774 - Project REFER (Reinforcing Engagement on Follow-ups for External Referrals)

Publication Number: 1750.774

Katherine R. French, University of Texas Southwestern Medical School, Dallas, TX, United States; Abhishek Makkar, University of Texas Southwestern Medical School, Dallas, Texas, United States, TX, United States; Carlos Sepulveda, Children's Health, Dallas, TX, United States; Pamela Ramirez, CHILDREN'S HEALTH DALLAS, Grand Prairie, TX, United States; Arun Prasath, University of Texas Southwestern Medical School, Dallas, TX, United States; Tavleen Sandhu, University of Texas Southwestern Medical School, Dallas, TX, United States; Elyse Clark, Children's Health, Dallas, TX, United States; Sushmita Yallapragada, University of Texas Southwestern Medical School, Dallas, TX, United States; Tetyana H. Nesterenko, University of Texas Southwestern, Dallas, TX, United States

Background: Closed-loop communication is vital for ensuring safe and effective patient handoffs. Standardized handoff protocols and structured feedback mechanisms improve collaboration across neonatal care teams. Enhancing post-transfer communication with referring providers may improve outreach effectiveness and strengthen community partnerships.

Objective: Project REFER aims to improve community provider satisfaction and strengthen partnerships with regional referral sites in alignment with the institutional goal to expand out-of-network NICU referrals to Children's Health Dallas by 10% annually over five years. The specific aim is to increase the callback rate between Children's Health Dallas neonatologists and out-of-University of Texas Southwestern (UTSW)-network referring providers from 52% to >90% by June 2027.

Design/Methods: This quality improvement project was conducted in the Level IV NICU at Children's Health Dallas. Eligible facilities for a callback included all out-of-UTSW-network transfers, excluding emergency departments and primary care offices. A multidisciplinary team performed a cause-and-effect analysis to identify barriers to follow-up calls (Fig 1). Key drivers to address the barriers included process standardization, provider education, and promotion of a culture of closed-loop communication (Fig 2). The primary outcome was the percentage of callbacks completed among eligible transfers. The process measure was the proportion of callbacks completed within 24 hours. Balancing measures included referral volume and Children's Health Dallas provider satisfaction. Interventions tested through sequential Plan-Do-Study-Act (PDSA) cycles included (1) implementation of a standard operating procedure and Epic documentation template and (2) use of automated reminders and a "Star Rewards" system to reinforce compliance. Statistical process control charts tracked outcomes biweekly.

Results: Baseline callback completion from November 2024 to April 2025 was 52%. After two PDSA cycles, the rate increased to 89.5% by September 2025 (Fig 3). The out-of-UTSW-network referral rate remained stable with a slight upward trend over the last three months.

Conclusion(s): Project REFER improved follow-up communication between Children's Health Dallas NICU providers and out-of-network referring physicians, promoting continuity of care and strengthening regional partnerships. Although the long-term goal has not yet been achieved, improvement is evident. The next PDSA cycle will incorporate Maintenance of Certification (MOC) credit incentives, and ongoing provider satisfaction surveys will guide continued process refinement.

Fishbone Diagram
The fishbone diagram demonstrates potential hindering factors to the problem of inconsistent closed loop communication with external referring providers.

Key Driver Diagram
The key driver diagram demonstrates the primary driver, secondary drivers, and change ideas identified for Project REFER. The change idea highlighted in yellow (obtaining MOC IV credits for physician participation) represents an intervention that will be implemented in a future PDSA cycle for the project.

Results
Statistical process control chart (p-chart) tracking the primary outcome over time on a biweekly interval from November 1st, 2024, to September 30th, 2025. The x-axis displays the biweekly time blocks formatted as the first half of the month (example: Nov 1'24) and the second half of the month (example: Nov 2 '24). The y-axis displays the primary outcome measure of percentage of callbacks performed out of the total number of eligible patient transfers. The central line (CL) 52% represents the baseline callback rate prior to the start of Project REFER with favorable upward shift to 89.5% following 2 PDSA cycles.