Light a fire under doctors to get orders back in a flash

The winner’s circle: Race to get 95% returned in 30 days

If you smell burning rubber in Ann Arbor, MI, it’s because a home care agency there needed to put the pedal to the metal to get physicians’ orders signed and filed on time.

"In the fourth quarter of 1996, our indicator for timeliness of physician’s orders, which is a patient record audit, told us we weren’t meeting our goal of receiving them in 30 days," says Susan Johnson, acting director of quality management for Huron Valley Visiting Nurses, which serves southern Michigan and parts of Ohio.

Instead, fewer than 85% of the referring physicians returned their orders within 30 days. The average return time for all orders was 31 days, Johnson says.

The small agency was racing against time, and against the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, which was planning a nice little survey in only a few months.

The Joint Commission has just reworded its standard about physicians’ orders in its 1997-98 manual. Previously, the standard specified that orders be returned in a timely fashion. Now the requirement says 95% of them have to be returned within 30 days.

So the quality manager and others at the agency, which makes 10,000 to 11,000 visits per month, set up a task force to make changes.

When the Joint Commission surveyed Huron Valley in February, the agency still had not achieved its goal of 95%. Although the survey went well and the agency received an overall high score, it was given a warning to improve the timeliness of its physicians’ orders, Johnson says. The agency made comprehensive changes, and by June 30 it had achieved the 95% goal. Here’s how Huron Valley did it:

Set up a QI task force.

The agency set up an eight-person task force that consisted of the directors of information services, clinical services, quality management, operations, and administration, as well as employees who were in charge of sending and tracking physician’s orders.

The task force first measured the size of the gap by using a focused chart audit to track the orders on a daily basis, Johnson says. A task force member went into the filing room to look at the physician’s orders to note the following:

— when they were written;

— when they were sent to the physicians;

— whether they had been returned;

— whether they were returned within 30 days.

The task force determined that the agency needed to improve its return rate by 10 percentage points, from an 85% rate of return within 30 days to 95%.

Ask staff for improvement suggestions.

"The second thing we did was inform our staff that we weren’t meeting our timeliness goal, and we asked them for suggestions on how to improve the format," Johnson says.

The task force solicited suggestions through staff meetings and a company newsletter. A few people offered pointers, and their input helped the task force eliminate a few bottlenecks and speed up the process.

Finding the physician of record

For example, the nurses frequently couldn’t locate the correct doctor. The hospital physician who referred the patient to home care often wasn’t the community physician who would see the patient after the hospital discharge. So the nurse would send the physician’s order to the referring physician, only to be told days later that a different doctor needed to sign it.

The task force composed a letter addressed to the physicians, and it is attached to each doctor’s order. The letter lists the regulatory guidelines for patients in home care, and it asks the physician to contact Huron Valley immediately if the doctor is not the physician of record for a particular patient.

Use a flow chart.

The task force flow-charted the existing process and asked all employees who touched the physician’s orders to sign off on when they received it and when it left their hands.

"The flow chart allows you to identify each individual step of the process and to make sure it’s happening in a logical fashion," Johnson says. This way, the task force learned that it took an average of 14 days for orders to leave the agency.

Set goals for improvement of specific elements of the process.

The task force re-engineered the process, selecting goals for each stage of the physicians’ order journey. The goals were:

— Nurses have three days to turn in the paperwork.

— Clerical and other staff have five days to send the physician’s orders out the door.

— The doctors have 14 days to return the orders.

— At day 22, if the order isn’t back in the agency, an administrative assistant would label it "urgent," call the physician who has not returned the order, and ask him or her to fax the order within 24 hours and then mail the original copy as soon as possible. Physicians who are chronically late are called by a nursing supervisor.

Obtain staff buy-in.

Members of the task force told other employees why the agency was making these changes, and that it was up to each person to make it work.

"They said, ‘Yes, I can do that, and I understand why I shouldn’t leave that in my in-box for three days like I used to. I now know this is a priority,’" Johnson says.

Set goals for progress of the overall improvement effort.

The task force established these goals:

— Huron Valley would have 86% of the orders returned within 30 days by March 31, 1997.

— The agency would have 92% returned within 30 days by April 30.

— The agency would achieve the 95% goal by June 30.

Hire necessary staff.

The agency hired a full-time administrative assistant to handle the physicians’ orders.

Buy any necessary equipment.

Huron Valley purchased a fax machine, a new computer, and six additional telephone lines.

The computer was necessary to allow a data entry clerk to enter information upon referral regarding the need for physician’s orders, and to write letters to physicians. Johnson says this activity was all new and would require the clerk to type hundreds of these a day.

The new telephone lines are dedicated to the physician’s order process.

Make changes in the process.

The agency stopped mailing the physician’s orders individually. Instead, they are grouped together for each physician and delivered by courier.

This alone could save six or seven days off the time clock, Johnson says. The mail bogged down the process because many of the physicians are located on campus at the University of Michigan Health System, and the campus mail delivery could take an additional three days, she explains.

The agency already used the courier for other deliveries, so this extra chore added only about three hours a week to the job.

Capital and personnel resources dedicated to this process now exceed $51,000 total to date. "It’s a lot of money, but it’s something we had to do to keep our accreditation," Johnson says.

Monitor improvements and give feedback.

The task force monitored the staff’s improvements at each biweekly meeting. Each member of the task force spent part of the meeting writing thank-you notes to nurses and other employees who had improved or met their time goals. And they wrote reminders to those who hadn’t met their goals, Johnson says.

"We’d say, ‘Dear Jane, you shaved three days off your process — great work! You only have a day and a half to go,’" Johnson says. "We wanted to give them immediate feedback."

Set new goals.

Now that the agency has met the task force’s goals, the task force will set new goals. Johnson says one new goal is to have all the physician’s orders routinely in hand within 21 days. "This would give us eight days to concentrate on the late ones, and it allows us to be a little more relaxed," she says.

The task force continues to meet regularly to solve problems as they arise. For example, during the summer months some of the crucial administrative assistants had scheduled vacations. Since the agency is so small, there would be no way to replace these employees.

So, Johnson says, they’ve been working at cross-training employees so other staff could pick up the work. "So now we have someone who has that experience, but to cover for the vacationing employee means somebody else is going to do double duty," she adds.