IL requires doctors' orders back in 7 days
IL requires doctors' orders back in 7 days
On-time orders boosted from 68% to 93%
Can your agency get physician orders back within a week? An Illinois agency has had to do exactly that.
Freeport Memorial Home Health Care of Freeport, IL, had only one deficiency noted in its survey last year by the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL. That problem was that too few of its physician orders, about 68%, were returned on time, according to the agency's study in July and August 1997.
Raising that percentage was no easy task because the state of Illinois requires the orders to be returned within seven days, and the agency's policy reflected that state requirement, says Ann Schoenhard, RN, home care supervisor of the hospital-based agency that serves five rural counties in northwestern Illinois with about 1,500 visits a month.
"Our policy stated the orders had to be in by seven days, and although the Joint Commission allows up to 30 days, you have to follow your own policy," Schoenhard says.
Home care advocates have been trying to convince the state to change that policy to a more reasonable 14 days. The change was approved, but had not been made final by the time Homecare Quality Management went to press.
Freeport Memorial Home Health started a quality improvement process to get more of the orders returned within a week. By fall 1997, the agency's compliance rose to 89%, and a more recent month showed it to be 93%, says Jeff Lubbers, RN, who is in charge of quality improvement for home care at Freeport Memorial Home Health.
Lubbers says when the state changes its requirement to 14 days, then the agency's compliance rate will rise to 98%. But either way, the agency's goal is to achieve 100% compliance.
Here's how the agency achieved fast outcomes:
1. Create a flowchart.
Lubbers made a flowchart that outlined step by step the current route of orders received from the physician, based on the agency's procedures and what staff reported would happen at each step. The chart highlighted problems that delayed the process.
Then Lubbers created a new flowchart that would eliminate some delays by changing part of the process. (See new flowchart on p. 78.)
2. Eliminate a step.
Typically, the nurses would send the orders to a secretary to be typed, and then when the secretary finished them, she would send them back to the nurses to be proofread. Then the agency began using hand-held computers that allowed nurses to type in medication changes. Dressing changes still were handwritten. But the agency continued to have the secretary send all of the orders back to the nurses to proofread, although there were infrequent mistakes.
So the agency eliminated the proofreading step and now the secretaries send the orders directly to the physicians. This has saved the agency an average of 5.5 days off the process, Lubbers says.
"We went from 68% to 88% with that step," he adds.
3. Send courier to physician offices.
Then Lubbers began to track the physicians who were not returning the orders on time. Many of these physicians had offices that were out of town, with some up to 45 miles away.
So the agency required its courier to deliver the orders each day to the physicians who lived out of town and to pick up any orders from them, Lubbers says.
It didn't cost any extra money because the couriers already were going to those outlying clinics twice a day to pick up blood cultures for delivery to the hospital laboratory.
"We just gave them something else to take with them," Lubbers says. "This helped a little bit."
Then Lubbers tracked the compliance of physicians who lived within Freeport. Some local physicians also had trouble with compliance, so he had the courier service deliver the orders to them as well. The courier service also stopped at those physicians' offices at no extra charge because the doctors were part of the Freeport Health Network.
4. Use a computer to keep track.
Lubbers can find out exactly how many orders are late or due back on any particular day by checking the computer's log. The physician orders are logged in when they leave the office and when they are returned. The secretary and sometimes Lubbers manually check these logs each day to see how many have been out for three or more days.
5. Follow up all orders at three days.
The agency's secretary will call all the physician offices where orders have been outstanding for at least three days.
"She'll talk to nurses and let them know there are orders we're waiting on, and make sure they've received them," Lubbers says. "Sometimes they say they haven't received it, and if that's what has happened, she'll send them a duplicate."
6. Make another call at seven days.
"If the order is not back within seven days, we'll send them another order, regardless of whether they say they have it or not," Lubbers says.
"The secretary would call the office nurse and inform her that there should be an order there because we sent two out, and another one will be arriving," Lubbers says.
7. Crack down on the chronically tardy.
"When we first started out, we had quite a few doctors who were late," Lubbers says.
So the agency notified them that state law required all physician orders to be returned to home care agencies within seven days, so they wouldn't assume it was some policy the agency made up, Lubbers adds.
The hospital also has instituted several different levels of suspensions, from a partial suspension that limits privileges to a full suspension for physicians who are not compliant with their orders, Lubbers notes. "Generally, the doctors who are non-compliant with our orders also are noncompliant with the hospital."
Since the Joint Commission survey showed tardy physician orders to be a problem, the hospital has been more prone to use the suspension rules, Lubbers says.
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