How to Make a Successful Transition …and Not Lose Your Mind and/or Your Job in the Process
Special to ADVANCE
Re-engineering, cost-justi-fying, cost-containing, streamlining and other similar words have entered our working vocabularies in recent years, and more than likely we attach very unpleasant connotations to these words and their ultimate outcomes when applied to health information management (HIM).
No doubt when the chief financial officers (CFOs) look at cost vs. revenue-generating centers, HIM definitely falls into the cost center side of the spreadsheet. We also suffer a double whammy, because we are considered a non-patient care department. When it’s time for the annual ax to fall prior to the new fiscal year, HIM is high on the list of those departments that must make the most significant financial sacrifices for the good of the organization.
The outcome of this painful axing frequently results in serious consideration being given to outsourcing one or more of the HIM functions, with medical transcription being the most commonly chosen sacrificial offering to the financial deities.
The purpose of this article is to provide you with some basic guidelines to assure that your outsourcing project is a successful one. While the focus will be on outsourcing transcription, many of the guidelines will apply to other areas such as release of information and coding.
There are four keys to creating a successful outsourcing transition for your HIM department, your users, your health care organization, your patients and your medical transcription service (MTS):
- Gather accurate data and analyze it; know who you are, who your users are and what each of you wants from an MTS.
- Consider the endeavor of outsourcing as a project with a coordinator and a plan; create a team or advisory board consisting of those who will be involved in the final selection of the outsourcing firm.
- Develop a detailed implementation plan with a realistic timetable for that implementation; decisions made in haste often lead to waste…as in wasted time, effort and money!
- Establish continuous quality monitoring guidelines and apply continuous quality improvement techniques. Remember, you have outsourced the work, but you are still responsible for assuring its quality.
Please note that tips 1 and 2 should be completed prior to developing a request for proposal (RFP). Tip numbers 3 and 4 should be accomplished in conjunction with the selected MTS, as the first steps of developing a strong working partnership.
Keys to Success
Gather and analyze data. This can be an enormous task even for a small HIM department, so don’t underestimate the scope of this task. Without accurate data, you will not be able to provide your outsourcing partner with all the information necessary to predict your dictation volume and meet your expectations for service.
Begin by making a list of all the data you will need to gather:
- Information pertaining to the dictation system—including an inventory of all hardware, model, age, own/lease, last update(s), storage capacity of each system, and upgrade and expansion capability of each system, as well as the dictation volumes by work type, by site and by system, if more than one system is currently in use. Don’t forget to include any dictation that might already be outsourced and recorded on outside equipment. Volumes should be recorded in hours and minutes, and at least one year’s data should be reviewed. This can be by reported in monthly totals.
- Information pertaining to the transcription system including current hardware (PCs, typewriters, word processors), network configuration (DOS vs. Windows vs. NT) or the lack of a network, transcription software utilized, latest version installed and when, age of PCs currently in use and any additional modules currently in use or planned for use in the near future (physician viewing, electronic signature, etc.). Include the volume of transcription by work type and by site. Define the volume in total lines of transcribed documents with a line being defined as specifically as possible. Remember, your volume will depend on how you define that line. If you define a line as having 85 characters, keystrokes, codes or spaces, and your potential outsourcing vendor defines a line as having 55 characters without spaces, you may grossly underestimate your potential costs.
- Current staffing of transcriptionists, supervisors and clerical personnel including full-time employees (FTEs) and part-time employees (PTEs), shifts worked, union status if applicable and whether or not you expect the transcriptionists to be offered positions by the outsourcing company. Also include their salaries and benefits.
- Do a true cost accounting for transcription as you are currently configured. Don’t just include your salaries. Include benefits (usually 22 percent to 33 percent of salary), the cost of your space per square foot, including the cost of furniture, equipment, supplies, heating and air-conditioning, telephone service, etc. Most of this information can be obtained through your accounting department.
- Make a list of all your work types and required turnaround times (TATs) and average volumes of each work type per week, per month and per year. Review each work type format and make certain you are not wasting valuable time and money on outdated, cumbersome formats. Be reasonable about the required TATs. If discharge summaries can be returned within 48 hours, don’t ask for them in eight hours. This will allow you to pay extra for rapid TATs for special report types, such as emergency room notes, radiology reports, etc.
Create a project team, a project team coordinator and a project plan. 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 assuring a smooth transition and successful operation is planning.”
Once a decision is made to outsource transcription, an advisory board or project team should be assembled with a representative from each department that will be involved in the final decision-making process. This team should include at least one experienced transcriptionist, at least one transcription supervisor, the team coordinator (an HIM professional with hands-on knowledge of transcription) and representatives from the information systems (IS), purchasing and legal departments.
In addition, it would be helpful to have a physician on the advisory board, especially if you have one who is also involved in planning the computerized patient record (CPR) strategy for your organization. The physician representative could offer a valuable user perspective. Ultimately, the physicians are your customers, so gaining their support will facilitate the outsourcing transition.
Now with the data gathered and a project team and plan in place, prepare the RFP. Don’t underestimate the time it will take to prepare this document, and don’t leave any detail to chance. The clearer you are in making expectations known to all potential bidders, the less time you will spend in weeding through unqualified transcription services. However, don’t make the RFP so strict that the only services that respond are those that are too naïve to know they are getting in way over their heads.
One of the major decisions that must be made is whether or not you will retain ownership of the dictation system. While at first glance this would seem to be a way of cutting capital expenditures and annual maintenance costs for the HIM department, you are in effect handing over all control of your health care facility’s documentation input process. If the MTS does not deliver a quality product within TATs, you will have the ability to aim the voice in a different direction. Since many health care organizations are planning to have voice integrated into the clinical workstations, you should seek IS support for an open architecture digital voice system on an NT platform.
The RFP process could take an entire issue of ADVANCE to describe. So assuming that you have reviewed all proposals, invited all qualified bidders in for presentations and finally selected a service that meets all of your requirements, it’s time to sit down with your new partners and develop an implementation plan and timetable.
Develop a detailed implementation plan with a realistic timetable. This is the first step in solidifying a working partnership with your newly selected MTS.
According to Mr. Seale, “All aspects must be considered, defined, analyzed and procedures put in place to resolve any unforeseen problems. Again, this is a time to make your expectations implicitly clear to the MTS.
The two problem areas that are most likely to surface are: 1) disparities between expectations and reality; and 2) lack of understanding of the method of counting and, therefore, billing for transcription completed. By forging a strong partnership and putting into place a mechanism for bringing problems to light, finding reasonable solutions and then following up to make certain that the actions taken truly do resolve the problems, outsourcing can become 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 American Health Information Management Association (AHIMA) meeting, I questioned representatives from the Health Care Financing Administration (HCFA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) about the need for quality monitoring of outsourced services. Both representatives responded that there would be an increased emphasis placed on assuring quality at all levels of the health care delivery network. In particular, they emphasized that facilities would have to show proof of having performed quality assurance monitoring on any and all outsourced work.
In the June 9, 1997, issue of Modern Healthcare, an article titled, “HCFA Report Criticizes Kaiser Hospitals,” specifically lists one of the violations as being, “The hospital doesn’t evaluate performance of its outsourced services.”
All too often, the contract fails to define a measurable level of acceptable quality or a means for monitoring the attainment or failure to meet the quality requirements. It is very important for the HIM department to receive frequent (bi-weekly at first, then monthly or quarterly) quality assurance reports on an agreed upon percentage of all work transcribed. In most cases, 98 percent accuracy is required at a minimum and once that level is attained, then 5 percent of the total transcribed documents are chosen for random audit.
But, and this is a very big “BUT,” you—the HIM department—must perform some type of routine review of quality of all outsourced services. This means that you either must retain an experienced transcriptionist or a team of transcriptionists, in the case of large facilities, who are qualified to perform quality assurance, or you must hire a qualified consultant to do it for you.
A process must be in place for identifying a problem, recommending a solution and making certain that the solution has worked and quality has returned to an acceptable level… that is the standard continuous quality improvement/total quality management method.
In summary, a successful transition to outsourced transcription can be attained without losing your mind or your job in the process. Gather accurate data, empower a project team and project coordinator, prepare an RFP with a balance between expectations and reality, develop a realistic implementation plan and timetable, partner with your MTS, establish a problem-solving framework and make quality a priority from day one.
* About the author: Catherine S. Baxter, president of Health Info Transitions, has been involved in the health care industry since 1971. She is considered an expert in medical transcription and is a member of AHIMA, AAMT, ASTM and HL7.