Greg’s story

t i n u i t y o f Ca r e
C o n
David Price
Ward Flemons
October, 2014
Greg’s story

• Wednesday, May 16, 2012 - Surgery
• Friday - Trip back to Emergency Room
afternoon
• Saturday - the following day, Greg died in our
home

Greg’s quotes to live by
• “The men who try to do something and fail are infinitely
better than those who try to do nothing and succeed.”
• “My best friend is the one that brings the best out in me.”
• “A century from now it will not matter what kind of car I
drive, what kind of house I lived in or how much money I
had in the bank… but one hundred years from now the
world may be a better place because I was important in
the life of a child.”

HQCA
• Dr. Ward Flemons
• Continuity of Patient Care Study

Background
•Over the years the HQCA has heard from many Albertans about
their concerns with breakdowns in the continuity of patient care;
• people contacting the HQCA with their stories
and
• through surveys (Satisfaction and Experience with Healthcare
Services*)
‣ < 50% felt that coordination of their healthcare by professionals
was excellent / very good
‣ ~ 50% report their physician not informed about ED care
‣ ~ 35% report their physician not informed about specialist or
hospital care
‣ 10 to 15% report their physician not informed about DI results and
MRI scans they had undergone
* 2003 to 2012

Continuity of Care
The degree to which a patient
experiences
a series of healthcare encounters as
coherent, connected and coordinated

Threats to Continuity of Patient Care
Procedures
Advanced DI
testing
Specialists
• Referral ➠ Appt
• Triage ➠ Waiting
• Service
• Report
Time-sensitive
diagnosis and treatment within days ➟ 2 weeks (max)
‣ known compromise of vital limb or organ function or
‣ high probability of this developing

Threats to Continuity of Patient Care
Procedures
Advanced DI
testing
Specialists

Methodology
In-depth study of the experience of an individual patient➾ Greg
‣ Info from:
 Patient health records
 Interviews
 Detailed flow mapping
 Literature review
 Review of leading EMR practices (Mayo, Geisinger, Kaiser)
 Information technology experts
 Published documents (e.g., CPSA Standards of Practice)
‣ Analysis broadly inform ☛ recommendations that will
improve continuity of patient care
‣ Recommendations for system improvement

• System focused approach
http://www.hqca.ca/index.php?id=257
‣ does not address or judge the
performance of individuals
‣ focus on issues with broad implications
 not on single or a few provider issues
 the case is only representative of a
larger issue
 should be able to substitute many
different providers into the ‘story’
‣ recommendations
 look for win - win
 widespread impact
 accountability
Methodology

• Chronology of Events
• Findings & Lessons to be Learned
• ⇒ 10 Findings
• ⇒ Lessons to be Learned
‣ Price family’s perspective
‣ HQCA’s perspective
• Issues - Analysis - Recommendations
⇒ 10 Recommendations
• Supplementary Finding

Greg’s Journey
2 3 4
1
33
49
94
Greg dies

• Chronology of Events
• Findings & Lessons to be Learned
• ⇒ 10 Findings
• ⇒ Lessons to be Learned
‣ Price family’s perspective
‣ HQCA’s perspective
• Issues - Analysis -
Recommendations
• Supplementary Finding

Findings
&& LLeessssoonnss ttoo bbee LLeeaarrnneedd
1. Referral to specialists – knowing the process and timeframe
2. Co-ordinating patient care – having more than one ‘quarterback’
3. Expediting diagnostic imaging studies for patients with time-sensitive health conditions
4. Radiology self-referral
5. Followup and review of test results
6. Ensuring that a patient’s transition of care has been successful
7. Co-located practice groups: co-ordinating services and clarifying relationships
8. Post-operative care – physician responsibility for patients
9. ‘Jousting’ in healthcare – how it affects trust and confidence in handovers of care
10.Electronic health records – patient access to important health information

Patient Referral for ‘Specialized Healthcare’

Findings & Lessons to be Learned
1. Referral to specialists – knowing the process and timeframe
2. Co-ordinating patient care – having more than one ‘quarterback’
3. Expediting diagnostic imaging studies for patients with time-sensitive health conditions
4. Radiology self-referral
5. Followup and review of test results
6. Ensuring that a patient’s transition of care has been successful
7. Co-located practicegroups: co-ordinating services and clarifying relationships
8. Post-operative care – physician responsibility for patients
9. ‘Jousting’ in healthcare – how it affects trust and confidence in handovers of care
10. Electronic health records – patient access to important health information

Patient engagement?
The ‘System’
“As a general rule the most
successful man in life is the man
who has the best information.”
― Benjamin Disraeli
Electronic Health Record

Electronic Health Records
Patient access to important health information
EHRs Patient ➟ portals - functionality (Geisinger / Mayo / Kaiser)
• View lab / pathology results (almost all results in real time).
• View diagnostic imaging results
• Message healthcare providers
• View portions of the medical record, including outline of current
health issues, medications, allergies, immunizations, and health
reminders.
• Track chronic conditions and provide updates
– Patients enter their own healthcare data into their patient
record (e.g., glucose values, blood pressure, and weights)
– can be viewed by their healthcare providers.

Electronic Health Records
Patient access to important health information
EHRs Patient ➟ portals - functionality (Geisinger / Mayo / Kaiser)
• Schedule appointments with their primary care providers.
• View of upcoming appointments
• Requests to reschedule appointments
• Grant proxy access to the patient portal for family members to assist
with their care.
• Medication list, allergy list, immunizations.
• Pre-visit questionnaires and forms that can be completed online.
• Notification (reminders) of preventive health services to be
completed (e.g., colon cancer screening).
• Refill prescriptions online, registration, insurance, authorizations.

Standard!24!(Preventing!FollowJup!Care!Failures)!requires!a!physician!who!orders!a!diagnostic!makes!a!referral!to!another!health!professional!to!(subsection!1):!(a)!have!a!system!in!place!of!test!results!or!Findings Findings consultations!and!& &
arrangements!Lessons for!to followup!be Learned
care!when!necessary,!(b)!place!to!contact!the!patient!when!followup!care!is!necessary,!(c)!document!all!contacts!and!contact!the!patient,xii!and!(d)!make!arrangements!for!responding!to!“critical”!diagnostic!test!reported!Price by!family’s a!laboratory!perspective or!imaging!facility!for!urgent!attention!after!regular!working!hours!absence!of!the!ordering!physician.(total = 6)
9!
Lessons to be learned – Family perspective:
“Never, ever assume there is a critical smooth hand off between doctors.”
!
Lessons to be learned – Family perspective:
“Never assume that when a referral is made to another doctor that the case will be treated
with any particular priority.”
Lessons to be learned – QAC perspective:
Providers:
1. When a provider’s office knows the date and time of an appointment for an important
test like a CT scan, staff should book the patient’s followup appointment for one or two following the scan (results will be available on Netcare), rather than rely on the arrival of paper report to trigger the booking of the next appointment. This is especially important patient with a time-sensitive health condition.
2. Providers who are leaving a practice and transferring the care of patients to another
!
Lessons to be learned – QAC perspective:
Users: If you have not heard about an appointment followup with the physician or clinic you
have been referred to, or the physician/clinic who referred you.

Findings & Lessons to be Learned
HQCA’s perspective (total = 7)
L e s s o n s t o b e l e a r n e d – Q A C p e r s p e c t i v e :
U s e r s : I f y o u h a v e a s e r i o u s m e d i c a l i s s u e a n d i t i s n o t b e i n g a d d r e s s e d i n a t i m e f r a m e
t h a t y o u b e l i e v e i s a c c e p t a b l e , i t i s q u i t e a p p r o p r i a t e t o a s k y o u r h e a l t h c a r e p r o v i d e r t o
r e c o n s i d e r t h e u r g e n c y o f y o u r c a r e n e e d s .
P r o v i d e r s : ‘ U r g e n t ’ l a c k s a s t a n d a r d d e f i n i t i o n i n t h e h e a l t h c a r e s y s t e m . I f a p a t i e n t w i t h
a t i m e - s e n s i t i v e h e a l t h c o n d i t i o n n e e d s a n a p p o i n t m e n t f o r a t e s t , p r o c e d u r e , o r c o n s u l t
w i t h i n a v e r y s h o r t p e r i o d o f t i m e , t h e o n l y r e l i a b l e w a y t o e n s u r e t h i s h a p p e n s i s t o s p e a k
d i r e c t l y w i t h a p e r s o n w h o h a s t h e a u t h o r i t y t o a p p r o p r i a t e l y e x p e d i t e t h e a p p o i n t m e n t . N o
o t h e r a p p r o a c h o r p r o c e s s c a n r e l i a b l y t a k e t h e p l a c e o f d i r e c t p r o v i d e r - t o - p r o v i d e r
c o m m u n i c a t i o n .
S y s t e m ( R a d i o l o g i s t s ) : I n s i t u a t i o n s w h e r e o n e d i a g n o s t i c t e s t f o r a p a t i e n t i n d i c a t e s a
c l e a r n e e d f o r a d d i t i o n a l d i a g n o s t i c i m a g i n g s t u d i e s i n a t i m e l y f a s h i o n , r a d i o l o g i s t s a r e
a r e a c t i n g w i t h i n t h e i r p r o f e s s i o n a l d u t i e s i f t h e y o r d e r t h e r e q u i r e d t e s t o r t e s t s o n b e h a l f
o f t h e p a t i e n t a s s o o n a s p o s s i b l e . I d e a l l y , t h e r a d i o l o g i s t s h o u l d a t t e m p t t o c o n s u l t w i t h t h e

Reliable continuity of care when patients are referred for specialized
healthcare services.
1.
Radiologists expediting additional diagnostic imaging studies and the
next level of care for patients with time-sensitive health conditions.
2.
Prioritization criteria for outpatient CT scans.
3.
Formal transfer-of-care responsibilities for time-sensitive health conditions
and availability of responsible healthcare providers.
4.
Co-located practice groups: co-ordinating services and
clarifying relationships.
5.
Issues - Analysis - Recommendations

5.
• Recommendations 9 & 10 focus on a particular group of co-located
specialists but is applicable to any group of physicians or
healthcare practitioners who choose to co-locate
‣ take opportunities to optimally coordinate services such as central
triage and call answering
‣ create a single process for patients and referring physicians to
contact a specialist
‣ ensure all forms of communication clearly outline the relationships
between the physicians and sponsoring organizations

Formal transfer-of-care responsibilities for time-sensitive health
conditions and availability of responsible healthcare providers.
• Recommendation 5 targets physicians – to make clear (to the patient
and to other physicians involved in the patient’s care) who the
responsible physician(s) is (are) for managing a patient’s important time-sensitive
condition and how the patient should contact that physician if
they are needed.
• Recommendation 6 challenges Alberta’s physicians with making a
public declaration (as part of the new Alberta Health Charter or a stand-alone
document) about their commitment to patients who have serious
time-sensitive health conditions to be available 24/7 and responsive to
concerns patients may have about their condition or possible
complications stemming from having undergone a procedure.
4.

• Recommendation 7 suggests that Alberta physicians consider
partnering with Health Link Alberta as one possible mechanism to make it
easier for patients to contact their physicians after hours when they have
substantial concerns.
• Recommendation 8 encourages the College of Physicians and
Surgeons of Alberta to develop a proactive process to monitor its After
Hours Access to Care Standard.
4.

Prioritization criteria 3. for outpatient CT scans.
Alberta Health Services to revise their criteria for assigning
priority to patients requiring body CT scans so that patients with
known time-sensitive conditions are made priority 1 regardless of
whether they have a confirmed diagnosis of cancer.

2.
Radiologists should be supported to
directly arrange the next logical DI test (if it
is clearly required) for patients with T-S
conditions and /or directly referring them
to a clinical service
49

2.
Radiologists expediting additional diagnostic imaging studies and
the
the next level of care for patients with time-sensitive health
conditions.
Prioritization criteria 3. for outpatient CT scans.
4.
5.
49
8
Radiologists should be supported to
directly arrange the next logical DI test (if it
is clearly required) for patients with T-S
conditions and /or directly referring them
to a clinical service
2.

1.

Alberta Health and Alberta Health Services
should strongly consider making additional
investments in the provincial electronic health
record and e-referral system to standardize
workflow processes for all specialized healthcare
services
**including a patient portal**
1.

Reliable continuity of care when patients are referred for
specialized healthcare services.
✓ Closed loop referral
✓ Referral creation & submission
✓ Provides wait times
✓ Send for consult or advice
✓ Standard referral requirements
☛ allows for intake & triage
☛ direction to the correct specialty service
✓ View referral history
✓ Checks for completeness
1.
Issue - Analysis - Recommendations
✓ Track referrals in real time
patient & / or
At all stages in the referral life cycle, any health care professional
associated with a referral can track its status and view its details.

1.
Two Important Principles
1.Engage patients in their own care (and give them access to
their own clinical information so they can play an informed role)
•Design the health system at all levels to make it safer (to
make it harder for people to do something wrong and easier for them to
do it right); and if something does go wrong - make it easier
for healthcare providers and patients to see it in time to
intervene

1.
e-Referral
Netcare
Patient-portal

Price Family’s Goals
Care that is:
‣ Safe
‣ Continuous
‣ Collaborative
‣ Patient-centred

Progress to date
Recommendation
1.s Netcare ⇒ patient portal / eReferral; standardize referral mgmt
workflow
2. Update standards for referral practices for specialized healthcare
services
3. Radiologists can expedite the care of patients with T-S health
conditions
4. Revise current criteria for prioritizing CT scans
5. Clarify physician accountability and availability for patients’ T-S
conditions
9. Review the business model of the SAIU to provide better
6. Physicians commit (publicly) to be available to patients with T-S
coordination of care
conditions
10. SAIU / AHS to review communication to clarify
7. Consider partnering with Health Link Alberta to improve MD
relationships

Making healthcare safer
"to err is human,
to cover up is unforgivable,
and to fail to learn is inexcusable”
Sir Liam Donaldson
Former England CMO and
Chair of World Alliance Patient Safety

• Healtharrows.ca
@healtharrows
https://www.facebook.com/HealthArrows.ca

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