Initiatives

Identifying and reaching the responsible physician

General implementation strategies:

• Reliable identification and notification of the responsible provider is a very complex process in most institutions; in general, community hospitals with a stable group of providers have less difficulty with this than academic medical centers with multiple providers from different levels of the medical staff i.e. house officers, fellows, and attendings
• Keep focus on getting results to the clinician who is responsible for taking clinical action based on test results; strongly consider direct MD notification; clarify expectations between nursing and medicine if calls routed to RN’s
• Calling to the results to both the RN and responsible provider for inpatient results, builds support for the patient and adds reliability to the system
• Agree on the care model, then deal with coverage issues
• Negotiate win/win solutions if at all possible, such as:
• Alpha page all stat requests (that notifies provider that results are available in computer) but continue to phone critical results
• Clarify expectations about phone calls clear to the diagnostic testing center at the time of test entry
• Be sure all clinical team members have equal access to information about the responsible provider; make it easy to access this information; make web-based if possible, or have communication center serve as node for all coverage information
• Create a coverage module that includes all members of the team associated with the care of the patient
• At the time of admission, link the patient with a specific provider or service; identify the attending and verify the primary care provider at the same time
• Link all ambulatory providers to a corresponding chief in the physician order management system
• Centralize your call system (institution-wide); assign responsibility and accountability for the accuracy and completeness of the call schedule information to one person in the communication (call) center
• Assign the responsibility for updating system contact information to one group within the institution
• ISD for the provider database with internal communication systems such as, phones, printers
• Program administrators initiate changes at unit level
• If implementing CPOE, be sure covering physician plan is built into design of CPOE
• Link updating provider contact information with an existing process, e.g. credentialing
• Test the accuracy of the call list periodically using the emergency preparedness drill; follow up on all inaccuracies
• Periodically track page response times

Some implementation strategies to help with identifying the responsible provider

• Add a forcing function to identify the provider at the point of test entry
• Require name, and beeper number, on test requisition; make it a forcing function if using a computerized order entry system
• Consider using a “copy to” function to identify ordering physician information: attending is identified on requisition but resident (true ordering provider) can be identified in “copy to” function

Some implementation strategies to help with reaching the responsible provider

• Develop matrix of key contacts for after-hour processes and outpatient clinics; identify potential “failure modes”
• Consider having the laboratory call both the physician and the nurse caring for the patient with a critical test result; the nurse can assess the patient and prepare patient information to discuss with the physician
• Test different notification strategies; lab page MD directly (need name and beeper # of MD); lab page inpatient RN, then RN identifies and notifies MD (RN needs MD name and beeper #), lab pages MD to patient unit number with code for critical result, then MD makes call directly to inpatient RN (lab needs MD name and beeper # and patient unit name/number
• Get “back line” numbers for all PCP offices; keep numbers up to date by building updates into existing regular process
• Test a variety of notification options with a “willing volunteer” service(s); try dedicated beepers, cell phones, dedicated role (one provider on service picks up all criticals), direct notification, on-line call schedule access and notification, use alpha pagers with formatted text of “critical value call XXXX” (one beeper number to pick up all criticals); providers know at outset that this value is critical
• Try different acknowledgement systems to let the sender know the message was received; fax or text page acknowledgment

Some implementation strategies teams have found helpful for laboratory findings:

• Create a communication center within the lab (stat connect) to identify and locate the responsible provider; provide the option of then connecting immediately to the floor; communication center has information on responsible provider and patient location, acts as liaison; bench staff can call floor, communication center notifies providers

Some implementation strategies teams have found helpful for radiology findings:

• Build teamwork within the radiology department for communicating critical results
• For communicating to office practices, radiologist tries to call for 15 minutes; if no response, techs continue attempts to reach ordering provider; when ordering provider on line, call turned over to radiologist
• Create tracking system and make one person responsible for tracking all critical test results

For more information, contact Paula Griswold at pgriswold@macoalition.org or (781) 272-8000 x152.