NU813 Unit 9 Seminar Reflection Example

Placed Is Not Seen: A Seminar Reflection on Declining a Classmate's Fix for Lagging Podiatry Referrals, Adopting Booking Before the Patient Leaves and Reserved Weekly Slots, and the Sliding-Fee Question No Schedule Can Answer

[Student Name]

Purdue University Global

NU813: DNP Project Implementation

Unit 9 Seminar Reflection

[Instructor Name]

[Date]

The seminar, classmates, health center and podiatry practice are composite; classmates appear by role only, and counts and dates are bracketed.

The Seminar and the Problem I Brought

Each of us brought one live implementation problem and had fifteen minutes of the group's attention. I brought referral follow-up. In my project, medical assistants at two health center clinics now check feet while rooming patients with diabetes, and that part is going well: at the midpoint, protocol coverage at the main clinic was [82] percent and exams were complete [91] percent of the time. The part that is not working comes after the exam. Of the [14] high-risk patients whose referrals had reached the [30]-day mark, only [8] had been seen by the partner podiatry practice. My evaluation plan set the target at [80] percent. Finding a foot at risk and then leaving the patient without specialist care is close to not finding it at all, and I said so when I presented.

What Was Offered

Three suggestions came from the group. A classmate who manages a primary care quality program suggested changing the measure: count a referral as closed when it is placed, which is how her health system reports referral completion to its payer. A classmate working in an emergency department suggested that the referral coordinator book the podiatry appointment while the patient is still in the building, rather than placing the referral and calling later. And a classmate whose project runs in a rural clinic suggested asking the podiatry practice to reserve a fixed number of slots each week for our referrals, so that booking would not depend on whatever happened to be open.

What I Declined, and Why

I declined the first suggestion, and it deserves the longest explanation because it was offered in good faith and it would have made my numbers look better overnight. Under that definition my referral completion would have been [100] percent, since every high-risk patient without a podiatrist had a referral placed.

I had two reasons for declining. The first is that the measure was fixed in my evaluation plan before implementation began, and changing it at the midpoint because the result is disappointing is exactly the kind of change that makes a project's results hard to trust. Implementation research distinguishes outcomes that describe delivery from those that describe whether the intended service actually reached people (Proctor et al., 2011), and a placed referral describes only the first. Reporting guidance for improvement work also expects any change to a measure to be described and explained, which is hard to do honestly when the change is made because the old result disappointed (Ogrinc et al., 2016). The second reason is about the patients. The six who had not been seen are the reason the referral component exists. Counting them as complete would remove them from every report the clinic manager reads, at the moment they most need someone to notice them.

A definition that makes six unseen patients disappear from the report is not a better measure; it is a quieter one.

I said this in the seminar, perhaps more firmly than I meant to, and the classmate replied that payers often accept the placed definition. That is true, and I will report the placed figure alongside the seen figure in the final summary, labeled, so a reader can compare them. What I will not do is replace one with the other.

What I Adopted

The suggestion to book before the patient leaves addressed what my referral log already showed: of the [6] patients not seen, [4] had never been reached by phone after the referral was placed. Two numbers on file were disconnected, and two patients did not answer calls from an unfamiliar number. Starting [Monday of week 11], the referral coordinator walks to the exam room or meets the patient at checkout whenever a provider marks a patient high risk, and books the podiatry visit with the patient present. The coordinator owns this step, and the clinic manager has agreed to cover her desk for the ten minutes it takes.

The suggestion to reserve slots needed a conversation with the podiatry practice, which I had with its owner on [date]. Her answer was yes: every Thursday, [two] first-visit appointments now stay open for our patients, and any still empty on Tuesday go back to her own schedule. Carroll and colleagues describe facilitation strategies as supports that help an intervention be delivered as designed (Carroll et al., 2007), and both changes are facilitation of that kind: neither changes the exam or the referral criteria, only the path from one to the other.

What Remains Open

One question came up at the end of the seminar that no change in booking can answer. Of the [6] patients not seen, [2] are uninsured, and the podiatry practice does not use the health center's sliding fee scale. Both patients were quoted a self-pay price for the first visit, and neither booked. The referral agreement I helped write covers how referrals are sent and how results come back; it says nothing about cost. Whether the practice will accept a reduced fee for health center patients, whether the health center can subsidize visits from its enabling services budget, or whether the county hospital's podiatry clinic, with its longer wait, should be the route for uninsured patients, is a decision for the medical director and the practice, not for me. I have written it up as an open item for the handoff list, with the medical director as owner, and I will report the two patients' outcome either way.

References

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7