Transcript Definition of a Service Agreement

Service Agreements
Mike Davies, MD
Mark Murray and Associates
Other Industries
• “Live and die” on the product
• Define the timelines and handoffs
• Define expectations of each party
• Constantly measure conformity to
expectations
• Refine and improve handoffs
Big System Flow
External
Demand
Test
PC
Test
SC
Surgery
“We Are All Related”
Definition of a Service Agreement:
Understanding or agreement between
any 2 parties, one of which sends work
to another, defining work flow rules.
Agreement
• Sender – sends the right work packaged
the right way
• Receiver – is accessible for performing
the right work right away
Why are Service Agreements
Important?
• Define relationships between primary
and specialty care
• Reduce demand for specialists
• Improve referral process
• Decrease delay in care
Who are the stakeholders in the
referral relationship?
Patients
• Reassurance
• Expectation for the process
• Knowledge of the process
• Certainty
• Speed
• Quality of the care and the experience
• Appropriate referral
Primary Care
• Access to SC
• Speed
• Know SC expectations
• Simple process
• Certainty of appointment
• Questions answered
• Let my people go
Specialty Care
• Knowledge of which doctor is referring
• Right patients sent with right
information
• Patient expectations
• PC expectations
• (When do I) let the people go?
Common Interests
• PC and Patients
Speed
Certainty of appointment
Answers
• SC and PC
Expectations of each other
Four Components to Service
Agreement
1. Define and discuss the work –
Who? What? How much?
2. Sender – sends right work packaged
the right way
3. Receiver – does right work right
“right away”
4. Referee – monitors agreement
1. Define and Discuss the
Work
What is the work?
Who is sending it?
How much work exists?
Psychiatry
Urology
Cardiology
Dermatology
ENT
Neurology
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Orthopedics
Consults 2nd
Quarter 02
Provider
Neurology
Sample of Consult Rate Q2 ‘02
0
0
0
0
6
0
1
2
0
12
4
3
0
5
4
12
0
1
2
11
0
2
6
1
8
8
4
1
15
2
18
2
0
1
14
0
15
4
0
15
7
30
2
11
17
9
1
0
1
7
0
6
10
0
6
9
7
0
10
9
1
0
0
0
2
0
0
0
0
1
2
1
0
1
0
1
0
0
0
0
0
6
0
0
6
4
6
2
5
13
2
0
0
0
4
0
2
2
0
3
4
2
0
3
3
0
0
0
0
6
0
1
2
0
12
4
3
0
5
4
Reasons for Referral to Urology Q2 '02
70
60
50
40
30
20
10
0
BPH
UTI
M. Hem S. Mass
Incon
B Tumor R Tumor
Urology Referral by Provider Q2
'02
15
10
5
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
Number of Referrals
20
Provider
Areas to Target for SA
• High volume diagnosis
Areas to Target for Focused Education
• High volume referring providers
Halt!
Face-to-Face Communication
Needed at This Point!
• Organize all service members or key
representatives to a meeting – facilitated
if necessary
• Present the data
• Discuss the data, practices, history,
problems, potential solutions and
recommendations
Draft Improvement Ideas
• Draft list of appropriate reasons for
referral
• Draft list of work up needed before the
specialty appointment
• Circulate the proposal to everyone
affected and consider all comments
2. Sender Sends Right Work
(Packaged) the Right Way
What is the right work?
System-wide BPH Referral Guidelines – Refer When:
1. Medical failure – symptoms not
controlled, residual urine not reduced.
2. Adverse reaction to recommended
medication
3. Possible obstructive uropathy –
elevated BUN/Creat – not improved with
medication
4. Patient desire for definitive surgical
treatment.
2. Sender Sends Right Work
(Packaged) the Right Way
a. Physician Factors
b. Referral Process
c. Patient Experience
Physician Factors
Packaging the referral
Physician Factors: Package Right
Way
• Refer the “right” problem
• “Sell” the consult to the patient
(closing the visit)
• Clarify expectations
• Provide the right information to the
specialist
Microscopic Hematuria – Refer With:
1. Verify presence of three UA’s with at
least six RCBs/HPF
2. Negative C & S of urine
3. IVP or Renal Ultrasound (if renal
insufficiency or contrast allergy) prior
to consult.
Structured Consult
Tool to assist packaging the right
way…
Referral Process
Consult Flow
Patient Flow
Colonoscopy
Ordered
Chart reviewed by RN
to find indications/
contraindications and
last exam
Chart Reviewed
by Surgeon
.15 to 2 hours X 25/wk
= 6 to 50 hours
5 to 20minX 25/wk
= 2 to 4 hours per week
Meets
Criteria
Call to Provider
to Clarify
RN Calls patient to
schedule and educate
Rn sends prep
Provider
Orders
Colonoscopy
Provider fills out
structured consult
Surgery schedules test,
educates, sends prep
5 min X 2/week
= 10 minutes
Ideal Patient Experience
• Has clear understanding about and buy-in
for referral from PCP
• PC Clerk
reinforces expectations for referral
negotiates ideal time and place for referral
within 5 days
schedules specialty appointment at the time
of check out from PCP
• Patient receives reminder material or call
before appointment
Ideal Patient Experience (cont)
• Specialty clerk
warmly welcomes patient
mentions who referred the patient
Reinforces reason for and expectations
from referral
• Specialty provider
is familiar with key historical facts
is able to provide needed care in 1 or 2
visits
facilitates smooth hand back to PCP
3. Receiver: Is accessible for
doing the right work right
away
Ways for Specialists to be Accessible
• Measure access parameters
(wait, supply, demand, no-show, etc)
• Work down backlog
• Balance supply and demand
• Telephone
• “Question only” consults
Wait Time for Urology
60
50
40
Days to
3ed next
30
20
10
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Now Make and Agreement….
•
“Primary Care will send the right
patients appropriately worked up……in
return, the specialists will be available
to primary care anytime they are not in
the OR and see patients quickly”
4. Referee – monitors for fair
play
Audit: How we know it’s working
Develop measures (audit) for:
• Wait time
• Audit of work (who is referring what?)
• Audit of important parts of process
% Compliance
Service Agreement Audit Quarter 4 '04 GI
120%
100%
80%
60%
40%
20%
0%
GI Question #1: Receiver saw patient in agreed timeframe
GI Question #2: Sender referred the right cases
GI Question #3: Sender provided the right information
How to do it…
Ideal Service Agreement
Implementation Steps
1. Volume, reason, and source of existing
referrals are measured and shared
2. Consultation scheduling process is flowmapped
3. Face-to-face discussion between PC and
Specialists occurs
Discuss current data
Discuss referral process
Small group tasked to work out agreement
Ideal Service Agreement
Implementation Steps (Cont)
4. One or 2 specific topics for future SA’s are
chosen.
5. Simple SA is drafted
6. Consensus is reached among PC and SC
providers for SA content, scheduling
process, and audit criteria
7. Agreement is formally adopted by medical
executive committee
Ideal Service Agreement
Implementation Steps (Cont)
8. SA implementation tools (structured
consults, patient education, etc.) are
implemented
9. Audit measures are tasked to be done
periodically
10.Results of audit regularly discussed in
face-to-face meeting of PC and Specialty
providers
Ideas for improvement considered and
adopted as needed
Specialty ACA Faculty
receive for preliminary
review
Amb Care SLM
assign team to
review service
agreements
Returned to
Specialty section
w/ recommended
changes &
rationale
PC Team reviews
TAT 4 weeks
Consensus
required
No
Accepted?
1. Accept w/o revision
2. Accept w/ minor revision
3. Not accepted
Make minor
revisions if
needed, get
concurrences
Yes
Signed by PC SLM
& Specialty Chief
and distributed
Annual review by
Specialty and PC
for concurrence and/or
amendment
Approval Process
• Agreement by
subspecialists and Primary
Care
• Signatures by Specialty
Care Chief and Primary
Care Chief
• Approval by Executive
Committee of the Medical
Staff
Individual Focused Education
• Find the most frequent referrers to the
service
• One-on-one, or facilitated discussion
about reasons for referral
• Measure before and after discussion
Effect of Strategies on Demand Reduction
in Specialty Care
Service Agreement
20
18
Focused Education
16
14
12
Mean 8.6
10
8
6
4
2
0
Each Bar Represents 1 MD
SA Example
Surgery Example
n
Completed Office Visits
4500
4000
3500
3000
2500
2000
1500
1000
500
0
OR Cases
4274
3674
Ratio: 3.9
3606
Ratio: 3.2
Ratio: 2.7
1783
1092
FY 00
*FY 03 data as of 4/30/03
1138
FY 01
1315
Ratio: 2.3
786
FY 02
FY 03
Major Cases, FY 94-02
Bivariate Line Chart, Major Cases vs Fiscal Year
Grouping Variable: Service
Data Sources: Surgical Service Summary Report; Special Procedures Logbook
1200
1100
Major Cases
1000
927
800
600
764
846
835
869
916
953
958
1999
2000
2001
5C Services
ENT
Neurosurgery
Ophthalmology
Orthopedics
Urology
400
200
0
1994
1995
1996
1997
1998
2002
FY
Oklahoma Example Agreement
AGREEMENT BETWEEN PRIMARY CARE AND
GASTROENTEROLOGY
• To facilitate patient care by reducing waiting time to
obtain a screening colonoscopy.
• To facilitate patient care by increasing the
percentage of patients who are appropriately
screened for colorectal carcinoma.
1. To facilitate patient care by decreasing the interval
between a positive test for blood in the feces and
initiation of therapy for colorectal carcinoma.
Primary Care Will
1. Issue hemoccult cards to each non-screened patient
over 50 who is not terminal and agrees to screening.
2. Evaluate those patients who have positive result.
This colonoscopy, to fully inform patient about risks
and benefits of a colonoscopy, and to set up
appointment including ordering preparatory
medications.
3. Adjust anticoagulant therapy as needed for those
patients on warfarin.
4. Enter pre-colonoscopy note in the record.
5. Call patients prior to scheduled exam to reduce noshow rates.
Gastroenterology Will
1. Maintain enough open capacity to accommodate
scheduling within 2- 4 weeks.
2. Enter reports including CPT codes into the record.
3. Recommend appropriate follow-up for patients
after colonoscopy.
4. Open appointment capability so that Primary Care
may schedule directly following guidelines.
5. Educate clinicians regarding appropriate
screening intervals and techniques.
Clarify the Pathways:
Back Pain Example
• Services that treat back pain
Physical Therapy
Neurology
Neurosurgery
Physiatry
Orthopedics
Summary
• Define and discuss the work:
Who is
sending it and what it is
• Sender sends the right work the right
way
• Receiver does today’s work today – and
is accessible to the sender
• Referee audits agreement
National Database “Mining”
(Audit)
Bill Barr
Eye Care carries a large
proportion of Established
Patients in its Case Load.