Improving Referring
Provider Communication
Performance Improvement
Leadership Development Program
Center for Health Care Quality
University of Missouri – Columbia
1
Team
• Provider Champion/Coach/Facilitator
– Kevin Dellsperger, MD
– Kristin Hahn-Cover, MD
• Team Members
–
–
–
–
–
–
Cindy Feutz, RN, Clinical Nurse Specialist (Cardiology)
Jordan Magdits, Assistant Manager (Admissions)
Sherry Rickard, RN , Case Manager (Family & Community Medicine)
Tracy Riecke, RN, Case Manager (Orthopaedic Surgery)
Krista Romanetto, Supervisor (Medical Records)
Matt Wilp, Manager (Provider Relations)
• Resources
–
–
–
–
Candice Monnig (Cardiology)
Colette Nolin (Admissions)
Becky Morton (Medical Records)
Carol Toliver (Finance)
– Joanne Burns (IT)
– John Guyton (IT)
– Scott Barger (IT)
– Doug Garrison (Admissions)
• Executive Sponsor – Marty McCormick, Director, Planning
2
Focus Area & Aim
• Problem
– Over the past 12 years, communication has consistently ranked as
the leading cause of dissatisfaction for referring/primary care
providers.
• Timeliness of communication
• Quality of communication
– Poor communication has a negative impact on:
• Patient safety and outcomes
• Referral volumes
• Aim Statement - we aim to improve communication
within one business day of discharge to external
referring and primary care providers whose patients
receive in-bed services at University Hospital by
increasing successful transmission of discharge
documentation from 28% to 100% by April 1, 2011.
3
Timeline
• August 2010 – Project Began
• September - November 2010 – Diagnostic Journey
• November 2010 – Interventions chosen – reintroduce
scripting & pursue automation
• November 2010 – Admissions/Registration reinforces
scripting to staff
• December 2010 – Dr. Hahn-Cover presents recommended
changes to Executive Committee; approved by Executive
Committee
• December 2010 - February 2011 – Rapid Cycle PDSA
• February 2011 – Pilot process of faxing Depart Summary to
referring and primary care provider
• February 2011 – Dr. Hahn-Cover presents updated
recommendations to Executive Committee
4
Relationship to Strategic Goals
• Service Column of Excellence
– FY15
• Goal - To become the provider of choice through exceptional
patient- and family-centered care
• Targets/measures - referring provider satisfaction mean score of 80
– FY11
• Objective/tactics
– Develop and implement a process to provide communication within one
to two business days of discharge to the referring/primary care provider
– Develop a succinct discharge summary that meets the needs of
referring providers and improves coordination of care and outcomes
• Targets/measures
– Implementation of inpatient discharge notification process; 80% of
external referring physicians receive a phone call within two business
days of patient discharge
– Development of discharge summary
5
Fishbone Diagram
Knowledge
Internal System
Patients don’t know
definition of PCP
Patient
Internal
communication with
PCP disconnect
scripting
Physician Referral fax
number not correct
Establish new PCP
Staff not verifying
Cerner/IDX not talking
Depart Summary
Patients don’t have PCP
Timely discharge
summary by
Residents
Timely signature on
discharge summary
by attending
Referring providers/
PCP not getting information
At discharge
PCP not Identified
on emergent/
urgent admissions
Referring physician not
identified on emergent/
urgent admissions
Elective identified
6
Incorrect
faxing
Medical Records
Admissions
10/13/10
Stakeholders
• External referring/primary care providers
• Patients
• Patient care staff (e.g. physicians, fellows, residents,
nurses, case managers, discharge planners, etc.)
• Revenue cycle
• Information technology
• Provider relations
7
Driver Diagram
Knowledge
•
Internal System
Internal
communicatio
Patients don’t
n with PCP
know
disconnect
III
3
definition of
PCP
scripting
Depart
Summary
Physician
Referral fax
number not
correct
8
Incorrect
faxing
Staff not
verifying
II - 2
Cerner/IDX
not talking
Patient
I-1
IIII - 4
Establish
new PCP
Referring providers/
PCP not getting information
At discharge
Timely
discharge
summary by
Residents
Timely
signature on
discharge
summary
by attending
Medical Records
Patients don’t have
PCP
PCP not Identified
on emergent/
urgent admissions
Referring physician not
III
identified on
emergent/urgent
admissions
Elective
identified
II - 2
-3
Admissions
10/13/10
Interventions Chosen
• Immediate/Short-term
– Reinforce scripting for registration/admissions staff to better
clarify what a referring and primary care provider is to patients
– Fax Depart Summary to referring and primary care provider by
next business day after patient discharge
• Long-term
– Develop an automated process to send out all communication
(admission note, operative notes, succinct discharge summary,
clinician summary) within timeframe outlined in Medical Staff
Bylaws
– Roll out this process to all areas at University Hospital as well as
all other MUHC facilities (WCH, MUPC, EFCC, clinics, etc.)
9
Evolution of Medical Records Process Flow
Patient is
discharged
from in bed
location
Physician is
required to
complete
Discharge
Summary
upon
discharge
Once
Discharge
summary is
complete and
signed by
attending it
shows up on
Diamond
Mine Report
@ 1159pm
that day
Staff pulls up
diamond
mine report
next business
day after
attending
signs
Staff Paste all
patients to
excel
spreadsheet
YES
UHC
Physician noted on
spreadsheet and
nothing is sent
Is referring
physician a UHC
doctor or outside
physician?
Staff go into each
patient’s account in
IDX
Is there a
referring
Physician
listed?
OUTSIDE PHYSICIAN
Note
Physician on
Spread sheet
If admit note and DOI is not present
only the Discharge Summary is sent.
NO
It is noted on
spreadsheet and
nothing is sent re:
no referring
physician
Staff look up
physician’s
fax number
Staff go into powerchart
and fax discharge
summary, DOI, and admit
note
Staff record sent,
signed, number on
master spreadsheet
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10/13/10
Evolution of Medical Records Process Flow
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Measurement
• Measure the percentage of external referring and
primary care providers who are sent follow-up
communication
• Key measures for this process include:
–
–
–
–
–
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Primary care provider complete
Referring provider complete
Proportion of providers that are external
Time interval between date of discharge and date documentation is faxed
Fax sent successfully
Baseline Data
• 429 discharges measured in November 2010
63
366
13
External Referring
Provider
Internal Provider,
Self Referred,
Provider Not In
Dictionary
Baseline Data
• 63 External Referring Providers
Days Until Discharge Summary Signed By Attending
30
25
20
15
26
10
18
5
8
11
0
0-3 Days
14
4-6 Days
7-9 Days
10+ Days
Baseline Data
• 139 discharges measured in January 2011
– 94 external referring or primary care providers listed
• 28% (26 of the 94) of patients’ providers receive follow-up
communication
• Low percentage due to current UH process of only sending
documentation to referring provider
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Pilot Data – February 2011
156 Patients Discharged
61 Internal Referring
Provider or PCP or Self
95 Patients with External
Referring Provider or PCP
12 Patients Depart
Summary Not Required
4 Patients Expired
79 Patients with External
Providers
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75 Providers Received
Documentation (95%)
Process & Outcome Indicators
• Process Indicators
– Registration Services to include the completion of referring and
primary care provider field into daily QA process
– Medical Records to include QA process of recording verification
of faxes sent to referring and primary care providers
• Outcome Indicators
– Continuity of care for patient safety and decrease in avoidable
readmissions
– number of referring and primary care providers receiving followup communication
– Referring physician satisfaction
– Referrals volumes
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Benefits
•
•
•
•
Quality – improving communication to referring physicians will enhance the
coordination of care and patient outcomes and prevent avoidable
readmissions
Service - increased referring physician and patient satisfaction
People – increased physician satisfaction and retention
Growth - the Advisory Board states that physicians are the most important
driver of market share:
–
–
–
–
•
35% - primary physician is affiliated with hospital
31% - hospital provides specialized services
31% - advice/referral from physician
21% - hospital is up-to-date with medical advances
Finance
– Reimbursement increasingly being tied to quality of care and outcomes
– FY10 net revenue/adjusted case YTD (excl. FRA and retail pharmacy revenue)
• University Hospital - $13,712
• CRH (now W&CH) - $ 13,152
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Anticipated ROI
• MUHC has aggressive growth and financial targets
– FY10 actual discharges were 21,279 and the FY11 budgeted discharges
are 23,064. This is an 8.4% (1,785) increase in discharges
– The FY11 budgeted change in net assets is $30.0 million
• Assuming average net revenue per adjusted case of $13,500,
MUHC could experience the following improvement in
performance:
– 2% (425) increase in discharges would result in an additional $6.5 million in
net revenue
– 6.5% (1,383) increase in discharges would result in an additional $18.6
million in net revenue
– 10% (2,127) increase in discharges would result in an additional $28.7
million in net revenue
• Medical Records estimates a saving of at least 2 hours of
employee time per day when implementing the process of faxing
Depart Summaries
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Lessons Learned
•
•
•
•
•
•
•
•
•
The situation is more complex than anticipated and requires collaboration on the
part of many
Patients need clarification of what a primary care physician is
Residents and attendings have ownership in completing discharge summaries
and signing off in a timely manner
A clear/concise discharge summary or Depart Summary for referring and
primary care providers needs to be developed
The provider dictionaries need to be combined and maintained and IT systems
need to interface
The process needs to be centralized to improve quality and reduce inefficiencies
Both the referring physician and the primary care physician should receive
communication
The reason that documentation was sent to only referring providers was
because years ago the referring provider field was the most filled out field
Sometimes change to hospital policy is needed and can be time consuming
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Summary
• We have only taken on a very small part in improving overall
communication to referring providers
• In an ideal world an automated process is the best answer, but the
bottom line is it can only be as good as the data that is available to
it; the goal is to achieve automation by July 2012
• With a major emphasis on outcomes and avoidable readmissions,
improved coordination of care through communication to referring
and primary care providers is essential
• Improving quality of care and outcomes and increasing the
satisfaction of our referring providers will assist in achieving the
volume growth needed to support MUHC’s strategic financial plan
• We feel our biggest accomplishment so far was discovering that
primary care providers were not receiving communication and
mirroring our current process to get communication to them
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