Kelley Jenkins

NURS 3241
Quality Improvement Project Proposal Worksheet July 23, 2019

Project
Goal Develop a standardized referral process between specialty care practices within the organization
Keep in mind the IOM Quality Goals: Safe, Timely, Efficient, Effective, Equitable, Patient Centered (STEEEP) , Magnet Standard
Team
Members Nurses, specialty care practice administrators/managers, practice physicians, health system administration
Identify your team members.

Step 1 - Problem Identification & Baseline Data

My global aim is to improve the referral process between specialty care practices

in the organization. I expect that by working on this problem, we will

Global Aim – fill in the blanks
Reduce lost or uncompleted referrals by 50%. It is important for us to work on this

Because patients are being lost to specialty care follow-up due to inconsistency in referral processes
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between practices.
Observations made:
Data to support - What are some -Each practice has a different process for handling referrals: some require both electronic and faxed copies of the same referrals, some require
electronic referral and faxed copies of patient demographics, some process electronic referrals only, while other process faxed paper referrals only.
observations you have made? What -If a provider is not designated in an electronic referral, it goes into a referral “bank" where it is left unaddressed for extended periods of time,
are some of the factors that stand in causing delay in contacting patients
Factors that stand in the way:
the way? -No administrative support to develop consistent method -insufficient staff to monitor referrals
-Cost associated with making changes to electronic medical record system (EMR) for referral process -lack of standard protocols

Outcome Data – How prevalent is
the problem? Provide results here
Of the selected sample of 25 referrals sent from our practice to specialty care practices within the
organization, including cardiology, maternal fetal medicine, and general surgery, 9 referrals either had a
significant delay in scheduling the patient or patient's were not scheduled at all requiring our staff to call
the specialty practices and get patient's scheduled over the phone. This sample of resulted in 36% of
referrals that did not get completed appropriately.

Clinical Improvement Project Worksheet 1

 Step 2 - Link Current Evidence & Benchmarking Best Processes
Evidence from literature – what Referral Management by MacColl Center for Health Care Innovation at Kaiser Permanente Washington Health Research Institute.
evidence in the literature supports or Advises that practices need to “ensure all referrals meet time-sensitive needs of patient, support patients by providing care and
informs your goals? information they need, establish relationships with other practices to develop trust, and develop connections with other providers to
facilitate timely flow of patient information.” Also suggests implementation of a referral coordinator who “orchestrates and tracks the
progress and outcomes of referrals”.
Provide the following for TWO sources of
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literature: title, author, intervention, Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era by the Institute for Healthcare Improvement (IHI). A focus
group study was performed which found four common breakdowns in the referral process and identified common causes of
sample, details, results & your own malpractice claims related to incomplete referrals. Additionally, a 9-step “loop” process was developed to help close the gap in the
comments. referral process. This document provides excellent guidelines for how to address potential barriers at each of the 9 steps.

Evidence from industry – Find evidence
from other institutions or the industry:
what are others doing that would support
your goals?
Provide the following for TWO sources:
title, hospital/organization, intervention,
population, details, results & your own
comments.
Use of an Electronic Referral System to Improve the Outpatient Primary Care-Specialty Care Interface by The Agency for
Healthcare Research and Quality. Hospital: University of California San Francisco – San Francisco General Hospital.
Developed “eReferral”, an electronic web-based referral system where referring physician fills out internet form with patients
relevant history and reason(s) for consult. The system automatically extracts pertinent patient information from the EHR, links
it to the request and submits the referral to the specialty practice. A referral reviewed is designated by each practice to review
and monitor all referrals.
Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center by
Barnett et al. Discusses successful implementation of “eReferral” in Brigham and Women’s Hospital in Boston, MA. Also
provides several “Teaching Points” that provides areas of further consideration when implementing such a system.

Step 3A – Understanding the Process (Context – readiness to change, evidence of teamwork, quality culture)
Directions: Review each principle that determines readiness for change. Score a principle “yes” if you believe you have established support and
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readiness.
If you have not achieved support, redefine your opportunity and realign your strategies.
(Note: re-evaluating and re-scoring is not necessary for the assignment, but it would benefit your project.)
When all criteria is scored as a “yes” you should proceed with your improvement strategy. As you continue, remember to:
1. Use the PDSA process with a focus on continuous evaluation and reflection. (Use only PD from PDSA cycle)
2. Follow the implementation process as a team
3. Measure effectiveness continuously
4. Market the outcomes to your team and the organization
5. Celebrate success

Define agreed upon project & goals: Do you Yes, organizational administrators, practice administrators, and physicians all agree with project and goals
have senior leadership buy-in? Yes or no?

Clinical Improvement Project Worksheet 2

 Step 3A Continued
Yes; the customer is the patient
Customer Focus: Have you clearly defined
the customer who will benefit from the
improvement? Yes or no?

Yes; the process of submitting and monitoring electronic referrals between specialty care practices in the
Eliminate Blame: Have you defined the outpatient setting
process (not the people) that requires
redesign? Yes or no?

Yes; practice managers will utilize data available within the electronic medical record system to generate
Rely on Data: Have you defined data needs monthly reports of number of referrals sent, referrals received, and referrals completed. All uncompleted
and required support for data management referrals will be investigated to determine why they were not done.
and analysis? Yes or no?

Yes; nurses, medical assistants, practice managers, specialty care physicians, organization administrators
Team Approach: Have you defined an inter-
professional team creating a neutral problem
solving environment? Yes or no?

Include all levels of employees: Have you Yes; the initial refer begins with the physician deeming it necessary. The physician places the electronic referral (or
defined all employees involved in every level the nurse/MA places refer on verbal or written order). The referral goes to a designated referral coordinator for
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of process? Yes or no? receiving specialty care practice. Referral coordinator calls patient to schedule follow-up and marks referral in
process. Patient is seen for follow-up care by specialty provider who closes the loop by marking referral complete.
EMR system automatically generates summary report from visit and sends to original referring provider.

Economic Support: Have you identified
economic needs of the project, including
time, personnel and financial support? Yes or
no?
Yes:
-Designated employee for each specialty practice who functions as referral coordinator; may be existing employee if job roles can
accommodate expanded tasks and time commitment
-Financial resources for hiring referral coordinators if necessary
-Financial resources for potential minor adjustments to existing electronic referral system
-Time for monthly meetings of team members to assess success or failures of process and make adjustments as necessary

Clinical Improvement Project Worksheet 3

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 Step 3A Continued
Celebrate Success 1: Have you identified
ideas for various levels and types of team
success? Yes or no?
Yes; completed referrals improve patient satisfaction, which can in turn improve revenue for the
organization due to patients returning for future care or patients referring other people to receive care at the
organization. Also may improve patient outcomes by getting them to specialty providers sooner and
receiving appropriate care.

Yes; of all the employees, managers, physicians, and administrators who the project was discussed with
Celebrate Success 2: Have you obtained buy- agreed there were major flaws in the current referral system and looked forward to seeing how the new
in for celebration of success? Yes or no? changes could improve the referral process.

Step 3B – Understanding the Process (Diagnosis of system performance, process map, fishbone diagram)
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Fishbone Diagram - We use fishbone diagrams to help identify what caused a particular event to occur. Begin by placing the event at the head of the fish.
Then think about the causes of this event as they relate to each of six categories: People, Methods, Machines, Materials, Measurements, and Environment.

People: Process: Equipment:

Electronic health
Lack of designated e-Referrals lacking provider EHR physician catalog
record system name do not get sent to
personnel to monitor and for referrals not Specialty
specialty practice
follow up with referrals routinely updatedcareto
Referrals not processed reflect all specialty
referrals
timely, patients not getting care physicians
called for follow-up care failing to be
completed
Problem:
in a timely
Materials: Environment: Management:
manner or
No staff appropriated to Organizational leadership at all
monitor referrals not pursuing a fix to
referral processes
Busy work environment

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1odule
Step 3B Continued
Process Map – Make a process map any way you can, save it as a picture, and include it below. Click the grey box to insert a picture.

Click Here to Insert Image

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Step 4 – Specific Aim & Timeline

By January 1, 2010, we aim to reduce the number of uncompleted outpatient specialty care referrals by
50 %.
Specific Aim – What are we trying to
accomplish? Make sure your aim is SMART:
Specific, Measurable, Achievable, Realistic,
and Timely.
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Step 4 Continue Proposed
Timeline – Make a timeline any way you can, save it as a picture, and include it below. Click the grey box to insert a picture of it below.

Sample
Timeline:

Literature & Organizational Process Specific Aim Data Identification of Data Collection: Storyboard
Industry Readiness Diagram & Collection: Change Strategy & Post-Pilot Study
Assessment Fishbone Baseline Implementation
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Click Here to Insert Image

See attached Appendix

Clinical Improvement Project Worksheet 6
 Step 5 - Measures
Survey or interview guide: Create a short 1. What problems do you currently see with the outpatient specialty care referral process?
survey or interview guide (2 -3 questions) to 2. What changes do you think should be made to improve the process?
collect additional information from the people 3. What barriers do you see to making those changes?
who you work with and a patient regarding
the process you are trying to change.

The outcome measure is to reduce the number of uncompleted patient referrals.

Outcome Measure: Identify the outcome
measure: what are the desired results?

The operational definition identifies uncompleted patient referrals as those that do not meet the following criteria:

Outcome Measure: Identify the operational
definition: how will you measure?
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Those that are called and scheduled within 24 hours for urgent referrals and 72 hours for routine referrals
AND
The patient is seen and evaluated by specialty care physician.

Process Measure: Identify the process

measure: are the parts of the system
performing as planned?

Process Measure: Identify the operational

definition: how will you measure?

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 Step 5 Continued
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Balancing Measure: Identify the balancing

measure: are changes to improve one part of
the system causing new problems in other
areas?

Balancing Measure: Identify the operational

definition: how will you measure?

Step 6 – Identify and Choose Change Idea (What changes can we make that will result in an improvement?)
Directions: Fill out the table below. Enter a change idea then answer yes or no to each question in that row. Give a point for each “yes” response
and include the total
` number of points for the change idea in the “total” column.
Advantage
Evidence to Available Easy to New
Change Idea Over Current Total
Support? Resources? Implement? Innovation?
Process?
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Clinical Improvement Project Worksheet

8
Step 5:
Process Measure: Identify the process The process measure is the number of referrals that are actually
measure: are the parts of the system called and scheduled.
performing as planned?

Process Measure: Identify the operational
definition: how will you measure?
Balancing Measure: Identify the balancing
measure: are changes to improve one part of
the system causing new problems in other
areas?
This will be measured using data reports generated by the
electronic health record system to determine the percentage of
total referrals that are actually recorded as attempted to schedule
or scheduled.
A balancing measure for this proposal is:
Is the designation of a referral coordinator causing disconnect
between the provider’s knowledge of the status of the referral?

Balancing Measure: Identify the operational Upon a test of change, subjective surveys will be conductive to
definition: how will you measure? assess the provider’s opinion on the use of referral coordinators to
help in the referral process.

Step 6:
Change Idea Evidence to Available Easy to New Advantage Over Total
Support? Resources? Implement Innovation Current Process?
? ?
Implement completely different referral yes yes no no no 2
system
Convert back to non-electronic (paper) no yes yes no no 2
referrals via fax
Update electronic referral system to yes yes yes no yes 4
reflect standardized referral process for all
practices but do not use referral
coordinator
Update electronic referrals system to be yes yes yes yes yes 5
standardized and include referral
coordinator
 Appendix

Assess Team Assess Perform Implement Review first Team Implement Final roll-
referral meeting for specialty EHR update referral data on meeting to change ideas out of
practices referrals: #sent,
process project to reflect process #received, brainstorm referral
from an design plan readiness and any changes change methods to process
#completed per
acceptance of
individual necessary to practice; eliminate
change evaluate
practice support causes of
incomplete
referral referrals for
incomplete
process cause referrals

Aug. 1, 2019 Sept. 1, 2019 Sept. 15, Sept. 30, Oct. 1, 2019 Nov. 1, 2019 Nov. 5, 2019 Dec. 1, 2019 Jan. 1, 2019
2019 2019
 References

Barnett, M., Mehrotra, A., Frolkis, J., Spinks, M., Steiger, C., Hehir, B., Greenberg, J., & Singh,

H. (2016). Implementation Science Workshop: Implementation of an Electronic Referral

System in a Large Academic Medical Center. Journal of General Internal Medicine,

31(3), 343-352. doi: 10.1007/s11606-015-3516-y

Bell, D., Straus, S., Wu, S., Chen, A., & Kushel, M. (2012). Use of an Electronic Referral

System to Improve the Outpatient Primary Care – Specialty Care Interface. (AHRQ

Publication No. 11(12)-0096-EF). Retrieved from Agency for Healthcare Research and

Quality Website:

https://healthit.ahrq.gov/sites/default/files/docs/citation/ereferralimplementationreportfina

l.pdf

Gandhi, T. (2017). Improve the Referral Process, Improve Safety. Retrieved from

http://www.ihi.org/communities/blogs/improve-the-referral-process-improve-safety

Improving Primary Care. (2019). Referral Management. Retrieved from

http://www.improvingprimarycare.org/work/referral-management

Institute for Healthcare Improvement/National Patient Safety Foundation. (2017). Closing the

Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Retrieved from Institute

for Healthcare Improvement website:

http://www.ihi.org/resources/Pages/Publications/Closing-the-Loop-A-Guide-to-Safer-

Ambulatory-Referrals.aspx