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Improving Referring Provider Communication

Performance Improvement

Leadership Development Program

Center for Health Care Quality

University of Missouri – Columbia

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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) – Joanne Burns (IT)– Colette Nolin (Admissions) – John Guyton (IT)– Becky Morton (Medical Records) – Scott Barger (IT)– Carol Toliver (Finance) – Doug Garrison (Admissions)

• Executive Sponsor – Marty McCormick, Director, Planning

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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.

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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

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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

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Fishbone Diagram

Referring providers/PCP not getting information

At discharge

Internal System

Medical Records

Patient

Admissions

Knowledge

Incorrect faxing

Patients don’t have PCP

Establish new PCP

Internal communication with

PCP disconnect

Staff not verifying

Patients don’t know definition of PCP

scripting

Cerner/IDX not talking

Depart Summary

Physician Referral fax number not correct

Timely discharge summary by

Residents

Timely signature on discharge summary

by attending

PCP not Identified on emergent/

urgent admissions

Referring physician not identified on emergent/

urgent admissions

Elective identified

10/13/10

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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

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Driver Diagram

•

Referring providers/PCP not getting information

At discharge

Internal System

Medical Records

Patient

Admissions

Knowledge

Incorrect faxing

Patients don’t have PCP

Establish new PCP

Internal communicatio

n with PCP disconnect

Staff not verifying

Patients don’t know

definition of PCP

scripting

Cerner/IDX not talking

Depart Summary

Physician Referral fax number not

correct

Timely discharge

summary by Residents

Timely signature on

discharge summary

by attending

PCP not Identified on emergent/

urgent admissions

Referring physician not identified on

emergent/urgent admissions

Elective identified

10/13/10

III - 3

II - 2

I - 1

IIII - 4

II - 2

III - 3

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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.)

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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

Is there a referring Physician listed?

Staff go into each patient’s account in

IDX

It is noted on spreadsheet and

nothing is sent re: no referring

physician

Is referring physician a UHC

doctor or outside physician?

Note Physician on Spread sheet

NOYES

OUTSIDE PHYSICIANUHC

Physician noted on spreadsheet and nothing is sent

Staff look up physician’s fax number

If admit note and DOI is not present only the Discharge Summary is sent.

Staff record sent, signed, number on

master spreadsheet

10/13/10

Staff go into powerchart and fax discharge

summary, DOI, and admit note

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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:– 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

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Baseline Data• 429 discharges measured in November 2010

63

366

External Referring Provider

Internal Provider, Self Referred, Provider Not In Dictionary

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0-3 Days 4-6 Days 7-9 Days 10+ Days0

5

10

15

20

25

30

26

18

811

Days Until Discharge Summary Signed By Attending

Baseline Data• 63 External Referring Providers

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• 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

Baseline Data

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Pilot Data – February 2011156 Patients Discharged

12 Patients Depart Summary Not Required

95 Patients with External Referring Provider or PCP

79 Patients with External Providers

61 Internal Referring Provider or PCP or Self

75 Providers Received Documentation (95%)

4 Patients Expired

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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 follow-

up 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