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Vendor Issues Management: A Problem List for ITPresented by [Joe Wivoda] (67-minute Webinar) [00-00-2010]

Angie LaFlamme: Good morning, I’m Angie LaFlamme and I’m an Outreach Coordinator with REACH and I’d like to welcome you to today’s webinar.

I want to start the webinar by giving you a brief overview of our REACH Program. REACH is a non-profit Federal HIT Regional Extension Center, dedicated to helping providers and clinics, small hospitals and other settings in Minnesota and North Dakota implement and effectively use their EHRs. Our mission is to assure that each of our REACH clients achieve meaningful use.

REACH is a program of the Key Health Alliance, which is made up of a partnership of Stratis Health, the National World Health Resource Center and the College of St. Scholastica, which also collaborates with the North Dakota Healthcare Review and the University of North Dakota School of Medicine and Health Sciences Center for Rural Health.

With that I’d like to welcome today’s speaker. Today we have Joe Wivoda to present for us. Joe is an HIT Consultant with the Regional Extension Assistance Center for HIT (REACH). Joe’s been working in information technology since 1990 and with health information technology since 1993. He has been IT Mgr. Director of IT and CIO at several hospitals, clinics and other healthcare organizations. In addition to his healthcare experience, he has worked as a software developer and has worked in several other industries, including manufacturing, engineering, education and legal.

Joe’s expertise in IT leadership, strategy, service delivery and the process of innovation. He has led several selections and implementations of various HIT systems, including LIS, RIF and EHR. Joe received his BS and MS in physics from the University of Minnesota, Duluth and is currently pursuing a PhD in business administration from North Central University.

Thanks Joe for being with us today.

Joe Wivoda: Thanks Angie. I’m looking forward to talking about vendor issues management today. It means a lot of things to a lot of people and there are a lot of different perspectives on it. This talk will focus quite a bit on what the perspective from the vendor is compared to the perspective from a healthcare provider. So keeping that in mind, it’s about getting your issues resolved in a timely manner, that’s all vendor issues management is about.

Once again, we need to consider the perspective of the vendor that can help you get your issues resolved in a timely manner. We’re going to look at all those contrasted differences between the two perspectives, because they are different, and there will be quite a bit of discussion on some of the techniques to use to track issues, escalate them and also some things to look out for. It’s important to remember that the vendor is your partner.

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This is not about beating up the vendor or trying to get everything, it’s about keeping in mind that the vendor is your partner and using these tools in conjunction with understanding what their perspective is, to get the issues that are most important to you escalated and resolved. So keep that in mind.

Starting off with looking at what the point of view of the vendor is, what I did here was to use a hierarchy of need for the vendor. We think of Maslow’s hierarchy of need and on the bottom we have that survival. They want to sustain the business and part of that is to avoid liability. They want to make sure they don’t have a product that endangers patients, that is unsafe, so that bottom is that they want to sustain the business.

Next up on the rung is that they want to have a profitable business. If they’re public and they’re traded, as many vendors are, than they want to have a dividend to their stockholders. They also want to keep the existing customers and acquire new. Keeping a customer is much less expensive than acquiring a new one. They want to keep existing customers happy.

On the top of the pyramid is engaging their employees and making a difference in the community. For many vendors making a difference means that they want to give back to their local community. Making a difference may also mean improving healthcare with their clients. Many of them do have an altruistic part of their model that says they want to make a difference in healthcare.

Some of the efforts they do to try and support these needs to sustain their business and avoid liability, they want to minimize liability actually and the contract will specify things that will limit their liability. Typically, it’s a limitation of liability clause. To keep customers and be profitable they charge support fees, that’s a big part of their income is that support fee. They need to manage their support efficiency through a multi-tiered help desk.

The way that they can also get new customers is to have a product development effort. All vendors have product development and they manage that, so for their employees they have workforce development. They have plans for people to move between development and support. They have plans for people to grow in their positions and part of the thing with these is there are barriers to these efforts that make it more difficult.

On support fees they have to make the product affordable. If they wanted to provide the top level of support that’s probably going to cost more, so they have to balance that with the affordability of the product. In support, one of the barriers is how to manage the priorities. Everybody’s problem is always considered number one and high priority, but that’s just not the case. They have to manage the priorities and some will be low and some will be high, which can be a barrier to support efficiency, making sure they effectively manage those priorities.

I’ll talk about how those priorities are managed from a vendor point of view and how you can escalate your issues to be a higher priority from their point of view.

They need to balance their product development and support. If you put too much money into development and you have a large development crew and you don’t put enough money into support, that will cause issues. You have to have a good balance between development and support and they have to be linked pretty closely.

The final barrier that I’ll talk about is the HIT workforce shortage that we’re going through at this time. There’s a significant shortage of healthcare IT staff. It’s true for providers as well as vendors. Go to your vendors website and I recommend this to people, go to their main site and look at what job openings they have. Be aware of how many people they’re looking for. Be aware of what areas they’re looking for staff in.

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Many vendors have hundreds of job openings for implementation, development and support people. That’s a significant barrier right now. Vendors are all growing and there’s a lot of pressure on their existing employees that have a higher workload and they’re having a harder time finding newer employees. This is a barrier that’s important to keep in mind.

As you look at the point of view of the vendor, think about what drives them, what their business is and let’s look at the point of view of the healthcare provider.

You may disagree with some of this but I put in some of the hierarchy of needs for a provider too. This is a hospital or a clinic and their main priority is to keep the facility open, have financial security so that they can provide their mission and make sure the facility is safe and sound. Basically, I’ve worked in hospitals and clinics where the goal, particularly for hospitals is to be around forever, to be a resource for the community and that’s what that bottom part is talking about.

Moving up the ladder, patient safety is a critical piece as well as quality clinical care and making a difference in the community. Again, healthcare wants to engage their employees and physicians. They want to make sure that it’s a good place to work and they’re motivated. Some of the efforts they put in place, many of the facilities have ballot scorecards where they look at finance clinical and try to balance that. You can see the balance scorecard is one effort, while quality measures whether… most facilities are mandated to do certain quality measures and report them publicly.

They’re also doing quality measures that aren’t mandated just to make sure they’re delivering quality care. Facilities have safety programs where they make sure there’s a fall prevention program. To support patient safety many facilities are putting in electronic health records to improve quality and deliver that information out to the patients and make them more active participants in their care. The electronic healthcare record is a major effort right now.

All facilities have a workforce development program, whether that’s a physician engagement or staff development. There are paths for people to grow in their jobs and there’s awareness about how important it is to have engaged staff. Some of the barriers here, quality measures, how do you collect the data? Is the data put in the right place in the electronic health record if you have one? If you don’t have one in place then how are you doing your chart reviews? It’s a lot of work to go through to capture that data off paper and look at it.

The EHR support safety, do you have to put processes in place in facilities that actually make it less safe because of the EHR? That can happen and can be a significant barrier to safety. Does the EHR really support safety? How easy is the EHR to use? If it’s difficult to use you may not get physician engagement. You’ll have a harder time getting the staff to use it. That can be a barrier. Again, for workforce development, you’re dealing with an HIT workforce shortage as well and in rural areas in particular there aren’t many people, if any, available.

The HIT workforce shortage is causing a significant hardship for organizations to be able to implement and maintain electronic healthcare records. Workforce development there are other barriers too of availability of staff, physicians and other things I’m sure you’re aware of.

Contrast this a little with what the point of view of the vendor is. You can see that patient safety is an important thing for you and is also a fundamental thing for the vendor. So if something is a patient safety issue then you can bet that that will take a high priority for the vendor. If it’s how do you measure quality, that may not be as important to the vendor as it is to you.

So keep these points of view in mind. The vendor is coming from a little bit of a different angle.

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Now I’ll talk a little about what issues are. It’s fundamental but I want to talk about what is an issue and what may or may not be an issue. Some things that are serious issues, a patient safety problem like orders that are lost, missed orders. If an order is placed in order entry or CPOE and is never delivered to the lab or pharmacy, that can be a significant patient safety issue.

Same thing with results coming back or mis-delivered results. Reliability can be a serious issue, so if there’s a software flaw that causes the system to be unreliable and you constantly have to put in paper processes or work around because of a software flaw then that’s a serious issue. If there’s a productivity waster, the screen changes are slow and you have to do some extra screens more than you think you should, those can be productivity wasters that probably aren’t considered a serious issue.

Those are usually considered a non-critical or minor issue. Look and feel things are never a serious issue. They can certainly help with engagement but they aren’t critical. Non-issues, at least for the vendor, are things like reliability due to your inaction. If the vendor has said you have a problem in your network because it’s outdated and some of the hardware is faulty or if the vendor tells you that your computers are so old that they aren’t going to work with our newer versions of the software very well. That’s a non-issue and they will shove that off.

If it’s due to a PC problem or something of your inaction then that’s a non-issue from the vendors point of view. It’s not their vault. If you take a poor workflow and overlay it onto the EHR and then say it’s not working because the way we overlaid our workflow onto the EHR isn’t helping. For example, if your workflow is to, you know, in the paper world to place lab orders on a piece of paper or order sheet and fax it to the lab, where somebody in the lab hears a fax machine go off, grab the order and enter it into the system. Then you implement CPOE and you want to mirror that.

You want to have CPOE put a fax down in the lab and have them react to that fact. It’s not designed to do that. They aren’t going to put special procedures into their system to support that kind of poor workflow. Workflow that’s not taking into account how the order should flow in the electronic healthcare record. Those are non-issues.

The next chart is intended to give you an idea of which items are appropriate for an issues list. One of the main tools for managing your issues is the issues list and I’ll go over what that should include. At this time I want to talk a little about categorizing your issues. I’m looking at something here that on the X axis going left and right is a measure of the risk versus convenience.

Something on the far left hand side is going to be something that’s closer to an inconvenience for the user and something on the right hand side is going to be a patient safety risk. The further you move to the right the riskier the problem is. On the Y axis I have the number of users that are affected. So going down it’s very few and going up it’s all users are affected.

The critical issues are going to be those that pose a significant risk and all or many users are affected. Some way you’ll manage through those is by putting in double checks, so if you’re losing orders, if low orders aren’t getting to the lab, the pharmacy or physical therapy and dietary than you may put in double checks where you’re having the order placed by nursing and then nursing makes a phone call to ensure the order is in.

You may put in backup procedures that are in place just to make sure that things are covered. In some cases, the system may need to be disabled. If the patient safety risk is high enough and it’s affecting all users, it may be wise to disable the system and go to a complete paper process, depending on the amount of risk.

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Those are what I consider critical issues. These are issues where they take on a high importance. Going down to the yellow box, important issues are those that have a significant risk, but maybe don’t affect many users, maybe it’s one or two. You’d probably use checks and balances, maybe some double checks, but these are problems that usually require escalation and you should track those diligently.

Something that’s affecting all users and is an inconvenience further away from the risk scale, you may have a work around for it. It might decrease productivity, it’s called a non-critical issue, it’s something that’s non-critical. It’s not of high importance and it’s the sort of issue that should also be tracked. Keep an eye on these.

Something I would consider a non-issue or something that’s annoying. It doesn’t affect many users, it causes closer to the end of the inconvenience scale that you may have work arounds. You may be using the system improperly and this isn’t anything that’s worth fighting over with the vendor. It would be an enhancement request and the vendor might say it’s a great idea here’s how much it will cost if you want it put in place and you’ll have to figure out if that’s something that’s wise.

These two should be focused on the most. Those critical and important issues are the biggies.

Let’s look a little bit at what the vendors point of view is. On the X axis for the vendors point of view, when they’re looking at your issues and trying to prioritize them, they have a little bit of a different look. They still have a risk scale going from left to right on the X axis, which is low risk to high risk. Remember one of their fundamental needs is to minimize liability and make sure things are safe.

They’re also going to look at how many customers are affected. It’s probably a 3-dimensional graph, but for now let’s talk about risk and number of customers affected. On the Y axis we have the amount of effort. They need to balance their amount of resources that they have is limited so they need to balance what they work on, if it’s going to take a lot of effort versus a little effort.

So, you’ll see a little bit of a different take here. Things that are high risk that take a lot of effort are probably going to be things that are considered all hands on deck. These will typically be rare. They’ll pull programmers off other projects, delay things to get these resolved. It’s the sort of enhancement that will go out to customers very quickly. Each vendor has a different term for that. It could be a priority 1 or code red. Things that are high risk and don’t take much effort will generally be those that become high priority.

They’ll go to the top of the priority list and if it lingers there too long it could become an all hands on deck. It’s high risk. It may not require too much effort, but it could be many customers affected.

Things that get prioritized now are things that may not require much effort. They aren’t high risk. There may only be a few customers that are affected. Those will be put into a prioritized queue, medium-low, whatever scale is used. The priority will depend on a number of factors. So the vendor may look at the amount of risk, how many customers are affected, if it’s a module they’re interested in improving because of something going on. If it’s a state or federally required report, that will all affect the priority.

Things they won’t get done and this may surprise some people, are those things that don’t affect a lot of customers and are low risk, but they take a lot of effort. It may do it as a paid enhancement if you request that, but generally these take a long time to get completed, just because there isn’t a lot of incentive for them to do it unless they get paid to do it.

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This is important to remember. From the graph I want you to take away the scale, keeping in mind what the vendor is going to look at. They’re going to look at how much effort it’s going to take to do what the risk is and how many customers are affected. That’s an important distinction between what your priorities may be. They have to work with a number of customers so those are the values that they’ll look at to help them prioritize.

Enough about what the differences are between the vendors and the providers. I’m sure you know they’re different, so let’s talk about some of the techniques and methods used to manage your issues. Probably the number one tool is the issues list, it’s important to use this before you go live. If you’re going through an implementation it’s important to have an issues list started to keep track of issues.

Then you should keep using it as you are post go live. Issues lists should be shared with a vendor and in many cases the vendor will put up dates and send it back. Some vendors have a website where you have access your issues and see them. That can be used as an issues list as well. There are a number of variables.

Other ways the manager issues that maybe some people aren’t aware of are collaborative efforts. This is where you work with a peer or a neighbor, another hospital or clinic, maybe in the same geographical area but maybe not. It could be somebody that’s similar to you but has the same problem. This can be a powerful method for managing issues that the vendor maybe doesn’t consider to be important or they aren’t resolving fast enough. That can be a powerful tool.

User group meetings can be a good place to work on getting your issues a higher priority. They’re kind of a good forum to discuss issues and issues in general. You have to make sure you bring your issues up in the proper context. If it’s a keynote presentation by the CEO then it may not be the best place to talk about your issue with CPOE, for example. Make sure you use the proper context.

The user group meeting is the best place to seek out collaboration partners. Look for those facilities that are similar to you, maybe some that are a little larger and make some friends. That’s very powerful. Talking a little more deeply about the issues list, there are a number of items that an issues list should have. I’ll share with you a reference to a good issues list.

It should have a vendor reference number. It’s usually the ticket number, the issue number, whatever the vendor issues to you when you submit a problem. If they don’t submit some sort of tracking number for your issues then create your own, but typically all vendors do that now.

There should be a detailed description and make sure you have room in there for follow up. If you have a description you may want a column and these are typically done in Excel. Have a description column and then another column that says follow up. There should be columns also for assessing the risk or assigning priority. Your priority for the issue, but you should be careful that you don’t have too many high priorities.

Sit back after you update the issue list and look at how many are high priority. Think about whether you’re assigning high priority just because you want to get them done or are they truly high priority. Go back to access, how much risk is involved? How many users are affected? This should be your priority and not what the vendor thinks. You can negotiate that with a vendor but these should be your priorities and what you consider to be high priority.

Keep track of who reported the problem that’s important, especially as you want to have follow-up with physicians and staff to say here’s what we’re doing with that issue. Keep track of what module is affected. It could be helpful as you look through

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that spreadsheet to see how many issues there are with the CPOE module. How many issues are there with the lab system? It’s handy to have that.

Use the modules the vendor has. Some vendors will separate out CPOE from order entry, so make sure you follow their protocol and their division of their system, not what you think it is.

What users are affected? This might be a column that says lab users are affected, all physicians, all nursing, all clinical, all coding, something that explains what users and if it is just one user list their name so you have that person’s name on record. Who is the issue assigned to? Whether it’s vendor, internal staff or both, usually the vendor will have an individual assigned to it if it gets high enough. If your vendor is the Acme software company then you’d put Acme in there, but if they assigned John Smith then you’d put John Smith, just so you know who to track.

Generally you don’t want individual’s names in there because it may escalate around. When the issue is assigned and when the date of the next follow up is. Try to pin the vendor down on having milestones. If they say they’re going to resolve it by the 15 th

of April then make sure that’s the date you enter in there. Do the same thing if it’s internal. Let’s say the next step is to test it. Assign a date there for the internal person to test and verify that it works.

You should have an indicator of when the problem is escalated and to whom. That column could be something like, vendor priority or vendor escalation, like if it’s escalated to development. The resolution date, those resolutions generally have to be agreeable to you, the customer. If the vendor says it’s resolved and you disagree, than ask it to be reopened and say why. Issues should not be resolved unless you feel they are resolved.

Importantly, learn to use what tools your vendor provides. Nearly all vendors now have a website where you can go to manage your issues and view them. It’s important to look at that periodically. Depending on the situation it could be hourly or daily or even weekly. Look at all open tasks and make sure that something hasn’t been closed that you didn’t know about. If someone is working on it than see what they’re doing and make sure they’re on the right path. It’s important to look at that and use the vendors tools for tracking issues.

If you aren’t aware of them than talk to your account manager and ask how to keep track of all the open tickets you have, because you need to know. If they don’t have anything than find out who you talk to, but make sure that if they have a tool that you’re using it and routinely log in to look at those issues. Next is an example of an issues list, it’s from the health information technology toolkit which is available from Stratis Health for download.

This is an example of some of those columns for an issues list. This is a good format for an issues list and I recommend you take a closer look at it and learn to use it. You can sort by all sorts of columns and manage your issues more effectively this way.

To use the issues list, like I said it’s important before you go live to get in the habit of using the issues list. The vendor may want to call the issues list something else, pre- go live, it could be a tracking issues document. Regardless, make sure you have an issues list pre- go live if you’re going through implementation. If you already have an EHR and you’re just going through the implementation of CPOE for example, and you’ve never used an issues list, start now.

Don’t necessarily take the issues list from the vendor, there’s may track things that aren’t as important to you and may not have all those fields. Have your own issues list. After go live, the issues list should be something you use as one of your fundamentals to managing your systems. It should be something you use on a day to day basis, just like backups.

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This is something that’s important and it’s good practice, best practice and something you should be in the habit of doing. If it gets too large or if there are a lot of high priority items that aren’t being resolved in a timely manner, you need to have meetings with the vendor to see what’s going on. It could be that there’s a significant disagreement over the amount of risk or the priority of the issues. You may have to resolve that disagreement with the vendor and understand why they don’t see it as high priority.

It could be that the vendor is having internal staffing issues or is unable to keep up due to the fact that many support staff have been assigned to development or implementation and they don’t have the time. That’s an important time to talk to the vendor and express that’s unacceptable and you need to keep moving forward. So I’ll talk in a little bit about getting to know how your vendor works internally, but you may need to talk to an account manager internally.

Weekly status meetings are oftentimes a good way to approach this to look at that issues list on a weekly basis and it may seem like nagging but it’s a good time to do that. Then, you may want to ask for an assigned project manager or a developer. Sometimes a developer may need to be assigned to something and you can ask for that. Generally, if you’ve talked with a developer and they’ve seemed helpful, it might not be wise to say can’t you just assign Jim to this because he helped us before?

He may be a developer in one area and may not understand the other area of your software. Keep in mind that a lot of vendors out there have grown by acquisition. They’ve acquired a lot of systems and some systems have different code in each of the modules in the background that you may not be aware of.

Another tool that’s useful is collaboration as I mentioned earlier. If you’ve gone through the issues list and asked for priority and you’ve started doing weekly status calls, the collaboration could be a way to really escalate it if it’s not going anywhere from the issues list discussions, then you may want to collaborate. You still use an issues list but this time you’re sharing it with your collaboration partners.

So if your hospital is having a hard time getting something resolved and you team up with another hospital in Tennessee, for example, you want to put together a shared issues list. That’s very powerful. Don’t work from two issues lists, work off one that you both share and agree on. That means that all your issues won’t show up on that shared issues list, it’s only going to be those issues that’s shared between your two facilities, three or whatever it might be.

Get to know as many hospitals and clinics that you can that use your system, especially those that are similar to you. If you have a unique billing model and you find another hospital or clinic that uses the same kind of billing then you want to get to know them well and see how they’re resolving their issues and doing their work. You generally want to find someone who’s at the same level of adoption as you.

Just because they’re the same size and are running the same system, are you both at the same level? Are you both doing order entry? Are you both doing CPOE? Are you both running the lab system? Make sure you’re at the same level of IT adoption. Similar size and service offerings can be important. You don’t necessarily want to partner with a hospital that’s much bigger or smaller than you. If they’re a little bigger that can be helpful because then you have a little more weight.

Geography is generally not important, unless we’re talking about issues that revolve around state specific billing or reporting requirements. Again you want to have periodic calls and maintain that issues list with your partners, but you want to have some periodic calls with your peers, those partners that you’re collaborating with, separate from the vendor and then have the vendor calls.

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You want to make sure you have a unified front. If you go to a call with the vendor with your peer and you find out halfway through that they’ve already resolved the problem and it turned out to be an internal issue, you don’t want to be embarrassed by that you want to have that call first. Talk to the peer separately. Only use this when they are critical issues or when you find folks that have unique requirements like yours and there’s an enhancement that you both feel is important.

That may be one of those issues that the vendor will never work on, but if you get enough weight behind it, enough customers involved, remember one of their measurements is how many customers are involved. If you get more customers involved it suddenly becomes an important issue for them. Generally you want to use this for critical issues, but if there is an enhancement that will affect the number of customers than this is a way to convince the vendor of that.

Another technique that’s used in conjunction with issues management is the user group meeting. Most vendors have an annual users group meeting, some have regional user group meetings, these are important to attend because you want to be able to network with peers and discuss issues directly with the vendor and with your peers, so you can talk to other hospitals or clinics to say we’re having a problem with this that never seems to get resolved, are you having the same problem? You can team up.

This is a good place to get some priority. Then it’s also a good opportunity to talk with the executives of the vendor, which can also be important. As we talk about escalation they are the last line of defense. Getting to know them at the user conference is very helpful, so if you have an opportunity to go to dinner with them or at the part they throw, get to know them.

Make sure you don’t sound like a chronic complainer. When you bring up issues in public it shouldn’t be with the intent to embarrass the vendor. You should just want to discuss. It shouldn’t be something to point out a flaw about. You want to make sure your issues are well articulated, they have a significant impact on your organization as well as others. So make sure if you’re bringing up something in public it’s something that will affect all the customers and not just you.

I mentioned escalation earlier and part of vendor issue management is to understand how to escalate and when it’s important to escalate. If you escalate too quickly then you take your issues and you demand they be escalated for every one of them. It’s like crying wolf and you don’t want to do that. Generally issues start out at the bottom with support, where you call in, email or submit it on their web page and it goes to support. Most supporter arms have multiple levels of escalation within support.

Maybe the first level is someone who knows the system fairly well and can resolve 80%. They might have a measure of their effectiveness where they say 70-80% of calls should be resolved in first level. Keep in mind that that first level probably has the number they’re tracked on, to see how well they’re doing. They’re going to be reluctant to escalate it up because that’s going to count against them.

Sometimes you have to ask, so there are levels of escalation within support. One of the industry standard numbers is 75-80% of issues should be resolved at first level. Some organizations don’t design their support desk that way. The first level help desk basically takes down the information and hands it down to second level to call you back. So you want to understand how it’s escalated within support. Sometimes there’s a magic word, like can I get this escalated to second level?

Most issues should end there, but they all start there. Once you’re frustrated with support and they aren’t managing your issue very well, sometimes you have to go to the support manager. This isn’t true for every event, but in general the support manager is the next person to talk to. A lot of vendors have a separate support

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manager for each module of their software, so you want to get to know how they’re organized internally.

The next rung up is your account representative. They could be called an account manager, it all depends. The account representative, they’re kind of a salesperson. It may not seem like and sometimes you’re not even going through this step but account representatives are motivated to sell you something, but they may be the next step up, so you may want to talk to them and say you aren’t getting something, because the last they want to do is lose a customer or have an unhappy one.

So, the account representative can be somebody and in most cases it will be the account manager. This is somebody whose role it is to make sure that you are happy. They will talk to you and gather information on how support is working for all their customers and they use that to improve support. They’ll use information on how the system works to help improve the system. Account managers often have a very good handle on the system and what the issues are, and can be very helpful.

Therefore, if you aren’t getting what you need from the support manager, the account reps and managers, depending on the organization you’re working with, can be extraordinarily helpful.

The next step up, and now things are getting serious, this is the executives. So if you’re escalating to the executives this should be done with the assistance of the account manager, ideally. If the account manager is trying to do everything he can and he’s just not getting the support from the support manager than that account manager will say, if you really want to talk to the executives they can help because I’m not getting anywhere.

Typically the account manager will report it up through sales and doesn’t have a lot of influence over a support manager, so it may be helpful at that time to go to the executives. If you don’t get that introduction it’s more difficult to go to the executive, so try to get the account manager to sponsor you and to bring you into that executive.

If you still aren’t getting the resolution you need and it’s getting critical, your last resort is to go to the board of directors. I’ve only had to do this once in my career. It worked and was the sort of situation where it was a last ditch where we said we’re probably going to get rid of this vendor if we don’t get them to resolve this by the end of the year. That was the message that went to the board members. Like I said that’s the last effort and is when you’re ready to separate from the vendor.

This isn’t something you should have to do but sometimes it’s a necessary thing. The key here is to knowing what your vendors path is. Don’t go around people. Try to find out what the escalation path is. You can ask what it is, especially for account managers. They’ll usually tell you everything. Try to get a copy of the organization chart. If you can understand how the organization is put together, who reports to who that can really be helpful as you need to escalate issues.

They don’t usually want to share the real organizational chart with you, but you can do some homework to see what the executive contacts are on the website and when you look at that you can get an idea of the top level of the chart. Then, when your account manager or whoever it is that visits your site periodically to see how you’re doing if you have that, you can share that with them and say I’m trying to put together the organizational chart and they will usually flesh it out pretty well.

Be mindful of stepping on toes. Don’t go over people’s heads to get your issues resolved. Try to have an introduction in. Remember, the vendor is your partner and you don’t want to burn bridges. As you escalate higher and higher on that escalation path, you’ll need to get more specific and have more evidence, so it’s important to use the issues list that you keep track.

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As you get higher on the list you want to be more specific in a sense, as well as more general. You need to say CPOE doesn’t work for us and it’s causing patient safety concerns because. Then you have the more specifics in there. Start with the generalities because as you get higher up they’ll be more focused on some of the risk.

I can’t stress enough that it’s important to understand your contract. Your contract probably spells out things like response time, remedies for disputes, when you’re allowed to withhold payment. You want to understand your contract, make sure you know where it is, pull it out and review it thoroughly.

An aspect of getting your issues resolved is leverage. If things are getting real serious and they aren’t resolving issues or taking them seriously, they aren’t assigning the resources they should be, you have to start thinking about how much leverage you have with a vendor. Basically leverage, you have it when the vendor needs something, whether it’s money or a recommendation. Maybe they want more happy customers or want to quiet a customer who’s being very vocal at user group meetings.

Those are all leverage points. You can create leverage by withholding payment. Once again, you have to look at your contract. Many contracts will say if you want to withhold payment because of non-resolution of issues than you need to notify us in writing. We have 30 days to resolve them and if we don’t resolve them than you’re allowed to withhold payment.

Your contract will spell that out for you. Sometimes the contract will say if you’re 30 days late on a payment than you’re in default and we can disable the system. So you want to make sure you look closely at the contract again, and if you’re just going into a selection process right now, look at some of the webinars we have on contract negotiation and things to look for in contracts, it’s very important.

You can also create leverage by talking with peers and bringing in that collaborative aspect of it. Also, by escalating issues, just by getting an issue escalated and moving it up the path. If it’s a valid issue, if you’re not crying wolf than escalation actually creates leverage. You want to make sure you use that leverage wisely. Don’t go in saying we’re going to switch vendors, if you don’t really mean it.

Understand what their priorities and motivations are. That will help you to get your issues prioritized properly. If you understand what their perspectives are, which is why I spent so much time talking about the vendors perspective. You have to understand that and something that’s high priority to you may not be high priority to them and that’s why. Don’t forget vendors are your partners. Don’t burn bridges. It’s important to be the squeaky wheel, but you don’t want to cry wolf.

Keep in mind the timing. If you just had a major issue resolved and it took a lot of effort, of escalation and convincing the vendor why it was important, and because it was a critical issue, if you come back and say now I have a look and feel issue I want resolved and you do the same thing, that’s crying wolf. Be sure to watch the timing and only escalate things when it’s appropriate.

Ask why. Why hasn’t my issue been resolved? Why isn’t it prioritized? Why hasn’t it been handed over to development, for example? Then ask to escalate, don’t threaten and say, you’ve had this long enough I want this thing escalated immediately and if it’s not then the following will happen. Don’t do that. Just ask if it can be escalated and if not then you need to go through the path of talking to the account manager, support manager or whatever it takes to get it escalated.

You want to make sure you step back to look at if you’re being the squeaky wheel or crying wolf.

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If resolution time is becoming a chronic issue than it’s probably time to request a weekly meeting with the support or account manager, until the resolution time improves. Most of the time vendors don’t have, in their contracts with you, something that says we’ll resolve issues within a number of days. That isn’t going to happen, because issues can take a lot of resources or they can take very few.

If you’re seeing a pattern where your issues list is getting longer and longer and you see a chronic problem, it’s time to become more of a squeaky wheel. Talk to the support and account manager, maybe they’ve had a significant loss of staff and they’re overloaded right now and don’t have the resources. That’s important to understand and that can also be a red flag.

Don’t make escalation a routine procedure. If it is then there’s either a major issue with the vendor or you’re crying wolf, so step back and understand if you’re trying to escalate everything just because the vendor isn’t performing and they never resolve anything until it hits third level of support or am I trying to do that because I want my way all the time? Take a reflective look at yourself to see what’s going on.

Ask your peers if they’re experiencing the same issues. You can learn a lot from your peers in the industry, so make sure you talk to them. If things are getting really bad then there are red flags you want to be aware of that might tell you the vendor is in trouble. If they have a chronic shortage of staff but you look on their website and they don’t have any job openings, that tells you they’re probably in financial difficulty.

If they have a high turnover in sales that’s a red flag. Sales staff are typically paid by how many things they sell and how many customers they have out there that are staying. So, if sales staff are leaving it’s because they can’t sell the product because there’s a problem. Maybe they aren’t incentivized but it’s something to keep an eye on. If you keep getting a new account manager or rep, there may be something going on.

Ask what happened. Ask if the person left for greener pastures or did they get promoted. Maybe there’s so much going on in the company right now it’s growing so fast that they have to bring in new sales staff and the more experienced ones are getting promoted. You want to find out what’s going on.

If critical issues aren’t being resolved than look at those issues on the vendors scale and say these are things that should be considered critical issues and they aren’t resolving them and you talk to your peers who are having the same issues, that’s a red flag, something that indicates that either the vendor is in trouble or they’re disengaging.

We all know that switching vendors is very expensive much more so than just the software and implementation cost. It’s expensive for your internal staff and productivity, so you want to make sure you make this decision in a well thought out way. You do have a contract and you and the vendor will both need to live up to it. You’ll need to get the data out of your system. Does your contract specify that once the contract is severed that you have access to the data.

One thing a lot of people don’t understand is that you don’t actually, in all likelihood, own the software that you run at your facility. It’s a right to use. You have a right to use the software as long as you’re paying support fees, in most cases. So again it’s important to understand your contract.

Once your vendor believes they’ve lost you as a customer, once you’ve told them you’re going to put in a new system, you’re not welcome to try to improve it they will start to provide minimal support. They’ll go back to the contract and will say we’re only obligated to do this. That’s what they’ll do is the minimum, so you want to make sure if things are getting bad and you’re making that decision that that’s what’s going to happen.

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Many contracts don’t have an out, so you’ll have to pay it until the term is over and follow all the procedures defined in the contract. Many you have to notify in writing and in writing could include an email, but maybe it doesn’t. Maybe it only includes a paper memo that lists those issues out which could be your issues list.

What does your contract specify for data migration? You own the data in there but you may have to pay a significant fee to get the data out and in a format that’s acceptable to your new vendor, so make sure you understand what the contract specifies.

They may have a clause where you can get a read only system for a period of time, where you can go in and look at information but you can’t change it. That’s important information to look at.

Now to summarize, keep in mind the point of view of the vendor. It’s important whenever you’re negotiating with anybody that you understand where they’re coming from and prioritizing issues could be thought of as a negotiation exercise, so keep in mind the point of view of the vendor and how they’re motivated because it will most likely be different than what motivates you.

Do your homework. Understand the contract and the vendors website. Keep an eye on it. Watch for changes in executives. Look for job openings and see what openings they have. Other information, like if they have a news page that shows the new contracts they have, watch for that it’s good to know.

Keep the issues list going, that’s important. Start using it before you go live. Start today putting one together if you don’t have one. Learn how to use your vendors tools if they have a website for tracking issues. Know how to escalate and know your leverage points. Like my mother always said, you attract more flies with honey than vinegar, so some phrases I like to use when I’m trying to get my problems escalated are:

I would really like to be a reference account, make me a reference account please by making me happy and resolving these issues.

Should this issue be escalated? Why or why not?

Where is my issue on your priority list? That’s sometimes good to ask a developer if you’re ever escalated to development.

Where is this on your priority list? They may say, right now I’m trying to get CPOE finished so hopefully I can work on your issue next month.

What is the best way to escalate issues that I feel are important with your vendor? That’s a great question to ask. The support manager, account manager and other people, find out what the best way is to escalate issues is. They will be happy to tell you.

With that thank you. Let’s see if there are questions.

Angie LaFlamme: I do have some questions, thanks.

What do you do if a vendor isn’t responding in a timely manner to your issues, even after we’ve tried some of the techniques you’ve shared with us?

Joe Wivoda: That’s a good question. I get that a lot. You have to go back to some of the techniques I talked about, especially with regards to escalation. Are you escalating the right way? Are you using the right path? Find out if you’re not escalating to the right people and start talking to more people in the company.

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Start talking to more of your peers. The example I talked about where I had to go to the board of directors, that one was an example where we had an issues list that we couldn’t get response to, meetings were being cancelled and I was getting more and more concerned. We had actual patient safety concerns and a number of double checks put in to ensure that reports were being delivered.

That was an example where I went around a lot of people on that one and eventually stopped at the board of directors and sent out letters, so sometimes go back to that escalation path and start looking at that. Watch for the red flags that might indicate the vendor is in trouble. Most vendors now are fairly healthy but there are a few who may be struggling and you want to know that.

Angie LaFlamme: So then at what point should someone withhold payment?

Joe Wivoda: Again, you have to look at your contract. The contract may have a clause that says when you can withhold payment. Understand the contract and see. If the contract doesn’t specify that it’s either acceptable to withhold payment under these circumstances or it doesn’t specify that withholding payment indicates that you’re not longer welcome to use the system anymore, then you’re in that middle ground.

Many vendors contracts are like this. The first step with doing that is to tell your account manager. Say I’m not getting my issues resolved. These are serious issues I’m going to withhold payment next week. That’s the place to start. If you tell the account manager that until these are resolved I’m going to withhold payment, that generally gets things going pretty quick.

You have to make sure you operate within the confines of your contract, because if things get ugly that’s the thing that you’ll be held to as well as the vendor. Make sure if your contract says before you withhold payment that you have to give them a written list of issues then send them your issues list and then they have 30 days to resolve them or whatever the contract specifies.

Angie LaFlamme: That’s great. So then sometimes, wouldn’t it just be best if a vendor would just let us talk with developers directly?

Joe Wivoda: Generally not. The developers have their own priority list that they’re working on. Usually they don’t have the ability to prioritize their own work they’re given an assignment that says you have to have this enhancement done by this date so they usually don’t have the flexibility to change the schedule. In addition to that, most developers are not completely aware of all the support issues surrounding a module and a product.

They may not be aware that there’s a configuration setting that support has learned, causes issues. They may not be aware of the complete bug list, because they may not be working on that module in their priority list. Support has more flexibility on how things are prioritized and the only way to really get on a developers priority list is for somebody internally at the vendor to say we need to pull so and so developer off that project for a while to resolve this problem.

It’s usually not a good idea to try to assign issues directly to a developer.

Angie LaFlamme: That makes a lot of sense, thanks.

With that I’d like to thank Joe for a very educational presentation. I think we all learned some valuable information and techniques on how to resolve and manage vendor issues, as well as how to prioritize the issues.

I’d like to thank you, the listeners, for participating in the webinar and we hope you found it to be of value.

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Please remember to complete the survey for the webinar. Certificates of participation will be available upon request within the survey and will be emailed to participants on a weekly basis.

Thank you again for participating. Take care. Bye.

This material was prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human

Services. The contents presented do not necessarily reflect CMS policy.

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