Electronic referrals to speech & language therapy (SLT): Design and implementation of an electronic referral system in MUH

Abstract

Background / Problem Identified: Since the establishment of the Speech & Language Therapy (SLT) service in MUH in 2005, internal inpatient referrals to the service have been made using paper referral forms. The paper-based referral system was audited for quality, safety and efficiency in 2018, in the context of increasing referral rates to SLT. A number of issues of concern were identified within this audit, across the domains of quality and safety, economic costs and data use/security. 1. Quality and safety issues: Delayed receipt of referrals E.g. 25% of referrals were delayed in reaching the SLT service in 2017 and this increased to 36% (267 patients) in 2018. Paper referrals often lacked essential information. These issues resulted in inaccurate and inequitable triage of referrals and provision of services, leading to delayed hospital discharge in some cases. 2. Economic costs: Opportunity costs in terms of staff time: NCHDs, SLTs, nursing staff and clerical staff time was lost in generating referrals, collecting referrals from wards, checking the status of referrals, duplicating referrals and restocking referral forms on wards. The paper referral system workflow encompassed 15 steps, from the SLT viewpoint alone. 3. Data use & security issues: Incomplete referral information limited the scope for data analysis which impacted on service audit, planning and development (Harman and Cornelius, 2017). Manual data analysis of paper forms led to inefficiency and human errors in data analysis. Hardcopy referral waiting lists were kept in storage in the SLT department, representing a data protection risk associated with storage of confidential information (Data Protection Commissioner, 2017, Health Service Executive, 2013, Burke and Weill, 2013, Harman and Cornelius, 2017, Hoyt et al., 2012). Measurement Methods / Design / Strategy: In order to address the above quality and risk issues, a health information technology solution was implemented in March 2019 in the form of an Electronic Referral system. The design and implementation of the E-referral system encompassed a number of phases, all based on the HSE change management approach; 1. Stakeholders were identified: A change in referral processes was found to affect the SLT department, ICT department, NCHDs and Consultants, ward clerks, ward CNMs, patient flow service and the hospital stores department. 2. In-house technology solutions were explored: The existing Social work E-referral system was reviewed. The Social work manager shared learning from the design and implementation phases involved in rolling out the social work E-referral system. 3. Literature review: Current literature on the implementation of internal referral systems in acute care settings was reviewed. 4. System design & end-user consultation: The NCHD committee 2017-2018 was consulted on system design in order to design a user-friendly system and to promote end user buy-in the change initiative. A member of NCHD committee with background qualifications in IT provided support to SLT and ICT department in the design of the system. The ICT department redesigned the existing social work referral system in order to capture the data required by the SLT service. 5. Education & training: Stakeholders were informed in January 2019 regarding the new system via emails to Consultants, NCHDs, CNMs and patient flow, presentations at intern education session, information handouts on wards and communication to ward clerks. 6. System testing: The E-referral system was tested on St. Finbarr’s ward for a seven day period in February 2019. Changes to the system were made by the ICT department in response to feedback from stakeholders. 7. Implementation: The E-referral system was rolled out to all clinical areas March 2019. 8. Gathering of feedback and audit. Results / Lessons learned / Limitations: A number of beneficial results were noted in practice, which echo the findings in current literature on the subject. These benefits can be described across the three areas of quality and safety improvements, economic benefits and data security and data use improvements. 1. Improvements in service quality & patient safety - Completeness and legibility of referral information enables accurate triage and equitable prioritisation of referrals, ensuring that patients are seen for SLT assessments in order of most urgent clinical need (for example, a dysphagia assessment in the case of a patient who is nil by mouth) (Kim-Hwang et al., 2010, Adaba and Kebebew, 2018, Bates and Gawande, 2003, Ash et al., 2004). - Delayed referral rates have dropped to 0%. Referrals are received immediately by the system, in chronological order and can be triaged as such (Shaw and de Berker, 2007). - Delayed hospital discharges no longer occur as a result from delays in the receipt of referrals (Bates and Gawande, 2003). - Increased numbers of patients can be seen by the SLT service as a result of the time saved by the new system. 2. Economic Benefits –hospital costs, staff time & productivity - NCHDs do not have to search for hardcopy forms on each ward. - Automated completion of demographic information and tick box options ensures that each referral takes less than 2 minutes to complete and submit. - Feedback from NCHDs on the wards is that the system is an improvement on the paper-based one, in terms of ease of use and time efficiency. - The system confirms when referrals have been submitted- NCHDs and nurses do not have to contact SLTs to check if referral was received, or submit multiple referrals. - Stores department do not have to order or deliver paper referral cards. - Ward clerks do not need to monitor and reorder stocks of referral cards for wards. - The E-referral system workflow reduces the steps required for an SLT to process a new referral to 7 steps (down from 15). - SLT time saved over the course of a year on referral processing is 65 hours, which can now be used to see 130 extra patients. This represents a cost saving of 2,340.32EU. - The system automates the process of calculating SLT response times to referrals. Time saved over the course of a year on such data analysis is 24 hours, which can now be used to see 48 extra patients. It also represents a cost saving of 864.16EU. 3. Data use & data security improvements - Complete referral information has resulted in improved scope for SLT service analysis, planning and development. - Efficiency and accuracy of data analysis has been achieved (Adaba and Kebebew, 2018, Bates and Gawande, 2003). - The system can be used as an activity management tool, as SLT response-times to referrals can be analysed automatically. - Referral data is now computerised and therefore stored on the hospital’s server, ensuring maximum security of digital information. - There is no longer a need for duplication of referral information into spreadsheets to calculate referral delay times and SLT response times to referrals, as this is automated within the new system. Conclusions / Reflections This project showcases the internal resources and skills available in MUH with which a health information technology solution can be implemented to address organisational inefficiencies, quality and safety issues (Burke, 2013). However, as a ‘frontline ownership’ model was adopted for the most part, the project developed across a two-year time period, which is a lengthy timeframe for a project of this nature. If carrying out a similar initiative, top-down project sponsorship and championing by senior management may be beneficial in securing protected resources with which to complete a similar project in a shorter timeframe. Based on the positive results on service efficiency and patient safety outlined above, there is a strong case to be made for rolling this system out across other clinical services, such as HSCP services, medical/surgical consults for inpatients and MDT referrals. Indeed, it could be used to streamline processes and collect data on operational services also, such as catering requests or requests for continuous supervision on wards. Reflection and stakeholder consultation upon completion of the project revealed a number of additional features that could be incorporated into practice, in order to maximise efficiency. For example, the E-referral system generates unique referral ID numbers. These could be quoted in the healthcare record, instead of printing and filing copies of referrals. It would also maximise transparency and accountability re the processing of referrals.