eRFA

(electronic Request For

Admission) Karen Berry

District Access Coordinator

Danette Holding

Project Manager

Melbourne

12 November 2012

HNELHD

John Hunter Hospital – Elective Surgery In Context

• 27,000 procedural/ surgical cases pa, of which 37% (9,885) are elective.

• Level 7 Tertiary Referral Service, Level III Trauma Centre

• Approx 800 bed facility

• Approx 17000 on waiting list (6000 at JHH),

• Annually: 15,753 added to JHH list, 13,823 admitted for surgery, 2,144 removed for other reasons.

Planning For Admission

Handwritten RFAs

• Over the full year, nearly 100% error rate!!

• Average of 2.45 errors/ RFA

– Consent with a large number of consent and planned

procedure not matching.

– Special OT requirements also strongly represented as

missing data.

• Illegible

• Incomplete

• Staff chasing specialist for clarification

• Patient Questionnaire often incomplete

Admissions processes galore

• Series of detailed cumbersome processes

including:

– When RFA required elsewhere, photocopies made

and the copy left in Admissions (straight forward

admission avg 8 movements)

– Photocopies are annotated and then transcribed

onto original, doubling the handling

– iPM Waitlist comments transcribed to the paper RFA

– Paper RFA must be unfiled, annotated and re-filed

Audit

• Manual Auditing

– over 1000 audit letters for each 150 day audit run

every two weeks

– returned audit letters must be filed with the RFA

– each RFA retrieved, attached, annotated and re-

filed

– Phone calls generated from the auditing process

The Pre-Admission Process Limitations

• Individual services wanting individual systems

• Multiple versions of “RFA’s”

• Multiple Pre-Admission Clinics

• Resource intensive complex manual systems at capacity

• Margins for error

• The geographical lay out = risk of RFA “misadventure”!

• Demand for review of “RFA document” by various services

• Transfer between Dr’s and sites

• Documentation

Unquantifiable risks

• Inability to track:

– How many RFAs were lost?

– How many RFAs are never sent to Admissions?

(Wait List Policy compliance)

– Ensure the return of a postponed or cancelled

patient’s RFA’s to Admissions from Operating

Theatre.

– Communication with sites/ AMOs

JHH Campus Perioperative Services

Medical Specialty

RFA’s

Surgical Specialty

RFA’s

Cardiothoracic

JHHCH

RFA’s

Admissions

Audit queue

Rheumatology

Dermatology

Respiratory

Sleep Clinic

Nuclear Medicine (different RFA)

Cardiology (non procedural)

Immunology

General Medicine

Endocrinology

Nephrology

Rehabilitation (RNC)

Endoscopy

Neurosurgery

General Surgery

Colorectal Surgery

ENT

Max Facs

O&G

Gynae Onc

Vascular

Vascular cath lab

Gastroenterology (requring surgical intervention)

Lung Cardiac

Surgical

(Sedation)

Gastro

(Sedation)

Surgical

(GA’s)

JHH peri op

Procedural Cardiology

(including some cardiology

pacemakers)

Various referral

sources on

various types of

RFA’s

RFA sent for

Procedural

Cardiology team

review

Cardiology

Periop triage

assessment

Procedural

Cardiology

ends here

Admissions wait

list queue

If Periop

assessment

requested on

RFA

eRFA system will forward

to the “other” periop

queue (JHH Periop

responsible for actioning

to correct periop service)

Pt awaits admission advice

from Bed Manager who has

copy of undated pt’s RFA in

a folder

Gastro

(GA’s)

Endoscopy NUM

for Periop

JHH/RNC Campus

Perioperative Flow

Chart

Urology

Elective Orthopaedics

Opthalmology

RNC Periop

Cardiothoracic

Periop

Endoscopy

NUM

Periop

JHHCH

Periop Service

JHH/RNC Periop

RFA received

via paper or

electronically

(EP) cardiology

Periop triage

assessment

RFA sent for

Procedural

Cardiology team

review

Various referral

sources on

various types of

RFA’s Procedural Cardiology (EP)

(including some cardiology

pacemakers)

Why an eRFA???

Developing A Solution

• DOH offering $250,000. HNE funding the remainder

• JHH Pilot site for eRFA (electronic Request For

Admission)

• Utilising existing Admissions and IT staff with a part

time Project Manager

• Main cost software, based on “adobe livecycle”,

smaller extent, scanners and bar coders

Our Information Systems

• Chief Information Officer

• Clinical Systems Team

– Over 300 applications, over 9000 individual

computers, over 15000 users.

– CAP (Clinical Access Portal)

• eRFA developed by the Applications

Development Team, launched from CAP

What else could be

improved?

Streamlining Processes

• Opportunity to Align Medical Admissions and elective surgical patients to a singular “Pre Admission” model

• The traditional “Anaesthetic Clinics” (Perioperative Service) to sit within this process.

• Pre-Admission processes guided by TCRA Policy (NSW MOH new Discharge Policy) 5 key elements for pre admission assessment.

Meeting KPI’s

• Doctors KPI of ensuring RFA is submitted to Hospital

within 3 working days of seeing the patient.

• Manage workflows to improve compliance with

requirement to add RFAs to the waiting list within 3

days of receipt of RFA

• Ensuring matching documentation between iPM and

the RFA

• Introduction of mandatory fields ensures complete

RFA documentation

• Ensure patients requesting deferral are not added to

the waiting list

• The eRFA Facilitates

– Transfers of RFAs between facilities

– Sharing of relevant clinical data

– Management of short notice bookings

– Discussion with pre-op services (both here and off

site).

Meeting KPI’s

Implementation

Experience

Implementation Process

• eRFA Working Party established, with representation from the key teams.

• Regular forums to discuss progress, process challenges, prioritise work flow and feedback

• Process of back scanning some 6000 RFA’s into system

• Clinical engagement

• Forums with Service and Clinician groups for feedback and identification of requirements/enhancements

eRFA Process

Electronically submitted eRFA

Paper RFA received and scanned in to

eRFA system

Admissions waitlist entry

and audit process data

entry into patient

management system (iPM) updates eRFA

system

Electronic routing to

various periop services

Periop

Periop

Periop

Periop

+/- Perioperative

Clinic assessment

notes scanned into eRFA

eRFA and perioperative

notes available for review

through CAP (token from

rooms/home etc)

“Batch print”from

Admissions 2 work days prior

to surgery forwarded to

DOS unit

Pt presents for surgery notes

progress with pt

eRFA Process Flow

Electronic Submissions

• Since commencement of electronic submissions

(April 2012) there have been 8986 RFA’s submitted

• 976 of these have been electronically submitted

(11%)

• The remaining have been scanned into the eRFA

system as a pdf document.

Benefits for Patients

• Legibility and completeness of procedure,

equipment, special requirements

• RFA cannot be lost in the system risking a

cancellation

• RFA cannot be lost by a patient or ward for a

staged or deferred procedure

• Patient questionnaire form pre-filled from

iPM and previous RFAs

• Better prepared for procedure and discharge

planning

Benefits for Clinicians

• eRFA user friendly

– Pre-filled data for procedures and patient details

from iPM (including infection control alerts)

• Surgical list within (CAP) Clinical Applications

Portal

• RFA available within (CAP

• Ability to view previous RFA’s with

accompanying perioperative documents.

Benefits to the Organisation

• Congruence between paper and pt information

systems

• Improved quality in documentation

• Admissions from “stretched” to increased

capacity for throughput

• Provision for mandatory check for procedure

information and risks

Other Clinical Implications

• Mandatory consent for blood transfusion and

products on eRFA and infection control alerts

(transcribed from iPM)

• Critical Care referrals pre operatively

• Tissue Bank consent

• Discharge Planning (NSW TCRA Policy)

– Case managers on wards for complex

procedures/patients

– Referrals to Allied Health

The Perioperative (service) process

• Improvements to Triaging and requirement to review

special instructions on the eRFA

• Application within CAP that enables a GP referral

(containing a health summary) to be reviewed at

point of triage

• Clerical efficiencies with negating the need for RFA

retrieval, copying and tracking

• RFA no longer required for clinics

• Periop Service efficiencies with clinic notes being

scanned into eRFA rather than summarised into

patient information system (iPM) and visible in CAP

Challenges/ Risks

The Challenges

• Managing the process change (size of project and stake holders, many directions with each challenge)

• Clinician support (tech savvy)

• Patient questionnaire and obtaining signature for consent (sig pad, printer issues in OP)

• IT limitations, new software, CAP (actual electronic form)

• IT Resources

• Managing the scope of the initiative and prioritising

• Maintaining Integrity of the Medical Record (Water Marks)

Challenges

• RFA now singular pages (Pt ID and MRN)

• Pharmacy

• Children’s Hospital involvement (precursor to review

of their own perioperative systems)

• Managing the multiple systems through admissions

during implementation phase

• Maintaining the integrity of the medical record and

patient safety

• Momentum, enthusiasm and managing the

implementation till embedded

Managing Admissions Processes through

Implementation

Moving Forward

• Tackling the challenges

– Without complete roll out to ensure electronic submission the eRFA will

be little more than an electronic wharehouse

– Complete JHH Campus roll out, currently limited by IT resources

– Roll out to Private Rooms

– Roll out to the rest of HNELHD

– Facility Representatives (Clinical and Administrative) – and change

champions!

Thank you!