Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter. Pooled referrals are quickly becoming a very popular choice among patients being referred to a specialist. Some Saskatchewan specialists that are using pooled referrals are reducing patient wait times by as much as a half. Better Care Corrine Jabs

1. Pooled Referrals
Dr Corrine Jabs
This Session is sponsored by:

2. Pooled Referrals
Dr. Corrine Jabs
Dept Head, Obstetrics & Gynecology
Regina Qu’Appelle Health Region
Inspire Conference, Regina, April 2013

3. Disclosures
• Speaker’s bureau
– Pfizer
– Astellas

4. Objectives
• Understand:
– The concept of pooled referrals
– The challenges encountered in implementing the
concept of pooled referrals
– The rewards and advantages of pooled referrals

5. Regina Department of Obstetrics and
Gynecology

6. Department Obstetrics & Gynecology
Regina

7. The Problem

8. Waitlists

9. Waitlists

10. Referral
Consultation
Surgery
Patient need

11. Department of Obstetrics and Gynecology December
2010
Saskatchewan Specialist Registry
0 0 7 14 14 21 28
365 365 365 365 365
A B C D E F G H I J K L
Days for elective gyne referral to be seen

12. Issues:
• Long waits for some patients and very short for some patients
• Referring docs do not have consistent information regarding
waiting lists.
• Overload of some offices, concerns about job security in
others
• Multiple requests for referral/lost referrals
• Redirected referrals due to overload
• Redirected referrals due to skill set
• No control over inflow when ill, on leave, etc.
• Don’t know overall capacity or backlog in the dept and can’t
predict manpower needs

13. • Demand = patient need
• Supply = capacity of the providers
• The trick is to balance these

14. Pooled Referrals

15. Why consider
pooled referrals?

16. Why Pooled Referrals?
• Patients, through the Patient First Review,
stated they want improved access and well
coordinated care.
• Pooled referrals is a strategy to reduce wait
time variability among a group of specialists
that perform similar procedures and helps
improve access

17. The Solution?

18. What did we want to do?
• Level the workload / Work as a team
• Determine our capacity and backlog as a group
• Reduce wait times for consultation
• Ensure patients are seen by the appropriate
specialist/subspecialist (skill task alignment)
• Ensure GPs and patients are kept informed about the
status of their referral and appointment

19. Dept of Obstetrics & Gynecology Regina

20. “Our Plan”
• As a Department, we agreed to adopt pooled
referrals as a quality improvement project to
streamline the referral process and improve patient
access to our specialists
• Patients now have a CHOICE:
1. they can select a particular specialist, or
2. they can choose to see the next available specialist able to
treat their condition

21. How did we get there?
• Sask Surgical Initiative – Pooled Referrals on Agenda Feb 2010
• Discussion – Dept Meeting, Grand Rounds, Suppers Dec 2010
– What were the advantages/disadvantage/risks?
– Effect on Dept, patients and our referring practitioner?
• Practice Matrix – who does what? – Feb 2011
• Referral form – essential for sorting, database – Feb 2011
• Family physician focus group – April 2011
• Business rules – agreement on how to work together –October 2011
• Referral Management System – single entry point/fax line; allocation
of referrals; development of database
• Launch April 30, 2012
• Measurement - ongoing

22. • We were eager to start
• We did not expect
perfection from the start
• We anticipated change and
challenges
• We are making changes

23. “Our Challenges”
• Unlike the other early adopters of pooled referrals, our 15
specialists do not share a single office
• Multiple offices multiple fax lines
• Consulting with GPs not an easy task
• Database and Referral Management Service did not exist
• Perfection was expected. People confused because they were
expecting this to be a traditional project. We used the PDSA
approach: moving from good to better over time

24. What we did…

26. Patient Allocation

27. Impact of Pooling Referrals on:
Patient choice

28. Our Information Given to Referral
Management Service

29. Distribution of Patients in Obstetrics
Based on Capacity

30. Distribution of Patients in Gynecology
Based on Capacity and Demand

31. Other valuable information

32. Where should we direct our attention?

33. Impact of Pooling Referrals on:
Wait times

34. Determine our capacity and backlog
as a group

35. Determine our capacity and backlog
as a group

36. Counter measure: urgent wait times

37. Backlog Reduction

38. Where is our backlog?

39. Reducing wait times

40. What is the Data telling us?
• Wait times for our department are coming down and
becoming more consistent.
• For obstetrics: women appear to value their
relationship with a particular specialist
• For urgent and elective gynecology issues: women
appear to want to have their issues addressed
quickly
• We do not need to pool all patients to see
improvement (~ 40% of obs, ~ 50% of gyne)

41. The Value of Data
• This data includes
• number of referrals received,
• reasons for referral,
• capacity of the department as a whole and
• data related to patient waits

42. The Value of Data
• For the first time ever, we have valuable data about
our entire department’s workload
• This data is already proving to be a valuable planning
tool for further quality improvement and access
initiatives in our department

43. The Value of Data
• Outliers and anomalies can be identified
• countermeasures can be determined

44. Who is/will be pooling referrals?
Department Region No. of Surgeons “Go Live” Date
Orthopedics PAPRHA 4 Live Mar 19, 2012
Ob/gyn RQHR 15 Live -April 30, 2012
Neurosurgery** RQHR 5 Live - June 23, 2011
Neurosurgery** SHR 5 Live -June 23, 2011
General Surgery PAPRHA 5 Live -Nov 22, 2012
Ob/gyn* SHR 9 Live Jan 12, 2013
Thoracic Surgery SHR 3 Self-initiated
Vascular Surgery SHR 4 Self-initiated
Urology SHR 7 Self-initiated
Vascular Surgery RQHR 3 Self-initiated
Cardio-thoracic RQHR 3 Self-initiated
Ob/gyn FHHR 3 Spring 2013
Ob/gyn PNHR 3 Spring 2013
General Surgery PNHR 4 Spring 2013
Plastics SHR 4 Summer 2013
Cardiology SHR 13 Summer 2013
* A group practice of 9 surgeons
** Back pain patients are pooled through the spine pathway, includes several orthopedic
surgeons

45. Thoughts/Discussion/Questions

46. Thank you