Munroe Regional Medical Center (MRMC) had a long history of prioritizing performance improvement initiatives. Leaders at the 421-bed, not-for-profit, community hospital were well-versed in Six Sigma and other performance improvement strategies. The organization had already streamlined many care processes and had eliminated waste throughout the system. However, MRMC leaders recognized the need for a standardized process to ensure timely clinical communications, especially given the high volume of communications events at the organization: the 450 physicians and 2,500 clinical staff members completed more than 150,000 calls per year. MRMC had been using a home-grown system for contacting physicians, relying on telephone calls to physician offices or answering services, which often proved unreliable and inefficient. Leaders realized the organization needed a systematic, reliable process for contacting physicians. Senior Vice President of Medical Affairs and Chief Quality Officer Lon H. McPherson, MD, had previous experience with PerfectServe in another healthcare organization. McPherson was familiar with the benefits of PerfectServe and was able to champion the project using his past experience with implementation.
While the implementation of PerfectServe helped MRMC improve all forms of clinical communications, this case study focuses on the ways in which PerfectServe specifically helped the organization monitor and refine its physician consultation process.
Eliminating inefficiencies with PerfectServe
PerfectServe is a comprehensive and secure communications platform that routes voice, text and Web- and system-generated communications based on clinician workflow and personalized algorithms, allowing physicians, clinical teams and practice groups to selectively filter and control when and how they are contacted. PerfectServe’s “rules engine” filters communication events based on multiple variables unique to each clinician, which can be updated easily via a phone or mobile device.
To contact a physician using PerfectServe, the individual calls a single extension or uses the web-based texting function. By indicating either the physician’s name or specialty, the caller is automatically connected to the physician via the mode of communication preferred by the physician at the time. If the physician prefers not to take the call or text at the time, a message is sent. Either way, the contact is tracked and documented. The caller does not need to know the physician’s call schedule or office hours beforehand — PerfectServe stores this information and routes calls and messages accordingly. Data are housed securely with PerfectServe rather than on the caller or recipient’s device, ensuring compliance with HIPAA regulations.
A communications process ready for change
Prior to PerfectServe implementation, staff at MRMC used a fairly common process for communicating with consulting physicians. During the day, the secretary in the relevant unit would telephone the consultant’s office staff, who would relay information about the consult request to the physician.
On nights and weekends, however, the process was variable and rife with delays. Staff at each unit would enter consult requests in a log book. Non-urgent consult requests were held over for first shift staff the next morning, or on Monday mornings after a weekend, creating a backlog of work for the clerical staff. Urgent consult requests were telephoned to the answering service of the consultant on call, sometimes based on inaccurate on-call schedules or word-of-mouth requests to call a specific cell phone number. Because the hospital requires that patients are seen by consultants within 24 hours of consult request, staff felt pressured to stay on top of the communications and yet found the current system unmanageable. Bottom line:
The process resulted in delays in the notification of consultants and in patient care, as well as frustration for nurses, physicians and clerical staff.
MRMC leaders were not only concerned about the timeliness of consultant contact, but were also looking to assist physicians in dealing with the overwhelming number of calls and emails they fielded, a portion of which had been directed to the wrong physician.
Implementation with consult requests initially overlooked
Having identified an opportunity to improve clinical communications, the organization implemented PerfectServe in 2010. Implementation across the hospital went smoothly, according to Diane Coleman, performance improvement manager at MRMC. After an initial adjustment period, staff and physicians were pleased with the ease and reliability of communication. Staff readily adopted the tool for contacting physicians throughout the hospital and beyond its walls.
Several months after implementation, MRMC leaders reevaluated the process to ensure that all components were in place and that users had no concerns or issues. During a meeting with unit secretaries, it became apparent that some aspects of the old process were still in place. Coleman and the performance improvement team performed a gap analysis based on PerfectServe analytics, and found that the number of consult requests logged through PerfectServe was smaller than the number registered in the computer order entry system. With further investigation, Coleman discovered that the staff were using PerfectServe for much of their clinical communications, but had retained the old process for requesting consults. Physicians continued to advise the unit secretary to “hold routine calls.”
Coleman says the finding was surprising: “During implementation and education we emphasized that PerfectServe was to be used for all clinical communications.” Instead, staff members were continuing to use paper log books and to hold consult requests on nights and weekends.
“Knowing this helped us to understand the required shift in culture that needed to accompany the use of PerfectServe,” says Coleman. “In the past, MRMC staff had followed the instructions of each physician about what to do with their calls. To be successful with PerfectServe, we needed staff and physicians to be compliant. By further addressing the culture and having dialogue on where we needed to be, we were able to change this process.” As staff and physicians began using PerfectServe for all communications, the variance was eliminated, call time improved and users gained more confidence in the system.
Improvement in care processes
With PerfectServe in use for referral requests as well as otherclinical communications, MRMC is better able to manage the consult process, with a standardized, streamlined process that includes tracking and analytic capabilities. Now, the unit clerk accesses PerfectServe either by phone or the web link and requests the consultant by name or specialty. The consult request is transmitted directly to the physician, based on data stored in the rules engine regarding contact preferences, time of day and call schedule. The process removes the middle person — the consultant’s office staff or answering service — thus streamlining communication and reducing the chance for human error.
As Coleman describes it, “Without all the ‘noise’ on how to communicate to whom, we could focus on the timely and safe delivery of patient care.” Leaders are assured that staff are consistently using PerfectServe for all communications, and the number of consult requests in the PerfectServe logs now matches the number in the order entry system. PerfectServe analytics demonstrate the substantial increase in call volume related to consults once staff had been re-trained in late 2012 (see figures below). The use of PerfectServe has removed variability in the process of contacting consultants and has decreased call-cycle time.
MRMC has seen positive results in a number of areas. A value stream map showed that the process for contacting a physician dropped from 17 steps to six. Use of web contacts versus phone calls increased from 2 percent to 51 percent, saving staff time and reducing the need for repeat calls. In addition, because of the reduction in rework (e.g., making multiple calls to contact a physician), labor requirements for clerical staff dropped from 72 to 46 hours per day, which resulted in $232,000 in hard savings per year. Simultaneously, the throughput time in the emergency department (ED) also declined, and the organization is meeting its target numbers for door-to-physician and door-to-discharge time in the ED.
According to Coleman, consulting physicians appreciate the fact that they can receive urgent requests for consults in the communication mode they prefer and can have routine requests sent to them in the morning rather than during the night. Also, by accessing the stored routine requests on Sundays, they can better plan their Monday morning rounds and workflow.
Clinical and clerical staff appreciate the streamlined communications process. Office staff can make changes in a physician’s call schedule easily via the computer. The standardized, reliable process ensures that they contact the right physician the first time. Beth Bennett, RN, charge nurse on the cardiology unit, appreciates that she can send a consult request when it is ordered, even in the middle of the night, and can receive a confirmation that it was sent. In the past, she would need to call several times if a consultant’s office was closed, which meant another task to remember until the call was completed.
Shirley Regal, secretary in the cardiology unit, likes the quick access to physicians in emergencies: “If they have set their preferences to call directly, I will ring and the physician will answer immediately. Or I can text the patient’s status via the web link, which the physicians like because it saves them having to call back.” Ebony Jones, secretary in the cardiology unit, also finds the text feature to be time-saving: “The best part of PerfectServe is being able to text. I can include information specific to the patient. Plus, I have proof that the message was sent.”
Coleman points to some additional benefits. PerfectServe allows for multiple clinicians to be notified at once, reducing delays or gaps in care. For example, a surgeon who is beginning a surgical procedure while on call can have a physician’s assistant and other surgeons notified to cover for consultation requests or new admissions, which means that patient care issues can be addressed more quickly.
The four cardiovascular surgeons of Munroe Heart exemplify communication streamlining with PerfectServe. Before implementation, the call routing process included many variations and particulars, requiring staff to make multiple calls to contact the surgeon and the on-call team. Now staff make just one call and five different team members receive notification. The new call routing supports their team efforts in the delivery of patient care. According to Coleman, “If it can reduce time to notification for heart surgeons, then it will work for any service line.”
Plus, the data regarding team calls have helped with resource planning. Managers have used PerfectServe analytics to assess and adjust staffing levels for specific care teams.
MRMC implemented PerfectServe to improve the standardization and reliability of clinical communications. Having identified a gap in the consultation referral, the organization provided additional training and facilitated the use of PerfectServe for contacting consultants. Within a few months, call-cycle times for referrals had dropped. MRMC also experienced decreased staffing needs and increased throughput in the ED. MRMC plans to continue using PerfectServe analytics to improve clinical communications and optimize patient care throughout the organization.