Service Agreement Template

The purpose of the service agreement document is to define guidelines for the patient’s care to be “packaged” the right way by the sender and for the receiver to complete the agreed upon work in a timely manner. The overall goal of the service agreement is to decrease referral delays from primary care to specialty care or any two parties, from one to another.

The following components help achieve the purpose of the service agreement document and are to be included when writing or revising a service agreement.

1. Title Include facility name and all departments involved in the title.

2. Rationale Briefly describe the specific problems that prompted this service agreement. You may consider including waiting time data, clinic backlog, and other pertinent issues. It is helpful to include baseline service agreement measures such as referral volume, reasons, and sources. A flow map of the referral process is a helpful tool to include as an attachment.

3. Communication Methods Define the method for communications about patients between primary care and specialty care providers on an ongoing basis. This includes the process for immediate communications such as consultative phone calls and pages and the expected response times.

4. Pre-Work & Referral Information Describe the information both the sender and receiver agree to include with each consult for the service agreement topic. List specifically all information the primary care provider agrees to provide. Include an item to indicate that the patient has been notified and agreed to be seen in the other clinic/service. You may wish to create a structured consult in CPRS as a tool to communicate this information. Include collaboration with midlevel providers in the process, as appropriate.

5. Timeliness of Consult Completion List established timeliness standards for consult completions that are agreed upon by the group. Include definitions of urgency, consistent with VA policy.

6. Consultant (Specialty Clinic) Services Define the services to be provided by the consultant, such as what will be included or excluded as appropriate. List specifically services the specialty provider agrees to provide. 7. Communication of Recommendations Describe the method for communicating recommendations and the care plan from the specialty clinic to the referring provider.

8. Discharge from Specialty Clinic Define the criteria for discharge from the specialty clinic and any related issues. Include the specialty clinic’s review process for discharge.

9. Co-Managed Patients Define the criteria for co-managed care, care by the specialist and primary care Provider, when a non-VA provider is involved.

10. Signatures Attach signatures of the service chiefs from all involved services and the Chief of Staff.

11. Posting of Service Agreements Identify where the document is posted on a web site for access to all users. Include the method for distributing the final service agreement to all providers and clinic staff.

12. Review & Renewal Dates Define service agreement review and renewal dates and the process, including responsibilities. An annual or more frequent review is recommended.

13. Service Agreement Monitoring Describe how and when the service agreement will be evaluated and monitored and by whom, including identification of data sources, timeframes from consult reporting mechanisms, and process for action plans as needed.

The following elements are recommended for quarterly audits:

a) Number of referrals sent appropriate to agreement (Numerator) Total number of referrals (Denominator) Sender Responsibility

b) Number of times correct information is sent (Numerator) Total number of referrals (Denominator) Sender responsibility

c) Number of times referrals are seen in agreed upon timeframe (Numerator) Total number of referrals (Denominator) Receiver responsibility