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December 2013

How to Address Transcription Fluctuations
By Susan Chapman
For The Record
Vol. 25 No. 16 P. 18

The up-and-down nature of workflow presents severe challenges to department managers.

Advances in technology are transforming the medical transcription industry, creating fluctuations in dictation volumes. Managing this unstable and unpredictable workflow presents challenges to managers of back-end transcription departments who must quickly transcribe dictation and furnish documents to EMRs and waiting clinicians while also balancing the economics and morale of an efficient workforce.

In the past, physicians and clinical staff generally dictated everything that had to be documented in the medical record. However, as practitioners begin to adopt technology such as front-end speech recognition, documents now are generated as they are dictated and then distributed to the EMR and authorized colleagues. “As an illustration, my department used to transcribe stress tests and echocardiograms,” says Cheryl Klopcic, RN, BSN, CMT, transcription supervisor at Southern Illinois Healthcare. “However, in the past five to six years, that process has gone by the wayside and is done in a system that creates documents in real time. We also used to transcribe endoscopy reports. Now those, too, are done in a system where the physician creates the report concurrently with the surgery, capturing images and sending them to the EMR. These changes affect staffing and, when volumes decrease, undoubtedly, staffing needs to be analyzed.”

Timing significantly affects workflow stability. For example, on Mondays, Klopcic’s department has more available personnel than it has work. On days when there are fewer projects, known as low-census days, some medical transcriptionists (MTs) will take those days off. “When there is not enough work, they can take vacation time or time without pay,” she says.

Heather Steinfeld, senior director of US transcription operations for Nuance, oversees a team that works with an on-demand, enterprisewide medical transcription platform that includes an integrated back-end speech recognition solution. Medical language specialists (MLSs), who work on specific accounts, perform more like editors than transcriptionists. “Like any highly transactional-based business, we have ebbs and flows within the business,” she says. “Most MLSs have schedules aligned with the incoming volume; however, there are some [especially as volumes change over time] that have schedules misaligned with the workflow of their account.

“In those cases, they may have to adjust their schedules or work with their managers to find an account that better aligns with their shifts. Our MLSs are closely connected with their managers, who send out communications to alert them of both influxes and drops in volume,” she adds. “During holidays, for example, there are fewer physicians dictating. In the summer months, new residents get deployed into their rotations and don’t have speech profiles built yet in front-end speech recognition solutions, which means that more back-end transcription is required.”

Maintaining Morale
Decreases in work volume significantly impact staff morale. Because some MTs are paid based on production, they are not earning wages if they are not typing or editing. Generally home based in the United States and abroad, MTs log into their respective work systems daily to see whether there are projects available. Fluctuating backlogs can cause anxiety for those individuals who want and expect to work. “I keep abreast of transcription blogs and listservs, and see a great deal of distress over the lack of work available and a great deal of comments about it, particularly on days with no work,” Klopcic says.

 “We try to ensure that our staffing is in place,” says Johnna Shook, director of transcription operations support at Precyse. “We try to look at the amount of minutes of dictation coming in per client. There is a formula that we use based on an average line per hour that they would type. From this, we try to determine and staff accordingly. Still, we don’t always know when there will be decreases in volumes. Internally, we use the term ‘NJA’—no jobs available. When we have those high volumes of NJA, that’s when we have morale issues.”

Dismayed MTs can take steps to combat a lack of work. “When our colleagues experience NJA, they are instructed to reach out to their workflow coordinators or their managers for reassignment to a different account,” Shook says. “Our workflow coordinators are trained to look at the trends and see if they are affecting the colleague’s shift consistently and, if they find those trends, they will make recommendations for changing schedules to the manager and colleague to minimize the amount of NJA.”

As part of the process, Precyse allows MTs to “flex.” “When NJA is reported by an MT, our workflow coordinators will assess whether the colleague can be moved to a different account based on their level of skill and experience and whether or not they are qualified,” Shook says. “If the workflow coordinators cannot identify additional work or the colleague does not meet the quality assurance criteria for the account, they are advised to log off and can optionally check back in later during their shift to see if there is work available.”

To help ameliorate morale issues, Klopcic strives to be transparent with her team members and share everything she knows about the changing landscape so they know what to expect and no one feels like she is hiding something. “As the industry began to transform a couple of years ago, I encouraged staff to move in a new direction,” she says. “Some started training for other areas of HIM and at least one is transitioning to an entirely new profession.”

Steinfeld says MLSs can get frustrated with workflow changes, which also results in a drop in morale. “When workflow is heavy, overtime may be requested of our MLSs or extra hours from our part-time MLSs,” she says. “For example, if the census is high at a hospital, we try to plan for it. But work can also be slow, and that is equally frustrating. To help ease these issues, an experienced MLS can create a strategy for seasonality changes. When overtime is available, I would advise MLSs to take advantage of it as a hedge against inevitable but seasonally planned slower times.”

Workflow Management
According to Klopcic, there are several ways to manage the number of full-time employees needed to address workflow fluctuations. “The first method is to determine the total volume of work and divide it by the standard number of lines per hour,” she explains. “Some managers look at this monthly, yearly, or even biannually to determine if staffing levels are adequate or need adjustment.”

For example, assume a department requires 160 lines per hour. An MT working at such a pace would transcribe roughly 1,200 lines per day, or 24,000 lines per month. If a manager knows the monthly volume is 200,000 lines per month, then approximately nine employees would be needed to complete the required volume.

Precyse analyzes data on an hourly basis. “Our workflow coordinators analyze trends in an effort to forecast when we might see increases and/or spikes in our volumes,” Shook explains. “For example, due to seasonal activities, in Florida, we may see an increase in hospital stays and physician visits when snowbirds travel there in the winter. For the bigger picture, we analyze on a week-over-week, month-over-month, and year-over-year basis to track and understand trends so we can plan accordingly. What we know with certainty, despite some trends we can see, is that there is no scientific method to managing workflow overall because it can be all over the board.”

Managing workflow in an internal transcription department—one within a hospital facility or health system—is different than doing so in a medical transcription service organization such as Precyse. With a wide book of business from varying clients, Shook says, “Our teams are regionalized. There is a north, south, and west region with a group of clients and colleagues associated with that region. Therefore, when we look at our analysis, we do so from a regional perspective, keeping in mind we may need to make adjustments on the fly as the volumes fluctuate regionally. For instance, earlier this year, there were pockets of a flu epidemic on the West Coast, which increased our volumes in the west region. So we had to shift our colleagues around so that we could continue to meet clients’ needs in the west yet keep a proper balance in the other regions. It’s generally feast or famine. Very rarely do we find ourselves at an overall, balanced level.”

Mandates from the Centers for Medicare & Medicaid Services, The Joint Commission, and other agencies can require short turnaround times, which also affect staffing. “It may take five MTs 24 hours to complete 100 reports; however, it could take up to eight MTs to turn those same reports around in five hours,” Klopcic says. “To relate this to an everyday experience, imagine you own a dry cleaning business. The staff you have can meet most of the customers’ needs and have the dry cleaning available for pickup in a few days. But if a customer comes in with 50 shirts that need to be pressed in four hours, then the current staff would not be able to meet that demand. It would become especially difficult if such a scenario became a daily occurrence.”

Supervisors and schedulers have found other creative ways to successfully address irregular workflow. Klopcic recommends creating a policy or guideline that details the procedure if work volume is low. Another effective management tool is to ask for volunteers. “I have found there is usually someone who would want time off if the backlog of dictation is low,” Klopcic says. “Some staff may have more earned time off than others, and this can be taken into consideration to a degree while maintaining fairness.”

Establishing a standby schedule also can be beneficial, she adds. For example, managers can create a schedule for each day of the month, placing two people daily on standby for a low-census day. Having a visible, shared schedule allows the entire department to see that everyone is included and scheduled. Additionally, MTs can plan for days when they have off.

“Another option is to ask staff to split up their shifts to take advantage of times when volume picks up,” Klopcic says. “I find many staff willing to do this. Or, when work volume is low, you can ask everyone who is scheduled either to start late or stop early.”

Nuance has a somewhat easier time finding immediate solutions for their MLSs because of the scalability of a large client base. If they lose work to front-end solutions, workflow managers can provide MLSs with a new primary account or a different backup account because of a robust sales force that helps bring in new, ongoing clients.

Tips for Effective Management
Klopcic has created a plan to help managers cope when work volume is low. “First, I would say that it’s important not to overreact and then not have enough people to get the work done,” she says. “Stay calm and analyze such factors as who already has scheduled time off and the hospital census to see if the patient load is low. Encourage a few MTs to log off the system and check back in later to see if work is available. If work continues to be low, consider having staff listen to and review reports already done on dictators they have difficulty with or learn a new work type. Plan ahead if at all possible; for example, if volume is low at 8 PM, then not as many staff will likely be needed the following morning.

“One very important thing that staff need to understand is the nature of a medical transcription department and how it is dependent upon assuring the number of staff working is adequate to meet the turnaround time targets,” Klopcic adds. “Unfortunately, it is something that is difficult to judge and cannot be predicted, no more than a nursing supervisor can predict how many patients will be on his or her unit the next day. It’s a daily assessment and judgment call that only someone with some insight into the business can make.”

Economic Factors
To maintain a steady income, MTs sometimes work for more than one company or have other part-time jobs. Other MTs may have full-time jobs and do transcription on the side as a way to earn additional income. “For example, there are MLSs who are retired and don’t want to stop working,” Steinfeld says. “They like the benefits of working from home so that they don’t have to go into an office. The part-time hours enable them to have money for their grandchildren and/or travel.”

As the industry transforms, MTs are enhancing their training in traditional fields—general transcription, anatomy, pharmacology, and physiology—while also learning how to edit dictation from front-end programs.

According to Steinfeld, Nuance hires workers who have broad training and general experience, although the company does serve accounts with specialized needs. “We also have a proprietary training program that we recently launched: ENRICH, a free e-learning portal available to all Nuance MLSs,” she says. “We encourage our employees to engage in continuing education by participating in the program’s specialized learning modules to help them invest in their educations and have profitable, long-range careers.”

Klopcic supports that line of thinking. “Continuing education is very important,” she says. “As MTs, managers, and transcription departments and companies in general, we have to remain flexible and adapt to these changing times in our profession in a variety of ways. We have to constantly remind ourselves to think outside the box, be open to suggestions, and use our creativity. If we try new ideas that don’t work, we have to be willing to go back to square one. We don’t know what to expect from this profession. But while we can’t control the wind, we can certainly adjust our sails.”

— Susan Chapman is a freelance writer based in Los Angeles.