Woodbridge P (Roudebush VA Medical Center), Flanigan M
(Indy HSR&D COE), Doebbeling B
(Indy HSR&D COE)
Consult completion is a major operational and quality problem in many Veterans Affairs (VA) Medical Centers. First quarter 2006 national data indicate consult completion rates vary from 69% to 100% at the facility level. Our objective was to identify practices linked to high consult completion rates.
We conducted telephone interviews of key informants at 20 VAMCs (8 from the top quartile, 6 from the middle quartiles, and 6 from the bottom quartile) to identify common consult completion practices, barriers and facilitators. From these interviews, a written survey was developed and administered to participants of the 2006 VEHU meeting (N=170). Logistic regression analysis was used to determine which consult completion practices were associated with high performance.
Several common practices were identified as barriers to consult completion: failure to assign a note title to the completed consult or to enter a consult note into the computerized patient record system, duplication of consult requests, and scheduling and appointment errors. Also, upper management attention to consult completion rates, implementation of written service agreements, and inconsistencies in treatment of clinic “no-shows” significantly impacted consult completion performance.
High-performance sites typically used specific interventions in their consult completion workflow, built in redundancies within that workflow to reinforce the need for completion, and supported the staff with extensive technical training to assure competence in the consult completion process. Many of the gaps in performance attributed to user error could be eliminated through more careful usability testing and design of the electronic tool.
Recommendations for performance improvement in consult completion include developing processes for integration into workflow driven by human factors principles for implementing technological innovations, adjusted metrics for consult completion, and effective leadership. Furthermore, new approaches to provider training (just-in-time), written policies on failed appointments and clinic cancellation, templates of consult notes, and formal intra-departmental service contracts to foster improvement are other potential solutions.