Urban practice NE has approximately 14,000 patients, five partners and four sites spread across its ‘patch’. The patch is centred on a traditional market town that is becoming a commuter town but still has areas of high deprivation. The original two site practice took on a smaller practice about five years ago – due to contract issues, these two sites are effectively separate from the main practice.
One of the issues facing the partners at the practice, indeed any practice, is the amount of extra information they have to absorb in addition to the workload from their consultations during the day. This (mainly) comes in the form of paper, and this extra absorption comes at the point in the day when they have time – more often than not – at the end of the day when the capacity for making decisions is often overwhelmed with the second guessing that occurs at the end of any work day that consists of making what could be crucial decisions. Hence the basket and email box gets left for tomorrow because tomorrow has to be better, right? Only it doesn’t and that basket starts to overflow…. Email programs can automatically label and filter so some of that focusing can be done automatically but unfortunately paper doesn’t have that function and never will.
This frustration came to a head within urban practice in the autumn of last year with all the partners feeling submerged under paperwork, they discussed the situation and out of this discussion they asked me in to help with the problem. I was already working within the practice as the bookkeeper for the practice, have a background as a nurse / midwife (although long out of clinical practice) and an academic background in information management (one of my areas of interest just happened to have been information overload). My husband also happens to be one of the longstanding partners in the practice. And then he had to have a shoulder operation so we decided to trial the filter process while he was ‘on the sick’.
Within urban practice there were already staff allocated to scanning letters into the system, staff who had the job of data entry, and a pharmacist has been employed to help with med reviews, med requests and so on and obviously admin staff. After discussion, we decided that seven things could happen initially to letters:
1. Ones that had to go to a GP
2. Ones that needed to go to a nurse (the smaller site is auditing all A & E consultations to see whether the A & E /OOH visit is necessary)
3. Ones that simply needed the meds reviewing or discharge meds adding
4. Letters that needed some sort of action by admin staff
5. Work that could be handled by secretaries
6. Letters that simply had some data to be entered eg. Diagnoses, blood pressures, lab results etc.
7. Letters that could just be scanned.
We ended up with the following stamp
For auditing purposes we had a date stamp made to highlight the fact it had been filtered and had a small space for initials. (I now know why Dr’s signatures are usually a scrawl…).
We also had a red DNA stamp made so we could highlight this on letters that came from trusts etc.
We started. First hitch was using the wrong highlighter colour – anything other than yellow we found obscured the very data we were seeking to extract when scanned. This was quickly rectified and yellow highlighters acquired, oh and lots of paperclips.
The basic process from the beginning has been the same (with a few tweaks) a letter arrives into the practice (by post, fax or hand) and it is put into a post basket. Once the post has arrived and has been date stamped, I collect it, stamp, date it and then read it. Highlighting key phrases / sentences paragraphs.
Rule of thumb:
1. Goes to a GP first– complex diagnosis, review required, test results (unless it is negative and consultant has dealt with it), safeguarding issues, frail elderly and dementia cases. Any mental health & CAMHS letters (unless simply copies of appointment / waiting list letters). After discussion and prompting by myself, it was decided to get two more stamps – a ‘GP Action required’ and ‘GP information Only’ to help the decision process about how urgently something must be dealt with. Also – here is the flexible thing and tricky area – things that the reader thinks the GP will want to know – maybe someone being admitted from A & E or an out of hours issue that may need them to follow up.
2. Goes to a Nurse first – this is complicated. Essentially any letter that requests food supplements prescribing needs to go through the nurses for them to authorise. In one surgery A & E / OOH consultations go to them, the main surgery doesn’t have that project running.
3. Goes to MED Check first – when medication has been changed by a consultant but letter doesn’t need reviewing by a GP. Or if a patient has a long list of medication or is on complex hospital prescribed medication – it is then sent for review to ensure that everything is correct and correct information is on the system to ensure that system triggers are deployed when clashing medication is prescribed.
4. Goes to Admin Action first – ‘dodgy addresses / probably not our patient’, letters from screening services asking for confirmation of population data, if there is a simple request for bloods / results / screening from a hospital. DNA letters from everything apart from MH, CAHMS and child development got to admin (unless they have clearly got another appointment booked already). Complaints are sent in a sealed envelope to the practice manager. All A& E / OOH that require a child safeguarding trigger form are sent to Admin to have that done before being passed to the Child safeguarding lead in the practice.
5. Goes to Secretary first – requests for patient notes from ins cos / solicitors. Requests from opticians for referral to local eye services where there is no other medical condition being queried and the request is straightforward e.g. ‘this patient is elderly and has a cataract and it needs removal, please refer.’ Some podiatry referrals (but never had one of these).
6. Goes to Data Entry first – if there’s nothing else but a BP / test result ‘your mammogram was clear’ – ‘your pt was referred to the colposcopy clinic because of a borderline smear’.
7. Goes to Scan only – anything that doesn’t need action / sight by a clinician or contain any useful information that could be added to the patient record. DNA’s that have an appointment, letters that basically say, patient came – await investigation results.
Obviously it can happen that several boxes are ticked to indicate a downward cascade, all letters are signed off to indicate relevant person has seen them, they are actioned, sent further on or put in the scanning basket.
Once all post has been filtered then the separate groups are collated, counted and put into relevant folders to go to their respective destinations.
Results have been impressive – overall there is near enough a 60% reduction in the amount of post going to each individual GP and all of the partners have expressed relief at this.
Several issues though are worth considering.
1) Paperwork / letters will always be a part of GP practice. It will always take someone’s time to filter them – even setting up email filters takes a human to do it. I roughly allocate two hours / per day to complete the task – takes more on heavy days.
2)Needs practice staff with confidence / knowledge / time to do this. I notice there is a slight uptick of the amount of paperwork going to GPs once my mentor GP stopped (ie went back to work) because I want to be sure that the letter wouldn’t be missed.
3)Folibles of individual GPs – the principal GP at smaller site would ‘rather know what’s going on’ than not so proportion of letters he sees doesn’t necessarily equate to what he *should* be seeing.
4) System at present depends on me being present every day to do this as I am the only one that is trained to do this, at present.
5) Possibly more letters could be sent to Nurses at main site – asthma, diabetic reviews etc but their work schedule (at present) does not have the admin time built into it.
6) System creates a time lag in letters being available to Gps but not by much (usually overnight if that) – is this noticeable in practice?
7) Systems always have cracks in it – human nature – one letter with information was missed because it didn’t go through this screening process.
8) Quite frankly some of the information that comes back from secondary or community care needs to be looked at. Is it worth sending a two sided letter which is basically a repeat of the referral letter with ‘await investigations ‘ as the only input from secondary care on? Why oh why don’t secondary / primary care systems not talk to each other – the amount of computerised assessment forms being printed out and mailed …
Filtering seems to work, but as always a project like this will need continual tweaking so suggestions are always welcome. The important part though is that filtering helps the clinician to focus – they know what they have in their baskets need to be looked at and acted upon principally by them. It is up to each practice to decide if the practitioner time gained from being able to focus in this way is worth the cost in the time it will take a member of staff to do the system.
Comments are welcome.