PCD Awards - PCD Solutions Category


Submission Deadline 1 August 2007 (before midnight GMT -4:00)

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PCD Solutions are intrinsic or embedded and exclusively focused on the business or organizational performance outcome in measurable ways.  For example, a PCD Outcome that replaces the interface of an enterprise application such that (a) the frequency of data entry errors is reduced; (b) the frequency of incomplete information entered into the system is reduced; (c) the speed with which data is entered is substantially increased; and (d) the need for any form of learning in advance of doing is substantially reduced or , preferably, eliminated is performance-centered.  

Entry Title ASK PA
Submitted by: Christensen/Roberts Solutions
Contact Name: Hal D. Christensen
Phone: 718-793-8935
E-mail: hchristensen@crsol.com
Address: 8 Lunar Drive
Woodbridge, CT  06525

Purpose: The ASK PA system was developed by Christensen/Roberts Solutions for the Patient Accounts Department of Memorial Sloan-Kettering Cancer Center (MSKCC); the renowned cancer diagnosis, treatment and research institution.  Memorial patients who have questions about their hospital bill call a single number and the Patient Accounts Inquiry unit is responsible for answering those calls. Many of the calls are fairly routine requests for clarification of items on the bill. Others are more complex, often stemming from the patient's misunderstanding of hospital or insurance company policies. The Patient Accounts Specialists must review and analyze the patient's accounts, explain their findings to the patient, and take whatever follow-up actions are appropriate to resolve the inquiry. This is a difficult job because of the complexity of insurance coverage, which varies from carrier to carrier.  To resolve the patient’s inquiry, the specialists must have an expertise in all areas of billing and collection irrespective of which insurance a patient has.

MSKCC places great importance in serving its patients and the proper handling of each call is important. Consequently it continually seeks to make its call handling as effective and efficient as possible. For that reason Patient Accounts asked C/RS to help it:
  • Reduce the amount of time the inquiry representatives spent trying to determine how to handle a patient's specific question. This meant reducing both the amount of time spent searching for information and resources and/or asking their Group Leader or Supervisor for help.
  • Increase the consistency in the answers the inquiry representatives provide to a patient. 
  • Increase the confidence level of the inquiry reps by providing immediate and detailed information on how to correctly respond to each type of inquiry. 
  • Reduce the amount of time it takes for new representatives to learn the job and be prepared to handle live patient calls.
  • Disseminate information to all staff members as soon as it is known.  Information includes any changes in procedures and policies and updates about health insurance company requirements and national and state government regulations.
  • Assist representatives from other Patient Account units who provide back-up when the call volume is high or in times of short staffing.  Since these staff members spend a small percentage of their time responding to phone inquiries, they generally do not have the level of expertise of the inquiry reps.




The solution C/RS developed, with Patient Accounts, called for the following:
  • Involve both the representatives and management in identifying, capturing, and codifying the workflows and best practices for review, analysis and response to each type of inquiry. 
  • Created a performance support system (ASK PA) that would simultaneously display: 
    • The workflows so that the reps can quickly view the entire flow and as well as identify each step in that flow.
    • Instructions for the precise actions, including alternative paths, for each step in each workflow.
    • Resources and tools for each step to facilitate carrying out those actions.
  • Make this performance support on-demand, immediately available to all reps, to be used both as the "official" reference for the workflows and as a step-by-step coach through them.
  • Make the interface simple enough so that reps can access and carry out the instructions they need while on the phone with the patient.
  • Make the content dynamic and easy to edit and create, ensuring that the administrator can update it daily as well as keep all reps posted of new changes.
  • Integrate the performance support into the training, both formal and informal, thereby reducing the need to create additional instructional materials and ensuring that new reps would become comfortable with it when they begin answering phone calls themselves.
The key element of the delivered solution was the ASK PA performance support system. In the initial phase, ASK PA addressed the five call types for which reps most frequently required assistance, as identified by the Group Leader and Supervisor. (PA plans to add additional call type workflows in the fall.) ASK PA was built within the structure provided by Contextware, from Contextware, Inc. Contextware’s technology allows businesses to capture and communicate the step-by-step detail of how to perform any business process, procedure or task. 

ASK PA was designed with a tri-panel interface for displaying the knowledge and resources the reps needed within the flow of each call type. The ASK PA menu presents each step in the workflow process. The reps can review the procedure from beginning to end or select an individual step. Each step contains detailed instructions on what to do and what to say as agreed to by management and the reps.  The details include contingency actions for the reps to take in response to additional questions asked by a patient or a finding from analysis of the account.  At the same time, ASK PA displays a list of links to resources (procedures, information, contacts, forms and tools) the rep might need to perform each task

A sample tri-panel ASK PA page

ASK PA was supplemented with a series of web-based exercises, which mimic patient calls and questions and require the rep to search through a simulation of the hospital computer systems for the answer. These were designed for use in training and preparing new reps for the responsibility of answering live patient calls, using ASK PA as a resource.

Creating the deliverables described above required a well-designed multi-faceted approach. The goal was to not only create the performance support solution but to use the development process to simultaneously address the key problems and issues.
  • All of the current reps were engaged in the process of refining and codifying the best procedures for the five workflows. To provide input, they had to consider, and articulate, each step that they currently followed.  In the review meetings, differences in approach were discussed and when necessary, management determined what should be the best practice.  
  • By participating in the development of ASK PA’s content, the reps had the chance to discuss all approaches and the reasoning behind them.  This produced support for the final workflow process among all staff members.
  • Once agreed upon, the approved flows were entered into the Contextware platform to create ASK PA. (Some enhancements to the platform were added to accommodate the institution's specific needs.) At that point, ASK PA became the single source for the correct way to handle call flows. 
  • Current reps use ASK PA for finding or validating answers; new reps use ASK PA in training and preparation for manning the phones and to walk them through procedures that they have not yet internalized.
  • The content in ASK PA is updated daily, and an e-mail feature is available to send suggestions or questions to the ASK administrator.  Based on the feedback, workflows may be revised or resources added.

Classification and state of deployment: 



How would you classify your PCD Solution?  Check one:

 Traditional EPSS - external or extrinsic "EPSS" solutions with designs rooted primarily in learning or reference

 X   Performance-centered workflow solution - any PCD solution with a focus on directly supporting business processes (aka workflow)

PCD makeover - solutions that replace existing user interfaces with ones that exhibit attribute and behaviors of performance-centered systems

Embedded/ intrinsic PCD solution - performer-centered solutions that are strictly embedded in the task context and focus on task completion - not learning - without breaking the task context or flow

PCD featuring innovative technology - any performance-centered solution that features technology other than just a user interface to enable or enhance performance

Other category (describe): 

This entry is (check one):    X In production (being used today in a live work setting)         In a formative stage (prototype, proof-of-concept, introduced a sample of its intended users)                   

Further details: 


  1. Supports performers through best practice processes. 
The process that was followed in identifying and articulating the workflows insured that all the participants--reps, supervisors, and management--contributed to determining the best practices and rules to follow. The assumption was that the reps, the front line in handling patients' questions, should have an equal voice in clarifying what practices were being followed and evaluating which ones should be identified as "best." Any inconsistencies among the representatives on how they were handling the calls, as well as between what management and the representatives viewed as the proper procedures, were brought to light and resolved. This ensured that the Best Practices would be identified and there would be agreement among the participants.
As representatives use ASK PA on the job they find the information they need in the context of those workflows. Each step in the procedure prompts the appropriate next step. A new representative can follow the flow, from the patient's call through to the resolution of the problem. More experienced reps can quickly locate the step in the flow they are on and immediately find instructions for how to proceed from that point. They can also use ASK PA to verify decisions they have made or actions they should take to complete the flow.

A sample flow menu showing both the overall flow and the steps within that flow. A hierarchial menu proved to be the most effective way to present the key paths and to facilitate recognition by the reps.

2. Establishes, or aids in establishing, goals.

The representative's goal is to serve the institution's patients by answering and resolving any problems they are having with their bills. In ASK PA the goal of the workflow is stated clearly and representatives are guided through the correct steps, branching where appropriate based on the specific circumstances of the patient's query. The instructions for each step place it within the context of previous steps, make clear what should be done, and clarify under what conditions this step should be performed.

A sample middle panel with instructions for completing this step. Note the Where you are section to orient the rep to this step and the alternative paths depending on the patient's insurance.

3. Minimizes terminology translation or interpretation.

The terminology used in ASK PA is consistent with both what the reps would know and what the patient is likely to understand. This makes it easier for the representative to communicate complex rules, acronyms, and medical/insurance terminology to an audience that is likely to have difficulty understanding them. This is particularly important because the patients are often under stress due to the nature of their medical illness.

The program also contains a glossary, which the representative may use to help clarify difficult terms or concepts even further.

A typical glossary entry

4. Provides access to supporting and learning resources.

The principle behind ASK PA is to provide a single page that simultaneously gives the reps:
  1. The exact Knowledge of what actions to take,
  2. The precise set of Resources and tools they need to help them to do it, 
  3. The Context within the current workflow for taking those actions .
Consequently, the resources thart are displayed on the page are directly related to the flow and current step. The reps do not have to search for the links to supporting resources or wade through a long list of resources that are not appropriate for the step they are one.

A sample right-panel list of one-click links to relevant resources for the current step    

A sample resource: a list of codes that reps frequently reference, made instantly available

5.  Focuses on task(s), processes, and the natural flow of work.

The flow of the work is always visible through the hierarchal menu in the left-hand panel of the screen. Representatives who are unfamiliar with the workflow can easily follow it from beginning to the end. If the representative has a question about how to proceed on a specific step within the workflow, he or she can quickly click on that step to display the instructions needed. Within the instructions for completing each step are warnings to alert the representatives of potential problems or to make sure that certain conditions apply before going down a specific path.

A sample opening page for a workflow. Note that ASK PA
states the purpose of the flow and provides a summary of the steps.

Continual use of ASK PA ensures that the representatives will eventually internalize the workflow and have less need to reference the workflows they have learned in this implicit manner--somewhat in the way a child learning to ride a bicycle eventually weans herself from a set of training wheels. But the reps can still return to ASK PA for quick access to the enabling resources. And, because they are continually alerted to changes to the workflows through the administrator's daily updates, reps will return to ASK PA to ensure they are following the latest instructions.

6.  Reduces or eliminates the need for training/learning.

The structure of the content in ASK PA mimics the flow and the goals of the work. This reduces the amount of cognitive effort needed to understand and remember the flows and the steps within those flows. Consequently, the use of the program continually reinforces the proper flow. After the reps have used ASK PA a few times, the knowledge becomes internalized. What they did not know before, they learn while doing.

Because of the great importance the hospital places on serving its patients as effectively as possibly, and because the representatives' job demands a variety of skills specifically related to departmental procedures and insurance requirements, the department requires that new reps spend time becoming familiar and comfortable with the job before beginning to take live calls. ASK PA reduces that orientation period in several ways:
  • New reps are able to access and review the flows and steps in ASK PA at any time, knowing it is the accurate source of the knowledge they will need to master.
  • New reps can begin to take live calls without having to memorize all of the content they may need to handle patients' queries. They can quickly look up and follow the correct actions or access the resources they need in ASK PA while on the phone with a patient.
  • New reps use ASK PA during the training simulations to answer any questions they have, ensuring that they will become familiar with the workflows, the step-by-step actions required, and the appropriate resources for carrying out those actions. They will also become comfortable with using ASK PA to support their interactions with patients.

A sample page from a simulation of call flows. Note that the learner is directed to ASK for assistance.

7.  Supports performance FIRST, and learning only as a secondary consequence of doing.

ASK PA exhibits all three essential elements of performance:   
  • The organization of the knowledge in the program reflects and supports each step of the process workflow. 
  • The representatives have considerable flexibility in their use of the ASK PA, depending on their own experience with the flow of the call they are currently handling. They may choose to 
    • follow the flow from beginning to end while working with the patient
    • skip to the specific step on which they have a problem or question
    • check in ASK PA to validate the action they will be taking
    • launch an appropriate resource to assist them in completing the goal.
  • The information presented in the ASK PA represents the essential data, information, and knowledge the reps need to satisfactorily respond to the patient's question.
All three of these elements work together to ensure maximum performance and a minimum of confusion and error.

8.  Is innovative with respect to supporting performance. 

ASK PA is remarkable for its efficiency, both in presenting the precise support needed at precisely the time it is needed and in its ability to integrate and promote an ongoing high-performance environment.
  •  The ASK PA structure--knowledge and resources available within context--simultaneously 
    • represents the workflow to be followed, 
    • provides the exact instructions for how to proceed based on the user's current place within that flow, and 
    • offers one-click access to any resources, tools, and websites that will help the user follow those instructions to move through the flow. 
Additional searching is not required. Nor is it necessary to have previously memorized any of the instructions or resources in order to complete the task successfully.
  • The ASK PA, as created within the Contextware platform, does far more that store and present the content. It also:
    • Can be used to capture the workflows and present them quickly for all who are participating in the process of identifying and codifying the workflows.
    • Enables the administrator to quickly update any changes to the content so all new information or procedures are available on a daily basis.
    • Enables the administrator to notify the representatives of new changes via an update screen. This is the first screen the reps see each morning when they launch ASK PA.
    • Permits the administrator to audit the reps use of ASK PA, recording each time a rep accesses a workflow, reviews a page within the workflow, or uses a resource. This information enables the administrator to identify content that the reps may not be making full use of.
    • Enables reps to send an instant email to the administrator if they question, or don’t understand, the content as well as make suggestions about how to improve the workflow. 
    • Allows the administrator to assign workflows which reps have access to which workflows, so reps can be presented with only the workflows they need. This will become more important as ASK PA is expanded to other units with the department. 
  • ASK PA has become the hub of a powerful learning "econet," which stresses the ongoing and interactive nature of learning and performance:
    • The content in ASK PA has become the official "gospel" to which all reps turn for information on how to complete their tasks.
    • Reps use ASK PA to both verify the actions they take to resolve patients' queries and provide them with easy-to follow instructions and valuable resources while they handle calls.
    • New reps learn and master the workflows implicitly through their continual use of ASK PA on-the-job.
    • ASK PA serves additional duty as a key tool for training new reps, especially when combined with simulation activities that mimic the handling of a patient's call, navigating through the data systems to locate needed information, and responding to the patient’s inquiry completely and accurately.  
    • The content in ASK PA is continually updated by the administrator, aided by suggestions and observations from the reps as they do their job.

Prior State:


Prior to the introduction of ASK PA, reps learned how to handle patients’queries partially from a formal training class and through informal observation and abbreviated training sessions with the group’s Supervisor and Group Leader who also had their own responsibilities to handle. Feedback from the staff indicated that more individual sessions would have been preferable and would have decreased their concerns about taking calls.  Once on the phones, reps generally turned to the Group Leader or Supervisor to get answers to questions they had about the procedures. This meant either putting the patient on hold and sometimes ending the call and calling the patient back at a later time. They often asked other reps for help as well.  In addition, some reps would ask the same question numerous times to be sure that they were doing the right thing.
Without an official statement of the proper procedures and Best Practices, the reps might receive conflicting instructions. In those cases, calls of the same type were handled differently, increasing the chances that the patient would be given partial, or incorrect, information or all necessary follow-up actions might not be taken.  In addition, when a rep put the patient on hold to get an answer from the Supervisor, patient satisfaction with the call center was reduced, contrary to the department’s and hospital’s goals.

User Profile:


Inquiry Unit reps may have relevant experience within the hospital or a similar health care related organization, but there is no established channel from which new candidates are routinely selected. Historically, new reps require three to four months of orientation before taking live calls from patients. Currently, incumbent reps in the Inquiry Unit have from eight months to four years experience on the job.



Evidence gathered so far on the results of the ASK PA initiative has been qualitative, gathered through interviews with members of the Patient Accounts Department. Among the responses:
  • Reps reported that they no longer had to ask the Supervisor for answers about the workflow that are now in ASK PA.
  • The Supervisor reported receiving fewer questions related to those workflows. He also has been able to save his time by referring the reps back to ASK PA for the answer rather than answering the question himself.
  • Reps reported that they spent less time on calls related to those workflows because they no longer had to leave their desks to seek answers to their questions. Fewer patients had to be on placed on hold and the reps relied far less on call backs at a later time.
  • Reps reported that they spent less time searching for the relevant resources, which are now available from within ASK PA.
  • Managers reported fewer escalated calls related to those workflows.
Other Evidence: Reps report that they have far greater confidence that they are giving the right information to their patients, because they can validate their responses by checking the content in ASK PA. Given the complexity of health care finance and insurance reimbursement, there were times when they felt unsure if they had handled a call correctly. Eliminating this uncertainty has made their jobs less stressful. They appreciated being able to find answers for themselves rather than continually asking for assistance from the Supervisor or others.