Process improvement helps PCP relations

30-minute guarantee increases referrals

A new process for handlings calls from primary care physicians not only has improved ED communications at Doctors Hospital in Columbus, OH, but it also has boosted relations with family physicians in the community — thanks in no small part to a 30-minute guarantee offered for those doctors' patients.

"The old process we had was basically a clipboard," recalls Bruce G. Jones, DO, FACEP, the ED medical director. "When people called in, there was no good way to track when they called, what to put on the board, and how to re-communicate the information to the other two sections of ED." The ED, which sees more than 60,000 patients per year, he explains, has three "pods" for handling patients — A, B, and C — with Pod C set aside for minor acuity patients.

To improve this process, Jones created an orange sheet, which is filled out by the ED physician who takes the call. [A sample of the call-in log is available.] The sheet includes the name of the referring doctor, the name of the patient, their main complaint, and who the primary care physician would like them referred to if they need to be admitted.

This sheet made the process very easy, says Marcus Topinka, MD, the ED research director and president of the Doctors Hospital medical staff. "We call out to the triage nurse and let them know the patient is coming," he says. It also gets called out to the registration person, who makes a copy and walks the copies over to other pods.

The bottom half of the sheet, explains Jones, is torn off and attached to the chart for prioritization. "When the doctor sees it, he hangs it up on the grease board alerts," he explains.

Because of the small ED [with only 23 beds], wait times often would be longer than Jones preferred. This wait time especially was a problem when primary care providers (PCPs) sent patients in to be evaluated, and they would have to wait.

"In an effort to get the work-up started on these more critical patients who were referred in from the PCP's office, we developed a '30-minute door-to-doc guarantee' for those patients," he explains.

Most important of all, he says, was that "we made a more concrete, well-defined, definitive process with communications." Having done that, however, "I took one step more and rolled the 30-minute guarantee into it."

The program initially was rolled out in November 2006 and then refined through a process of "trial and error," says Jones. "We knew there were three things we had to do: take the phone call, photocopy the form to the other side, and call out front," he explains. "But, that means we expected our docs to do all of these three things."

To ensure compliance, Jones placed an "accountability box" on the bottom of the form for the physician's name, the date and time of the call, whether the form was copied to the other pods, and whether the front desk was called. "In addition, you must put the name of the person at the desk who you talked to," says Jones.

A 30-minute guarantee that was only for patients of family physicians initially was a concern for the ED doctors, Topinka concedes. "Our first reaction invariably was the worry that they might be triaged ahead of someone else," he shares, "but once we reassured that would not happen, then all of us quickly bought into it."

Doctors Hospital uses a five-level triage process, with Level 1 being the sickest. "If a '30-minute guarantee' patient comes in, they will never bump a patient who is a level above them," even if it means missing the 30-minute timetable of the guarantee, Topinka says.

They communicated the changes to physicians through inservices, staff meetings, and one-on-ones with each doctor, Jones says. "We have 32 residents, so we wanted to make sure this was only an attending-to-attending call," he says.

There also was some initial sensitivity among those patients who were not referred by their family physicians, he relates. "We changed the name we use from 30-minute guarantee to 'orange protocol,' because some patients had become curious when other patients were referred to as 30-minute guarantees," he notes.

Jones says the new process clearly has improved relationships with family physicians in the community. "Unfortunately, since our past process was loose, we have no way of knowing how many people called in before; thus, we have no baseline," he says. "I do know that since November 2006, we have obtained over 700 call-ins."

In addition, says Jones, "I am definitively aware of at least seven or eight patients that were heading to another hospital but were rerouted to us because of this process. Although I would like to think it is tons more, I can't prove that."

Jones also has extended the guarantee to local junior high school and high school athletic directors. "I have them call my cell phone," he says. "If I'm working, I take the call; if not, I call it in."

As for the guarantee itself, Jones reports that "Overall, we're averaging 28 minutes, and we hit our 30-minute goal 86% of the time."


For more information on handling referrals from primary care physicians, contact:

  • Bruce G. Jones, DO, FACEP, ED Medical Director, Doctors Hospital, Columbus, OH. Phone: (614) 544-1813.