A member of MemorialCare, Orange Coast Memorial Medical Center is a not-for-profit, 218-bed hospital located in Fountain Valley, CA. The organization serves the community with more than 12,000 hospital admissions and 23,000 visits annually. Both the hospital and the health system have a long history of focusing on quality and safety and were early adopters of an electronic medical record (EMR) system to improve clinical communications.
Although Orange Coast Memorial Medical Center had implemented lean management techniques for several years, leaders saw additional areas in which to remove excess waste, including the clinical communication process. As part of an ongoing commitment to performance improvement and reliability, leaders focused on improving clinical communication in two key realms: between nurses and physicians and between emergency department (ED) staff and physicians. The organization’s specific goals were to reduce variation in time to call back, reduce time wastage for “phone tag,” increase nurses’ time in direct care and improve nurse satisfaction.
Communication inefficiencies caused delays
According to Orange Coast Memorial’s executive director of information services, inefficiencies in the communication process prior to the improvement efforts affected throughput, added costs and caused frustration for patients and staff. Nurses spent a significant amount of time contacting physicians, which sometimes translated into delays in care.
Tim Horttor, BSN, RN, CCRN, a critical care nurse at Orange Coast Memorial, notes that before PerfectServe, nurses often searched in three different locations to find telephone numbers to contact physicians—a paper list of the call schedule, within the EMR system to identify the assigned physician and on notes taped to patient charts. When nurses contacted the physician’s answering service, they spent precious minutes providing a host of information, including the patient’s name, status and room number.
A time-motion study found that the communication cycle for nurses contacting physicians was complicated and disjointed and included multiple potential points for gaps. In addition, nurses waiting for callbacks after a shift change clocked overtime hours (at 1.5 times the standard hourly rate), which increased costs.
Emergency department staff struggled to communicate efficiently with primary care and specialty physicians. The delays sometimes translated into slower flow through the ED, with patients waiting for admission or additional care.
More times than hospital leaders would like, the ED was required to go on diversion status.
In addition, executives in the information systems and compliance departments were concerned about unsecure texting on personal phones. They wanted a secure communication system that would also provide physicians with autonomy to control the mode by which they are contacted.
Streamlining the clinical communication process
Orange Coast Memorial implemented PerfectServe over the course of four months in 2012. A dedicated team helped train staff and enroll physicians. After a relatively short learning process, hospital staff noticed a substantial streamlining of the communication process. With PerfectServe, nurses can open a Web portal and send a secure text to a physician. Often they find that the requested order change is entered directly into the EMR by the physician within a few minutes — with no additional time required for callbacks. Nurses are more confident that their message is received with the new communication process. They can also easily place a telephone call to the right physician if a direct conversation is needed.
Pre-implementation process flow
With a single secure communications platform, Orange Coast Memorial leaders are now confident that texts and other modes of communication are HIPAA-compliant. They can track communication cycles if need be, to identify whether messages have been sent to unsecure devices and, if so, to ensure that personal health information was redacted.
Orange Coast Memorial has reported seeing a number of improvements in clinical communications since implementation. A repeat time-motion study confirmed that the communication process was much more streamlined, with nurses spending less time in the communication cycle than prior to implementation (see figure below).
Physician call-back time was shortened substantially, from an average of 45 minutes to an average of 14, and the proportion of call cycles completed within 2 minutes increased from 11 percent to 22 percent. In addition, the variability in response time was reduced, with fewer outlier cycles (see figures below).
Pre-implementation response time (in minutes)
Post-implmentation response time (in minutes)
Percent of contact cycles completed within 2 minutes
Nursing satisfaction has improved since implementation due to reduced frustration and more time for direct patient care, according to Horttor. Orange Coast Memorial has received unsolicited comments from frontline nurses and nursing executives about the substantial improvement they’ve seen with PerfectServe. One nurse shared, “This is the best thing you’ve ever done for us…” Orange Coast Memorial believes their response reflects the fact that PerfectServe has a direct impact on their daily life, enhancing their workflow and quality of life.
Horttor has found that PerfectServe has vastly simplified the process of communicating with physicians. “PerfectServe has changed contacting physicians from a 10-step process to a one-step process,” he says. He notes that it has reduced the time spent on communication and the frustration level of patients due to delays in care, “The patients didn’t know that the delay in receiving their pain medication was due to waiting for the physician to call back. They were just frustrated with the delay. Now there is less delay, patients are in pain for less time and we receive fewer complaints.”
Improving patient experience and reducing costs
Patient satisfaction has also improved. Overhead paging has been virtually eliminated, reducing the noise level within the hospital and improving the patient experience. The hospital’s HCAHPS scores have increased by 2.4 percent between the year prior to PerfectServe implementation and the year after implementation. The specific measure of pain control was improved by 4.4 percent, a change that Orange Coast Memorial believes is directly tied to the faster communication cycle with PerfectServe.
Administration at Orange Coast Memorial is pleased with the investment made in PerfectServe. In addition, the hospital has received a direct cost savings since PerfectServe implementation. The number of overtime hours was reduced by more than 1,000 over the year after implementation, translating to a savings of more than $56,000.
Orange Coast Memorial Medical Center implemented PerfectServe in 2012. Use of PerfectServe has streamlined clinical communications, improved ED flow, reduced response time, improved nurse satisfaction and enhanced the patient experience. PerfectServe is helping support increased direct care time and an improved patient experience as part of Orange Coast Memorial’s ongoing commitment to providing high-quality care.