Running head: QUALITY IMPROVEMENT PROPOSAL 1

Quality Improvement Proposal

Kelley Jenkins

Bon Secours Memorial College of Nursing

NURS 3241 – Quality and Safety in Nursing Practice

July 23, 2019

“I pledge.”
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Abstract

According to the U.S. Department of Health and Human Services, quality improvement

“consists of systematic and continuous actions that lead to measurable improvement in health

care services and the health status of targeted patient groups” (2011). In health care, information

is always being reviewed to assess effectiveness, safety, and quality of services delivered to

patients. When an area is identified that could benefit from an improved process, a quality

improvement project is developed to make necessary changes. This paper will discuss a quality

improvement proposal for my practice and organization. It will describe the problem, identify

contributing factors, review the PDSA cycle and a proposed timeline for the project as well as

describe a small test of change.

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Quality Improvement Proposal

Identifying the Problem

Working in a very busy obstetrics and gynecology office, we see 75 to 100 patients per

day office-wide. The provider whom I work for sees about 30% of the total patients because she

is the busiest provider in the office. For this reason, she orders a large amount of referrals to

outside specialty care providers that I am responsible for handling. On one particular day, I had

to place referrals for different patients to see five separate specialties, including maternal fetal

medicine and cardiology, which was an unusually heavy day for referrals. Each of the referrals

were placed digitally in our electronic health record (EHR) system, some with specific providers

designated, others not because we didn’t care which provider the patient saw within that

specialty.

We typically refer obstetrical patients to maternal fetal medicine several times a day

because they are the high-risk doctors who evaluate problems with pregnancies, so I’m familiar

with their process. I input the electronic referral in our EHR system, but when the referral prints,

I have to then fax it to their office. For most other referrals, it’s just the use of the electronic

ordering of “Referral to X specialty”, selecting a provider as desired and putting a comment in

for why the referral is being placed. I always tell my patients who are being referred to outside

practices that if they haven’t heard from the practice to get an appointment scheduled within 48

hours to contact me and let me know so I can follow-up to figure out why.

Later this particular week, I had two patients call me and let me know that they had not

been contacted to get their appointments scheduled: one with cardiology and one with physical

therapy. When I called the cardiology practice to determine why, they informed me that because

a specific provider was not originally identified in the e-referral (it was left blank because we
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didn’t care who the patient saw), the referral went into a “bank somewhere” and they didn’t

receive it. They informed that I needed to put a provider’s name on the referral and then indicate

in the comments that the first available provider may see the patient. With the physical therapy

referral, I actually did indicate a provider because it is one we had referred to previously, and

when I called they informed me that provider no longer worked there, so it too went into a “bank

somewhere”. This is when I realized there was way too much inconsistency in the referral

process.

Contributing Factors

There are many factors that contribute to the issues with our referral system. Working in

a busy environment does not allow adequate time for nurses or medical assistants to call referrals

directly, which relies on the electronic system. However, the electronic system isn’t streamlined

or efficient, and the physician catalog within the EHR is not routinely updated to reflect the

providers who work for certain specialties. Additionally, organizational leadership doesn’t

prioritize working to identify a fix for the referral system nor do practice managers assist with

ensuring that referrals get completed. Finally, there are no designated personnel to handle

referrals within each practice, which would make a significant difference.

PDSA Cycle

In the plan phase, a project team will be formed to collect baseline information on total

referrals and percentage completed, reports will be generated in the EHR to deliver this

information. The data will be collected by the designated referral coordinators, practice

managers, and organizational leadership in order to evaluate progress of the project. Data

collection will take place prior to beginning the study, at month one, and then monthly until final

implementation. Beyond implementation of the new process, data will be monitored on every 3-6
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months to make sure no further improvements need to be made to achieve better results. The

referral coordinators will be put into place to place, monitor, and call all referrals that come into

the practice. Additionally, with minor changes to the e-referral system in the EHR, we will see if

these changes help to achieve a goal of a 50 percent overall reduction in incomplete referrals.

Timeline for Proposal

The timeline for this proposal would begin August 1, 2019 with assessing the referral

process from an individual practice to gauge the inefficiencies and end on January 1, 2020 with

the final roll-out of the new referral system. A team consisting of nurses, medical assistants,

practice managers, specialty practice physicians, and organization administrators would meet to

discuss and decide on the project plan and goals, then a mandatory survey would be sent to all

medical practices within the organization to assess their readiness for and acceptance of changes

to the referral system as well as obtain feedback on ways that it could be improved. An update

would be completed on the EHR system to reflect any changes necessary to support the new

referral process, and then the test run of the new process would be implemented. A month later,

each practice would collect and submit the number of referrals sent, number received, and

number completed to the team leading the QI project, and any incomplete referrals would be

evaluated for cause. The team would meet to evaluate the data and brainstorm methods to

eliminate causes of the incomplete referrals and then those change ideas would be implemented

On January 1, 2020, if the referral process is working smoothly, this would be considered the

official roll-out.

Test of Change

Once the project design was completed and the EHR update was finished, a small test of

change would be performed. To do this, the new electronic referral system would have to be
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rolled out organization-wide for consistency, but for a trial, a newly hired or designated referral

coordinator would be put in place in a single practice location to handle their referrals. When a

provider enters a referral into the standardized e-referral system, it would be sent electronically

to the practice that has the referral coordinator. The referral coordinator would be responsible for

contacting the patient to schedule their initial appointment. Criteria of 24 hours for urgent

referrals and 72 hours for routine referrals would be expected. After one month of using the

referral coordinator and new e-referral system, data would be evaluated to see how the process

compared to the previous system.

Recognizing Improvement

Improvement would be apparent based on several factors. Quantitative data that is

obtained using reports built into the EHR system to generate information on the number of

completed referrals would show whether or not the system led to improvement. These would

also provide data on the causes of incomplete referrals to determine if the process is more

efficient in eliminating sources of failed follow-up. Additionally, patient satisfaction scores

would be evaluated to see if they improved in the area of follow-up care.

Summary

Referrals are an important process in healthcare, because often times that is how patients

get connected with new providers. For this reason, using evidence-based practice to make this

change and develop a solid process for handling referrals improves patient safety through

making sure they get the proper follow-up care. Implementing a project like this would take

significant teamwork and collaboration, particularly in the early stages, as everyone adjusts to

the new process – change is never easy in healthcare. At its core, this project relies on

informatics as the whole system is based through the electronic health record. Without
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informatics in this day and age, antiquated processes would not make for a successful healthcare

system. We have to rely on quality improvement projects, such as this one, to develop and

improve our processes in such a way that supports superior healthcare delivery.
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References

U.S. Department of Health and Human Services. (2011). Quality Improvement. Retrieved from

https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf