A team from the Sydney Children’s Hospitals Network (SCHN) is working to improve the delivery of virtual care through streamlining administrative processes.
SCHN is responsible for providing tertiary and quaternary (highly specialised) care across NSW and the ACT. This care is delivered at the Sydney Children’s Hospital Randwick (SCH) and the Children’s Hospital at Westmead (CHW). In 2022, the NSW population aged 0-15 years was 1,589,052; this is projected to grow by 12% by 2041, reaching 1,775519. Considering the increased demand caused by this growing population, SCHN has integrated virtual care across multiple paediatric care models.
Virtual care usage peaked during the COVID-19 pandemic; however the rate of virtual care usage has decreased since social distancing measures eased. A team from the Integrated Care Department at SCHN conducted department-level virtual care roadshows to identify common barriers to its adoption. The barriers identified included:
- Consumer and staff expectations of consistent access to and delivery of virtual care follow-up appointments were not being met.
- Clinicians lacked enough information to accurately document unscheduled virtual care appointments. They were only documenting clinical information, while omitting necessary activity documentation.
- Some inpatient departments shared administrative responsibilities with outpatient departments. In these arrangements, staff from both departments were unclear about their responsibilities due to a lack of assigned accountability. Where responsibilities were assumed, staff did not receive the necessary information to book and manage virtual care follow-up appointments.
- There was a lack of clarity about process ownership and accountability, resulting in delays for clinicians, patients and their families. This led to frustration, missed or delayed clinical care and reduced use of virtual care.
Streamlining virtual care processes
The General Medicine Department at CHW was selected as the ideal department to investigate these barriers and find solutions that could be scaled across SCHN. In the General Medicine Department, virtual care was first introduced during the pandemic, but it was implemented without comprehensive consideration of the required infrastructure, time and resources. Consequently, processes became fragmented, and the use of virtual care fell below the key performance indicator set for SCHN by the Ministry of Health.
This project aimed to improve the virtual care administration and documentation processes in the General Medicine Department at CHW, so staff and consumers can seamlessly access, connect to and receive virtual care.
During the diagnostic phase, the project team undertook secondary data analysis, process mapping, value stream mapping, a time and motion study, process capability analysis and stability analysis. They also conducted staff and consumer surveys and focus groups. Nine different activities with more than 90 stakeholders participated in diagnostic activities. The project team found that:
- current processes were inadequate in meeting the expectations of consumers and staff
- clinicians were unable to bill Medicare for most virtual occasions of service
- eligible unscheduled virtual care occasions of service could not be counted for Activity Based Funding (ABF) purposes due to the lack of proper documentation.
Providing seamless access
Over 40 stakeholders participated in developing solutions. In addition to active participants, all staff members in the General Medicine and Outpatients departments were involved in secondary consultation and feedback processes. Through these activities, the project team presented three high-level solutions to the steering committee, of which the following three were endorsed for implementation.
Provide seamless access to the virtual care waiting room:
- Auto-populate a letter from the scheduler with appointment details, a virtual appointment link, referral end-date and alert if the referral has expired (if it is a billable clinic).
- Send an SMS to consumers the day after booking an appointment with appointment details, a virtual appointment link, referral end-date and alert if the referral has expired (if it is a billable clinic). A second SMS will be sent to consumers 5 days before an appointment as a reminder, along with a link to join the virtual waiting room.
- Provide a page on the SCHN website with information and resources for consumers to prepare for virtual care, as well as a department-specific web page with a link to join the virtual care waiting room.
Increase virtual care activity documentation for unscheduled occasions of service:
- This solution will ensure consistency of labels across ad hoc forms in the electronic medical record; reword reference text to be clinician-friendly; implement new business rules to document unscheduled activity; and provide training for all staff to document activity.
Develop standard operating procedures for future workflow to assign accountability and process ownership:
- Train staff in implementing procedures and refine governance to monitor performance.
The project has an evaluation plan with 17 process measures being monitored, contributing to 3 objective measures:
- Staff report that administration activities are streamlined and efficient.
- Consumers are booked and receive appointment and virtual care details within one day.
- Improved rates of documenting unscheduled virtual care activity.
The evaluation will continue over the next twelve months to monitor progress and inform continuous quality improvements.
