We have created categories in the Library. Each doctor has a ‘referral peer pending’ category. Other categories are ‘referrals agreed’, ‘advice & guidance’ and ‘ referrals rejected’.
We submit the C&B appointment request in the usual way but we do not print out the paperwork. We inform patients that each referral is discussed among the partnership to comply with commissioning requirements and to ensure that referral is the best option for that patient. The secretary types and saves the referral letter in EMIS. She also saves the letter to a temporary folder and uploads it to the relevant category in Library. The secretary adds a due date of seven days to each uploaded Library document.
The doctors read the letters in the Library ‘referral peer pending’ categories and add their comments to each document. Comments may include ‘clinical pathway followed’ which is useful for commissioning audit. If the referral is approved (we have chosen a quorum of two doctors sanctioning the referral to allow it to progress) the document is workflowed back to the secretary with the relevant instructions e.g. ‘upload to C&B’ or ‘convert to A&G’ or ‘referral rejected’ etc. We may also add instructions in the workflow comments box such as ‘upload to C&B and attach MRI scan’ etc.
The secretary then completes the C&B process by uploading the letter. She contacts the patient with instructions to collect the relevant paperwork to book the appointment. The secretary then re-categorises the Library document from ‘peer review’ to ‘referrals agreed’. If it is decided by peer review to convert a referral to Advice & Guidance the secretary re-categorises the letter appropriately in Library. In these circumstances the secretary amends the referral letter in EMIS from ‘C&B Referral’ to ‘C&B Advice & Guidance’. She cancels the C&B appointment submission (it is impossible for the patient to have booked the appointment at this stage in the process), changes it to Advice & Guidance and attaches the letter electronically. This allows the consultant who receives the Advice & Guidance request to see the full clinical details rather than a few words typed in the Advice & Guidance box that we used previously.
Library provides a number nof advantages and safety nets that would be very difficult to achieve without an electroic system:
- there is no loose paperwork in the surgery, documents cannot be ‘lost’ in Library, only re-categorised
- all activity is electronic and audit trailed
- referrals from doctors who are subsequently absent from the practice can be easily viewed and actioned via the Library
- referrals can be peer reviewed at the doctors’ convenience
- referrals that require group discussion in our weekly face-to-face meeting can be reflected upon by the doctors prior to the meeting
- referrals that sit in the ‘peer review’ category beyond one week are automatically flagged up by Library software as ‘overdue’. No referrals can be overlooked or misplaced. This is particularly useful for advice & guidance as at present there is no simple mechanism for flagging up patients who are awaiting replies from the hospital consultant
- The final workflow to the secretary contains all the comments and instructions and provides an excellent audit trail.