Quality Improvement from the Front Lines

An interview with Lorraine Kanelos, Practice Manager, North Shore Physicians Group, Beverly, MA

Back in 2010, Lorraine Kanelos received a call from Tufts Health Plan regarding a member who had filed a complaint. The member explained that his PCP had recommended a colonoscopy and had told him that either his office or the gastroenterologist’s office would contact him to set up an appointment. Eight months later and still no call, the member filed a grievance (aka complaint). Lorraine subsequently investigated the office practice’s process for arranging appointments and found that their system had a number of gaps. In 2011, when her office practice was approached to participate in a PROMISES quality improvement project, Lorraine immediately knew what process she wanted to fix.

Lorraine explained that their original process began when a member was told by the PCP that a colonoscopy was needed. Paperwork was subsequently completed and faxed to the gastroenterology specialist group in the community to request that a colonoscopy be scheduled. While the PCP’s group practice did maintain a file folder with the faxes that had been sent, there was no formal reconciliation or follow-up process in place. The office did not track to see whether or not the patient actually underwent a colonoscopy.

North Shore medical Center diagram

Process Improvements

Enter the PROMISES project in 2012: Nicolas Leydon from the PROMISES project worked with Lorraine and the North Shore Physicians Group’s team and began with small tests of change to improve the process. The first improvement was to create a manual list that was reviewed weekly to see if all patients who needed a colonoscopy had their information faxed to the gastroenterologist’s office. The office also started contacting the gastroenterologist’s office to see if they had received the previous week’s faxes. The gastroenterologist’s office also did not have an existing process to be sure that all faxes were followed up — this was added to the project. The team constantly used the PDSA approach (plan/do/study/act).

As the project grew, the process improved. New steps were added that included faxes being sent on the day the member was seen, a telephone call to the gastroenterologist’s office to confirm that the fax had been received, follow-up with the patient to be sure they responded to the outreach to schedule a colonoscopy, and tracking the date that the member underwent the procedure.

From there, Lorraine’s team got their IS department involved and an electronic template was created that would automatically populate the demographic information into the request form. The gastroenterologist’s office added a process to follow up with a member at least twice, and if there was no response, a follow-up letter was sent to the member and documented in the medical record. As these improvements were made, the loops were closed in the process. Now the practice tracks each patient’s course in the process — from the point the colonoscopy is recommended by the practitioner all the way to the procedure and any follow-up.

By working closely with the gastroenterologist’s office, even more improvements were made. For example, the gastroenterologist’s office previously prescreened each patient’s chart before outreach to the member; now, using the prepopulated form, the office can rely on the PCP’s initial screen, so the gastroenterologist’s office now just needs to review the list of the patient’s medications and BMI to determine whether the member can be scheduled immediately or if a practitioner will need to review the record and schedule a follow-up appointment with a nurse practitioner. Even insurance referrals are now processed along with the colonoscopy request form.

The success of this program has been phenomenal. In 2013, the number of North Shore Health System’s screening colonoscopies increased by 2000 and the turnaround time for a colonoscopy is now within one week of the request! Lorraine explains that they have plans in the near future to use the same kind of process for tracking skin screening for melanomas. The best news is they have been able to sustain this new process, as it is an integrated system.

April 23, 2014