Speech Technologies and Its Impact on Clinical Decision Making Rose Reedy, BSN, RN, C and JAMES ZADINSKY, MS Case Study: Dwight David Eisenhower Army Medical Center This case study provides an overview of one military treatment facility's (MTF) approach to process improvement leading to business process re-engineering, and the process to monitor and track the effectiveness of change. The case study reviews mapping and monitoring strategies success factors as well as potential barriers to a successful process re-engineering implementation effort. Managed care penetration within the Military Health System (MHS) became significant in the 1990's and has increased over the past years. The need to provide excellent health care in a timely and cost efficient manner as well as the resulting reductions in reimbursement for services forced many MTFs to look at how services were being delivered and what those services cost. In response to regional economic dynamics, Dwight David Eisenhower Army Medical Center (DDEAMC) undertook a process re-engineering initiative called RAD-CSR (Radiology - Computer Speech Recognition). The reengineering initiative, which started in December of 1997, culminated with a commitment to reduce three full time support positions (annual cost to the facility of $ 100K) by 31 March 1998 from the department of radiology. A multidisciplinary quality improvement team (MQIT) was used to help navigate through Radiology’s process improvement phase. DDEAMC dedicated a team of six internal staff members to work as the process improvement team throughout the scope of the project. The composition of the team: ! Health Care Administrator (HCA) ! Officer in Charge (OIC), Department of Radiology ! Non-Commissioned Officer in Charge (NCOIC), Department of Radiology ! Informatics Nurse ! Database Administrator (DBA), Composite Health Care System (CHCS) ! Network Manager for the facility's local area network (LAN). Eisenhower Army Medical Center has adopted the FOCUS-PDCA approach for improving organizational performance. The FOCUS-PDCA approach refers to an approach whereby the activities of a process are captured utilizing graphical models. 9 The FOCUS-PDCA approach provides a systematic means for capturing and representing processes while, at the same time, providing a framework for making changes to those processes in order to maximize opportunities for success. FOCUS-PDCA takes a full life-cycle approach that encompasses strategic plan implementation, process reengineering, and technology deployment all of which are coordinated and integrated through the use of a change management infrastructure. A principal goal of the MTF is to promote process improvement efforts specifically related to improvement in efficient healthcare delivery. Process improvement will be accomplished by improving the integration of
existing methods, tools, and techniques and enhancing their use in patient care delivery through the use of emerging information technologies. FOCUS-PDCA refers to an approach to process improvement that takes a comprehensive approach to improving performance by: ! F focusing on an area to improve; focal point: Availability of Radiology Reports • organize an interdisciplinary team: MQIT ! C clarify the process or function to improve: Exam interpretation-report generation ! U understand process variation: Exam interpretation-report generation ! S select the process to be improved; specify: Report Generation ! P plan an approach to implement change; blueprint: Process Re-engineering Design ! D do – implement change; execute blueprint: Project Implementation ! C check – evaluate the changed process; audit: Incident Mapping and Analysis ! A act – continue with the effective change, or re-evaluate and continue new process: Analysis The roles of data and other resources help explain the interdependent behavioral relationships between activities that make up a process. An examination of these interdependent relationships helps one to understand the impact of making a change in one area of the organization. The process, Report Generation, like any process, has its own variables. We evaluated four components: • Input: Data used to produce an output • Control: Data that converts inputs to outputs • Output: Data produced by the activity • System: Resources that provide energy to, or perform, the activity; typically people Examples of each of the following components are as follows: • Input: Physician Order, Procedure Scheduled, Exam completed • Control: Radiologist views and interprets film and dictates results, transcriptionist enters report into CHCS • Output: Radiology Report Verified/Available • System: Administrative, Radiologist, and Medical Staff Five areas of process variation were initially identified. These five areas are related to waiting for action, sitting in a queue, thus the need for streamlining the report generation process (Figure 2) . Since the department of Radiology decided to make a change to the process, Report Generation, the model required that changes be made not only to the other processes but also to how the transactions occur between those processes. Therefore, the department of radiology now requires the radiologist to directly enter their results into CHCS (i.e., a change in the Control: Radiologist interprets films -> enters results in CHCS; on the System: Administrative and Radiologist-> medical transcription position eliminated and Radiologist enters results by dictating
directly into CHCS; and on the process: Report generation -> dictation of results and verify transcription of report in one encounter) (Figure 3) , this, in turn, impacted the process: Radiology Report Completion. With radiologists now required to enter results directly into CHCS, the department of radiology was able to redesign the process so that the review, editing and correction of transcriptions were performed by the dictating/interpreting radiologist. Through the identification and analysis of each process that made up a process and its related components, the department of radiology was able to better understand the relationships between processes and the impact of changes to any of those processes or processes. Understanding these interdependencies had a profound effect on helping the department of radiology successfully manage change. Although the radiologists acquired several steps in the process deemed to be clerical, the end result of faster turn-around time for reports validates the worth of the process (Figure 4) . This approach to process improvement allowed us to not only analyze the existing operations but also to explore alternative ways to redesign processes to improve organizational performance. The MHS had proven methods for deploying process re-engineering from inception of the program through implementation planning. However, there were no proven cost reductions monitoring and mapping models that DDEAMC could assimilate for its implementation phase. Literature research indicated that initiatives that failed did so during the implementation phase, where cost reductions were a lower percentage of what was originally agreed to during process re-engineering. There had to be a strategy developed to track the progress of DDEAMC’s process re-engineering implementation phase and cost reductions/avoidance that would result from its re-engineering efforts. Projected cost reductions/avoidance had to be compared to actual implementation practices to assure cost reductions occur. A system was needed to determine where slippage was occurring during its process re-engineering efforts and for what reasons slippage was occurring. It became apparent during the first three months of implementation that outputs from the measurement and mapping systems were key to DDEAMC leadership’s success in achieving cost reduction goals. This case study of DDEAMC Radiology starts with process reengineering and cycles through to tracking and monitoring of approved cost savings ideas that preempts business as usual for more effective services and lower costs. There are important factors to the success of any process re-engineering program. We have focused on those essentials that assure cost reductions occur. The following fundamentals are addressed within this case study: • Essentials needed for a successful process re-engineering program. • Approach taken by DDEAMC in defining components for mapping and monitoring. • Critical reports and monitoring tools used during implementation. • Communication of reports/steps took to analyze and evaluate implementation. • Potential barriers to implementation.
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