November 22, 2010

Establishing Reality-Based Turnaround Times
By Elizabeth S. Roop
For The Record
Vol. 22 No. 21 P. 10

Multiple factors come into play when healthcare organizations define what they can reasonably expect from transcription vendors.

Establishing appropriate turnaround times (TATs) has always been an important negotiation point between hospitals and medical transcription service organizations (MTSOs). Today, however, the growing prevalence of EHRs and the steady march toward real-time information access has made the speed and consistency with which an MTSO can deliver quality transcriptions more critical than ever.

“Turnaround time is critical, especially as we’re moving more and more toward EHRs and real-time patient care decisions,” says Susan M. Lucci, RHIT, CMT, AHDI-F, vice president of field operations for Webmedx and a past president of the Association for Healthcare Documentation Integrity (AHDI). “In the contract environment, we have to consider not just historical turnaround times but the here and now. Let’s face it—our needs in almost every walk of life are different from 10 years ago. We have to constantly be reevaluating the needs of the facilities.”

Also raising the profile of TATs is their impact on a hospital’s bottom line, most notably the role they play in accelerating the billing cycle.

“It is one of the key service levels and an area where a client can certainly have pain [because] it impacts the billing process, patient care, and physician satisfaction,” says Sharon Fremer, vice president of transcription for Precyse Solutions. “Transcription is the start of the process for patient care and coding or billing. It’s critical.”

Given their wide-ranging, multifaceted impact, achieving the appropriate balance between speed, quality, and consistency with TAT service-level agreements is crucial. Success, however, can be elusive if proper weight is not given to facility demographics, volume, and clinician dictation practices.

Speed vs. Quality
One of the first things hospitals must establish is how much quality they are willing to sacrifice for speed. Taking that one step further, they must also come to grips with just how much they are willing to pay if both are top priority.

According to Bob Thomas, an HIM consultant for transcription and computer-assisted coding, most hospitals demand three things from their MTSOs: high quality, the ability to meet TATs, and affordability.

“Think of it as a triangle. If you shorten any one of those sides, it affects the others. If you shorten turnaround time, it affects quality,” he says. “Something has to give. You can’t cut costs without quality or turnaround times suffering.”

This does not mean hospitals requiring fast TATs should expect shoddy work. Rather, hospitals should be honest with themselves and their MTSOs about their real expectations and compromise on ways to achieve them.

For example, if both high quality and high speed are expected, then the hospital should be willing to pay a premium to ensure the MTSO can meet those needs. Or if fast turnaround and lower costs are crucial, then they might agree that quality assurance audits won’t be conducted on all transcriptions, which could mean a dip in quality—provided it does not decline to unreasonable levels.

“Turnaround time, as important as it is, should take a backseat to quality of content,” says Lucci. “You should never compromise on having it fast over having it right. Make sure that quality comes first and then make sure that turnaround time is being met. That is one of those things that should be foremost.”

Facility Characteristics
Another equally important aspect of negotiating TATs is addressing any unique facility characteristics that impact the types of reports, frequency, required skill levels, and staffing fluctuations. Central to this is the hospital type and specialty mix.

For example, a community hospital is likely to have fewer complex reports than an academic medical center. Facilities with high-level trauma services will require a higher volume of fast TATs than those with lower level or no trauma care.

“One of the key steps in setting up any vendor program is to establish thoughtfully the required TAT for each work type and specialty. In most cases, the patient workflow in the facility will determine TAT requirements for each work type,” says Robin Lloyd, vice president and general manager of Nuance Transcription Services.

In most cases, pre-op, history and physical (H&P), emergency, neurology, cardiology, and radiology reports require a much faster TAT than other types. Meanwhile, level 4 and 5 trauma reports add a higher level of complexity to the time constraints.

Dictation for other services simply takes longer. Thus, when negotiating TATs, hospitals need “to be sensitive to the issues that are important to them and define them in the contract. If orthopedic surgery H&P reports need to be a priority, that has to be spelled out. The clearer you are in contract negotiations with your expectations, the fewer surprises there are for either side,” says Thomas.

On the MTSO side, Lucci recommends establishing higher priority levels for those specialties that consistently demand higher TATs. Assigning transcriptionists with higher and/or specialty-specific skill levels can also help ensure TAT needs are met.

“You can have a good mix of people who are geared toward just a few specialties and some that are really good at them all, but you set the work types to those quick turnaround times so [reports] are getting back to the hospital quickly,” she says.

Expect the Unexpected
Another area where MTSOs can be tripped up on TATs is when a hospital experiences fluctuations in volume or unexpected capacity disruptions. In many cases, cyclical peaks and valleys can be anticipated based on historical volume. In other cases, it may be due to an unexpected event such as a flu outbreak or a natural disaster.

Most MTSOs can manage a 10% to15% spike in volume. The problem occurs when volumes increase beyond that manageable range. When they are cyclical in nature, such as an influx of seasonal admissions, fluctuations can and should be anticipated in contract negotiations and plans established to manage them.

“By modeling typical dictation loads and clearly communicating any seasonal or predictable volume variability, vendors and customers can plan capacity more precisely and ensure the highest possible TAT performance,” says Lloyd.

Brenda J. Hurley, CMT, AHDI-F, a medical transcription industry consultant, notes that there are two scenarios where volume fluctuations are particularly difficult to absorb. First is when a hospital outsources all transcription and, as a result, has no in-house staff to pick up the slack.

Second is when an MTSO is supplementing the in-house staff to manage normal overflow. This becomes problematic when MTSOs are expected to cover times when in-house staffing levels decrease due to vacations or other absences.

“That part maybe wasn’t explained to the service because the volume didn’t change for the facility but it did for the service. It really becomes a squeeze,” Hurley notes. “Those are areas where communication is essential. Clarify those expectations; assuming is always a problem on either side. Services don’t have 20 MTs sitting around waiting to go to work on your account just because you have a lot of staff out.”

Hurley recommends establishing contingency plans addressing both the hospital and the MTSO actions that can be quickly deployed when volume peaks. For example, bringing in additional staff or adjusting report priority levels are solid strategies.

In some cases, adjustments simply can’t be made quickly enough. In those instances, “you have to be contractually fair to an MTSO that is now flooded with work that wasn’t a typical volume level, so you’ll want to develop a plan for catching up,” says Hurley, who notes that HIPAA now requires all business associates to have a disaster recovery plan—something every client should ask about.

“Contingency planning, emergency mode operations, and disaster recovery are part of the elements of the HIPAA security rule, so as a business associate, you should have a plan B,” she says. “In the past you could just say you had adequate safeguards. That doesn’t make it anymore. HIPAA is much more specific.”

Managing Clinician Practices
There’s another contributing factor to unexpected volume fluctuations: clinicians themselves. Busy clinicians often wait to complete all dictation at one time or simply avoid it until they cannot put it off any longer, causing a surge in reports.

“It’s really about understanding physician scheduling and behavior, and that comes over time,” says Fremer. “For example, who are the heavy dictators? What hours do they typically work? Some hospitals may also send out delinquency notices to physicians who are behind, so you can anticipate a bump in volume.”

Those are the times when communication is critical. When clinician expectations from transcription services are not being met, it can cause even solid client-vendor relationships to implode. That is particularly true when the client representative is unaware of an issue a clinician may be having with TATs, whether that dissatisfaction is the fault of poor service from the MTSO or caused by a clinician’s own dictation behaviors.

Thomas urges clients to establish proactive relationships with their clinicians. This helps avoid nasty surprises and ensures that clinicians are aware of how the quality of their own dictation can impact the speed with which they receive their reports.

“That’s very important because the biggest problem is being reactive to the medical staff instead of proactive,” he says. “You don’t want a reaction from the medical staff to be ‘I needed this’ when you had no idea it wasn’t being met. A report from the transcription company on turnaround times is very important to have. I would want daily access to the transcription supervisor or HIM of the turnaround times and what was and wasn’t being met. The worst thing is to have someone in your organization point out something you weren’t aware of when they think you have a handle on it.”

That kind of proactive approach to TATs can also reveal areas where processes or clinician behaviors could be improved. For example, if dictation is done via a cell phone with bad reception, it will take longer to transcribe and the chance for error is much higher.

Anther common problem that can cause delays is clinicians providing wrong report codes. Missing, incomplete, or inaccurate patient demographic information can also be problematic.

“Basically, it’s making sure that all the information is provided and correct. When that doesn’t happen, delays are just par for the course,” says Lucci. “It goes back to this: If I’m really in a hurry for my record, the more information I provide on the front end, the more clearly I dictate, the more quickly I will get my records. It’s all about connecting the dots.”

Reality-Based Negotiations
When it comes to establishing TATs, clearly defined expectations are crucial. For that to translate into service-level agreements that deliver maximum performance, transparency is a must.

MTSOs should request and hospitals should provide the historical data necessary to set minimum and maximum volume levels. This information will also help identify cyclical fluctuations that will require staff adjustments.

“Hospitals can help maximize TAT performance in two ways,” Lloyd says. “The first is to share all available data on volume trends, seasonal fluctuations, and planned or known events that impact dictation volumes. This information is critical to allow effective capacity planning by a selected vendor. The second is to avoid using vendors for ‘start/stop’ or overflow work. These types of outsourcing arrangements are extremely difficult to support consistently, as volumes can vary wildly from day to day.”

It’s also necessary to clearly define how TATs will be calculated. In most cases, “real” is superior to “average.” This is because when TAT is presented as an average, early TATs will offset those that are late, leaving the client with the impression that TATs are being met.

“Let’s say TAT is eight hours. If you have 100 reports during the measurement time frame and 50 of them arrive on time or early and 50 arrive late, you could get an average TAT of about eight hours, which isn’t too bad from an average standpoint,” Lucci explains. “But when, in fact, 50% of the reports were late, that isn’t the goal hospitals contracted for and are counting on. While this may not be a significant issue for some work types, for others, next-care decisions may depend on it. ‘True’ TAT will always give you a more accurate picture of how well or how poorly TAT is being met.”

More Recommendations
Industry experts offer other tips on how to manage TAT, including the following:

• Establish whether transcription work can be outsourced offshore and make any necessary accommodations to ensure TAT can be met if it will not be.

• Clearly define penalties for nonperformance as well as any “cure” period during which service can be brought back up to par. Also consider specifying rewards for outstanding performance.

• Conduct due diligence, including checking MTSO references with case mix and TATs similar to what will be expected.

• Select an MTSO appropriately sized for the expected demand and ensure it has the resources to handle fluctuations.

“That is the biggest red flag and what gets vendors in the most trouble. They try to cover up for their inefficiencies. You’re going to be found out one way or another … so be up front about your capabilities,” says Thomas. “You can’t be unrealistic about your capacity. A bad name in the transcription industry is the worst thing you can have. It doesn’t take much to get one, and it takes a long time to repair. I’d rather turn away work than take on work that I can’t do.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.