Download - eRFA - Electronic Referral for Admission
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eRFA
(electronic Request For
Admission) Karen Berry
District Access Coordinator
Danette Holding
Project Manager
Melbourne
12 November 2012
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HNELHD
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John Hunter Hospital – Elective Surgery In Context
• 27,000 procedural/ surgical cases pa, of which 37% (9,885) are elective.
• Level 7 Tertiary Referral Service, Level III Trauma Centre
• Approx 800 bed facility
• Approx 17000 on waiting list (6000 at JHH),
• Annually: 15,753 added to JHH list, 13,823 admitted for surgery, 2,144 removed for other reasons.
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Planning For Admission
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Handwritten RFAs
• Over the full year, nearly 100% error rate!!
• Average of 2.45 errors/ RFA
– Consent with a large number of consent and planned
procedure not matching.
– Special OT requirements also strongly represented as
missing data.
• Illegible
• Incomplete
• Staff chasing specialist for clarification
• Patient Questionnaire often incomplete
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Admissions processes galore
• Series of detailed cumbersome processes
including:
– When RFA required elsewhere, photocopies made
and the copy left in Admissions (straight forward
admission avg 8 movements)
– Photocopies are annotated and then transcribed
onto original, doubling the handling
– iPM Waitlist comments transcribed to the paper RFA
– Paper RFA must be unfiled, annotated and re-filed
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Audit
• Manual Auditing
– over 1000 audit letters for each 150 day audit run
every two weeks
– returned audit letters must be filed with the RFA
– each RFA retrieved, attached, annotated and re-
filed
– Phone calls generated from the auditing process
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The Pre-Admission Process Limitations
• Individual services wanting individual systems
• Multiple versions of “RFA’s”
• Multiple Pre-Admission Clinics
• Resource intensive complex manual systems at capacity
• Margins for error
• The geographical lay out = risk of RFA “misadventure”!
• Demand for review of “RFA document” by various services
• Transfer between Dr’s and sites
• Documentation
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Unquantifiable risks
• Inability to track:
– How many RFAs were lost?
– How many RFAs are never sent to Admissions?
(Wait List Policy compliance)
– Ensure the return of a postponed or cancelled
patient’s RFA’s to Admissions from Operating
Theatre.
– Communication with sites/ AMOs
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JHH Campus Perioperative Services
Medical Specialty
RFA’s
Surgical Specialty
RFA’s
Cardiothoracic
JHHCH
RFA’s
Admissions
Audit queue
Rheumatology
Dermatology
Respiratory
Sleep Clinic
Nuclear Medicine (different RFA)
Cardiology (non procedural)
Immunology
General Medicine
Endocrinology
Nephrology
Rehabilitation (RNC)
Endoscopy
Neurosurgery
General Surgery
Colorectal Surgery
ENT
Max Facs
O&G
Gynae Onc
Vascular
Vascular cath lab
Gastroenterology (requring surgical intervention)
Lung Cardiac
Surgical
(Sedation)
Gastro
(Sedation)
Surgical
(GA’s)
JHH peri op
Procedural Cardiology
(including some cardiology
pacemakers)
Various referral
sources on
various types of
RFA’s
RFA sent for
Procedural
Cardiology team
review
Cardiology
Periop triage
assessment
Procedural
Cardiology
ends here
Admissions wait
list queue
If Periop
assessment
requested on
RFA
eRFA system will forward
to the “other” periop
queue (JHH Periop
responsible for actioning
to correct periop service)
Pt awaits admission advice
from Bed Manager who has
copy of undated pt’s RFA in
a folder
Gastro
(GA’s)
Endoscopy NUM
for Periop
JHH/RNC Campus
Perioperative Flow
Chart
Urology
Elective Orthopaedics
Opthalmology
RNC Periop
Cardiothoracic
Periop
Endoscopy
NUM
Periop
JHHCH
Periop Service
JHH/RNC Periop
RFA received
via paper or
electronically
(EP) cardiology
Periop triage
assessment
RFA sent for
Procedural
Cardiology team
review
Various referral
sources on
various types of
RFA’s Procedural Cardiology (EP)
(including some cardiology
pacemakers)
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Why an eRFA???
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Developing A Solution
• DOH offering $250,000. HNE funding the remainder
• JHH Pilot site for eRFA (electronic Request For
Admission)
• Utilising existing Admissions and IT staff with a part
time Project Manager
• Main cost software, based on “adobe livecycle”,
smaller extent, scanners and bar coders
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Our Information Systems
• Chief Information Officer
• Clinical Systems Team
– Over 300 applications, over 9000 individual
computers, over 15000 users.
– CAP (Clinical Access Portal)
• eRFA developed by the Applications
Development Team, launched from CAP
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What else could be
improved?
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Streamlining Processes
• Opportunity to Align Medical Admissions and elective surgical patients to a singular “Pre Admission” model
• The traditional “Anaesthetic Clinics” (Perioperative Service) to sit within this process.
• Pre-Admission processes guided by TCRA Policy (NSW MOH new Discharge Policy) 5 key elements for pre admission assessment.
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Meeting KPI’s
• Doctors KPI of ensuring RFA is submitted to Hospital
within 3 working days of seeing the patient.
• Manage workflows to improve compliance with
requirement to add RFAs to the waiting list within 3
days of receipt of RFA
• Ensuring matching documentation between iPM and
the RFA
• Introduction of mandatory fields ensures complete
RFA documentation
• Ensure patients requesting deferral are not added to
the waiting list
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• The eRFA Facilitates
– Transfers of RFAs between facilities
– Sharing of relevant clinical data
– Management of short notice bookings
– Discussion with pre-op services (both here and off
site).
Meeting KPI’s
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Implementation
Experience
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Implementation Process
• eRFA Working Party established, with representation from the key teams.
• Regular forums to discuss progress, process challenges, prioritise work flow and feedback
• Process of back scanning some 6000 RFA’s into system
• Clinical engagement
• Forums with Service and Clinician groups for feedback and identification of requirements/enhancements
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eRFA Process
Electronically submitted eRFA
Paper RFA received and scanned in to
eRFA system
Admissions waitlist entry
and audit process data
entry into patient
management system (iPM) updates eRFA
system
Electronic routing to
various periop services
Periop
Periop
Periop
Periop
+/- Perioperative
Clinic assessment
notes scanned into eRFA
eRFA and perioperative
notes available for review
through CAP (token from
rooms/home etc)
“Batch print”from
Admissions 2 work days prior
to surgery forwarded to
DOS unit
Pt presents for surgery notes
progress with pt
eRFA Process Flow
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Electronic Submissions
• Since commencement of electronic submissions
(April 2012) there have been 8986 RFA’s submitted
• 976 of these have been electronically submitted
(11%)
• The remaining have been scanned into the eRFA
system as a pdf document.
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Benefits for Patients
• Legibility and completeness of procedure,
equipment, special requirements
• RFA cannot be lost in the system risking a
cancellation
• RFA cannot be lost by a patient or ward for a
staged or deferred procedure
• Patient questionnaire form pre-filled from
iPM and previous RFAs
• Better prepared for procedure and discharge
planning
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Benefits for Clinicians
• eRFA user friendly
– Pre-filled data for procedures and patient details
from iPM (including infection control alerts)
• Surgical list within (CAP) Clinical Applications
Portal
• RFA available within (CAP
• Ability to view previous RFA’s with
accompanying perioperative documents.
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Benefits to the Organisation
• Congruence between paper and pt information
systems
• Improved quality in documentation
• Admissions from “stretched” to increased
capacity for throughput
• Provision for mandatory check for procedure
information and risks
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Other Clinical Implications
• Mandatory consent for blood transfusion and
products on eRFA and infection control alerts
(transcribed from iPM)
• Critical Care referrals pre operatively
• Tissue Bank consent
• Discharge Planning (NSW TCRA Policy)
– Case managers on wards for complex
procedures/patients
– Referrals to Allied Health
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The Perioperative (service) process
• Improvements to Triaging and requirement to review
special instructions on the eRFA
• Application within CAP that enables a GP referral
(containing a health summary) to be reviewed at
point of triage
• Clerical efficiencies with negating the need for RFA
retrieval, copying and tracking
• RFA no longer required for clinics
• Periop Service efficiencies with clinic notes being
scanned into eRFA rather than summarised into
patient information system (iPM) and visible in CAP
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Challenges/ Risks
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The Challenges
• Managing the process change (size of project and stake holders, many directions with each challenge)
• Clinician support (tech savvy)
• Patient questionnaire and obtaining signature for consent (sig pad, printer issues in OP)
• IT limitations, new software, CAP (actual electronic form)
• IT Resources
• Managing the scope of the initiative and prioritising
• Maintaining Integrity of the Medical Record (Water Marks)
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Challenges
• RFA now singular pages (Pt ID and MRN)
• Pharmacy
• Children’s Hospital involvement (precursor to review
of their own perioperative systems)
• Managing the multiple systems through admissions
during implementation phase
• Maintaining the integrity of the medical record and
patient safety
• Momentum, enthusiasm and managing the
implementation till embedded
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Managing Admissions Processes through
Implementation
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Moving Forward
• Tackling the challenges
– Without complete roll out to ensure electronic submission the eRFA will
be little more than an electronic wharehouse
– Complete JHH Campus roll out, currently limited by IT resources
– Roll out to Private Rooms
– Roll out to the rest of HNELHD
– Facility Representatives (Clinical and Administrative) – and change
champions!
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Thank you!