Evaluating the efficacy in a nurse-led referral triage program in decreasing urology clinic wait-times:

Background: Veterans still face long VA appointment wait times despite policies like the Mission Act of 2018, which supports nurse-led Referral Coordination Initiative (RCI) Teams to improve access.
Purpose: For almost two decades, veterans have had difficulty accessing healthcare in the Veterans Administration (VA) due to prolonged appointment wait times. Despite numerous policy initiatives, veterans' healthcare access problems persist. This quality improvement project evaluated the impact of a nurse-led Referral Coordination Team on appointment wait times and on the timeliness of scheduling in a VA Urology Department.
Methods: This quality improvement initiative employed a pre- and post-interventional design guided by the Plan-Do-Check-Act framework at a Northern California VA Urology Department. Interventions: The intervention involved establishing a nurse-led Referral Coordination Team, hiring and training nurses to triage outpatient urology consultations, coordinating scheduling with appropriate providers, and overseeing the consultation workflow from receipt to appointment completion. This workflow redesign enabled urologists to focus more on direct patient care rather than administrative coordination.
Data Analysis: We collected monthly data over a 6-month period (3 months pre-intervention and 3 months post-intervention) on all outpatient urology referrals (N = 1,408). Outcomes were compared to national benchmarks of 28 days for appointment wait times and 3 days for scheduling timeliness. Statistical analyses included independent samples t-tests, Cohen's d effect size calculations, and statistical process control charts, using data from the VA's Power BI Performance Dashboard.
Intervention: The intervention established a nurse-led Referral Coordination Team trained to handle all incoming urology consultations. RCI nurses conducted chart reviews, triaged referrals by urgency, ensured that diagnostic testing was completed before appointments, educated Veterans about care options, and coordinated scheduling across 31 specialty clinics. This workflow redesigned urologists' time by removing administrative tasks related to consultation management, allowing them to focus on direct patient care.
Results: A total of 1,408 consultations were analyzed (631 pre-intervention, 777 post-intervention). Appointment wait times decreased from 44 to 36 days, a significant reduction of about a week, confirmed by statistical process control charts and a large effect size (Cohen's d = 1.88). Scheduling timeliness, however, remained at 5.3 days with no significant change detected.
Conclusions: The nurse-led team effectively reduced appointment wait times by approximately one week, although the 28-day national benchmark was not achieved. Scheduling timeliness did not improve because it is outside the nurses' scope of practice, making it a poor performance measure for this team. The short study duration (three months per phase) and the absence of patient satisfaction data were notable limitations.
Recommendations: Expand nurse-led coordination teams to other VA specialties, given the demonstrated improvements in wait times. Remove scheduling timeliness as a performance metric for RCI nurses since it is outside their scope of responsibility. Future research should involve extended data collection periods and include patient-centered outcomes along with timeliness measurements.