Improving Communication Barriers from Consult to Evaluation in Hematopoietic Stem Cell Transplant

Background: The University of Virginia Health System‘s (UVA) mission is to be the safest place in health care for patients and employees. The BE SAFE initiative outlines how to identify problems related to patient and employee safety via the A3 problem solving tool.  A3 methodology is a Lean process improvement system that standardizes workflows by removing unnecessary or wasteful practices; thereby, increasing efficiency of healthcare delivery. In support of the BE SAFE initiative, we examined our hematopoietic stem cell transplant (HSCT) inpatient consultation process using our electronic medical record (EMR) at UVA.  Full implantation of the EMR at UVA occurred in March 2011 using EPIC Hyperspace software.

Methods: A multidisciplinary team including social worker, financial coordinator, quality coordinator, program administrator, physicians and transplant coordinators conducted an audit of all inpatient HSCT consults requested from July 2013 to July 2014 examining the process from initial consult to transplant workup. Algorithms were created in Microsoft Visio to represent our current state and target state for the consultation process. Through the A3 process, we identified communication violations that are represented by 4 storm clouds seen in Figure 1.

Results: Seventeen patients, with high risk malignancies (14 AML/MDS, 1 ALL), had an inpatient HSCT consult requested during the twelve month timeframe.  Approximately 77% of consults experienced a connection violation resulting from poor communication. Frequent problems identified included failure to communicate the need for social work/financial screening, inability to view the consult order in EPIC, and the HSCT team being unaware of potential transplant patients. Patients were evaluated for transplant without insurance verifications and psychosocial assessments leading to patient dissatisfaction, transitions of care to other institutions, and excess out of pocket costs.

Solution:  Our working group designed a target workflow to optimize communication. To implement target workflow, the HSCT program collaborated with EPIC builders to create a systems list, a consult patient list for the transplant program. The systems list, implemented September 2014, captures all consults ordered by inpatient staff allowing the members of the HSCT program to monitor for new consults. In-service educational sessions will be provided to all involved staff beginning October 2014. The new processes will be reviewed weekly for 4 weeks and monthly for the first quarter allowing for real-time interventions and corrections. Once the target state is met, we expect increased cost containment and decreased external transitioning of care; thereby, improving patient care and satisfaction.

Figure 1) Current State