Rapid analysis methods [20,22] were applied to interview data to synthesize and provide prompt, actionable feedback to the cross-specialty team and capture iterations of the intervention. Two coauthors (SRH and HW) used a priori codes in a matrix analysis [26] in Excel (Microsoft Corp). Early results were presented to the cross-specialty team during a biweekly meeting to validate findings and in small group sessions to generate feedback.

Data from observational notes and document review were used to triangulate findings reported in the preimplementation interviews. Observational notes and interview transcripts were revisited as needed to validate or query findings. For the design thinking focus group, data were analyzed into three broad categories: what worked, what did not work, and ideas for future sessions.

This project received a nonresearch determination by Stanford University’s institutional review board (IRB #68792). Interview participants gave verbal consent before each recorded interview. Participants were told their privacy and confidentiality would be maintained. Interview participants were not compensated. As this is a report on the early phases of a QI project focused on cross-specialty collaboration, we did not involve patients or the public in the research design, conduct, reporting, or dissemination. However, we sought to include diverse health care employees to understand workflow perspectives. Participants did not receive any form of compensation for participation. The data supporting this study’s findings are available on reasonable request.

This cross-specialty collaboration with enhanced evaluation support identified core activities and milestones for intervention development and implementation. Major process components of our proposed Framework to Increase Cross-Specialty Collaboration (Figure 1) include (1) cross-specialty team meetings, (2) preimplementation interviews, (3) design thinking focus group session, and (4) small group meetings.

Engaging in these process components fostered collaboration and teamwork among the multidisciplinary team, supported early identification of barriers and facilitators, including divergent understanding of project goals and identification of creative ideas that contributed to intervention development.

The process resulted in a multimodal intervention that was informed by qualitative data (as described in Table 2), that addressed diverse needs and perspectives, and aimed to enhance quality through greater attention toward timeliness and appropriateness of ED-to-Neurology referrals. The intervention included two modifications to clinical practice and two structural changes. Element 1, enhancing clinical practices through procedures or treatments, optimized clinical management of conditions in the ED to reduce ED-to-Neurology referrals. For example, increasing the ED’s capacity to perform occipital nerve blocks to eliminate the need for referral. Element 2 embedded a referral considerations document within the electronic medical record, guiding physicians toward primary care or neurology follow-up when appropriate. Element 3 addressed timeliness by streamlining insurance authorization by having financial counselors call patients who could not be seen by Neurology. Element 4 addressed access by adding three Neurology appointment slots per week by the headache specialist and a potential weekend or night clinic.

The team met bimonthly from November 2022 to May 2023 (10 meetings; range 1‐2 h; Figure 1). Team members (5‐15 per meeting) included clinical, scheduling, QI, operations, and ESU. Members of the cross-specialty team attributed meeting success to having regular cadence, a primary ED leader, team-specific action items, and attendance by at least one physician from both ED and Neurology.

The initial meetings were attended by operations, schedulers, and physicians from Neurology and ED. The administrative director for quality and operations for the service line provided oversight and served as liaison between the cross-specialty team and operations. Initial aims included identifying all applicable contributors and establishing a specific, measurable goal for the collaboration. In these meetings, ED discussed prior experience with Orthopedics.

The ESU used the cross-specialty team meetings in the middle and late stages of the collaboration to provide rapid feedback [20] informed by the preimplementation interviews, design thinking focus group, and small group meetings (Process Components 2‐4). Two of the most prominent factors of the RIF reports from February to March 2023 were (1) hypothetical barriers to implementation, that is, limited neurology appointments; and (2) tensions between departments caused by divergent understanding of project goals. To address concerns regarding limited neurology appointments, the project team decided to focus only on the two most common reasons for referral—headaches and dizziness. The team also invited a Primary Care representative to these meetings, recognizing Primary Care’s role in the intervention. From March to May 2023, cross-specialty team meetings (Table 2) focused on developing and launching the intervention to enhance Primary Care usage.

The ESU met with individual or small groups, usually Neurology, ad hoc to explore emerging work thought to be peripherally related to the primary objective of the cross-specialty team meetings (Figure 1). These small group meetings were used to document intervention development progress in detail and then prioritize what to discuss in the larger implementation meetings. Small group meetings were essential for capturing the two structural changes: (1) streamlined insurance authorization processes and (2) increasing Neurology appointment availability (Table 2).

Given rising demand for ED services [28], coupled with a scarcity of specialty care availability [5], the urgency for effective and prompt ED-to-specialty referrals has never been more pronounced. To address this need, we outlined the process used by a cross-specialty collaboration at a single institution and a subsequent multimodal intervention aimed at enhancing quality through appropriateness and timeliness of ED-to-Neurology referrals. The intervention included two elements focused on modifying clinical practice: (1) optimizing management of the most common conditions like headache and dizziness in the ED to reduce preventable referrals, and (2) enhancing the use of Primary Care services to direct specialty follow-up care as needed. Two additional structural elements sought to directly improve referral timeliness by (3) streamlining insurance authorization processes and (4) increasing Neurology appointment availability.

The cross-specialty initiative was enabled through an iterative collaboration process that included regular cross-specialty team meetings, preimplementation interviews, a design thinking focus group session, and small group meetings. Each component provided key insights that shaped the development of the intervention elements and helped build rapport between specialties. Our experience informed the proposed Framework to Increase Cross-Specialty Collaboration for future QI endeavors requiring interdepartmental partnership for future collaboration between ED and specialties.

Our intervention shares commonalities with other successful initiatives aimed at improving transitions from the ED to ambulatory Neurology for follow-up, while also incorporating its own innovative but broadly applicable elements. For example, the emphasis on streamlining referrals and insurance authorization resembles process improvements made in clinics like UCLA Fast Neuro Clinic [29] and Florida Access Clinic [30]. However, our intervention’s focus on optimizing ED management and leveraging Primary Care expertise before referring to Neurology represents a more nuanced approach to ensuring appropriate referrals.

While some access initiatives have focused narrowly on increasing the number of Neurology clinicians or clinic availability [29-31], our intervention considered clinical appropriateness to promote more judicious referrals, as well as supporting ED clinicians to work at the top of their license. This balancing of timeliness and appropriateness through clinical practice and structural changes is a unique contribution based on currently available literature. There were concerns raised by the Neurology team about educating the entire ED on new workflows, but these activities are relatively straightforward for the ED, given existing processes for QI and education at faculty and resident monthly meetings. It was during these monthly meetings that inclusion and exclusion criteria to Neurology referrals versus Primary Care were identified.

The proposed Framework to Increase Cross-Specialty Collaboration fostered integration of diverse insights from ED, Neurology, operations, and Primary Care. Rather than moving forward with an intervention based on team assumptions about referral issues and prior experiences, we gathered input directly from participants through techniques such as preimplementation interviews and design thinking. The Framework allowed the team to identify and address four key hurdles to intervention design: (1) “us versus them” mentality; (2) divergent understanding of project goals (appropriateness vs timeliness); (3) narrowing scope to top Neurology referrals (ie, headache and dizziness); and (4) considering longitudinal health services, like Primary Care, for the patient when appropriate.

Existing evidence on the impact of design thinking in health care demonstrates that it improves intervention usability, acceptability, and outcomes compared to traditional expert-driven methods [15]. Indeed, design thinking is increasingly recognized as a promising human-centered approach for complex problem-solving in health care, moving away from authoritarian dynamics toward cocreative environments [15]. It emphasizes empathy, equitable engagement, and continuous refinement based on end user input [32].

Our use of design thinking in the proposed framework helped elicit openness to nontraditional interventions for improving access. By gathering perspectives on lived experiences of physicians and patients, the intervention resolved underlying problems, instead of creating just symptomatic fixes. This human-centered foundation was key in developing a contextualized, multimodal intervention acceptable to both specialties and aligned with end user needs. Collaborative approaches informed by design-thinking principles have also been shown to result in effective and usable intervention elsewhere [15].

This project has three major limitations related to generalizability, effectiveness, and representation. First, this work represents a single academic institution, which allowed us to leverage existing infrastructure but limited generalizability. Furthermore, the ensuing intervention focused on only the two most common reasons for Neurology referrals, headache and dizziness. Second, the implementation, effectiveness, and sustainability of the intervention remain untested. Third, although we included a range of perspectives, we lack frontline nursing and patient perspectives.

Overall, our process showcases the promise of partnership and design thinking to tailor localized improvements in complex systems like ED to specialty care transitions.

Interventions to optimize ED to specialty service transitions are vital given the increasing demand for ED services and growing shortage of specialty care availability. Our four-component framework enabled trust, rapport, and early identification of barriers and facilitators to implementation while increasing cross-specialty collaboration and was comprised of: (1) cross-specialty team meetings; (2) preimplementation (“premortem”) interviews; (3) a design thinking focus group; and (4) small group meetings. Development of future access interventions can further refine the Framework to Increase Cross-Specialty Collaboration and look to leverage key elements of our intervention: modifications to clinical practice (eg, including occipital block in ED clinician treatment repertoire) and structural changes (eg, streamlining insurance authorization processes).

Ultimately, this collaboration resulted in a multimodal intervention that called for both structural and practice changes, which were novel and supported by the results of comparable interventions. Future applications of this framework can validate its utility among different collaborative groups in new settings.