A Complete Guide to Discovering,Validating and Funding an On-Call Management System for your Hospital
OVERVIEWDemand for Automation
The healthcare industry is undergoing a significant shift with not only increasing federal regulations, but also rising consumer expectations. Healthcare consumers already are looking around the corner when they will schedule doctors' visits and review their medication histories online as easily as they order airline tickets and view itineraries. The travel, banking, and retail industries already have made the transition. Healthcare is next. The American College of Physicians released a report in 2009 on controlling healthcare costs while promoting the best outcomes, providing these recommendations for the future:
- Reduce avoidable, ineffective, and duplicate use of services
- Ensure an appropriate physician workforce specialty mix
- Reduce administrative costs
- Reduce costs from medical malpractice and defensive medicine
Each of these has a direct relationship to physicians and on-call scheduling in hospitals and clinics.
A Shift in Scheduling
Scheduling physicians with paper can no longer can keep up with today’s healthcare demand. Healthcare is changing and technology is taking center stage. Electronic Medical Records is just the beginning. A demand for automation , cost reduction and less duplication also has led an increasing number of hospitals to seek a better on-call management system to enhance both efficiency and patient care when trying to find and activate the on-call physician.
The shift from manual call schedule creation to using specialized software is driven by:
- Schedules are more complex than they used to be. This is due to many doctors are negotiating their schedule as part of their
employment contracts and to the merging of practices.
- Schedulers must prove fairness and equity. Providers prefer more flexible schedules and protect their free time. This makes the accuracy and fairness of the after hours call schedule is more important than ever.
- Physicians create the schedules. The complexity of the schedules and the political nature of building a schedule has shift the responsibility of on-call schedules to away from an hourly administrative assistant to the practice administrator or managing
- Too many changes. Doctors want changes pushed to their smartphones and hospitals want changes sent electronically. This type of automation requires specialized software.
BEFORE YOU BEGIN
The process to go from paper to automation doesn’t happen overnight. It takes careful evaluation and planning of your situation. This article is designed to help you:
- Determine if your hospital is ready for an electronic on-call management system.
- Understand how to gain buy in within your organization.
- Develop a process for evaluating options.
- Creating a system focused on results.
DEFINITIONS & DIFFERENCES
Call Schedule Creation, On-Call Management and Telecom
There are significant differences between software that a clinic or group of providers uses to create, maintain and communicate their on-call schedule and what a hospital needs to effectively manage and activate the on-call information they receive from clinics. Here’s a look at what they are and how they are different:
- On-Call Scheduling Software: On-call scheduling software is designed with the physicians clinical practice in mind. It primarily focuses on making it easier for an individual to create the routine and after hour’s on-call schedule for physicians. To facilitate the process, this software may allow clinics to create custom rules, a scheduling engine, availability notification, day-off tracker, and reports to prove fairness. It’s also common for this software to provide varying calendar displays, smart phone integration, and the ability to import and export schedules.
- On-Call Management Software: On-call management software takes the scheduling process to the next level. It is designed as an integrated communication system that combines the on-call schedules throughout a medical community. Users can selectively
pull certain jobs out and automatically display them by service in a complete merged daily view, without having to manually enter individual schedule oncall information.
This software typically has robust schedule change features that allow clinic call schedulers to make changes and have them automatically appear on the hospital’s daily call sheet and authorized hospital users to make changes after hours and weekends to the daily call schedule while sending communications back to the clinic scheduler so that all of the information is in sync. A good system will also have lock-out features that prevent anyone from making changes to the call schedule within a certain period of time before the on-call shift starts to avoid a gap in coverage and a possible EMTALA violation. An on-call management system does not always include activation tools such as paging or secure text messaging the doctor.
- Telecommunications Hardware: An on-call telecommunications tool is typically a small module installed in a phone system to allow operators and clinic schedulers to manually enter only on-call jobs that are directly associated with the hospital. Each change needs
to be manually entered. This extra step can be avoided if the local hospital has their phone system integrated with their on-call management system. Some telecom software companies work directly with Telecommunication Departments within hospitals, but their solutions are limited to data entry system. Users manually enter certain on-call jobs into their system so that an operator can page the correct doctor. This lack in direct connection between the scheduler and physicians create communication issues and the related on-call problems.
Telecommunication software may be very useful in certain situations; it’s just not call scheduling software or even on-call management software. It is best used as a way to manually enter daily on-call information so that the operator can see who is on-call and page the doctor without having to switch screens.
Hospitals and health systems can eliminate the problems associated with compiling spreadsheets of schedules from the area clinics into a three-ring binder at the hospital. The solution is as easy as using on-call schedule creation software that is integrated into the on-call management system. Here are two questions to ask when evaluating which solution best meets your needs?
- What problem are you trying to solve? Answering this question is the first step in identifying the priorities and determining
the essential features you need to operate effectively. If you desire to create a schedule for your doctors, then on-call creation software likely would for your clinic. If you need manage multiple schedules, then an on-call management would best fit your needs. If you’re trying to page a doctor then a telecommunications solution could suffice.
- Who needs to be helped the most? This is the question most often not asked. The result is unsatisfied physicians and inefficient processes. Determine who should most benefit from the solution really challenges organizations to weigh physicians, who generate much of the revenue, the clinics that refer patients to the hospital for large procedures, and a single department.
PROBLEM IDENTIFICATION & VALIDATION
The process to transition your hospital from a paper-based three-ring-binder on-call system to a technology based system is a much simpler transition than you might think. It’s all about a process.
Here are 11 specific steps to follow to discover if you should make the move:
- Assemble a small committee to discuss the problem. This committee should have broad representation with executive leadership,
medical staff, as well as professionals from nursing, IT and telecommunications. Set the ground rules and goals upfront. The sole purpose of this first meeting is discovery. Participants should not try to diagnose or solve the problem. It’s important to stay focused on listening and trying to learn more about the problem.
- Set-up a 1 hour meeting to discuss the current process. Conversations at this meeting need to center around what’s happening today. Try hard not to talk about the future. During this meeting, create a flow chart that outlines the current process all the way from the clinic generating the schedule to the hospital generating the daily call roster. Then, gain input on likes and dislikes – or what’s going well and what’s can be improved.
- Determine who’s affected by the change.Now that you understand the detailed process, identify all of the areas within the
organizations that this issue comes in contact with every day. A representative from those groups likely is already at the table as a committee member. But if there are any gaps, be sure to invite them next time.
- Determine if a change is needed. You have gathered the information. Now, it’s time to determine if what you discovered warrants a change. Lay out the facts and ask the committee to answer this question: “Should this be a priority?”
- Set-up a meeting with top leadership. During this meeting, briefly go through the committee’s initial discovery and ask for permission to validate the initial findings. Essentially, you’re saying, “I think there is a problem, should I look into this further?” This allows you to understand it in the broader scope of priorities for the organization. Although it may be a large problem, it may be less of a problem than other large problems. So if the answer is “hold-off,” be patient and revisit later. Not-now does not mean not-ever.
- Validate the findings. If you get the go-ahead, the next step is to validate the initial findings from the committee. Can you get others to say similar things that you heard during your initial discovery meeting? This is the time to gather more information about how-often things happen and what the effects are when they happen. Whenever possible, attach a dollar amount to a symptom.
- Present the facts. With additional information in hand, schedule a second meeting with the vice president to review the results. Stick to the facts and allow the vice president to decide if this is a problem to be addressed, tabled or killed. Remember, you are still not yet solving the problem; you are just all agreeing that you don’t like how it is being done today.
- Identify vendors. The most common ways hospitals accomplish this are by either asking colleagues for recommendations or conducting a search on the Internet. If you choose the latter, it’s important to use the search term “on-call management” to help hone the results. On-call management is different than call scheduling. Most hospitals don’t create call schedules. They manage 20 or more of them from the clinics in their community.
- Gain ideas on solutions. When contacting vendors, tell the sales professional about your problem and listen for ideas about possible solutions. Unless you want something custom built for your hospital, avoid going into the conversation with a specific solution in mind. You need to understand the problem – not the solution. That’s what a good vendor does well. (We’ll share steps on selecting a vendor in the next section).
- Take the test drive. Once, you have identified solutions that match your problems, ask the vendors to give you a brief show-and-tell demo and provide preliminary pricing. This step becomes the deciding factor for many and it rarely comes down to dollars. The features and flexibility can deliver a significant ROI faster than most organizations expect. You don’t need to select a vendor yet.
- Create an action plan. With research and recommendations in hand, meet with the vice president to determine the next steps and gaining budget approval. This is often the most challenging part, given all the priorities and initiatives a hospital balances. But this often is set a part because it improves both physician satisfaction and patient care – core tenants of any hospital. It’s important that you clearly articulate that and show you have physician support. Consider bringing the committee together for this meeting to help gain the final buy-in and funding needed for this project.
It may take everything you have not to designing a new system while learning about what the old system won’t do. But resist the temptation and stay focused on a long-term solution. It’s essential that others clearly understand the problem before you implement a new solution. The difference between projects that get budgeted and those that don’t isn’t always need. It’s really about the magnitude of the problem.
SELECTING THE RIGHT SOLUTION
What's the right solution?
So the problem has been identified and now it’s time to find the right solution. Sometimes choosing a supplier or service provider is as simple as asking respected colleagues who they use in their business. Other times, a more formal selection process is in order. During the discovery process outlined previously, you identified a few potential candidates. You conducted an initial review of the solution and their approaches. It’s important to identify three vendors that appear to be best suited to solve your problem. Then, compare.
The challenge is that you cannot compare them apples to apples. The key is to stay focused on the problem you need solved and find the best solution for it here are key steps to take during the selection process:
- Re-review the problem to be sure everyone is still on the same page and nothing has changed regarding the size and scope
- Identify the step in the decision making process in your hospital for vendor selection
- List the people who need to be involved
- Set criteria
The best way to set criteria is to identify the top three things that each user group needs to accomplish for the project to be considered a success. For example:
- Information Systems may be concerned about minimal downtime of the system, daily back-up of system data, and end user training and support.
- Telecommunications may be concerned about the ability to auto-generate a Daily Call Sheet, ability to easily make changes to the schedule after hours, and the ability to have a log of changes made to the schedule.
- The Emergency Department may be concerned about the accuracy of information, protocol and phone number information, and 24 hour lock-out/ EMTALA mitigation.
Once the criteria and goals have been established, set up an online demonstration where the vendors can each demonstrate the top three things that each user group needs to accomplish for project success. This demonstration should be done virtually at this point and take no more than 1 hour. Give each vendor 40 minutes to demonstrate and allow the group 20 minutes to ask questions.
Then, it’s time understand each vendor pricing model. The industry has not standardized itself so the pricing models vary greatly.
When you’re ready to make a decision, invite the top two vendors to your site for a demonstration and discussion with a broader group, including:
- The Committee
- Potential users from each defined user group
- Vice president level person who’s budget this project will come out of
- Physician representative (VPMA or CMIO would be good candidates)
After you and your colleagues meet both vendor candidates and listen to the demonstrations and value propositions, it is time to choose your favorite based on what is best for the organization. Vendor selection does not mean that a project will move forward, it just means that now you are ready to secure your budget. Keep in mind that you need to assemble the right leadership on the hospital end in order to be taken seriously from your vendors. The sales process is expensive for vendors to participate in. From a business perspective they only want to work with prospects that they feel they have a chance at winning the business. If you do not have decision makers at your demos or provide access to them before or after, you may have a difficult time finding vendors to participate in the process. If decision makers do not have time to meet with qualified vendors, then vendors are concerned the problem is not big enough and will probably not get funded.
Now is the time to be sure that your top needs can and will be meeting with the choice you make. It’s important to manage the wish list and focus on the core needs to keep the project focused and able to be implemented in a timely manner.
How do you pay for it?
Understanding the problem, identifying the solution and choosing a vendor take work and dedication. They all play into building the foundation for funding. Getting the project funded is the real test. You know it’s the right move, so how do you make it happen? The answer lies in understanding the four "P's" - people, process, priority and problem. Here’s a look at each and how they tie together.
Every hospital has a clear process and procedure for initiating a new project like an on-call management system. Understanding the process is the first step. It’s important to know:
- Who needs to sponsor the project?
- What will you need to show in terms of a return?
- How long will it take to get approval?
- What if the project is denied?
Priorities direct an organization’s focus and resources. In many cases, these priorities and initiatives are agreed upon at the Board of Directors level. Begin by learning more about the top strategic priorities already set by the hospital. Assess how an on-call management system ties in to the goals and timelines of the priorities. Many organizations have initiatives around patient care and physician satisfaction and employee satisfaction. On-call management directly affects all of these areas. Here are a few ways hospitals build the case:
- When a patient is waiting in the Emergency Department, the time it takes the department to determine who the correct consulting physician is and notify the physician affects how long the patient has to wait before further testing, admission or discharge. Each time the department pages the wrong doctor due to misinformation on the call schedule, the quality of the patient experience is diminished and care can be compromised.
- Physicians are dissatisfied when they are called incorrectly due to an error in the call schedule. The level of dissatisfaction greatly increases in the evening and overnight if a physician is contacted when not on-duty.
- Telecom and Emergency Department administrative employees are often verbally reprimanded by the physician when they contact them incorrectly due to an error in the call schedule. This interaction leads to lower employee dissatisfaction and is a contributing factor to high turnover rates in these administrative type positions. Aligning with top initiatives is one of the most important
steps in the “funding” process. This is where you will clearly build your case as to why this project is more important than another project because it directly aligns with the organizations priorities, initiatives and goals.
Each project needs a “White Knight” or sponsor at the vice president level or higher that can help champion the project. This champion often coincides with the budget that will pay for the on-call management system. The IT budget is the most common, but hospitals also have regularly chosen the budgets for the Emergency Department and Medical Staff because of the outcomes the solution provides. Often, an influential doctor also steps in to help build the case with hospital leadership.
One of the last questions you will be asked by the budget committee is “what is the ROI?” Determining an ROI in projects like this can be complicated due to hard and soft costs. The key is communicating how much it is costing the hospital today to achieve undesired results.
When calculating costs, include all areas:
- Clinic person who creates the original call schedule
- Person at hospital in MSO that receives all schedules
- Person at hospital MSO that collates/organizes schedules
- Person at hospital MSO office that verifies accuracy of daily shifts
- Person at hospital who creates daily call roster
- Person at hospital who sends out daily call roster
- Person at hospital who manages changes to the schedule
- Person at hospital who communicates daily changes to the schedule
Hospitals often use flow-chart like the one below to illustrate their point.
Without understanding the budgeting process, positioning your project to align with the organizations priorities, getting the right people to assist you and having a clear understanding of what it costs today, your project will likely become cannon-fodder.
Do your homework, all projects are good projects, some are just better prepared for the budgeting process, make sure yours is one of the prepared.
How do you put it into practice?
Now that your project has been given the green light by administration, you can begin to plan the implementation. This can be the easiest part or the biggest headache, depending on your process. Here are 10 tips for a successful implementation by hospitals:
- Choose a project owner. Someone with decision-making authority needs to own this project so that there is an advocate within the hospital. It’s recommended that this person be the VPMA or another high-ranking official.
- Review objectives. Essentially, begin with the end in mind. Understanding – and staying focused – on why the hospital will benefit from the on-call project will help direct the action steps and remind everyone of its importance. It works well to focus on 3 key objectives to keep them top of mind throughout the process.
- Set-up an onsite kick-off meeting.
You will need the support of your project owner or the Vice President of Medical Affairs (VPMA) to help with this step. Begin by meeting with him and providing a draft of the announcement to be shared with all of the local clinic administrators or department chairs explaining the new on-call management initiative at the hospital. This communication should come with the VPMA or another executive and invite employees to participate at a kick-off meeting. It’s important that everyone attends. Follow up with leadership to ensure they are attending and ask the project owner to follow up if you have not heard from them.
- Host the kick-off meeting. At this one hour meeting, focus on clearly communicating the objective and sharing “why.” The group of administrators and physician schedulers should leave knowing the hospital has identified a solution to a challenge. It is important that the VPMA speak directly to the importance of the project. The goal is to gain initial buy-in. Focus on the second half of the presentation on showcasing the new system, the positive changes clinics, doctors and the hospital will see.
- Schedule training while on-site. Having a representative from the vendor on site during the kick-off meeting allows hospital leadership to direct questions and provides clarity. It also serves as the first introduction of the person who will train staff and help with implementation. Before schedulers leave the kick-off, it’s essential they sign up for their first training session. It works best to have these training sessions begin within a week of the kick-off meeting.
- Show progress. Training can take time, so it’s important to track and show progress during the process. One of the best ways to do that is through a webpage or online portal that lists all the clinics that need to be trained. Clinics start out with a red dot next to their name, when they complete training and agree to maintain their call schedule, the dot changes from red to green. When all of the dots are green, you can ready to go-live with your new on-call system. This provides a quick visual of progress. The team should review this progress page at least weekly to be certain the project is moving in the right direction.
- Address lagers. During this process, there will be some people who do not wish to take part in training. Because the system requires everyone’s information in the on-call system in order for it to be useful, the hospital will need to make a decision about how to handle this type of situation. Some hospitals will tie participation to the doctor’s hospital privileges; some will choose to manually enter the schedule for the uncooperative group and everything in between. The most important takeaway here is that you have a plan to deal with the uncooperative. Most projects will have about 10 percent of these types of users.
- Commit to updates. Any system is only as good as the information put into. All physician schedulers need to commit to accurately maintaining the call schedule. It is preferred to get a written sign off to ensure accountability. You also might even want to consider a policy that addresses what happens if the information is not kept up to date. You will want to monitor this closely for the first six months to be sure that everyone is doing what they committed to.
- Go live. Now you have this new great system fully populated with schedules from each of the clinics or departments. This project will be all-for-not if it is not announced properly and placed in a visible location on your Intranet. This is designed to be a self-serve system that all caregivers need to be aware of. Coordinate a meeting in advance of your launch date to discuss placement on the
Intranet with your IT or web team. Also discuss with your internal communications team how best promote it. The good news is that you should be able to track the traffic on the new system. Your traffic should steadily increase each day the system is up and running. If not, this may indicate a communication or location problem. Do not skip this step, if no one knows it exists or where it is located, it will likely not be used to its potential.
- Review results. While there is no perfect system, progress is important. Be sure to schedule a thorough review of the system to discuss successes and challenges six months and one year after the initial launch. Be sure to include all departments, such as ED, ICU, Labor and Delivery, Telecom and anyone else that has a lot of on-call request needs. Do not forget about direct care providers. It works well to survey nurses and physicians to be sure the system is meeting their needs. This is not only a great follow-up method, but it can also be a place where great new feature ideas come from. Never be afraid to ask what could be improved upon.