my own wedding.

It took the full three months that my coworker was gone for me to figure out a system to deal with all of the issues I kept running into.

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At one point, I remember having a conversation with the Director who asked how I liked my job.  Ever the optimist and attempting to be positive, I commented that I really liked the “process list” aspect of MSOW – as it helped me to keep track of what was still pending and what I needed to do.  I also included a comment, “Checking things off the list helps me feel like I’ve accomplished something in my day.”

I received the response from her, “There is much more to credentialing than just checking off items on a list.”

We both missed a great opportunity that day.  She didn’t understand my comment had a much deeper meaning – that I was feeling out-of-control in my job.  And, at the time, I didn’t understand that her comment meant that I hadn’t been trained properly because at that point, I only knew how to check items off the list.

Every time I turned around I was being told that I was doing a great job.  The Director, the Chief Medical Officer (CMO), the Physician Liaison, the Credentials Chair – everyone insisted that I was doing wonderful.

So, why did I feel like a fake?  I felt like I was an impostor, like I didn’t belong in the Medical Staff Office.  I kept asking myself, the people I knew outside of the job, and a counselor (who I eventually started seeing) what was wrong with me.  Why couldn’t I get a handle on what I was doing and why was everything so hard?

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I had the counselor sum it up best after I had been in the job for about a year – I hadn’t actually had just one job; I had been asked and required to learn 4 jobs, all requiring extensive knowledge that I did not have, with next to no training.

But at the 6 month mark – I knew none of what the counselor finally pin-pointed.  I just knew that I was trying to juggle work (with no training), home (with a husband and kids who didn’t understand with their own problems and demands) and self (my self-esteem began to plummet during this time – the start of a three year depression that I’m finally, just now, clawing my way out of).

It took another 3 years before I realized that the problem was not me, that I was not a fraud and that I did have something to bring to the Medical Staff world.

Have you felt like a fraud at work?  What did you do to overcome the feeling?

Learn The Database

My next challenge was to learn the database that we used to store all of our provider information on.

There are several different software systems out there:

  • Cactus
  • Echo
  • MD-Staff
  • Morrisey/MSOW
  • And probably a whole bunch more that I’m not aware of

My particular company uses MSOW, but I have heard from others that Cactus and Echo are similar systems, with similar features.  I’m willing to guess that the other programs that I’m not familiar with are the same with similar systems and similar features.  The point of this post is not to highlight a specific database or to tout one as being superior to the others, but rather to speak on challenges that we all may face.

So what were my challenges in learning my credentialing database?

To begin with, remember me relating that my coworker and Director were not good trainers?  This carried over into the database realm.  I was instructed on how to log-in, how to look up a provider and which button to click on how to save “this particular document”.  Every few days, I would get another instruction on a different document and what to do with it.

The database was huge!  It had at least 2 dozen buttons, all doing different functions.  And heaven forbid you click a wrong button; you either lost yourself down a rabbit hole maze with no way out except to log-out or received a screen that might as well have said, “You’re not authorized to be here – GET OUT!”.

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It was intimidating to say the least.

As I have self-taught myself many computer programs over the years, I undertook the task to learn the credentialing database.  To be honest, it took me months to learn enough for me to feel comfortable enough with the program to actually explore on my own (as I was also having to learn my actual job duties – it left less and less time to “learn” a computer program beyond immediate day-to-day needs).

Growing up with computers, I have learned that MOST programs will not allow you to delete anything without double-checking that you really really really mean to delete it.  So I would explore by randomly clicking on buttons that I had no idea what they were used for or what they did.  If it asked me to “save” or “delete”, I usually said no – especially if I didn’t know what I was attempting to save or delete!  This is how I formed the majority of my working knowledge and “expertise” in my database.

Even after 6 months of being in the program, it wasn’t uncommon for me to exclaim out of the blue to my coworker, “Hey!  Did you know ‘this’ button does ‘that’?”

I usually received a response back of, “Yes, I just don’t use it.”  Well….that explained why I didn’t know about the feature before that moment, but since I considered it an awesome feature that needed to be used I would question ‘why not’?  I would get a range of answers of ‘I just never use it’, to ‘it doesn’t work properly’, to ‘why would we use it?’.

Case in point – MSOW has a Gap Analysis feature that isn’t very obvious.  The screen it is on uses the “print” icon.  I had overlooked it for months because I didn’t need to print that particular screen.  One day, I was really struggling to figure out if there was a gap in one provider’s education/work history, so I decided to print out the various screens of information so I could use a ruler and pencil system.  Imagine my surprise when the program calculated the information for me with just a couple of clicks of the button!  I think I mildly struggled with this task for almost a year before I stumbled upon this feature.

What my coworker and Director did not tell me, that I learned on my own, that I would like to share with you now is this:

  • There is online help for your program.  Google it.  I guarantee someone knows how to do what you are struggling with if the immediate people in your office are clueless.
  • If you have the desire – dedicate yourself to learning as much as you can about your database.  I am confident that the database developer has already programmed systems to help you do your job more efficiently.  Use the database to your benefit.
  • If you have the ability within your organization – have at least one employee within your department become a certified ‘super-user’.  This will allow you access and knowledge to utilize much more than just the surface-level of your database.

What did you find challenging about learning your credentialing database?

My First Challenge

Chaos.

That is what the department ran on.

Each day opened with some new crisis that had to be averted and solved before doing anything else.  It’s like the ladies thrived on chaos and crisis mode.

Most people who know me know that I do not like chaos.

I seek calm, organization and processes.

Challenge – yes.  Chaos – no.  Medical Staff was both at once.

As different challenges came up, I would ask, “Why is this not already planned for?  Why are we struggling to put out this fire rather than being on ‘fire watch’?”

The responses I received were varied, but similar: “We don’t have time for that” and “It’s not our fault that we’re behind”.  I tried to explain that an ounce of prevention is better than a pound of cure, but little changed.

So, as issues arose, I would make notes about what went well and what went wrong and planned for future responses if it or something similar happened in the future.

One of the reoccurring challenges that seemed to catch them unawares was the committee meetings we were responsible for – Credentials and Medical Executive.  Oh, they knew when the meetings were scheduled each month, but they seldom seemed ready for them to happen.

My first month there, I asked – “Why are we making copies and assembling binders?  Wouldn’t it make more sense to display this information on the overhead or use tablets?”  I was told, “Of course it would, but our attendees want paper.”

That first month, assembling binders for the various committees, was chaotic when it didn’t need to be.  I had experience in preparing for meetings in the past – I have never been so stressed out as I was that first time helping them with meeting prep.  I immediately began making changes.

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Fun Fact – our Physician Liaison told me that before I came to the department, he always wanted to come in on meeting day with a leaf blower to add to the chaos.

 

They waited to make copies until the day of – guaranteeing that the copy machine would break, run out of toner or paper.  Their rational – the documents sometime change, there’s no sense making copies if you just have to recopy them.  True – but when you are putting together 10-20 sections (with page counts anywhere from 1-100), you cannot wait until 2 hours before the meeting to make 20 binders and expect to be done on-time.

As soon as a document was “ready” – I made the required number of copies.  Sometimes that meant I was making copies a week in advance.  Even if I had to recopy the same document 3 times due to changes, I was gaining sanity for myself the day of the meeting.  Now – be reasonable – use common sense people – I did!  If it was only a one page section – piece of cake to copy multiple times.  If it was a 100 page section – I made darn sure it was 99% correct before I made copies.

I verified a month before, the week before and then again the day before that the meeting room and catering menu (as the meetings were held at lunch time) were confirmed.

I made sure the morning/day of the meeting I had nothing else of importance scheduled or planned.  My important task, my one frog, was preparing for the meeting.  That meant that, for me, emails were secondary.  I wasn’t on the phone like my coworker was, calling applicant references begging for that last verification that we were still pending.  Once I started processing files many months later, unless the decree came from the Chief of Staff, Chief Medical Officer or President, if an applicant didn’t have a complete file, they were tabled until the next month.

I planned, anticipated and, to the best of my ability, executed that everything would be ready by a minimum of one hour before the meeting.  This ensured that if something out of the ordinary did happen – broken copier, last-minute document change, roaming mariachi band (that never happened, but if it did to you – that’s awesome!) – I still had time to complete preparing for the meeting without stress.

I could always count on my coworker to tell me exactly how the meeting day would unfold.  She never told me in exact words that the day was shaping up to be calm or stressful – but she showed me in actions.  All I had to do was walk in the main office door and watch her reaction.  If she smiled and said “Good Morning!”, I knew it was a calm day.  If her eyes were huge and said, “Thank goodness you’re here!”, I knew it was a stressful day.

As the months went on, the day of the meetings became less and less stressful on everyone in the office.  Partly, because I knew what to expect and what I was doing, but mostly because I planned in advance how the day would run.  Was it always perfect?  No.  But challenges became minor inconveniences rather than full-blown panics.

What challenges are you battling?  How can you make it less stressful?

The First Three Months

I have no real memory of what my first actual credentialing task was.

Maybe it was scanning in a NPDB into the database.

Maybe it was pulling on-line hospital verifications.

Or maybe it was running a background check.

Whatever it was, I certainly didn’t know what it was that I was doing or why.  I was just doing what I was told to do.  The coworkers that I shared office space with, while wonderful people – they were horrible trainers.  My coworker was not able to explain what she knew or why she knew it.  The Director left the main portion of my training to the coworker, only supplementing with partial explanations when I asked for clarification.  There was no formal training.

I remember an office meeting where coworker and Director were speaking back and forth in this manner:  “The ACLS is preferrable to the BLS for the independent AHPs, but not for the dependent AHPs.”  And “But there is no regulation per the JCAHO or CMS…”

Blah, blah, blah….

I had NO clue what they were talking about, I couldn’t keep up with their acronyms and to top it all off, where we were sitting was under a heat duct, right after lunch and I couldn’t help but yawn.

The Director stopped her conversation, looked at me as I yawned and asked, “Are we boring you?”

“No, but I have no idea what you two are talking about either!”

I think they may have attempted to explain what they were talking about, but truthfully, it went right over my head.  It wasn’t anything I was prepared to understand because there was no basic frame of reference to know what it was they were explaining.

I had no foundation to build my knowledge from.

They did not explain to me what Bylaws are.

I had no idea what education was required for which specialty.

I didn’t know there was minimum requirements for liability insurance.

The first three months of me being in the department involved me being told what to do and not understanding what I was doing or why.  I had people in my life ask me what my new job involved.  I had no easy answer for them as I didn’t know what it was I was supposed to be doing.

So I defaulted to things I did know and understand.

I became the gopher and errand-runner.  If anything needed to go anywhere, I was sent.  Due to my previous job experiences, I knew where everything was in the hospital.  Take this to the Chief of Medicine in ICU for signature.  This needs to go to the doctor’s lounge in Surgery for display.  Please take that to Administration for the President’s signature.  On my first trip to Administration as a Medical Staff employee the main administrative assistant asked me, “So, have you had to get a tetanus shot from working over there yet?  It’s nasty over there and I don’t go to that office unless I have to.”  I was ashamed for the department that they had the reputation that they did.

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I remember filing stacks of files and loose paperwork.  One document had a date on it from 1980 – I began working in the department in 2012.  Every horizontal surface had stacks of paperwork that could not be shredded or tossed.  EVERYTHING had to be kept according to them – FOREVER.  I was told the regulations had loosened as they once could not “un-staple paperwork to make copies unless they stapled them back in the exact same holes to make it appear that it had always remained original”.  That made no sense to me.

I cleaned out the kitchenette area.  I found items that were out-dated by 10+ years (one item, I know for a fact was around 20 years old – even though I couldn’t find an expiration date on it).  The refrigerator might as well been its own science experiment.  I was astounded that women worked in the department as there was little evidence that anything had been cleaned in the previous 5 years.

I watered, trimmed and revived the dying plants (the Director referred to her plant as Lazarus as it had “risen from the dead” more times than she could count).  It was commented by my coworker that she didn’t have time to worry about plants and she didn’t understand why I had the time either.  Ummm….cause I have no idea what I should be doing with my day, so I’m filling it up as best I know how to!  I learned to do my plant-tending when she wasn’t present to watch and comment on my lack of productive work.  Less than five minutes of plant-tending a week became a refuge for me in an insane job.

It wasn’t all bad those first few months.  Part of the reason I was hired was because I already knew how to do other things that they didn’t normally do.  I ordered office supplies, scheduled meetings and ordered the catering.  I spent time updating documents and learning data entry in the department database.

I slowly learned a rhythm to my days that allowed me to feel in-control of my job.  Anyone who has been in Medical Staff for any length of time knows that once you start to feel comfortable, that is when all hell breaks loose.  My story is not any different.

Stay tuned for my first “attempt” at credentialing.