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MODULE 16: TIMEFRAMES, TURNAROUND RULES & ESCALATIONS
Section 5: Internal Timeliness Metrics
An inside look at the key performance indicators (KPIs) used to measure individual and team performance related to turnaround times, and how this data drives quality improvement.
SECTION 16.5
Internal Timeliness Metrics
Translating Your Work into Data: How KPIs Drive Performance and Quality.
16.5.1 The “Why”: From “Feeling Busy” to Demonstrating Value
In a community pharmacy, you often measure your day by a feeling of busyness. You know it was a productive shift if the prescription queues are clear, the counters are clean, and patients aren’t waiting. This sense of accomplishment, while valid, is largely subjective. In a structured healthcare environment like a hospital, health system, or PBM, this subjective sense of productivity is translated into a language that the broader organization can understand: data. Your hard work, clinical expertise, and patient advocacy are captured, quantified, and analyzed through a set of Key Performance Indicators (KPIs).
At first, the idea of having your work measured by metrics can feel intimidating. It can seem like an impersonal, “corporate” way to view the deeply human work of patient care. However, you must reframe this perspective. Metrics are not a judgment of your worth; they are a tool for demonstrating your value. When you successfully expedite a PA for a critical transplant medication, you haven’t just helped one patient. You have contributed to your team’s “Average Turnaround Time for Expedited Requests,” a KPI that your department manager can take to hospital leadership to justify hiring another pharmacist. When you overturn a denial through a successful appeal, you contribute to the “Appeal Success Rate,” a metric that proves the financial and clinical value of having a pharmacist in that role.
Understanding these internal metrics is crucial for your professional growth. It allows you to understand what your organization values, how your performance is perceived, and where you have opportunities to improve. It gives you a framework for discussing your workload and advocating for the resources you need to succeed. This section will pull back the curtain on the most common timeliness and quality metrics used in prior authorization departments. You will learn what they are, how they are calculated, and most importantly, how to use them not as a source of pressure, but as a source of power to improve your practice and prove your indispensable role in the healthcare system.
Retail Pharmacist Analogy: The Pharmacy’s End-of-Day Report
At the end of a chaotic Tuesday, you print the “End-of-Day” report from your pharmacy management system. It’s not just a record of sales; it’s a detailed breakdown of the pharmacy’s performance, translated into pure data. You don’t just “feel” like it was busy; the report tells you that you filled 450 prescriptions (Volume), with an average wait time of 12 minutes (Efficiency), and conducted 35 clinical interventions like DUR alerts and counseling (Quality). You also see that your team completed 15 immunizations and sold $500 in OTCs (Additional Services).
How does this data become a tool?
- Justifying Resources: Your pharmacy manager doesn’t go to the district manager and say, “My team is working really hard.” They say, “As you can see from our daily reports, our prescription volume is up 15% year-over-year, but our technician hours have remained flat. This is causing our average wait time to increase, impacting patient satisfaction. I am requesting an additional 20 technician hours per week to support this growth.” The data makes the argument objective and compelling.
- Identifying Bottlenecks: You notice that the wait time spikes every day between 4 PM and 6 PM. The data helps you pinpoint a workflow problem. You decide to shift your technician’s lunch break and overlap your pharmacist coverage during that peak period to improve efficiency. You are using metrics for quality improvement.
- Demonstrating Value: The report shows 35 clinical interventions. You can now quantify your impact. You can say, “My team didn’t just dispense 450 prescriptions; we prevented 35 potential medication errors or interactions.” This demonstrates the cognitive value of the pharmacy team beyond simple dispensing.
The internal metrics in a prior authorization department serve the exact same function. They are the “End-of-Day Report” for your cognitive services. They justify your role, identify opportunities for improvement, and quantify the immense value you bring to the organization and its patients.
16.5.2 Deconstructing the KPIs: A Guide to Common PA Metrics
While every organization has its own unique dashboard, most track a core set of metrics related to timeliness, workload, and quality. Understanding these KPIs is the first step to managing your performance and contributing to your team’s success.
Masterclass Table: Core Prior Authorization Key Performance Indicators (KPIs)
| KPI Name | What It Measures | How It’s Calculated | What It Tells Your Manager |
|---|---|---|---|
| Average Turnaround Time (TAT) (Standard & Expedited) |
The average time it takes from the receipt of a “clean” request to the rendering of a final decision (approved or denied). | $$ \frac{\sum (\text{Time}_{Decision} – \text{Time}_{Receipt})}{\text{Total Number of Cases}} $$ This is calculated separately for standard and expedited queues. |
This is the most fundamental measure of your team’s compliance and efficiency. A consistently low TAT shows the team is meeting regulatory requirements and processing work efficiently. A rising TAT is an early warning sign of backlogs, staffing shortages, or workflow issues. |
| Cases Processed Per Day/Hour | The raw volume of work completed by an individual or the team. | $$ \frac{\text{Total Cases Completed in Period}}{\text{Total Hours Worked in Period}} $$ | This is a measure of pure productivity. It helps with capacity planning and understanding individual differences in work speed. However, it can be misleading if viewed in isolation, as it doesn’t account for case complexity. |
| Denial Rate | The percentage of completed cases that result in a denial. | $$ \frac{\text{Total Denials}}{\text{Total Cases Completed}} \times 100 $$ | A high denial rate could indicate several things: rigorous adherence to clinical policy, a need for better provider education on criteria, or potentially, reviewers who are too quick to deny. It’s a metric that always requires deeper investigation. |
| Appeal Overturn Rate | The percentage of initial denials that are overturned and approved upon appeal. | $$ \frac{\text{Appeals Approved}}{\text{Total Appeals Submitted}} \times 100 $$ | This is a critical quality metric. A high overturn rate can suggest that the initial reviews are flawed or incomplete. It demonstrates the value of the appeals process and the specialists who manage it. For your team, a high success rate on appeals you initiate is a powerful way to show your advocacy is effective. |
| Pharmacist Touches Per Case | The average number of distinct actions or “touches” a pharmacist or technician takes on a single case (e.g., initial review, call to provider, call to payer, final review). | $$ \frac{\text{Total Documented Actions}}{\text{Total Cases Completed}} $$ | This is a sophisticated metric for measuring case complexity and workload. A simple case might take 1-2 touches. A complex case requiring multiple calls and follow-ups could take 10+ touches. A high average number of touches indicates your team is handling complex issues, not just rubber-stamping simple requests. |
16.5.3 Using Data for Quality Improvement (QI)
The true power of metrics is not in judging past performance, but in improving future outcomes. A well-run PA department uses its KPI data as a diagnostic tool to identify systemic problems, refine workflows, and provide targeted coaching to its team members. As a professional, you should learn to view your own metrics through this same QI lens.
From Personal Metric to Team Solution
Imagine your personal “Average TAT” is slightly higher than the team average. Instead of viewing this as a negative, view it as a data point. Look deeper. Do you handle a more complex mix of cases? Is there a specific type of drug or payer that consistently slows you down? Perhaps you discover that PAs for a specific health plan always require a follow-up call because their portal is unreliable.
You can now take this insight to your team lead: “I’ve noticed my TAT for Plan X is consistently high because their portal often fails to transmit the clinicals. I spend a lot of time on follow-up calls. Could we, as a team, consider making all Plan X submissions via fax as our primary method to improve our initial submission quality and reduce rework?” You have just used a personal metric to identify a systemic issue and propose a value-added solution for the entire team.
Masterclass Table: Interpreting Your Metrics and Taking Action
| Your Personal Metric Trend | Potential Root Cause | Actionable Steps for Improvement |
|---|---|---|
| High “Touches Per Case” Compared to Peers | You may be handling more complex cases. Alternatively, you may be less efficient in gathering all necessary information during the first provider interaction, leading to multiple follow-up calls. |
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| Lower “Cases Processed Per Day” | This could be related to high complexity (see above). It could also indicate opportunities to improve workflow efficiency, typing speed, or familiarity with various payer portals. |
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| High Approval Rate but Long TAT | This pattern may suggest that while you are excellent at building a strong clinical case, you may be spending too much time on each one, potentially creating a backlog. It’s a balance between perfection and efficiency. |
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16.5.4 The Human Element: Metrics as a Tool, Not a Weapon
A healthy, data-informed work culture uses metrics to foster improvement, recognize excellence, and justify resources. However, in a poorly managed environment, metrics can be misused, leading to unintended negative consequences. As a professional, it is important to be aware of these potential pitfalls and to advocate for a balanced approach that values both quality and efficiency.
The Dark Side of KPIs: Pitfalls of a Metric-Obsessed Culture
- “Cherry-Picking” Cases: If employees are judged solely on “Cases Processed Per Day,” it can create an incentive to handle only the easy, straightforward cases and avoid the complex, time-consuming ones that patients often need the most help with. This harms both patients and team morale.
- Sacrificing Quality for Speed: An intense focus on TAT above all else can lead to rushed, incomplete reviews. An employee might submit a PA with incomplete information just to “get it off their plate” and stop their personal clock, even though they know it will be denied and require rework later.
- Gaming the System: Metrics can sometimes be manipulated. For example, an employee might close and immediately reopen a case to reset the TAT clock. This makes the metrics look good but does nothing to help the patient. A healthy culture focuses on the integrity of the data.
Your Professional Responsibility: Your goal is not to have the “best numbers.” Your goal is to provide the best patient care. Use metrics to improve your efficiency so that you have more time to devote to the complex cases that require your clinical expertise. Advocate for a “blended” view of performance that considers not just volume and speed, but also case complexity, appeal success rates, and positive feedback from providers and patients.
