Table 1 Deficiencies identified at the primary-specialty care interface
Intervention Context Identified deficiency in Health services delivery •Impact of deficiency •Intervention types and objectives | |||
D.1. Deficiencies based in clinical decision making – Referral error | |||
Deficiency | Sub-types and root cause | Impact of deficiency | Intervention types and Objectives (see Table 1B) |
Referral errors as a natural consequence of diagnosis as a probabilistic process. | 1. Unnecessary and inappropriate referrals (False positives) - Referral is unnecessary or inappropriate. | Poor patient experience, delay in receipt of diagnosis/care, compromised patient outcome. Impeded patient flows at the primary-specialty care interface and decreased efficiency of the health system. Potential impacts include: access delays, increased short term costs, increased long term costs as a result of a higher proportion of patients with severe conditions | Preventive interventions to reduce the occurrence of Type I errors, Type II errors, triaging errors and communication delays Screening interventions – to detect Type I errors, Type II errors, triaging errors and communication delays that have occurred. |
2. Delayed referrals (False negatives) - Referral is warranted, but not made. | |||
3. Triaging Errors - Improper prioritization of patients based on urgency. | |||
4. Communication delays - Referrals are delayed due to missing information and/or diagnostics. | |||
D.2. Deficiencies based in information management- Technologies | |||
Deficiency | Root cause | Impact of deficiency | Intervention types and Objectives (see Table 1B) |
Delays due to outdated communication systems | Referrals and subsequent correspondence, forwarding of diagnostics, etc. via standard mail or fax. | Poor patient experience, delay in receipt of diagnosis/care, compromised patient outcome. | Electronic referral systems (e-referrals) and electronic medical records (EMRs) to expedite information sharing |
D.3. Deficiencies based in system level management of patient flows between primary and secondary care – Supply and demand management | |||
Deficiency | Root cause | Impact of deficiency | Intervention types and Objectives (see Table 1B) |
Delays due to care pathway structure and management | 1. Care pathway management Inefficient care pathway structure and resource use hinders patient flows. | Poor patient experience, delay in receipt of diagnosis/care, compromised patient outcome. Impeded patient flows at the primary-specialty care interface and decreased efficiency of the health system. Potential impacts include: access delays, increased short term costs, increased long term costs as a result of a higher proportion of patients with severe conditions | Care pathway management - streamlining |
Delays due to human resource management | 2. Role management (Inter-professional workload imbalance) Creation of bottlenecks within the care pathway as a result of insufficient specialty care providers (Short term and sustained). | Human resource management - Scope of practice restructuring at primary-specialty care interface to increase supply of services | |
Delays due to queue/referral management | 3. Queue/Referral management Intra-professional workload imbalance Disproportionate allocation of referrals amongst specialists producing an imbalance in specialist utilizations. | Queue/referral management - Centralized intake of referrals to improve access to specialty care. | |
D.4. Deficiencies based in quality/performance monitoring | |||
Deficiency | Root cause | Impact of deficiency | Intervention types and Objectives (see Table 1B) |
Inability for performance improvement due to Insufficient data capture | Lack of a measurement framework to adequately track system performance | Decreased efficacy of operational decision making | Continuous quality improvement frameworks |