(This case study is on the complexity of operational process in patient care, and is based on challenges in managing cross referencing of patients between specialities.)
Situational background
A large and
busy multi-speciality hospital is organized in various clinical departments and
each department has divided its OPD days, emergency duties and surgery days (if
applicable) between their team of consultants. As per its policy each admitted
patients should be visited by the consultant in-charge at-least once in a day.
Sometimes a patient admitted under a consultant may require a cross reference
from a consultant of another speciality. In this situation, the process is
that the consultant in-charge writes the orders for a cross reference from
required speciality in patient’s record. The duty doctor then fills up a
cross-reference form with necessary clinical details of the patient and send it
to the HOD of respective department. The HOD then allocates it to one of their
consultant, who should attend the patient and provide his opinion by
documenting it in the patient’s record.
However, frequently there are problems
that is being encountered by doctors, nurses and even patients which are as
described below.
Problems faced
1. Often time
the cross reference gets delayed in attending. There could be multiple probable
reasons for this. The consultant referred might already be busy with his/her
patients which is naturally a priority for him/her (a portion of remuneration
of the consultants gets determined by number of patients they admit and treat,
and there is no compensation attached to attending a cross-reference patient).
Secondly, mostly when the consultant plans out his schedule for entire day,
he/she may not anticipate or allocate his/her time for attending
cross-reference patients. As per some assumptions these delays are leading to
increased stay of patient by an average of a day, resulting in patient
dissatisfaction. The delay is even more pronounced if reference is sought
from over-burdened departments such as Medicine and Surgery, which often is the
case.
2. The delay in
attending cross reference patients affects badly when the condition of patient
is serious or reference is required on an urgent basis. As a working
arrangement, most referring consultant had started to talk directly to their
peer in relevant speciality, explaining them the seriousness/urgency so that
delay can be avoided. However, since this depends upon the intent and
activeness of the referring and referred doctor, sometimes grave consequences
as high as death of the patients has been faced by the hospital
3. On a tacit
note, most consultants perceive attending cross-reference an avoidable
additional workload and there has been instances of negligence in some cases.
Many times trainee or junior doctor from the speciality has been sent to attend
the cross-reference, which at times may be beyond their capability. Sometimes,
to save time, consultant having their OPD have asked the ward staff to send the
referred patient to their OPD, causing much inconvenience to patient and staff.
Several times, the consultant has just asked for patient’s record to be sent to
his cabin and the reference advice has been given based on records and without
even meeting the patients.
4. Documentation
has been another problem as frequently, the referred doctor write scanty
notes on patient’s records or would just pass on the advice to duty doctor
without even writing anything. This has led to confusion for consultant
in-charge and in several instance repeat cross-reference has been asked.
Measures attempted to address problems
This issue has been a regular
agenda in the clinician’s meeting. All clinician agree that they face problems
in managing their patients because of this issue. However, they equally give
compelling reasons for why they can’t help avoiding delays. High workload and
prioritizing patients has been cited as most common reasons for delay.
The clinical committee tried some
measures to overcome this problem but no significant success has been achieved.
The measures includes, adding a section in reference form to indicate if it is
an urgent/semi-urgent/non-urgent reference, putting a time-frame for references
to be attended, and asking duty doctor to follow up in case reference has not
been attended on time.
Complexity in dealing with the problem
Dealing with the above situation may not be
simple. There are several managerial issues involved in it. On first reading it
might appear as an operational problem but when you think deeper you will
realize HR, Economics, OB related issues also intertwined in it. It is also important to note that any changes
in cross referencing system may cast its effect on other operations of the
hospital. For example, if you strictly implement time-bound attending of
references, it may lead to increase in low quality referral advices. Or, if you
decide to attach compensation to attending references you run a risk of increasing
number of unnecessary cross references.
Approach to resolve this problem
The case situation described above should be comprehended by taking all its
ramification into consideration and come up with a balanced and feasible
approach to improve it, which should have a minimal negative effect on other systems. Some specific
thing must be considered while approaching its resolution are,
- Understanding the level of its seriousness. Consider what and how much effect it has on patient safety, organization’s performance and patient satisfaction. What will happen if the issue is left un-resolved.
- Relating motivational theories that can help in understanding Consultant’s behaviour in this case
- Identifying underlying causes to the problems listed above and classifying them in suitable clusters such as HR, operations, policies, group behaviour etc.
- Thinking about what additional information would be required to understanding the problem and its causes better.
- The situation may have one or more solution. It is imperative to assess how each solution are going to address the underlying causes. Also, it must be assessed what effect the solutions might have on other systems of the hospital.
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