Improving Referring Provider Communication

1. Improving Referring Provider Communication Performance Improvement Leadership Development Program Center for Health Care Quality University of Missouri – Columbia

2. 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

3. 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.

4. 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

5. 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

6. Fishbone Diagram

7. 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

8. Driver Diagram III - 3 IIII - 4 II - 2 I - 1 II - 2 III - 3

9. 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.)

10. Evolution of Medical Records Process Flow

11. Evolution of Medical Records Process Flow

12. 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

13. Baseline Data • 429 discharges measured in November 2010

14. Baseline Data • 63 External Referring Providers

15. 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

16. 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 75 Providers Received Documentation (95%)

17. 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

18. 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

19. 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

20. 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

21. 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