• Acute Medical/Surgical
• Women’s Health
• Oncology
• Allied Health

4000
3500
3000
2500
2000
1500
1000
500
0
Referral Performance
July - December 2013
Referral Count % Over Target
70%
60%
50%
40%
30%
20%
10%
0%
The graph shows percentage of referrals which exceeded the 8 day timeframe. The grey line shows the number of referrals received and the red line shows the % of those over the 8 day target in each specialty

Initial Findings:
The baseline data revealed wild variation in timeframe targets from specialty to specialty
Investigations into the reasons for the variations revealed the causes to be inconsistencies in the data due to areas using different databases to record referrals
Process mapping revealed the methods of processing referrals were unique to each individual area because each area had developed their processes independently. Indeed they varied from specialty to specialty.
The format and methods of correspondence with referrers and patients in relation to referrals had also evolved separately in each area

The players
We are working closely with each of the Specialist Clinic Managers from these areas to ensure the consistencies we are striving for accommodate the unique needs of the individual areas
The involvement of Surgeons and Physicians is seen as essential to secure engagement in the objectives
Any redesign regarding referrals will have an impact on GPs. It was seen to be vital to include a GP representative both to inform GPs of changes within the hospital and to invite input in regard to GPs needs and capabilities.
IT and data managers are vital players in this improvement. Many of the anticipated improvement will be achieved with the use of IT enablers. The data available to us from our Performance Reporting Unit allows us to track our progress in regard to our nominated milestones.
This all takes place in the context of the New Bendigo Hospital which is currently under construction due for completion in 2016. In this arena models of care are being reviewed across all areas of the organization. Essentially the management of referrals constitutes one aspect of operational models of care. So representation with this focus plays a vital role in this initiative.

Work required
From the outset, it became obvious that milestones could only be met through consistency across the four areas. We needed to achieve consistency in data capture & reporting; referral management processes; and correspondence.
Essentially there is universality in the objectives and the outcomes of care. The differences lay in the processes used to get there and the quality of the data available on the work being done.
Through the process mapping, delays/bottlenecks were identified in medical triage and in some clerical processing. In order for the timeframes to be met for key processes, with consideration to resource constraints, the clerical delays could be addressed. With regard to triage, a decision was made to move towards referral triage by nurses, midwives and allied health personnel. This would reduce a ninestep process to a four-step process
As this function was previously performed by consultant medical staff, there were no written guidelines or criteria. The most time consuming task was the drafting of these triage criteria and the approval process required to implement the use of these.
In the setting of moving towards a paper-light environment for the new hospital, there is work underway towards an EMR. The capacity to receive referrals electronically is related to this project.

Engagement of the stakeholders is the greatest challenge
As with any major change in processes, designing and planning the necessary changes to meet the goals is the easy bit. Engagement with all stakeholders is essential to ensure the success of implementation.
Firstly, the engagement of all four areas to work together towards the goals.
Secondly the engagement of staff within those areas to change their processes
Thirdly the engagement of consultants, many of whom are VMOs
Finally the engagement of IT, HIS, PRU to assist in the structures required to support the changes.

Milestones:
Develop triage criteria to facilitate nurse-led triage
• General Surgery, ENT, Antenatal – Pre-existing
• Orthopaedics & Oncology - May 2014
• Urology, Allied Health, & Gynaecology - July 2014
• Cardiology, Renal, & Respiratory - October 2014
• General Medicine - March 2015
Electronic referral project and electronic discharge correspondence are being developed in conjunction with the EMR
APAC 7 will enable the tracking of referrals returned to the referrer for further information.

Engagement of the Information Technology Department has presented us with additional opportunities to make improvements beyond the nominated milestones
We are developing an application in Sharepoint which provides us with the ability to track and keep records of the waiting list validation process.
Also with the use of Sharepoint, a database has been developed to record clinic start times in a manner which allows us to report easily on the results and trends .