Paperless scheduling and inspection solutions work for PAML

July 1, 2010

All of our scheduling information is now in one place.

MLO: Rosalee Allan, tell us what PAML “looks like.” Has it grown since initial implementation of the scheduling solution? How many outreach labs do you currently have? At what point in this growth process did you finally throw up your hands and say, “Enough!” What specific problems had you encountered by this time, and how did you even begin to search for a solution?

Allan: PAML has more than 1,500 employees working in hundreds of locations across the western U.S. Since we implemented a scheduling software solution several years ago, we have added about 25% more employees. PAML currently performs outreach in its main geographical area, and is a founder of five outreach joint ventures with hospitals in central and western Washington, north and south Idaho, and Utah. We have 42 patient service centers (specimen-collection sites) (PSCs), 68 physician office labs, and run more than 150 courier routes.

We came across the scheduling solution from our affiliation with the hospital across the street whose CEO was a strong advocate for the related product he had purchased for the hospital pharmacy. He liked the outcomes it was achieving. The scheduling product was being adapted for other service lines, and the lab seemed a natural fit. So, PAML was asked to be a beta site for the newly developed product.

Prior to this solution, we heard many complaints about scheduling. There was no standardization, and everything was done on paper. Although we required supervisors to post employee schedules, many leaders did not post schedules at all or posted them on such short notice that employees did not have enough time to make plans. Requesting vacations was an outright battle in some departments. I saw everything, from employees complaining about being denied, to a supervisor requesting five temporary positions so she could let everyone who asked potentially take vacation at the same time — hence, she did not need to say no to anyone.

MLO: In another corner of Spokane, John and Nancy Janzen were plying their software trade beginning in 1996. When did you being developing your staff scheduling and inspection-compliance software? Had you been involved in similar activities with other organizations prior to this time?

It takes a progressive, forward-thinking laboratory to work with a development firm to try to build something “from scratch.”

How did you become interested in these particular phases of healthcare IT? Is this type of software your primary focus, or have you developed other types of software for different types of operations problems?

Nancy Janzen: Our software company was formed in 1996. We began developing healthcare-specific, Software-as-a-Service (SaaS) scheduling tools in 2001. Our lab solutions went into development in 2006. We had worked heavily with Microsoft in the late 1990s, providing them with custom enterprise solutions for software testing. Our solutions have always been driven by enterprise database system design with Web-based user interface. We migrated to healthcare in early 2002 when a large health system in our area came calling and wanted to migrate our scheduling solutions for hospitality to their pharmacy department. We never went back to hospitality.

Our solutions have always been architected to be deployed and supported on the Web. We have been developing in this environment for more than 10 years, so our software is extremely stable and robust. Many software vendors are desperately trying to migrate their desktop applications to a more Web-based model, and I do not blame them. The problem is, that creates instability with their code base and is a tough transition to make if they did not start with a foundational code base written in Web-languages. Our business focus is and has been labs for the past five years. We are working with additional departments within health systems, such as radiology and nursing, as they often become aware of our solutions through labs which often bring innovative solutions into health systems.

John Janzen: We have built a reputation around delivering software solutions that work, even for the software issues that are difficult to solve. We naturally migrated toward healthcare, partially because the software issues are difficult in healthcare and partially because Spokane has a strong healthcare community with which to work. The company has produced solutions in a broad array of industries. For the first five or six years, we would work in any industry that needed solutions. We did a lot of work at Microsoft, marketing, and engineering companies. But there has always been a healthcare bent. Since 2002, we have focused more exclusively on healthcare.

MLO: How did you three meet? How long did it take you to “tweak” a software program for Rosalee — or did she buy something straight off the shelf? What “tips” would you give to the lab representative and to the software developer for working together toward a solution?

Allan: That CEO from the local hospital introduced us. When we agreed to be a beta version, the software was working well in other service lines in hospitals but had not been adapted yet for the nuances in a laboratory. It took several months and significant input from my managers to evolve the lab-specific scheduling from what we had at the beginning to what you see today. I would say the solution has been developed by laboratorians for the specific needs of our industry.

We designed our scheduling solution in 2002 for the hospitality market … migrated to healthcare when a large health system … wanted to migrate our scheduling solutions for hospitality to pharmacy …
we never went back to hospitality.

Four of my managers agreed to use the software: processing, patient services (phlebotomy), logistics, and client services. After we began using the solution, Nancy and John were great about taking our critique and making improvements. What my leadership team did well was to identify what we needed and then prioritize, listing items that were “deal breakers” down to “nice to have.” This allowed John to work first on the items that were the most important to us and deliver those quickly. When I first meet with a software developer, I do not want to see “vapor ware” or future state of the software being presented by a well-trained sales person. I would always rather meet with the technical expert who developed the solution and has pride of ownership in what he or she has created, someone who has intimate knowledge of what it can and cannot do.

Nancy Janzen: It takes a progressive, forward-thinking lab to work with a development firm to build something “from scratch.” Our software solution is a fully developed, lab-specific solution that has been developed with labs and for labs, and that has an established presence with respected laboratory clients.

If a laboratory is looking to build a custom solution of any kind with a software partner, there are several things to look for. Both the laboratory and the software vendor should have a record of accomplishment of working on collaborative projects. Software development is not unlike building a house where there are several entities that each play a role in building a successful, finished product with a great deal of information-sharing and creative collaboration going on among all parties.

There should be a good fit with the teams as they come together in terms of working styles, communication, and good reputations. There should be established reporting and meeting schedules in advance so the flow of information back and forth is understood and anticipated. Fees should be discussed in detail as well as what happens if the project runs into issues with the budget, in addition to deadlines and timelines.

Ideally, work with a development firm that builds software in a more 'iterative' fashion with development and payment done in chunks or projects — as opposed to paying the entire lump sum in advance and then not speaking with the developer again for six months.

John Janzen: The dominant future trend of software development will be the cooperative development effort similar to what we accomplished with the scheduling solution at PAML. Currently, software tends to be developed exclusively by vendors or exclusively by an internal development group. Combining efforts leads to solutions that are more efficient, cost effective, focused, and intuitive.

The first meeting for a cooperative effort is critical. The developer must demonstrate he is bringing something tangible to the table, not just a willingness to sell a product. The first meeting should establish a realistic timeline, an early first delivery that will provide productivity improvement for the laboratory, and — most importantly — a willingness to listen and learn. The developer must overcome the communication and productivity gridlock that seems to plague the software-development industry. My tips for the laboratory representative is, hold the developer to these standards. Expect a realistic timeline communicated in real-world terms. Demand an early return on investment but also be patient with the iterative process.

MLO: What sort of implementation/training did Rosalee require for her operation? How long did the implementation of the software and the training of her staff take? Does your team train everyone on their software products, or is the software program designed so that lab staff can train new employees on the spot? In terms of costs, just how “economical” is this type of software in comparison to the “old way” (paper, pencil, eraser, bulletin boards, and tacks) of scheduling and/or meeting inspection compliance — do you have some sort of financial reporting on the actual savings?

Allan: Each scheduling supervisor must be trained, and I will let Nancy answer how this is done more fully. As far as return on investment, we documented $16,000 per year savings from saved time in scheduling and from overtime savings. This was before our 25% growth.

Nancy Janzen: One important distinction to point out is that our scheduling solution is a Web-based or SaaS solution— also called “cloud computing.” This means that the software is accessed via the Internet and is not deployed directly onto lab computers or within the LIS. This allows us to get staff trained very quickly, as lab IT staff do not handle installations as there are no installations physically in the lab environment.

We provide what is called the Quickstart program for the full set-up of the software license and training of the staff. This is done virtually, so we utilize Web-X-like technologies to connect computers and conference-call technologies. We provide the full training of all administrators who will be using the software and that is part of a standard deployment. We do not send folks off with a new license and then a 1-800 support number.

Lab clients access their specific licenses via the Internet, and all data resides on our fully secure servers in Washington state. An average implementation of a license for a group of up to five administrators is two to three months with a total of 10 to15 hours total spent in the Quickstart setup and training. This can obviously be done quicker than the two- to three-month window, but we have found that lab staff are extremely busy and about once-a-week meetings are all we can squeeze in with folks.

Quickstart is a six-phase process with each phase lasting roughly two hours. These are the average times and lengths we experienced initially at PAML, and they are lower now due to the large number of staff using our scheduling software at PAML and the familiarity so many staff members and administrators already have with the solution. Each license of the product is customized by the administrators and staff using that license, so we do the custom setup for that reason and also help with training so they can they be on their own, using the software daily, making changes, adding new employees, and other things.

In terms of cost savings, most of our clients utilizing either our scheduling or inspection software programs experience, on average, a 50% reduction in the multiple tasks related to scheduling, including time actually spent producing schedules, processing leave forms, e-mails and phone calls being answered, and responding to in-office visits. Some labs experience the complete elimination of certain tasks and responsibilities, and recognize an even greater timesaving than 50%. Other significant return-on-investment experiences include increased employee morale, fewer dropped shifts, better control of overtime, better recruiting and retention opportunities, tidy inspections, and reduced paper storage and usage.

There are also opportunities for growth that are realized by utilizing the scheduling program which Muir Lab staff at the John Muir Health System in the [San Francisco] Bay area recognized that was recently detailed in a case study completed in April 2010. The lab indicated it would have been unable to continue with the rapid growth in its outreach program without that software.

John Janzen: As software continues to grow more sophisticated, training and implementation become larger issues. We see this every day in the workplace, from spreadsheet tools like Excel to massive resource-planning tools like SAP (systems, applications, and products). In five seconds, one person could finish s spreadsheet entry that might take his neighbor five minutes to do because he knows some trick or configuration or short cut. One reason SaaS gets so much attention these days is that it addresses this very issue. SaaS is not sold off the shelf. It does not arrive as a disk in a package waiting for you to figure out what to do next. I like to compare it to an airplane waiting at the gate with the pilot in the cockpit working away. The pilot is just as committed to a successful trip as the traveler. It is a service; software experts take care of the software, training experts take care of training — and not just when you purchase the software. These experts are there as long as you use the software or need the training.

MLO: Many of the people we have interviewed over the years have started out in lab medicine and ended up doing things like building laboratory furniture or becoming architects who design labs. Why did you, Nancy and John, decide to focus solely on the laboratory market? How did you get involved with this particular segment of healthcare? Do either of you have a background in laboratory medicine?

Nancy Janzen: We initially designed our scheduling solution back in 2002 for the hospitality market. Word of mouth about the success of the program spread to the medical community here in Spokane, and we were asked to customize the product for the pharmacy market. We eventually dropped the hospitality market completely and have focused solely on healthcare since late 2002 and on laboratories since 2006.

The core competencies of our company are focused on software development and customer support. We rely on our laboratory partners, such as PAML and John Muir, to provide the laboratory expertise and the insider's perspective to help us continually develop the solution for the changing needs of the laboratory market. We also like to partner with other businesses already in the laboratory market with other products to provide sales and marketing expertise. We are in the process of forming relationships such as that in the laboratory space.

John Janzen: Neither of us have a background in laboratory medicine. I did work for an HMO as a programmer many years ago. But that is as close as we have come to working for healthcare organizations. My college degree is in electrical engineering, so I guess I have transitioned but not out of healthcare.

MLO: What about you, Rosalee? You have a bachelor's degree in healthcare financial management from Whitworth — did you know about software solutions like Nancy and John's when you entered the field? How different does this type of IT aid make your work at PAML compared to past years when you did not have access to this solution? Would you explain how this solution was viewed by employees, and how it has changed their morale?

Allan: Yes, I have a degree in healthcare financial management; but I also have a have a rich background in human resources (HR) and was director of human resources at PAML for 16 years before taking on the COO role more than 10 years ago. I still maintain my membership in the Society for Human Resources Management and also maintain my Professional HR certification. When I worked day to day in HR, there was also no standard way for employees to request time off and no way to assess what days might have the best chance for their requests to be approved.

Although scheduling applications exist, none that I had seen were tailored to the specific needs of different healthcare service lines. Outreach laboratory as a business requires what I call “one-for-one” staffing. For instance, when short-staffed, it is not acceptable not to provide a phlebotomist for a day or to close a patient services site … and couriers have to be on their routes so that all specimens are transported in a timely manner. This makes laboratory-staff scheduling very stressful. Often, I would see supervisors doing desperate things to cover, including covering a vacancy themselves — to me, a sure sign of a department suffering because someone has poor scheduling abilities. Labs often train supervisors well in most other aspects of running their departments, but training them how to schedule is often non-existent. Ask and supervisors will tell you they are self taught and have developed their own processes.

PAML employees like being able to access predictable schedules from home, phone, or anywhere they have an Internet connection. Schedules are now published within a specific time. Employees can see which days already have multiple requests, then target their own request for a time when they will have the best chance of getting it approved. For those who would like extra time, their applications track this request, and the supervisor has a ready list of staff who are willing to cover when the demand outpaces the utility staff.

MLO: What about the inspection-ready aspect of this software — how has that improved PAML's ability to manage certification, training, annual competencies, compliance, overtime, and other staffing management tasks? Can you name two or three real obvious differences in the “before-and-after” of your experience?

Allan: One-stop shopping is the best feature. All of our scheduling information is now in one place. Before the new solution, it was on paper in multiple locations and difficult to track, review, and update. Inspectors are now used to seeing our automated solution. We no longer keep updated hard copies of the information at each site; considering we have more than 100 PSC and POL sites, this alone is quite an accomplishment. The solution automatically tracks and notifies users of items that need attention. The time managers and supervisors must take to oversee and document these items has been reduced significantly — they can now spend more of their time reviewing and improving processes, interacting with staff, and focusing on improved outcomes of their service. The new solution also has eliminated the big prep time for upcoming inspections — we have gained confidence that we are always “inspection ready” for all HR-related aspects. We are now working with the software support team on other inspection-related categories. Our overtime performance used to be at 3% for years, but we are now running closer to 2%.

MLO: Was this inspection-ready aspect of the software already built in, or did your software team design this after having met with PAML? It sounds as if this would be needed in every lab, so my suspicion is that the software existed prior to the Janzens' relationship with PAML. Do you “tweak” your software to suit individual labs? How often would programs such as your have to be updated? Is there a schedule for doing that among you and your clients?

Nancy Janzen: The idea of an inspection software program really developed in meetings with PAML in 2007-2008 as we wrapped up initial development with them on the scheduling project. They were so happy with that, Rosalee indicated that there were other significant challenges such as inspection data management that she wanted to tackle. After initial product development with PAML, we have also received critical beta-site feedback on our inspection software from Muir Lab in 2009 and 2010. We do not sit around our office and try to imagine what labs need next. We take our development and feature cues from our clients, and the idea for this product really originated at PAML. We believe we are world-class software partners in thinking of creative ways to solve the problems and challenges with which labs present us. Our clients are often amazed at how we take an idea one-step further and provide a solution that has a big 'wow' factor.

Each license that is opened for a laboratory group is customized with the data that is specific to that group, schedule, or job description (i.e., blood bank, microbiology, and others). The software code itself is not customized, but the software interface has been built to allow client-specific data to be entered through open data fields and pick lists. Options can also be selected to create patterns, set rules, policies, checklists, and so forth.

Upgrades are standard and also free-of-charge with a subscription to either the scheduling or the inspection programs. This is a standard benefit of most SaaS solutions on the market. We usually do upgrades at a minimum of once every quarter. Upgrades include new feature additions that have been requested, performance and speed changes, and other issues that we can fix remotely and push out to clients without having to do installations onsite. We do all of our upgrades late in the evenings so as not to impact our clients. They are notified a minimum of one-week in advance of our planned upgrades while the software is taken offline, on average from one to two hours.

John Janzen: We literally sat down with staff at PAML after our scheduling solution proved productive for them and asked, “What is another issue for which you would like to have a software solution?” The office we were sitting in at the time had one wall dedicated to shelves holding binders of personnel documentation related to inspections. In that meeting, we took on the challenge of producing a product that allowed a laboratory to be confident and constantly prepared for an unannounced inspection while reducing the paperwork by half or more. Much of the product already existed prior to this meeting because we own large amounts of reusable code from which we can draw. This has allowed rapid turnaround, which we have needed. We would deliver a new set of functionality to our beta sites, and a third of the features would be met with “I did not realize this could be done” features; another third would react with, “This makes no sense to me” features.

Through the beta process, we tweak features continuously; however, the software we build accommodates customization by design. I like to compare our software design to a keyed lock. In a keyed lock, there are typically five tumblers each of which can be set to one of five to seven settings. This lock design can secure door after door by adjusting the heights of the different tumblers. In our case, our software design can customize laboratory after laboratory by adjusting a dozen different settings across pre-built options.

MLO: What other programming is your company looking at in terms of servicing laboratories, if you can reveal that information? Have you had clients make suggestions for such projects? Where do you go to “show off” these products — trade shows like AACC in late July maybe?

Nancy Janzen: We are very focused right now on expanding the visibility of both scheduling and inspections products. We have spent considerable time developing very robust, elegant solutions that have been fully vetted by our beta sites and our current customer base. Our partners and clients continue to make suggestions on other significant operational challenges they face on a daily basis that could be addressed by software solutions built with similar methodologies and approaches as these two. So, yes, we have other projects in the works and always take the lead from our clients first. In the short term, however, we are focused on these two products and integration modules that are good next steps. Rosalee at PAML has great ideas and keeps us busy. We do plan to have a presence at AACC in late July, the Lab Quality Confab in November, and the Executive War College next spring (2011).

John Janzen: We believe the greatest concerns healthcare executives have today are staff related: finding and keeping good staff. We are pursuing a number of solutions related to this challenge and integrating these solutions into a flexible, comprehensive, intelligent suite of products.

MLO: Rosalee, do you have any new ideas in mind that might be candidates for software solutions, or are you fairly secure in what you currently have in-house? If you do, what are they and how soon do you expect a solution? Because it is hurricane season here in Florida, I am naturally thinking of “pandemic preparation” software, for example.

Allan: I think I was the catalyst for their inspection solution, as I could see the need. Once their scheduling solution was mastered, there was a need to know who the “right” person was who could be scheduled in any specific job for the day, whether it be a bench, a route, a patient services site, a courier, and so on. So when scheduling, there was a need to know if the person had been oriented, completed their training, had their competency checked, had the appropriate licensure and certificates, and such. These are the items that are checked during an inspection, and we took on a philosophy in our organization that we would always be “inspection ready.”

The list could go on and on with new ideas which I could dream up. I am a firm believer that after any process has been around for a while, it needs to be reviewed and improved. Then we need to work on automating it. Ask anyone. I have been pushing our organization to go paperless for several years, so anywhere I see paper and paper handling is where I see opportunity for software or middleware solutions. I hand out an annual “Shredder Award” for the leader who is nominated and voted by his or her peers as having made a significant reduction in paper or paper handling. Some amazing initiatives have happened. The winner is awarded a funky statue but, in addition, wins a personal laptop.

As far as new ideas, not only would a pandemic-preparation application be great but also anything to do with business-continuity planning, disaster recovery, FMLA, COBRA, compliance, pre-authorization, pre-employment screening. The list goes on.

MLO: Would something like “pandemic preparation” checklists or something akin to that be fodder for a laboratory-software solution?

Nancy Janzen: Our beta sites and key clients have all kinds of ideas on expanding the scheduling and inspection programs as well as completely new modules and products. Healthcare, in general, has been slower to move to digital solutions than other markets, so there are still very significant business and operational challenges where well-designed software can create significant budgetary and resource savings such as those being experienced by our current clients. Rosalee alone is not short on great ideas and others continue to flow in from our other very progressive, forward-thinking clients who have taken the step toward digital solutions for these tough operational challenges.

John Janzen: Our inspection product design allows for custom checklists in addition to the standard CAP, CLIA, and ISO checklists already handled. Furthermore, if someone comes up with a great idea like a “pandemic preparation” checklist, he or she can produce that within the inspection software and export that list to share with others. All the product features of documentation, reporting, assigning responsibilities, education, planning, and monitoring function equally across all checklists, pre-installed or custom. So … great idea, pandemic preparation. Let's do it!

MLO: Thank you, all three of you, for being part of this informative interview.