CASE STUDY - Cross referencing of patients between specialities

(This case study is on the complexity of operational process in patient care, and is based on
challenges in managing cross referencing of patients between specialities.)

Situational background
A large and busy multi-speciality hospital is organized in various clinical departments and each
department has divided its OPD days, emergency duties and surgery days (if applicable)
between their team of consultants. As per its policy each admitted patients should be visited by
the consultant in-charge at-least once in a day. Sometimes a patient admitted under a consultant
may require a cross reference from a consultant of another speciality. In this situation, the
process is that the consultant in-charge writes the orders for a cross reference from required
speciality in patient’s record. The duty doctor then fills up a cross-reference form with
necessary clinical details of the patient and send it to the HOD of respective department. The
HOD then allocates it to one of their consultant, who should attend the patient and provide his
opinion by documenting it in the patient’s record.

However, frequently there are problems that is being encountered by doctors, nurses and even
patients which are as described below.

Problems faced

1. Often time the cross reference gets delayed in attending. There could be multiple probable
reasons for this. The consultant referred might already be busy with his/her patients which is
naturally a priority for him/her (a portion of remuneration of the consultants gets determined
by number of patients they admit and treat, and there is no compensation attached to attending
a cross-reference patient). Secondly, mostly when the consultant plans out his schedule for
entire day, he/she may not anticipate or allocate his/her time for attending cross-reference
patients. As per some assumptions these delays are leading to increased stay of patient by an
average of a day, resulting in patient dissatisfaction. The delay is even more pronounced if
reference is sought from over-burdened departments such as Medicine and Surgery, which
often is the case.

2. The delay in attending cross reference patients affects badly when the condition of patient
is serious or reference is required on an urgent basis. As a working arrangement, most
referring consultant had started to talk directly to their peer in relevant speciality, explaining
them the seriousness/urgency so that delay can be avoided. However, since this depends upon
the intent and activeness of the referring and referred doctor, sometimes grave consequences
as high as death of the patients has been faced by the hospital

3. On a tacit note, most consultants perceive attending cross-reference an avoidable additional

workload and there has been instances of negligence in some cases. Many times trainee or
junior doctor from the speciality has been sent to attend the cross-reference, which at times
may be beyond their capability. Sometimes, to save time, consultant having their OPD have
asked the ward staff to send the referred patient to their OPD, causing much inconvenience to
patient and staff. Several times, the consultant has just asked for patient’s record to be sent to
his cabin and the reference advice has been given based on records and without even meeting
the patients.
4. Documentation has been another problem as frequently, the referred doctor write scanty
notes on patient’s records or would just pass on the advice to duty doctor without even writing
anything. This has led to confusion for consultant in-charge and in several instance repeat
cross-reference has been asked.

Measures attempted to address problems

This issue has been a regular agenda in the clinician’s meeting. All clinician agree that they
face problems in managing their patients because of this issue. However, they equally give
compelling reasons for why they can’t help avoiding delays. High workload and prioritizing
patients has been cited as most common reasons for delay.
The clinical committee tried some measures to overcome this problem but no significant
success has been achieved. The measures includes, adding a section in reference form to
indicate if it is an urgent/semi-urgent/non-urgent reference, putting a time-frame for references
to be attended, and asking duty doctor to follow up in case reference has not been attended on
time.

Complexity in dealing with the problem

Dealing with the above situation may not be simple. There are several managerial issues
involved in it. On first reading it might appear as an operational problem but when you think
deeper you will realize HR, Economics, OB related issues also intertwined in it. It is also
important to note that any changes in cross referencing system may cast its effect on other
operations of the hospital. For example, if you strictly implement time-bound attending of
references, it may lead to increase in low quality referral advices. Or, if you decide to attach
compensation to attending references you run a risk of increasing number of unnecessary cross
references.

Approach to resolve this problem

The case situation described above should be comprehended by taking all its ramification into
consideration and come up with a balanced and feasible approach to improve it, which should
have a minimal negative effect on other systems. Some specific thing must be considered while
approaching its resolution are,

 Understanding the level of its seriousness. Consider what and how much effect it has
on patient safety, organization’s performance and patient satisfaction. What will happen
if the issue is left un-resolved.
 Relating motivational theories that can help in understanding Consultant’s behaviour
in this case
 Identifying underlying causes to the problems listed above and classifying them in
suitable clusters such as HR, operations, policies, group behaviour etc.
 Thinking about what additional information would be required to understanding the
problem and its causes better.
 The situation may have one or more solution. It is imperative to assess how each
solution are going to address the underlying causes. Also, it must be assessed what
effect the solutions might have on other systems of the hospital.