Involving vendors in continuous quality improvement efforts.

San Jose Medical Center began a formal CQI initiative in 1991 with several management projects. As a result of work done in our emergency department, which analyzed our Patient Call Back Process, the turnaround time (TAT) for radiology reports was selected for study. This study revealed several steps in the production of the report that did not add value but did prolong the TAT significantly. With a major restructuring of the process to make it more effective, a dramatic improvement was demonstrated (see figure 1 on page 39).

[FIGURE 1 OMITTED]

At the successful conclusion of our first cycle, the team decided to "hold the gains" and begin our second cycle after our radiology information system had been installed. The selection of the system had been undertaken before our CPI team had begun its work, and the details of the implementation process had not been an area of interest or concern to our team.

Installation of the system began with the usual interaction between vendor and client. As is often the case, delays occurred and unexpected problems arose. The result was a marked deterioration in our radiology report TAT. Perhaps this deterioration could not have been avoided, but involvement of a vendor representative with our CPI team prior to implementation would have ensured that our manual process was understood and that the new computerized process would deliver the same or better TAT. With our knowledge of our process and the vendor's experience from other installations, the personnel requirements necessary to maintain an adequate TAT during the implementation phase could have been predicted more accurately.

Subsequently, another process that had been under study by a CQI team was to be dramatically changed by an outside vendor. The process was the production of a treatment authorization request (TAR), and the vendor was the State of California in the form of a nurse reviewer from the Medi-Cal field office. The nurse reviewer was invited to join the team to review our process and to educate team members as to the changes that would be required to accommodate her participation in TAR processing. On-site review would require a new cycle time concept within our process. All Medi-Cal admissions through midnight on Monday had to be processed internally to be ready for review by the nurse during her Tuesday visit. Similarly, subsequent admissions through midnight on Thursday had to be ready by her Friday visit.

Because of this effort to incorporate our vendor and adapt our process to the requirements of the Medi-Cal nurse reviewer, the transition was relatively smooth and was understood by all team members. In addition, the nurse reviewer was able to provide the team with important information on Medi-Cal documentation requirements when there is another state agency as the primary payer. Also, important information was exchanged related to Medi-Cal codes for payment of service to aliens and to available databases that made Medi-Cal verification a less complex task than it had been in our original process definition.

Delivery of health care services is under constant review at most hospitals. As patient-focused care models are explored and financial constraints make out-sourcing and vendor contracts more attractive, it is important that the process knowledge of CPI teams be utilized to monitor the necessary transitions. Of equal importance is vendor knowledge and experience in adapting products or services into multiple hospital environments, each with a different internal process. Key elements in vendor involvement in CQI activities are show in figure 2, below. Application of the supplier-customer relationship in the circumstances described has been beneficial to both the hospital and vendors, with increased efficiency and effectiveness. Participation of hospital vendors in such efforts is one way to identify high-quality suppliers.

Figure 2. How to Involve Suppliers with CQI Teams

* Management must be aware of the scope and key quality characteristics of multidisciplinary team efforts.

* Contracts and RFPs must include requests for documentation of suppliers' measures of their own key processes.

* All business plans for new services, technology, or outsourcing should include cost of poor quality analysis.

* Contracts an RFPs should require a statement of the supplier's willingness to participate in appropriate CQI team efforts.

* Management must look on multidisciplinary teams as an important resource in making decisions regarding supplier selection.

* The owner or team evaluating an important process must be willing to include outside suppliers, with consideration of their time constraints.

* Supplier input can be either intermittent or continuous, as appropriate.

* Supplier/team interaction is a two-way street to benefit both parties.

Mary C. McDevitt, MD, is Medical Director, Clinical Outcomes Research and Management, Good Samaritan Health System, San Jose, Calif.