How to Make a Successful Change...without Losing Your Mind and/or Your Job
Catherine Baxter, CMT
Especially for ADVANCE
Redesign, cost rationalization, cost containment, downsizing and other similar words have entered our working lexicon in recent years and we are likely to assign very unpleasant connotations to these words and their ultimate effect as they apply to (HIS) health information management .
There is no doubt that HIM is hitting the cost center side of the spreadsheet when the CFO compares costs to revenue centers. We also suffer doubly because we are considered a non-patient ward. When it comes to letting annual layoffs fall ahead of the new fiscal year, HIM tops the list of departments that must make the biggest financial sacrifices for the organization.
This painful slashing often leads to serious consideration of outsourcing one or more HIM functions, with medical transcription being the product most often chosen by the financial deities.
The purpose of this article is to give you some basic tips to ensure the success of your outsourcing project. While the focus will be on transcription outsourcing, many of the guidelines will apply to other areas such as information sharing and coding.
There are four keys to a successful transition to outsourcing for HIMs, users, healthcare organizations, patients and Medical Transcription Services (MTS):
- Collect accurate data and analyze it; know who you are, who your users are, and what each of you wants from MTS.
- Think of the outsourcing business as a project with a coordinator and a plan; create a team or advisory board that will be involved in the final selection of the outsourcing company.
- Create a detailed implementation plan with a realistic timeline for implementation; decisions made in haste often result in wasted... time, energy and money!
- Establish continuous quality monitoring guidelines and apply continuous quality improvement techniques. Remember, you've outsourced the work, but you're still responsible for its quality.
Note that Instructions 1 and 2 must be completed prior to drafting a Request for Proposal (RFP). Tips 3 and 4 should be implemented with the MTS of your choice as a first step in building a strong working partnership.
the key to success
Collect and analyze data. This is a daunting task even for a small HIM department, so don't underestimate the scope of the task. Without accurate data, you won't be able to provide your outsourcing partner with all the information they need to predict dictation volume and meet your service expectations.
Start by listing all the data you need to collect:
- Dictation system information - includes all hardware, model, age, owned/lease, recent upgrades, storage capacity per system, upgrades and expandability per system and by job type, site and system (more if current) The list of dictation volumes is used by more than one system. Don't forget to include dictation that may have been outsourced and recorded on an external device. Volumes should be recorded in hours and minutes and at least one year of data should be reviewed. This can be reported in the monthly totals.
- Transcription system information, including current hardware (PC, typewriter, word processor), network configuration (DOS vs. Windows vs. NT) or no network, transcription software used, latest version installed and when, age of the computer currently in use and Any add-on modules currently in use or planned for use in the near future (doctor preview, e-signature, etc.). Includes transcription volume by job type and location. Defines the number of lines of the total document transcribed, where lines should be defined as precisely as possible. Note that your volume will depend on how you define this line. If you define a line as 85 characters, keystrokes, codes, or spaces, and your potential outsourcing provider defines a line as 55 characters and no spaces, you may be significantly underestimating your potential costs.
- Current transcriptionists, supervisors, and office personnel, including full-time employees (FTEs) and part-time employees (PTEs), shift work, union status (if applicable), and whether an outsourcing company will offer transcriptionist positions. Including their salary and benefits.
- Actual billing for transcription costs based on current configuration. Don't just include your salary. Include benefits (usually 22% to 33% of salary), cost per square foot of space, including cost of furniture, appliances, supplies, heating and air conditioning, phone service, etc. Most information can be obtained through your accounting department.
- List all types of jobs and required lead times (TATs) and average quantities of each job per week, month, and year. Check every job format to make sure you're not wasting precious time and money on outdated, clunky formats. Be reasonable about the TAT you need. Do not ask for a discharge summary within eight hours if it can be returned within 48 hours. This will allow you to top up fast TAT for special types of reports such as ER notes, radiology reports, etc.
Create project teams, project team coordinators, and project plans. According to Robert M. Seale, a well-known and respected innovator, business leader and consultant in the medical transcription industry for more than 25 years, "The most important aspect of ensuring a smooth transition and successful operation is planning."
Once the decision to outsource transcription has been made, an advisory board or project team should be involved in the final decision-making process with representatives from each department. The team should include at least one experienced transcriptionist, at least one transcription manager, a team coordinator (HIM professional with working knowledge of transcription), and representatives from Information Systems (IS), Procurement, and Legal.
Additionally, physicians on an advisory board can be helpful, especially if they are also involved in planning a computerized patient record (CPR) strategy for your organization. Physician representatives can provide valuable user perspective. Ultimately, physicians are your customers, so having their support will make your transition to outsourcing easier.
Now, based on the collected data, project team, and plan, prepare the RFP. Don't underestimate the time it takes to prepare this document and don't miss any details. The more clearly you make your expectations known to all potential bidders, the less time you'll spend browsing through unqualified transcription services. But don't make the RFP so demanding that the only services that respond are those too naive to know they're getting in the way.
One of the main decisions you need to make is whether you will retain ownership of the dictation system. At first glance, this may seem like a way to reduce capital expenditures and annual maintenance costs for your HIM department, but in reality you are handing over complete control of your facility's record entry process. If MTS fails to deliver a quality product based on TAT, you will have the opportunity to have your say in a different direction. Since many healthcare organizations plan to integrate voice capabilities into clinical workstations, IS was expected to support open architecture digital voice systems on the NT platform.
The RFP process can solve the whole problemAchievementdescribe. So, assuming you've gone through all your bidding, invited all shortlisted bidders to demos, and finally selected a service that meets all your requirements, it's time to sit down with your new partner to create a roadmap and implementation timeline.
Develop a detailed implementation plan with a realistic timeline. This is the first step in strengthening the partnership with the newly elected MTS.
According to Mr. Seale, “All aspects must be considered, defined, analyzed and procedures developed to address any unforeseen issues. Likewise, now is the time to implicitly clarify your expectations with MTS.
The two problem areas most likely to arise are: 1) a mismatch between expectations and reality; and 2) a lack of understanding of the enumeration methodology and thus an inability to interpret the transcripts performed. By establishing strong partnerships and introducing a mechanism for disclosing issues, finding plausible solutions, and then monitoring to ensure the actions taken actually resolve the issues, outsourcing can be an excellent alternative to in-house transcription.
Establish continuous quality monitoring guidelines and apply continuous quality improvement techniques. A few months ago, while attending a local meeting of the American Health Information Management Association (AHIMA), I asked representatives from the Healthcare Financing Administration (HCFA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) about the need to outsource monitoring the quality of the service. Both representatives responded that there would be greater emphasis on quality assurance at all levels of the healthcare network. In particular, they emphasized that companies must provide proof of quality assurance inspections for any outsourced work.
June 9, 1997 issuemodern healthcareAn article titled "HCFA Report Criticizes Kaiser Hospital" singled out one of the violations: "The hospital does not evaluate the performance of its outsourced services."
Many times, contracts do not specify measurable levels of acceptable quality or how to monitor achievement or non-compliance with quality requirements. It is critical that the HIM department receives frequent (initially bi-weekly, then monthly or quarterly) QA reports on an agreed percentage of all transcription work. In most cases, at least 98% accuracy is required, and once this level is reached, 5% of all transcribed documents are selected for random review.
However, and this is a very big BUT, you - the HIM department - have to do some sort of routine quality review of all outsourced services. This means that you either need to hire an experienced transcriptionist or team of transcriptionists who are qualified to perform quality checks in the case of large facilities, or you must hire a qualified consultant to do it for you.
There must be a process in place to identify problems, recommend solutions, and make sure the solutions work and restore quality to acceptable levels...this is the standard approach for continuous quality improvement/total quality management.
All in all, it is possible to successfully transition to outsourced transcription without losing your mind or your work in the process. Gather accurate data, empower the project team and project coordinator, prepare an RFP that balances expectations and reality, develop a realistic implementation plan and timeline, work with MTS, establish a framework for problem-solving, and implement Quality comes first.
*About the Author: Catherine S. Baxter is president of Health Info Transitions and has been in the healthcare industry since 1971. She is considered an expert in medical transcription and is a member of AHIMA, AAMT, ASTM, and HL7.
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