Breaking the Mold

By Kelly L. Weber

June/July 2008

In days gone by, the front lobby was the showcase of a hospital, but this is no longer the case.  Most potential customers interact with the healthcare system through telephone or Web before presenting to the brick and mortar business.  This change in how our customers choose a healthcare provider is making an impact on the importance attached to the call center.  The word is out.  Call centers have an impact on an organization and well-informed hospital administrators are taking notice.  More than ever, the call center is a consideration in strategic business decisions. 

The evolution is not complete, however.  We have traditionally lived in a small corner of the organization - providing referrals, nurse triage, registering classes, and recently, disease management.  While these are all viable programs, they focus narrowly on the clinical call center.

Six years ago, our call center management decided to break out of the mold.  We set a long-range goal to integrate all call centers within our organization.  We adopted a definition of a call center to include any place in our organization where three or more staff answered calls.  Looking back, we did not realize how ambitious our goal actually was.  Perhaps that worked in our favor.  It seemed very logical to us.  We had the call center technology and experience.  We considered ourselves the customer service experts in our organization.  We realized that the economy-of-scale and the focus of control would greatly benefit our organization.  For others who would follow us down this path, there are clearly challenges to overcome and rewards that make the journey well worth the effort.

While each hospital system has a different configuration, most have some of the same structure.  The most obvious and common feature is the switchboard, or PBX.  We all have them - the hospital operator.  Many hospitals also provide their own technical support and help desk services.  In most cases, technicians staff the help desk. 

I have two points to make here.  First, technicians are normally not trained in customer service, and it is not cost-effective to staff a call center with agents in their pay range.  Secondly, most hospitals have a medical service organization (MSO) or physician's clinics.  Someone is answering those calls and scheduling physician appointments.  Centralized scheduling is also applicable to outpatient diagnostic procedures, such as CTs or MRIs.  There are many other call centers in a hospital system as well, such as bed board, staffing office, and patient transportation.  The important point is that in the vast majority of hospitals, these informal call centers are not in an ACD environment or managed as call centers.

Focus of control is the first realized advantage of the centralized call center.  When there are multiple ways that calls can come into your hospital, there are multiple points that must be kept in the loop of information related to new programs and services.  Integration allows for ease of data collection on all call center statistics.  Integrating all these disparate call centers into a true contact center also removes the duplication of effort, both management and infrastructure.  The real advantages come from the blending of agents into multi-skilled agents.  This economy-of-scale produces cost savings in addition to better customer service. 

Ask yourself these questions about your organization:

• If a caller to the hospital switchboard asked for a referral to a physician, would your operator be able to provide a referral to one of your physicians and schedule the appointment?  

• Does a triage nurse taking a 2 a.m. call from the frantic mother of an ill pediatric patient have the ability to schedule an appointment with the child's pediatrician? 

• Does your mammogram scheduler have the information the caller wants about your hospital's diabetes education program? 

Your callers are seeking this level of customer service.  Are you providing it?

To illustrate the economy-of-scale in a blended call center, I will use Erlang-C.  For those not familiar, Erlang's formula is the call center industry's standard methodology used to calculate staffing levels.  If you want to peek at the formula, it looks like this:

Fortunately, many programs do the math for you when you plug in the input numbers.  In the table, I have shown the pertinent inputs to the formula and the resultant staffing needs according to the formula for some of the call centers we integrated.

 The table demonstrates the total staff required for a single-skill agent call center for the selected product lines would be 21.  If we approach the same call center with blended, multi-skilled agents, staffing levels change completely.  Using Erlang's formula, the blended call center that uses multi-skilled agents would need 12 agents, or approximately 40% less staff.  This is mind-boggling! 

To further illustrate this point, picture a funnel.  The amount of water that can be poured through the funnel is dependent on the size of the neck.  In a single skill call center, the funnel's neck is very small so fewer calls can get through.  This will result in calls backing up in the funnel, which we fondly refer to as the call queue.  In a multi-skilled call center, the neck of the funnel is much bigger, so the water (calls) does not back up in the queue. 

Moreover, Erlang's formula does not demonstrate other advantages of the blended call center, primarily in the area of adherence.  Call centers measure the amount of staff adherence to the schedule.  As we all know, staff get sick or have other unscheduled absences.  In other types of work, remaining staff can work faster or work extended hours to pick up the slack for the absent worker.  This is not true in call centers for several reasons.  First, if call center management is doing their job properly, they have already trimmed the machine to run as lean as possible. 

Second, and perhaps more importantly, we do not control our workflow.  Our customers decide when they are calling and are unlikely to respond positively to the suggestion that they call back after business hours to give us a chance to catch up.  For these reasons, adherence is important. 

Call center mangers measure and plan for agent adherence in their staffing models to minimize its impact.  In the table, three agents staff the physician referral center.  If one of those agents has an unscheduled absence, the neck of the funnel gets 33% smaller.  If the call center used multi-skilled agents, the neck would have only shrunk by one of 12 agents, or 8.3%. 

How does that affect your callers?  With single-skilled agents, service levels would drop from 95% of calls answered in 10 seconds to 90% of call answered in 40 seconds.  That difference is huge if you are the caller. 

In all honesty, there are factors that mitigate some of the cost savings.  Despite the Erlang's formula suggesting 12 agents, we will have to add a few more agents to make this work right.  We need to allow for additional ongoing training time for multi-skilled agents.  They have a more complex job and require a significantly broader knowledge base. 

It has been my experience that 16 agents would be more realistic.  The other offset to savings is that workers that are more skilled require higher wages to retain.  Just to crunch raw numbers, you effectively reduced staffing 24% by going from 21 agents to 16 (if you followed my suggestion), so even a significant wage increase still results in notable cost savings.

As I previously mentioned, there are obstacles to overcome.  These obstacles fall into several broad categories: technical, process, and resistance to integration.

Oddly enough, the technical challenges to integration are the easiest to address.  Each area has its own software application, and there is no guarantee of compatibility between applications.  These incompatibilities normally stem from common files shared by the different applications. 

Having a software vendor dedicated to your success is of incalculable value.  Consider vendors that have an excellent record of accomplishment in customer support.  When our hospital integrated the switchboard into the call center, they had no technology to assist them in their job.  Plainly stated, they looked up patients on a census printed at the beginning of each shift and looked up numbers out of six-inch behemoth binders.  Our vendor of choice for call distribution software was SDC's IntelliDESK.  Whether luck or wisdom drove that decision, it set a standard for all of our subsequent vendor selections. 

To be successful, your software vendor has to be an active partner in your mission, and SDC was from day one.  There are some cases where two applications are simply not compatible.  If you find yourself in this situation, consider running one of the applications in a thin-client or Citrix environment.

As you evaluate integration of an area, you may encounter poorly defined workflows.  They lack sufficient process definition, and the department will find it difficult to express how they complete day-today operations.  Do not think it will work itself out.  Job-shadow the staff that are currently performing the task.  Whiteboard the workflows already in place, and write out formal protocols. 

While this may be frustrating because these should have already been in place, you will fail if you do not have clear, concise protocols for your call center staff to follow.  "Gray areas" equate to poor outcomes and future headaches.  Physician appointment scheduling was such an area of focus for us.  We created a matrix which included all the physician appointment preferences that had not existed before.  I would like to tell you we implemented this matrix prior to centralization of physician appointment scheduling, but that would not be true.  This was one of our "hard lessons."

This brings us to the issue of resistance to integration.  There are departments that never wanted to be in the call center business, and they will welcome you enthusiastically, relieved to have the experts step in and take over.  Other times, not so much.  Be wary of integration pushed out by a mandate from upper management.  In such cases, you will often find yourself caught between the reform upper management is mandating and maintaining relationships with the department you are servicing. 

Our experiences have led us to approach such situations in the following way:  Invest the time it takes to establish a good rapport with the department for which you will be answering calls.  This is not a checkbox to be checked; it will take ongoing relationship management.  Do not fall into a pattern of fielding complaints for that department and simply reporting back to them.  Make frequent visits with that department, get their feedback, and take action on that feedback.  Create an issues list and actively pursue resolution to their issues.  They may not ever be happy with the mandate of integration, but you can get them to accept the changes if they feel you are a partner in accomplishing their operational mission. 

You should also consider investing in a recording solution.  Regardless of your internal customer's demeanor, there will be times when you receive complaints that require investigation.  Having the ability to pull up the recording of a call is the ultimate tool.  Call reports can show that a call came into your call center and documentation in the appropriate application is fine, but there will be times when the call documentation is questioned.  Listening to the call ends all speculation. 

Our hospital invested in a recording solution that has proven its worth time and time again.  Let me relate one recent example.  A patient showed up for a physician appointment that had been cancelled the day before.  The patient swore that they had not cancelled the appointment, and the doctor was furious about the impact to his schedule.  The physician wrote a strongly worded email to administration regarding the situation.  With our recording application, we were able to pull up the call of the patient cancelling the appointment the day prior and send it via email to the physician and administration.  Recording solutions offer the call center management useful quality assurance tools through random call evaluation programs and real time dashboard analytical data.

Our approach was to look for those call areas that were least resistant to integration and where the impact would be greatest.  By targeting these areas first, we were able to put some "wins" under our belt before tackling the more complex and less enthusiastic areas.  In fact, once word got out about our integration services, prospective departments approached us more often than we approached them. 

Call center management focuses on several key factors: efficiency, customer service, and marketing opportunities.  Healthcare call centers are no different.  We have defined ourselves as the customer service portals for our organizations.  What has been different between healthcare and other industries is that we have limited our scope within the entire organization.  The need for our expertise goes far beyond the areas in which we have confined ourselves.  In today's reality of stiffer healthcare competition and lower reimbursement, there is urgency for us to embrace the entire breadth of our organizations.  For if we are not willing to do so, who will?

Kelly Weber is a call center manager at a leading healthcare system in East Texas.  Since 1997, he has been involved with the ongoing evolution of the medical call center at East Texas Medical Center Regional Healthcare System.  Kelly brings together over two decades of experience in information technology and over fifteen years experience as a registered nurse, providing a unique perspective within his field.  Kelly is also a freelance author and can be reached at lorinex@suddenlink.net.