Pooled referral gains momentum in Saskatchewan

Specialist "pooled referral" implementation is sweeping the province!  Here's a great story in the Prince Albert Herald about PA's orthopedic surgeons offering pooled access as of March, and general surgeons planning to implement it at the end of May.  The Regina Obstetrics and Gynecology department are also offering this option to their patients.

Pooled referral, also known as centralized referral intake (CRI), involves collecting referrals in a central location and then distributing the referrals so that patients have access to the specialist with the shortest wait time.  When our urology group implemented this system several years ago, the reception from referring physicians was very positive.  (Here's the post looking at wait times for pooled referrals.)  They liked the fact that they didn't need to do the "heavy lifting" of figuring out which urologist had the shortest waiting list, or which one of us subspecializes in a certain problem.  

When I have the chance to share our practice's learning and improvements, the idea of pooled referrals has an immediate appeal to both referring and consulting physicians.  However, physicians do have some trepidation about the system.

First, they're concerned about patients (and referring physicians) having the choice of which consultant they will see.  Our group's philosophy has been that patients and referring physicians have the choice of which urologist they see.  We don't require participation in pooled referrals, however, if someone "opts out" of pooled referrals, they may wait longer to see the urologist of their choice.

Continuity of care is also a consideration.  Physicians recognize that time and effort is wasted, and important clinical details may be overlooked, when patients switch between specialists.  A pooled system should try to maintain any previously-established patient-physician relationships (as long as the patient wishes to do so).

Finally, I'm often asked a very thorny question: How can a pooled referral system ensure that patients will have a consistent experience no matter which specialist they see (AKA not all docs are created equal)?  This applies to the interpersonal, as well as technical, skills of the specialist.  This is very difficult to answer as there is often no formal tracking and reporting of individual surgeon's treatment outcomes and complications.  Communication skills, empathy, and affability may only be judged through word of mouth.

This raises an ethical question: If we promote a new referral management system, and that system has the potential to adversely affect the experience and outcome of some patients, what is our responsibility to assess and improve the abilities of the specialists so that patients receive consistent, competent care that is constantly being improved?  

I think that, by its very existence, a pooled referral/CRI system begins to address this concern.  In order to implement this system, specialists must be prepared to communicate and collaborate, often to a degree that they previously didn't do.  This lets them share information about, and expose differences in, individual practices.  In our urology practice, learning about differences in our practice habits made us curious about what could be considered "best practice" and how we could offer more consistent care.  

Pooled referral/CRI has the potential to improve patients' access to specialist care, and make sure that they receive care from the appropriate practitioner.  However, it's not without drawbacks, and we must proceed with eyes wide open.

Great comment from a nurse about managing the drug shortage

This comment (made on the last post about the national injectable drug shortage) is great on several levels:

I am an Lpn at sch on the gyne ward.. I haven't noticed that my patients are suffering any more since the cut back on IV meds.. the use of gravol supps for nausea, regular use of oral analgesics and pain and nausea rating on rounds has I think ensured patient comfort..Patients seem hesitant at first but are reassured that if the oral or pr routes don't work we will go with the intervenous option. I wonder if Pre op clinic could instruct patients on the shortage so that they are less apprehensive post op when their nurse suggests something other than IV drugs..

• It's feedback from a front-line care provider telling us about how care-givers are perceiving the situation's effect on their patients' care.  

• The nurse tells us that pain and nausea rating is done in order to ensure patient comfort.

• We get some insight into how patients are being affected by the changes.  They may be anxious about the effectiveness of pain-killers or anti-nauseants being given other than intravenously.  The nurses on this ward are reassuring patients that they will switch to intravenous medications if the alternate forms aren't adequate.  I don't know if there has been formal training in a "script" to use when explaining the situation to patients, but I suspect that having such a script may be useful for nurses when counselling patients about these changes in practice.  This would also ensure that patients receive a consistent message across the entire health region.

• Finally, what a great suggestion to prepare patients preoperatively!  Hearing about our change in medication practice in advance would certainly be easier than hearing about it when a person needs relief from pain or nausea.  Transparency? Check! Respect for patients? Check!

Sounds like the gyne ward staff at SCH have some great ideas.  Maybe a gemba walk is in order...