I want to do project as the attached pdf but put on your mind in primary health care corporation (phcc) we have secondary care(subspecialized clinic) inside the primary care facilities as dermatology, ophthalmology and ENT clinics where the family physicians can refer the patient to their clinics. we can think about to do the study is the referrals that was done to the specialized clinic is it appropriate or it has to be treated by the family physicians and no need to be referred to the specialized clinics. Also to think about the solution to be done to decrease the referral to these clinic e.g to do session from the specialized doctor about most common cases and how to deal with it by family medicine..
Referral to Specialized Clinics (Dermatology, Ophthalmology, and ENT) by Family Physicians
PART I. Project Charter
| Project Title: Reduction of Referrals to Specialized Clinics by Family Physicians to Reduce Workload and Cost. | ||
| Problem Description/ Background:
The problem in question is whether to continue referrals by family physicians to specialized clinics (dermatology, ophthalmology and ENT). I have observed that many visits to primary care physicians end up in referrals to the subspecialized clinics within the health care facility. The rate of referrals by primary physicians in the US has been increasing since 1999. For example, between 1999 and 2009, the possibility of a referral increased from 4.83% to 9.29% (p<0.001), a 92% increase (Barnett, Song, & Landon, 2012). For the staff, the referrals could be warranted because some conditions require specialized care, while patients could be concerned about the cost. Thus, it is important to address the issue to ensure that patients continue to receive safe and quality care, and improve accessibility. Experts should understand the appropriateness of the referrals focusing on the patient population and the promotion of patient-centered care (Ringberg, Fleten, & Førde, 2014). Research on the significance of referrals will also focus on what could be done to improve the practice if found to be necessary. |
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| Project duration: | Start date: 1-9-2020 | End date: 31-12-2020 |
| What are we trying to accomplish? How much? By when? Where? |
| Aim Statement:
The project aims to reduce unnecessary referrals to the sub-specialized clinics (dermatology, ophthalmology, and ENT) by family physicians by 50% by the end of four months after implementation. |
| Evidence Review:
Referrals are an important part of the continuum of care, especially when patients require specialized care. Song, Sequist, and Barnett (2014) suggest that it is a critical link between primary and specialized care for patients. Among the non-elderly population, about one in three patients get a referral each year, while an average of two referrals occurs per patient yearly among the elderly population (Porter et al. 2018). Research indicates the possibility of specialists to provide more evidence-based care compared to primary physicians because the latter lack adequate knowledge of the specific medical condition (Ezeonwu, 2018). Regardless of the frequency of the referrals, many physicians indicate that the specialty-referral process is often frustrating due to its incompleteness and inefficiency (Jaakkimainen et al., 2014; Zuchowski et al., 2015). However, the issue is not in the referral process itself, but in how it is conducted and the limitation in completing the transition of care from the primary physician to the specialist. Thus, more research is necessary to improve the process and make referral experience favorable and satisfactory. |
| Scope of the Project:
The project will start on 1/9/2020 and end on 31/12/2020. The quality improvement project will be conducted in a primary health care corporation (PHCC) with secondary care (subspecialized clinic) inside the primary care facility. The project includes testing how the current physician referrals are conducted at the facility and aspects, such as waiting time, cost, and the level of satisfaction among referred patients. The change project will benefit family medicine doctors by improving the quality of care they provide to patients to prevent unnecessary referrals and the receiving subspecialized doctors by reducing their workload and reducing the waiting time to see patients. Referrals will be limited to the most necessary to provide specialized care. |
| How will we know that a change will result in improvement? | ||||||
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What data will be collected? (Measures) Consider Outcome, Process |
How will you collect the data? (Method) ex. Surveys, Audits, Observations |
Who will collect? (Name) |
When to collect? (Date) include time when applicable |
Where to collect? (Source of data) |
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| The outcome of the project is a reduction in the number of referrals to sub-specialized clinics by Family Physicians. Therefore, the data collected will be the number of referrals before and after the project implementation.
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The data will be collected using an audit of the number of referrals to specialized clinics by Family Physicians pre- and post-implementation of the proposed project. | The data will be collected by focal person for referrals. | The data will be collected for a period of one month, from 1/9/2020 to 30/9/2020 | The source of data will be the primary care facility | ||
| What changes can we make that will result in improvement?
(Every Aim could require multiple smaller tests of change) |
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| List the possible changes in the prioritization matrix and select the change to prioritize
A. Easy to do/high impact Training specialists B. Easy to do/low impact Reducing the number of patients seen in the hospital C. Difficult to do/low impact Increasing number of clinics D. Difficult to do/high impact Increasing specialists in the clinics The change to prioritize is training specialists to improve the way they provide care to referred patients and to improve the overall process. |
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| Describe the selected change
The selected change is to decrease the number of referrals to sub-specialized clinics by training and improving the capacity of primary physicians to handle many of the cases that are referred to the clinics. The intervention is necessary to reduce the cost of referrals and the waiting time that cause patient dissatisfaction. |
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| Constraints or Opportunities | To reduce the financial cost of the referrals to patients and the hospital. |
| Lack of adequate medical equipment to meet the demand of high number of referrals. | |
| Inadequate number of clinical specialists to meet the high demand of referrals at the hospital | |
| Behavior or attitude of physicians who do not want to change or not following the guideline or not qualified to handle simple cases. | |
| Awareness creation session and training family physicians to handle simple cases and avoid unnecessary referrals. | |
PART II. PDSA Cycle
| What is the purpose of this cycle? | |
| Test the change (Cycle No_ ) Implement the change Spread the change | |
| Cycle duration |
Start date: 1-9-2020 End date: 31-12-2020
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PLAN: How do you want to do the change?
| State the measurable Objective of the change that you selected. |
| The objective of the change is to reduce the number of referrals to specialist clinics to reduce the workload, reduce the cost, and improve the quality of care to patients in the hospital. To achieve the reduction in the number of referrals, the project proposes training and improving the capacity of primary physicians to handle more cases that currently result in referrals. |
Predictions
| Predict what will happen when the test is carried out
(Include how the change will affect positively or negatively other areas of the organization/Health Center) |
| The change will reduce the workload for specialists, improve the service provided to patients at the hospital and reduce the cost for patients and the hospital. It will also improve the relationship between patients and care providers at the hospital, hence lead to higher satisfaction. |
| However, the change might cause negative outcomes, such as poor patient outcomes due to lack of the experience among primary physicians to treat medical conditions that conventionally require referrals. |
- Measurement Plan for the Change and Prediction/s
| What data will be collected?
(Measures) Specify if Structure, Process or Outcome |
How will you collect the data? (Method)
ex. Surveys, Audits, Observations |
Who will collect?
(name) |
When to collect? | Where to collect?
(Source of data) |
| The data collected will include the number of referrals made before and after the change. | An audit of the hospital records for the number of referrals. | Focal person for referral in the phcc facility | Four months after implementation of the change, 31-12-2020 | primary health care corporation (PHCC) with secondary care |
- Action Plan
| List the tasks needed to set up this test of change
(Organize step-by-step the list of tasks with the responsible person beside each step along with the date, location and resources) |
Person responsible | When to be done | Where to be done | Resources Needed |
| Train primary physician on how to treat minor cases that traditionally lead to referrals at the hospital, such as minor ear infections.
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Hospital administrator | 1/9/2020 | the primary health care corporation (PHCC) with secondary care) | Finances to training primary physicians |
| Reduce referrals by improving resources and medical equipment available to primary physicians to deal with minor cases that traditionally lead to referrals at the hospital, such as minor ear infections. | Hospital administration | 1/10/2020 | The primary health care corporation (PHCC) with secondary care) | Medical equipment to support primary care |
| Evaluation of the effectiveness of the project by conducting an audit of hospital records to test the reduction in the number of referrals. | Nurse leader | 31/12/2020 | The primary health care corporation (PHCC) with secondary care) | Data from the hospital about improvement in the quality of care. |
STUDY: What were the results?
| Describe your measured results, finalize the analysis of the data you collected, compare to your prediction, whether or not the goal identified in the aim statement was achieved and by how much, and summarize what was learned.
You may also add graphs if any. |
| From where did you get this number?is it evidence based? |
References
Barnett, M. L., Song, Z., & Landon, B. E. (2012). Trends in physician referrals in the United States, 1999-2009. Archives of Internal Medicine, 172(2), 163-170. doi:10.1007/s11606-011-1861-7. 21.
Ezeonwu, M. C. (2018). Specialty-care access for community health clinic patients: processes and barriers. Journal of Multidisciplinary Healthcare, 11, 109. doi:10.2147/JMDH.S152594
Jaakkimainen, L., Glazier, R., Barnsley, J., Salkeld, E., Lu, H., & Tu, K. (2014). Waiting to see the specialist: patient and provider characteristics of wait times from primary to specialty care. BMC Family Practice, 15(1), 16. doi: 10.1186/1471-2296-15-16
Porter, M., Malaty, J., Michaudet, C., Blanc, P., Shuster, J. J., & Carek, P. J. (2018). Outpatient Referral Rates in Family Medicine. The American Journal of Accountable Care, 6(1), 25-28. doi:10.1177/0272989X05284110
Ringberg, U., Fleten, N., & Førde, O. H. (2014). Examining the variation in GPs’ referral practice: a cross-sectional study of GPs’ reasons for referral. British Journal of General Practice, 64(624), e426-e433. doi:10.3399/bjgp14X680521
Song, Z., Sequist, T. D., & Barnett, M. L. (2014). Patient referrals: a linchpin for increasing the value of care. Jama, 312(6), 597-598. doi:10.1001/jama.2014.7878
Zuchowski, J. L., Rose, D. E., Hamilton, A. B., Stockdale, S. E., Meredith, L. S., Yano, E. M., … & Cordasco, K. M. (2015). Challenges in referral communication between VHA primary care and specialty care. Journal of General Internal Medicine, 30(3), 305-311. doi:10.1007/s11606-014-3100-x
DO: When and how did we do it?
| Carry out the test and describe what happens during the test. Detail the actual impacts either internally or externally or both and include any unexpected events or problems. Begin data analysis. |
| The change will include reducing the number of referrals from the current average of 10 per day to less than five per day by 31/12/2020. |
STUDY: What were the results?
| Describe your measured results, finalize the analysis of the data you collected, compare to your prediction, whether or not the goal identified in the aim statement was achieved and by how much, and summarize what was learned.
You may also add graphs if any. |
| The anticipated data by 31/12/2020 is that the number of referrals will drop to an average of 4 per day and that the level of satisfaction among patients will improve from the current 55% to more than 70%. |
| Summarize what was learned from the change. |
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The change shows that although referrals are necessary, they can cause inefficiency in the care process. Thus, one of the positive changes is to reduce their number and improve the quality of primary care.
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ACT: What changes are we going to make based on the findings?
| From your learning above, decide on whether or not you want to adopt the change, amend it and test again or abandon. In addition, write a clear statement indicating what will happen next. |
The Model for Improvement
Appendix 2: Fishbone Diagram
| Fishbone diagram
Use the Fishbone diagram to identify factors related to the problem/issue. Begin by placing the problem on the right. Identify what causes a particular event to occur. Think about the causes as they relate to each of the categories: People, Process, Policies and Plant/Structure or create your own category. |
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