Barriers and Facilitators to Cross-Institutional Referrals: System Configuration Analysis of VA Staff Experiences.

Background: In 2014 and 2018, respectively, Congress passed the Veterans Access, Choice, and Accountability Act (Choice Act) and the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded eligibility for and use of cross-institutional referrals among U.S. Veterans enrolled in the Veterans Health Administration.

Objective: To identify facilitators and barriers to patient information sharing for cross-institutional, outpatient referrals resulting from policy changes.

Design: Applying the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework, we conducted work system and configural analyses of semi-structured interviews.

Participants: Clinical and administrative staff in six Department of Veterans Affairs (VA) facility community care liaison program offices.

Approach: Interviews focused on barriers and facilitators to sharing patients' information across healthcare institutions. Transcripts were summarized by domain and coded to consensus, followed by directed content analysis and visualization using configural diagrams.

Key Results: From 19 interviews, we characterized a nine-step, ad hoc referral process. Barriers were reported in four of nine referral steps: scheduling, coordination, sending of pre-visit clinical records, and receipt of post-visit records. Low adoption of new technology, strained relationships with CCN clinicians, and inconsistent policies were commonly reported barriers. Largely, perceived barriers were classified as technology, people, or organization factors. The COVID-19 pandemic and a transition between third-party administrators were reported as notable environment factors.

Conclusions: VA staff perceived increases in patient care delays and staff workload associated with social and technical barriers to sharing patients' information across healthcare institutions. In the cross-institutional referral process, we identified the primary configuration or combination of work system factors-technology, people, and organization- related to prevalent barriers. System-level interventions are needed to enhance relationships with clinicians across healthcare institutions, implement policies that guide patient information exchange, and design supportive technologies for efficient clinician communication during cross-institutional referrals.