DDHA 8006 Week 3 Bounded Problem Statement Example

Placed but Not Completed: A Bounded Problem Statement on Unclosed Specialty Referrals in a Nine-Practice Primary Care Group

Student Name

Walden University

DDHA 8006: Doctor of Healthcare Administration Foundational Concepts

Instructor Name

Month Day, Year

Placed but Not Completed: A Bounded Problem Statement on Unclosed Specialty Referrals in a Nine-Practice Primary Care Group

The Problem

At Tallgrass Medical Group, a composite primary care organization of nine practices used for this course, primary care clinicians place about 2,600 specialty referrals a month, an illustrative figure. A preliminary review of one quarter found that roughly 40 percent of referrals had no documented completed specialist visit within ninety days of being placed, and a further share had a visit but no report returned to the referring clinician. The organization has no routine way to know which referrals are unclosed, who is responsible for closing them or which patients are at risk because of them. This is the practice problem: specialty referrals placed by Tallgrass clinicians are not reliably completed and closed, and the organization cannot see which ones are open.

Boundaries

A problem statement is as much about what it excludes as what it includes. This one is bounded in five ways.

The most important boundary is the exclusion of clinical appropriateness. Some unclosed referrals may have been unnecessary, and some patients may sensibly decide not to attend. Whether a referral should have been made is a valid question, but it belongs to a clinical literature and to physicians' judgment. This statement treats every referral as an intention the organization made on the patient's behalf and asks whether the organization carried it through.

Table 1

What the Problem Includes and Excludes

Each boundary narrows the problem to what Tallgrass administrators can observe and influence.

The Gap

The literature describes referral breakdowns well. Mehrotra et al. (2011) followed referrals from the question a primary care clinician asks to the letter that comes back and found weak links throughout. A study in a large integrated health system found that a substantial share of referrals were never completed and examined patient, clinic and specialty factors associated with completion (Patel et al., 2018). And studies of electronic referral systems have reported improved communication and access in public and integrated systems (Kim-Hwang et al., 2010; Chen et al., 2013).

The gap concerns settings like Tallgrass: independent or loosely affiliated primary care groups whose patients are referred to many specialist practices they do not own, on different record systems. Most published work comes from integrated systems or single institutions whose primary care and specialty clinicians use the same chart and report to the same leaders. Less is known about which stages fail, and why, when the referral crosses organizational lines, and about what an administrator in such a group can do about it.

Significance

The problem matters for three reasons. For patients, an unclosed referral can delay diagnosis or treatment; for some referrals, such as suspected cancer or new heart failure, delay may carry real risk. For the organization, unclosed referrals represent unfinished care for which Tallgrass's clinicians remain accountable, including under value-based contracts that measure follow-up and outcomes. And for the field, a clearer account of referral failure across organizational lines would help the many groups that operate in fragmented markets. The growth in referrals over the past two decades (Barnett et al., 2012) means the problem is not shrinking on its own.

How the Problem Will Be Evidenced

The preliminary figure of 40 percent rests on one quarter's records and on scanned specialist reports that may be filed inconsistently. Before the problem is studied further, it must be measured more carefully. The first task will be to draw a random sample of 300 referrals from the last twelve months and trace each one through scheduling, attendance and report return, using the record, calls to specialist offices and, where needed, calls to patients. That sample will show whether the preliminary figure was too high, too low or about right, and at which stage the losses concentrate. A problem statement that rests on uncertain numbers should say so and plan to correct them, rather than hiding the uncertainty in confident prose.

Questions Kept Outside the Edges

Several questions are deliberately left outside this statement. Whether specialists' capacity is sufficient in the region is a market question beyond one group's control. Whether patients' insurance limits their choice of specialist matters, but it is a payer question. And whether an electronic referral platform would solve the problem is a solution question that should follow, not precede, an understanding of where referrals fail. Naming these keeps the inquiry focused and protects it from becoming a study of everything that affects specialty care. Each excluded question may return later as context, for example if specialist capacity turns out to explain most scheduling failures, but none will be the object of study.

Questions the Problem Raises

Within its boundaries, the problem raises three questions for later work. At which stage do Tallgrass referrals most often fail: scheduling, attendance or return of information? Which referral, patient and specialty characteristics are associated with failure at each stage? And which of those stages can administrators at Tallgrass change, alone or with the specialist practices that receive most referrals?

Conclusion

Tallgrass clinicians place specialty referrals that the organization does not reliably carry to completion or closure, and it cannot see which are open. The problem is bounded to outpatient referrals to specialists, from order to report back, for adult patients, and excludes questions of clinical appropriateness, specialist capacity and payer rules. The gap lies in fragmented settings where referrals cross organizational lines, and that is where this inquiry will look.

References

Barnett, M. L., Song, Z., & Landon, B. E. (2012). Trends in physician referrals in the United States, 1999-2009. Archives of Internal Medicine, 172(2), 163-170. https://doi.org/10.1001/archinternmed.2011.722

Chen, A. H., Murphy, E. J., & Yee, H. F. (2013). eReferral: A new model for integrated care. New England Journal of Medicine, 368(26), 2450-2453. https://doi.org/10.1056/NEJMp1215594

Kim-Hwang, J. E., Chen, A. H., Bell, D. S., Guzman, D., Yee, H. F., & Kushel, M. B. (2010). Evaluating electronic referrals for specialty care at a public hospital. Journal of General Internal Medicine, 25(10), 1123-1128. https://doi.org/10.1007/s11606-010-1402-1

Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: Specialty referrals in the United States. The Milbank Quarterly, 89(1), 39-68. https://doi.org/10.1111/j.1468-0009.2011.00619.x

Patel, M. P., Schettini, P., O'Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the referral loop: An analysis of primary care referrals to specialists in a large health system. Journal of General Internal Medicine, 33(5), 715-721. https://doi.org/10.1007/s11606-018-4392-z