Category: Healthcare Call Centers

Healthcare call centers articles by Peter Lyle DeHaan, PhD

An Eye For Customer Service

Post author By Peter Lyle DeHaan
Post date February 1, 2004

By Peter Lyle DeHaan, Ph.D.

It was an emergency run to the eye doctor. Being far-sighted and using a computer all day makes my glasses an indispensable tool – one that I treat with the utmost care. Imagine my dismay when in the midst of my morning cleaning routine, I heard the frame snap and a lens landed in my hand. I was panic-stricken. How would I be able to get any work done?

I arrived at my optometrist’s office, practically as the doors opened, glad that they would take a “walk-in.” I explained the situation and although they treated my disaster with matter-of-fact routine, I was comforted that they were willing to help. “We’ll need to order new frames,” the man concluded.

“Can’t you simply fix them?” I inquired.

“We could,” he droned, “but there is no guarantee…it might hold a day, maybe a few months. Don’t worry,” he added, “we’ll get you some loaner frames to use while you wait for your new ones.” Trusting his advice, I assented.

He disappeared into a back room and returned several minutes later. The look on his face braced me for bad news. “Your frames have been discontinued. We’ll have to fix your old ones…they can be soldered.” Now I have done my share of soldering over the years: in electronics to make an electrical connection and in plumbing to seal a joint. I was highly skeptical that solder would repair my damaged frames for more than a few minutes. I began to voice my apprehension. He smiled assuredly and clarified. “Actually, it’s more like welding.” Now I knew he was off base. During a stint working at a machine shop, I did more types of welding than most people know exist. I did not see any of those methods successfully repairing my delicate wire-rims. But I was out of options and reluctantly consented. He quickly outlined the details: the broken frames would need to be sent out for repair…they’ll be back in a few days, maybe by Saturday…it would cost twenty dollars.

He then set about finding a loaner frame. After half an hour with no success, he finally uncovered one old demo pair that, although not the right dimensions, would at least hold my lenses in place and keep them approximately positioned in front of my eyes – the temple pieces were much too short, which tipped the lenses forward, throwing off the bifocals. I would need to adapt. Grateful for a solution, albeit uncomfortable and less than ideal, I reminded myself that it was only for a few days and gratefully thanked him. His parting promise was clear; “We’ll call you when your frames come back – let’s hope for Saturday.”

As I left, I confirmed the plan at the front desk, “Yes,” she affirmed, “We’ll call you when they come in.” I believed her.

Saturday came but without a call. Monday they were closed. I called them on Tuesday. I got an answering machine. Dismayed that they did not answer their phone in the middle of the day, I left a message imploring them to call. No one called. Wednesday I called again. “Sure, they’re here,” she said cheerfully. “You can stop in any time,” she added, as though getting my frames back and returning my life to normal was a trivial and incidental matter.

By now, the tops of my ears were inflamed and the bridge of my nose tender because of the ill-fitting frames. “I’ll be there in twenty minutes,” was my firm and somewhat terse reply.

The man greeted me soon after I arrived. “It will only take a few minutes to switch lenses,” he said with a smile. I reminded him that the screws holding my lenses in my frames have a tendency to loosen and fall out. “Don’t worry,” he assured, “I’ll put in special screws with ‘lock-tight’ on them.”

“No,” I responded firmly, “you’ve done that before and they fall out too. Last time you said that you ‘glued them’.” I was dismayed that this critical information was not in my file, as he had re-installed my lenses four times in the past three years. He said nothing, but gave me a slight look of comprehension, retreating into his work area. A few minutes later, he returned and I donned my restored glasses; what a great feeling, it was just like slipping into a comfortable pair of old shoes!

I thanked him and segued to my next goal. “Will you please put my old lenses in another frame – any frame,” I inquired, “so that I can have a back-up pair?”

“Your frames have been discontinued,” he said, telling me what I already knew.

“Surely someone makes a frame that will fit my lenses,” I prodded.

“I already looked, remember?” Now he was becoming irritated with me. “You’ll need to order new frames and get new lenses, and before we’ll do that, you’ll need an eye exam.”

“That will be almost five hundred dollars,” I said in dismay, recalling the cost of my initial introduction to glasses. “I can only afford to buy a second frame,” I embellished.

“You really should have an eye exam every year,” he lectured. “And it’s been fourteen months for you.”

“I just want to buy a back-up frame,” I pleaded.

His reply was curt, “Sorry, we can’t help you.” He turned and walked away.

Later, I casually mentioned my ordeal – and desire for a back up pair of glasses – to my mother. Mom took this on as a personal challenge and the next day surprised me with a list of businesses willing to assist. Two days later, I visited the top one on her list. Their office was closer, easier to get to, and had free parking at the door. I walked in, explained my plight to the receptionist, and shared my goal. I waited a few minutes and was greeted by a kind and empathetic young lady. She listened to my tale of woe, acknowledging that it, too, would have been their preference for an exam, new frames, and new lenses. Nevertheless, she said she would do her best to help me. She began to look for suitable frames and I realized her intent was to handle my request immediately. She came back with a frame that she thought would work with some adjustments or by grinding my lenses. I had not expected an immediate resolution and since there were several other customers waiting at the time, I told her that I would be more than happy to come back later. She thanked me and promised to work on my glasses first thing the next day; I could stop by any time. I believed her.

I returned the next afternoon. She recognized me and immediately approached me, smiling broadly. “I have your glasses done,” she beamed with the pride of an artist. “I am really pleased with how they turned out.” Because of her genuine sincerity, I knew that I would be pleased as well. She had not had to grind my lenses down after all. I was only charged for the frames, there was no labor fee, and I got a free case and a discount, too. I thanked her profusely. She said that she was glad she was able to help me.

On my prior visit, I had noticed a sign that gave their repair rates. To solder frames was only five dollars. My old optometrist had charged four times as much! I realized that five dollars would not even cover shipping, so I reasoned that repairs were done in-house; I suspected I would not have to wait eight days either. I had already decided that they would be my new optometrist, but took one more step to confirm my decision. “By the way,” I inquired, “how much is an eye exam?” It was fifty dollars less than what I had been paying! I promised her that I would be back.

By giving poor customer service, my eye doctor had lost a loyal patient; by going the extra mile, someone else had gained one.

How to Lose Patients, Clients, or Callers:

Act apathetic toward their situation
Make promises you don’t keep
Don’t listen to them
Lose credibility by making recommendations that are self-serving
Fail to keep good records of previous interactions
Give them a reason to check out your competition

How to Gain Patients, Clients, or Callers:

Be genuinely sympathetic, even if it is a routine matter for you
Only make promises you can keep
Take time to really listen to what they say
Gain credibility by going the extra mile
Make sure their interaction with you is pleasant and memorable
Give them a reason to never return to their old provider

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

Peter Lyle DeHaan, PhD, is the publisher and editor-in-chief of AnswerStat and Medical Call Center News covering the healthcare call center industry. Read his latest book, Sticky Customer Service.

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Healthcare Call Centers

Voice Logging Overview

By Peter Lyle DeHaan, Ph.D.

Voice logging is an important and valuable call center technology, considered by many to be an indispensable support tool. Voice logging allows calls to be recorded for quality assurance, training, self-evaluations, verification purposes, and dispute resolution.

Because of the terrorist attacks in the United States on September 11, 2001 there has been a surge of interest in voice logging. Although voice logging cannot be viewed as a detriment to terrorism, it is deemed as an essential part of everyone’s overall goal of increased security and safety.

Peter DeHaan, Publisher and Editor of AnswerStat

Some centers record calls at random, many record all calls, and some continuously record all headset audio – both during and between calls. Past forms of voice logging equipment have ranged from reel-to-reel tape machines, to specialized audiocassette recorders, to modified VCR units, to today’s state-of-the-art computer-based implementations.

How Loggers Work: Voice loggers can be either external stand-alone systems or internal integrated software. Many of today’s CTI-enabled switches and call-processing platforms have voice logging as a built-in option, inherent in the system’s design and architecture. This provides for optimal performance and often allows the call record or captured data – be it a patient call, a telephone triage session, or a doctor’s instruction – to be directly linked to the voice file. This allows for a holistic review of all components of a particular call, as both the audio interaction and the information gathered can be easily accessed and reviewed congruently and simultaneously.

For other situations, stand-alone voice loggers can be interfaced to the switch or call-processing platform, tapping into audio paths at the agent headset, the switch destination port, or the source port. These later two configurations provide the ability to record voice mail calls as well. The advisability and desirability of doing so, however, is questionable and should be pursued only after careful thought and consideration of the ramifications and legal consequences.

Often vendors of stand-alone systems have designed universal interface adapters that allow audio to be easily tapped into at the handset or headset connection without affecting or degrading the audio level. For these external systems, a typical method includes tapping into the headset audio at the agent station and feeding it into the PC’s sound card.

For both internal and external voice loggers, the speech is digitized and often stored on the agent station hard drive, usually as wave files. At some point (either immediately or at a preset time or condition), the wave files are sent over the network to a central voice logging server where they are indexed and stored.

Indexes are commonly applied to all header field data, such as time, date, station number, agent login, source port, destination port, call completion code, and project ID. If needed, queries can be established to fine-tune the search even further. Searching by agent or time are the most common parameters. However, in the course of troubleshooting system problems, searching by specific ports, completion codes, or station numbers can be most informative.

The retrieval interface is a database, such as Access or SQL. As such, records of calls can be quickly sorted, filtered, and presented. Wave file access is then fast and efficient. If needed, archiving of voice files can be accomplished easily and quickly to CD-ROM or DVD.

Uses of Voice Logging: As mentioned, there are several possible reasons to record calls. These include quality assurance, training, self-evaluations, verification, and dispute resolution. Any one of these options often justifies the expense of implementing voice logger technology. The other features then become pleasant bonuses.

Quality assurance is the most often cited use of voice logging. With voice logging, supervisors and managers can easily and quickly retrieve, review, and evaluate agent calls. By integrating a program of silent monitoring, with side-by-side coaching and statistical measurements, an agent’s overall effectiveness can be evaluated and verified. Voice logging allows areas of deficiency to be discovered and items of excellence to be celebrated.
Training can be greatly facilitated using voice logging. One application is to capture examples of exemplary calls by seasoned representatives for trainees to review and emulate. Conversely, less than ideal calls can also be showcased for discussion and critique. Although both of these scenarios could be accomplished using fictitious examples or staged calls, there is great benefit in being able to demonstrate real-world examples.
Self-evaluation is a powerful tool of introspection whereby agents use voice loggers to retrieve their own calls and through a process of self-discovery learn how they can handle calls or situations more effectively. Although this is valuable during the training phase, it is also beneficial for seasoned representatives, as it allows them to keep their skills sharp and helps sloppy actions from becoming bad habits. Even more importantly, agents may specifically seek and review a specific call that had a less than ideal result so that a more desirable outcome can be determined and implemented.
Verification is another worthwhile use of voice logging, especially in an environment where critical information is shared and communicated, such as in telephone triage. By recording all conversations, the symptoms and nurse’s instruction to the patient is captured and verified that proper information was conveyed. Normally, the recording is never listened to unless there is an argument about the transaction.
Dispute resolution then comes into play. Whether it is a message, a medical emergency, or an accusation of improper phone behavior, the voice recording of that call essentially becomes an independent third party account of what happened and avoids the “he-said/she-said” disputes in which neither party can corroborate their own account of what happened. Though the agent is sometimes found to be in error in such situations, the consensus is that in the vast majority of cases the agent is vindicated; once the aggrieved party hears the recording, the problem resolves itself quickly and with little further effort.

User Input: It is rare to find a voice logger user who is not overwhelmingly positive about the benefits and value of the technology and what it means to their call center. “I wish I had a logger years ago,” is a sentiment commonly made within weeks of a new voice logger installation.

Others see how voice logging allows call centers to improver customer service. Interestingly, call center staff often initially view the recording of calls as a negative development, threatening the work they do and attacking their competency. It is only after voice logging technology is implemented that the agents begin to see it as a tool to protect their work and validate their quality. The reality is that only representatives with something to hide have a legitimate reason to fear voice logging.

Accounts abound from call centers that have increased the quality of their service, improved their training, and avoided a potentially costly lawsuit or a lost patient all because of voice logging. Although it may seem difficult to cost-justify a voice logger before it is bought, a high percentage of users indicate that it is one of the most important pieces of technology in their call center.

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

Tags Peter Lyle DeHaan's Vital Signs, software and equipment, technology

Healthcare Call Centers

It’s all Virtual: A Virtual Publishing Company

Post author By Peter Lyle DeHaan
Post date November 1, 2003

By Peter Lyle DeHaan, Ph.D.

When I started publishing AnswerStat’s sister magazine, Connections Magazine, it operated as a virtual company. This wasn’t intentional. It just worked out that way and continues to be the case. Not only am I the only one working in the “corporate office,” there are no local suppliers either. Indeed everyone who takes part in the production of this magazine is from out of state – different states!

Dave, our graphics designer and creative genius, is in Pennsylvania. Articles and ads get mailed or emailed to him and his staff. His work gets sent via the Internet to our printer in Ohio. They work up the proofs and put them on an FTP site for Dave and me to approve. For each issue, I output the mailing list to a file and email it to our list processor. They massage the data, sort the list, and forward it to our printer. The printer inkjets the addresses on the magazines and delivers them to the post office, which happens to be next door to them.

Another important team member is Valerie Port, our New York-based media representative. She handles the advertising sales that generate the revenue to produce this magazine. As editor, I plan, solicit, collect, and edit the articles and press releases. A team of proofwriters in North Dakota review each article, performing the final edits, correcting grammar, checking punctuation, and ensuring that each piece is clear and understandable. Finally, our website (AnswerStat.com) is hosted by a company in Arizona but I update content remotely from Michigan.

I have never met any of these people in person, except for Valerie who, after a year and a half, I recently had the privilege of meeting. We maintain contact via the telephone and make frequent use of email. Each issue is produced without any face-to-face interaction. At first this was somewhat disarming and disconcerting, but I am convinced that the results are better than if we all worked together in the same office. True, we miss out on some synergy, incidental communication, and camaraderie, but we are also each free to do what he or she does best and to do so with minimal outside distraction and interruption. For us, it is all virtual.

A Virtual Call Center: A call center (or contact center, if you prefer) is by definition, a centralized operation. Although the concept of a decentralized call center initially seems oxymoronic, technology has brought us to the place where virtual call centers are not only feasible, but also exist with increasing frequency. Although most decentralized call centers have a mix of local and remote agents, a few have gone completely virtual and have no agents in their call center. Indeed, their “office” may merely house a switch and network servers. But before someone takes issue with this statement, let me assert that these functions can be outsourced, completely fulfilling the vision of a virtual call center, one with no office, no location, no real estate, and no equipment.

The completely virtual call center, however, may be too futuristic for many to seriously consider. Nonetheless, aspects of a virtual call center are concepts that every manager who desires job security should be contemplating and investigating.

Distributed Agents: The first and foremost consideration for a virtual call center is a distributed staff, be it home-based agents, a satellite office, or outsourcing. Because of advances in computer and telephony technology, coupled with the ubiquitous Internet, all of these options are readily available.

As the name implies, a home-based agent is one who works from his or her own home. There are many reasons to consider home-based agents.

Expand your labor pool: Many capable and qualified workers are not part of the workforce because by choice or circumstance they do not leave home. Why let positions go unfilled or under-filled, when quality, albeit nontraditional, staff is readily available?
Expand your labor market: Home-based agents are viable wherever the Internet is. Therefore you can hire and employ call center staff in other cities and states. Plus you will never lose an employee to relocation again!
Respond to overcrowding: What happens when there is an agent station squeezed into every inch of your call center and every station is in use during peak times? How can you grow and expand without moving or remodeling? Quite simply, begin hiring home-based staff. A remote agent does not take up any space in your office, allowing you to process more calls without incurring a capital expense.
Eliminate commuting: In areas where commute times are long or the infrastructure congested, using home-based representatives is an ideal response. In some areas there are even mandates and incentives for organizations to take steps to minimize commuter traffic.
Facilitate split-shifts: Call center traffic demands never correspond to eight-hour work shifts. Unless you are prepared to be overstaffed part of the day and understaffed much of the rest, an eight-hour shift is a rare commodity in a call center. This means shorter shifts and even split-shifts to optimize labor to traffic. Unfortunately there is often resistance to split-shifts. However, when the employee is home-based, many of the objections (commute time and dress code) evaporate. In fact, some employees would enjoy split-shifts if they could do so from the comfort of their home.

A satellite office is a great option to tap into a labor market in another area while maintaining on-site supervision and control. In this case, a mini-call center is set-up, but it runs off of the switch and network at the main location. Although real estate and supervision is duplicated, hardware and software is not. This is also an option when the physical space in a call center is maxed out.

Outsourcing: A parallel consideration is call outsourcing. This can be manifested in four ways: all calls, overflow traffic, certain call types, or by time-of-day/day-of-week. Some of the types of calls that can be outsourced include telephone triage, medical answering service, physician referral, class registrations, and PBX/console calls.

Conventional wisdom says that you don’t outsource your “core competencies.” However, there are those who advocate that you can farm out your core competencies, too. What if someone else can do it better or cheaper? What if your labor market has low unemployment or if you’re just plain tired of the staffing ramifications of running a call center? All of these are prime reasons to consider outsourcing your calls. Since no one can master everything, it is pragmatic and wise to consider outsourcing the less strong areas or unmet demand.

Certainly, no outsourcing agreement should be entered into lightly or without due diligence. You should scrutinize an outsourcing partner just as you would any other vendor. “Look before you leap.” Referrals are valuable; check references. Unless they come highly recommended, visit them in person. What does their facility look like? Are they big enough to handle your traffic? Are they small enough to care about your account and your calls? Do you have a good rapport with and respect for the key people in their company? Is there the potential for a long-term business relationship? Lastly, find out who will be your primary contact on a day-to-day basis. How well do you mesh with that individual? What is their anticipated future tenure with the call center? If this contact leaves, will your satisfaction with the outsourcer’s service disappear as well, or will someone else be able to take over without negatively affecting your organization?

Conclusion: All of this is discussion is not to advocate that everyone needs to go virtual or to outsource, but there are some intriguing opportunities worth considering as you plan and consider how to make your call center better. Lastly, be aware that every outsource consideration is a dual opportunity. For some it is an option to off-load work (or costs) to another call center, while for others it is an occasion to pick up work (and hence revenue) from other sources. When properly structured, both perspectives can be beneficial.

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

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Healthcare Call Centers

Telephone Triage for the Medical Call Center

Post author By Peter Lyle DeHaan
Post date November 1, 2003

By Peter Lyle DeHaan, Ph.D.

Of all the exciting advances in medicine, there is one that falls outside the traditional scope new drugs, innovative procedures, or revealing research. This development is in the application of telephone technology to facilitate the provision of healthcare. Lumped into the broad category called telemedicine or telehealth, the telephone is cost-effectively improving patient care while increasing patient satisfaction. The application of technology to cut costs and improve quality in any industry is noteworthy; in medicine, it is critical.

One of the most exciting developments in telemedicine is telephone or nurse triage. The history of telephone triage dates back three decades. For Dr. Barton Schmitt, arguably the father of telephone triage, it was born out of the practical necessity of ensuring consistency and accuracy among those who interacted over the phone with parents concerned about a child’s well-being. His initial telephone protocols have been refined, expanded, and validated for the past 30 years. More than 400 call centers are using computerized versions of his work and an estimated 10,000 pediatric offices refer to the printed version. Others have independently developed similar protocols.

Telephone triage will be a reoccurring theme in AnswerStat, as we believe it is an important development, not only for medical related call centers, but also for healthcare as a whole. Our goal in this issue is to introduce the subject and provide some initial resources. Look for more information and articles in upcoming issues.

Telephone Triage Call Centers: There are several call centers that provide telephone triage on an outsource basis, or for a fee, to hospitals, clients, individual practices, and medical answering services. View our current list.

Telephone Triage Vendors: Lastly, here is a list of vendors who have integrated telephone triage protocols into call center software.

Books on Telephone Triage: As a primer for learning more about telephone triage, you might want to refer to some of the many books available on the subject. Here is a list of some of them (let us know your favorites and we will add them to our list):

Pediatric Telephone Advice by Barton D. Schmitt (Spiral-bound)
Pediatric Telephone Protocols: Office Version by American Academy of Pediatrics, by Barton D. Schmitt
Quick Reference to Triage by Valerie G. A. Grossman, et al.
Telephone Health Assessment by Sandra M. Simonsen
Telephone Medicine: Triage and Training: A Handbook for Primary Care Health Professionals by Harvey R. Katz, Harvey P. Katz
Telephone Triage: Theory, Practice, and Protocol Development by Sheila Q. Wheeler, Judith Windt
Telephone Triage for Obstetrics and Gynecology by Vicki E. Long, Patricia C. McMullen
Telephone Triage of the Obstetric Patient by Deborah E. Swenson
Telephone Triage Protocols for Adult and School Age Populations with Women’s Health and Infant/Child Protocols by Sheila Wheeler, RN, MS
Tele-Nurse by Marijo Baird, Sandi Lafferty

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

Tags Peter Lyle DeHaan's Vital Signs, telephone triage

Healthcare Call Centers

Legal Considerations of Voice Logging

Post author By Peter Lyle DeHaan
Post date November 1, 2003

Compiled by Peter DeHaan, Ph.D.

Legal issues regarding the recording of phone calls must be considered before embarking on voice logging. This varies on a state-by-state basis. Some states and countries require “one-party notification” in which only one of the two individuals needs to be made aware that the call is being recorded. This, of course, is most easily done by notifying the call center agents and staff.

This notice should be included in the employee handbook they receive when hired. By signing off on the handbook, it has been documented that employees have been duly notified that the recording will take place.

Check with a local attorney familiar with state employment law, as it may be advisable to have a separate sheet signed by each employee, which explicitly notifies him or her that calls will be recorded. (At least thirty-seven US States, the District of Columbia, the US Federal law, Canada, and England only require one-party notification. Note that there is some disagreement over the determination of the requirements for a few states.)

The other scenario requires that both parties be made aware that the call is being recorded; these are called “two-party notification” states. (Depending on the source, ten to thirteen US states fit this category.) This can be accomplished by playing a preamble recording on every call or inserting a periodic beep tone.

The preamble recording is common, but may prove to be a technical challenge to accomplish in a call center where multiple types of calls are taken and for various departments or clients. There is also the concern of how to respond to clients who object to an automated announcement before every one of their calls. Typical verbiage for the announcement or preamble recording is, “Thank you for calling ABC Clinic, your call may be monitored for training or quality assurance purposes.”

Alternately, many voice logging systems provide an optional beep tone. There are specific parameters to which this beep must adhere. According to VLR Communications, the beep tone needs to be a 1260 to 1540 Hertz tone, lasting 170 to 250 milliseconds, and broadcast for both sides to hear every twelve to fifteen seconds when recording is taking place.

The interesting part of this requirement is that both parties must be able to “hear” the beep tone; there is no measurable audio level specified. Therefore, it makes sense to set the beep level at a low volume, while still being audible to both parties. Still, many people find this beep tone to be disconcerting and distracting. Although call center agents typically grow accustomed to the beep tone, eventually tuning it out, this is not the case with callers, who generally find the ongoing beeping to be an annoying vexation. Callers may even discuss the beep tone or voice recording with the agents, thereby lengthening call time and decreasing the quality of service.

Several websites contain information about notification; unfortunately, they are not in complete agreement. This is shown in the chart below. Regardless of this information, be sure to consult a local attorney before recording any telephone calls.

Also, there are privacy concerns and issues. In general, one should take every possible precaution to avoid recording personal phone calls. A practical way of doing so is to only record conversations in the call center (and explicitly not in the breakroom or on any common area telephone) and to have an enforced policy against placing or receiving personal phone calls while in the call center.

These steps will help to ensure that personal phone calls are not inadvertently recorded and that privacy rights are not encroached. Again, obtain legal counsel before recording any phone calls. Voice logging is best used for quality assurance, training, self-evaluation, verification, and dispute resolution.

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

Tags Peter Lyle DeHaan's Vital Signs, technology

Healthcare Call Centers

Dr. Barton Schmitt Interview

Post author By Peter Lyle DeHaan
Post date November 1, 2003

Telephone Triage Protocols

By Peter Lyle DeHaan, Ph.D.

One of the pioneers of telephone triage protocols is Dr.Barton Schmitt. His telephone triage clinical content for pediatrics is used by McKesson, LVM Systems, Epic, Intellicare, Fonemed, and United Health Care (Optum). Together that is over 400 call centers. The book form is used in an estimated 10,000 pediatric offices. With a 30 year history behind it, we recently asked him to share his story with readers. Here is what he had to say:

How has the triage protocols changed over the last 30 years?

They have become more complete and more comprehensive including lots of background information to help nurses learn this field. They have also become more experience-based (I know 10 times more now than I knew then), and more evidence-based, thanks to research on them and the ever-expanding medical literature.

How did you get started? Why did you write the Telephone Triage Protocols?

I’ve always enjoyed the challenge of taking parent phone calls and trying to make the correct diagnosis without seeing the patient. In 1973, while I was Medical Director of the Urgent Care Center (UCC) for children at the University

By 1975, the collection of triage protocols had grown to 100. Graduates of our program who were going into practice began to ask for them and I provided them in binders. Over the course of a few years, I’d given away over 200 of these binders. By 1978, I’d expanded the collection to over 180 topics and tried to find a publisher. I submitted to the leading medical publishers. The book received unanimous rejection letters. The main reason they gave was that “it was heresy to suggest that nurses could (or should) ever triage medical calls.”

In 1980, the book Pediatric Telephone Advice was finally published by Little, Brown & Co. in Boston, who was just breaking into the medical publishing business. Within a matter of years, it was also published in French, Portuguese, and Japanese. It has continued to be a good seller and is going into its third edition. This book has remained a self-study guide for nurses or physicians in training.

In 1990, I wrote a streamlined (telegraphic) version for use by the advanced practice telephone triage nurses who worked in our call center at The Children’s Hospital (TCH) in Denver. The new book was called Pediatric Telephone Protocols. In 1994, I self-published this book because of the demand for it by call centers at other hospitals. I updated it yearly. In 2000, the American Academy of Pediatrics (AAP) picked up the publishing and distribution rights. The 10^th edition will be released in early 2004. In 1994, I also started collaborating with NHES (National Health Enhancement Systems) to produce a software version of pediatric telephone triage. Because our call center was covering for over 120 pediatricians, we needed to improve efficiency. In 1999 I became software vendor neutral. In 2000, I collaborated with David Thompson, MD.

Why did you partner with David Thompson, MD, FACEP?

David and I share similar backgrounds, and therefore we find it very easy to work together. Working in the Emergency Department (ED), David is involved with direct patient triage on a daily basis. That’s required in a setting where you have 10 patients in different rooms and you need to prioritize exactly who you’re going to see next, who gets a procedure, who gets an x-ray, and who can safely wait. I worked in an emergency department for five years, and know how important it is to have razor-sharp decision-making. At the present time, David is on the American College of Emergency Physicians (ACEP) and Emergency Nurse Association (ENA) National Triage Task Force that’s attempting to standardize emergency department triage.

The advantage of us working together is that the adult triage protocols and the pediatric triage protocols share parallel layouts, dispositions, and logic. This makes it easy for the nurse in a full age range call center to move back and forth from pediatrics to women’s health to adult health to geriatric decision making. Nurses appreciate the seamless flow between protocols. Having two people responsible for keeping the protocols compatible is an attainable goal. We have developed over 100 rules that we follow closely to achieve and preserve clarity and consistency. David is my best critic. We spur each other on to producing a better triage product.

How important is feedback from others?

It’s the lifeblood of the fine-tuning process. I’ve been medical director of the Children’s Hospital After-Hours Call Center since its inception in 1988. It is the crucible in which I test my protocols. I have the privilege of working with 40 pediatric telephone nurses who have specialized in this field. Their critiques and feedback are invaluable.

In addition, I work with 30 ED physicians who see the patients our call center refers in, and they have no hesitation in questioning my triage guidelines or judgment if we over refer to them. If their concern makes sense, I make changes in the protocol. I also have over 400 primary care physicians (PCPs) throughout Colorado, half of whom have trained here, that give me feedback if they think we have over referred or under referred one of their patients. For any under referral, we always do a complete review of the complaint, including listening to the phone encounter which is automatically recorded on all calls.

I also receive unexpected communications from nurse managers, medical directors and triage nurses in various call centers throughout the country. I value these questions and critiques. I respond to them directly and make appropriate changes in the protocols when indicated. In summary, I welcome input from anyone who uses my clinical content.

What are some of the health care goals behind your triage protocols?

Prevent all under referrals of emergent or urgent conditions (safe care).
Minimize over referrals (unnecessary ED and office visits) (cost-effective care and family-focused convenient care).
Help triage nurses use the most appropriate protocol through optimal search words and cross-linkages.
Provide the caller with targeted, current health care information/education.
Educate callers about misconceptions that lead to frequent unnecessary calls (e.g. fever, phobia, green nasal discharge, or productive coughs).
Achieve more than 98% triage nurse satisfaction with clinical content.
Achieve more than 95% caller satisfaction with service provided.
Achieve more than 90% primary care physician concurrence with decision-making.
Continuously improve clinical content by incorporating user feedback, reviewer feedback, quality improvement outcomes, research outcomes, and the current medical literature.

How do the philosophies of the three versions differ?

All versions use the same criteria for recognizing 911 symptoms or conditions.
All versions have similar triage questions and care advice. This helps with consistency of care. Mainly, the dispositions within each set are different.
The After-Hours version is for evening, weekend, and holiday coverage by call centers or physicians. Approximately 20% of patients are referred in to the ED or UCC. Whenever it is safe to do so, patients are referred to the physicians’ office on the following day.
The Office-Hours version is for triage when the office is open. No one is sent to the ED without the PCP prior approval. Approximately 50% of callers are brought to the office. Anyone who wants to be seen is worked into the office schedule. The remaining callers are provided with specific home care and self-care advice. The software version of office-hours triage is an expanded version of the book the AAP distributes to office pediatricians. This has the advantage of having the parent hear the same advice from the call center and their PCP’s office.
The managed care version is for health insurance companies. If a caller needs to be seen and doesn’t need to go to an ED, they are re-directed to call their PCP for further triage. Those who can safely be treated at home are advised similarly to the other versions.

Tell us about HouseCalls Online.

HouseCalls Online are Internet-based self-care guidelines. There is both a pediatric and an adult version. They are available in English and Spanish. Over 20 hospitals currently have them on their website and most report frequent use and a lowered call volume; in essence, they are off-loading some of their low-acuity calls to the web. An exit survey to one website documented 100% of parents thought both the triage and advice they received were understandable and easy to use and 60% said it prevented a call to their doctor’s office. An added benefit is that the content is compatible with Schmitt/Thompson nurse triage guidelines. Some call centers have launched marketing campaigns to redirect unnecessary calls to this resource.

Tell us about the after-hours call center program at The Children’s Hospital (TCH).

It is in Denver, Colorado and was established 1988. It is a statewide system in Colorado and Wyoming.

Will you highlight the stats for the call center?

Volume: 10,300 calls per month (2002)
Total: 123,000 calls/year (2002)
Provided for 477 physicians
- Private physicians: 337 (324 pediatricians and 13 family physician)
  (includes 98% of metro Denver pediatricians)
- Kaiser Permanente physicians: 140 (50% pediatricians)
Provided by 40 Pediatric RNs (both full-time and part-time)
- 1 RN can cover 15 pediatricians
- 1 RN can take 6 calls per hour or 42 calls per shift
Disposition of TCH Nurse-Triaged Calls
- See patient after hours: 20% (admission rate 1:88 calls or 1.1%)
- See patient within 24 hours: 30% (usually in physician’s office)
- Telephone advice for home care only: 50%
- Excludes: advice-only calls 6%
  - Clinical Nurse Manager: Kris Light RN
  - Software Systems Coordinator: Teresa Hegarty RN
  - Medical Director: Barton Schmitt MD

Thank you for taking time to share with our readers.

Thank you

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

Tags Peter Lyle DeHaan's Vital Signs, telephone triage

Healthcare Call Centers

Welcome To AnswerStat Magazine!

Post author By Peter Lyle DeHaan
Post date September 1, 2003

By Peter Lyle DeHaan, Ph.D.

Let me be the first to welcome you to the premier issue of AnswerStat magazine. AnswerStat is dedicated to providing you, our readers with practical, relevant, and useful information about healthcare and medical related call centers.

We are an advertiser-supported publication, which allows us to send this magazine to you, free of charge. Here is some more information:

Who Receives AnswerStat?: AnswerStat is sent free to:

Hospital call centers and phone centers
Medical answering services
Other healthcare related call centers.

What You Do: Readers of AnswerStat are involved in:

Switchboard / PBX Console
Medical Answering Service
Nurse Triage
Physician Referral
Event Registration
Scheduling
Data Collection / Verification
Insurance
Other Medical Related Call Center Functions
Consultants

You Can Help: As I mentioned, AnswerStat is an advertiser-supported magazine. This means that advertising revenue pays to have the magazine designed, printed, and mailed to you. You do not need to pay for your subscription. The more advertisers we have, the more useful content we can provide to you. If your call center vendors are not advertising in AnswerStat, please encourage them to do so. We will all benefit as a result.

Free Subscription: Let your colleagues and associates know about AnswerStat. The on-line form is quick and easy to fill out, asking only for information directly related to your subscription. Because your time is valuable, we won’t make you to fill out pages of irrelevant information or ask you to justify why you should receive our magazine. That is just who we are, straightforward and no-nonsense.

Calling all Authors: AnswerStat is looking for articles from our readers, those who work every day in medical related call centers and have real-world experience and knowledge that they are willing to share. Regardless of your level of writing ability or skill, we can work with you to turn your article into a quality piece of which we will all be proud. To get started, download our article guidelines from our website. If you have an article already done, you may email it to me directly. We will take it from there.

Our Website: The AnswerStat website is designed to be a useful resource for you, our readers, whom we serve. Here are some of the resources available:

A glossary of call center terms.
Area code listings, sorted by area code and by state. We also list codes that are being changed, as well as those that could be changed in the future.
An on-line version of our Buyer’s Guide.
An article archive, including relevant articles from our sister publication, Connections Magazine.
A subscription form. It is free and takes less than a minute to fill out.

About the Publisher: I, have over 20 years of experience in the call center and teleservice industry. Most of that time was spent working in a call center in various technical and management capacities. I also spent three years in the vendor side of the industry in customer support, programming, and documentation.

For the last three years, I have been working as a consultant, focusing on the needs of call centers. Two years ago I became a magazine publisher with the purchase of Connections Magazine, which focuses on the needs of outsource call centers.

The combined experience of consulting for hospital and medical call centers and publishing a call center magazine has brought me to this point – launching a magazine specifically for medical related call centers.

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

Tags Peter Lyle DeHaan's Vital Signs

Healthcare Call Centers

Benchmarking Your Call Center

Post author By Peter Lyle DeHaan
Post date September 1, 2003

By Peter Lyle DeHaan, Ph.D.

What is benchmarking? At its simplest, benchmarking is objectively comparing your call center with others. Brad Cleveland of Incoming Calls Management Institute states that “Benchmarking is comparing products, services, and processes with those of other organizations, to identify new ideas and improvement opportunities.” Whereas Dr. Jon Anton of Purdue University defines benchmarking as “A structured, analytical approach to identify, deploy, and review best practices to gain and maintain competitive advantage.”

Benchmarking is a safe, anonymous, and effective way to obtain input from peers which can be used to compare and contrast your call center operation to others. This feedback provides a baseline for determining areas of deficiency, as well as success. Benchmarking produces quantifiable results, real numbers from real businesses, thereby offering real solutions. Also, once a benchmarking process has been implemented, it can be easily repeated and updated on a periodic basis. This provides a time line of successive snapshots of your business. In essence, benchmarking makes it possible to create a report card showing your successes, your shortcomings, your improvements, and your relapses – all with respect to your peers, but done so privately and confidentiality.

Therefore, call center benchmarking is the comparison of your operation with statistical results from the norm of industry peers. These numeric measurements are called metrics. Metrics can be in the form of financial data, sales numbers, operational quality and efficiency, human resource efficacy, or whatever is deemed to be the most valuable to the participants, though typically and primarily they are operational in nature.

Successful benchmarking follows a progressive path towards a desired outcome. First and foremost, there must be a desire to obtain and use the information. Next, you need to determine who will be invited to participate. It is essential for participants to have an interest in the results and a commitment to contribute. Beyond that, it is imperative that all participants have sufficiently similar businesses. In many cases, it is wise to select those using common equipment or software platforms, since operational metrics are hard to reliably compare when their sources employ dissimilar statistical paradigms.

The third step is to determine which numbers to measure. It is recommended to start small, obtaining only a few key numbers (as participants become engaged in the process and realize the value of it, then other metrics can be added). It will then be necessary to develop a standard determination of how the information will be gathered or the calculations will be made. For without a standard methodology, each participant will make the calculations as they see fit, rendering any results unreliable. These two steps can be both time-consuming and contentious. Assistance from someone with experience in benchmarking or a background in statistical analysis is most beneficial at this point. This outside assistance serves to greatly simplify the process and save valuable time. Also, if this person does not have a direct vested interest in the results, they are better able to objectively guide the process.

The fifth step is a critical one. It is to develop the survey form, which includes documenting the source or calculation of the data. Although this seems like a simple and straightforward process, it is one fraught with peril, as a less than ideal survey form will doom the process to misanalysis or failure. Again, someone with experience in benchmarking or developing survey forms will be most helpful. Then, regardless of the quality of the survey form – or its developer – it is of paramount importance to test it. What may seem perfectly clear to those who developed and reviewed the form, could cause confusion or misinterpretation to those completing it. Therefore, a small field test should be conducted. Any problems uncovered in the test will need to be corrected before the benchmark survey is distributed to all participants.

The next two steps are the most important, as concerns in these areas can cause otherwise willing participants to decide not to complete the survey or to color their responses. Quite simply these steps are to gather the completed surveys and then to compile the results. Concerns reside in who performs these two steps. It is imperative that this person or group be trusted and respected by all participants and that there not be any perception of impropriety or a conflict of interest. As such, it is recommended that someone who is not participating in, and will not benefit from, the benchmarking results be assigned the task of both collecting and tabulating the responses.

The results of the benchmarking survey are only presented in aggregate form and then only to those who responded. All individual answers must be fully protected. In some cases, such as providing cross-sectional or demographic analysis, certain sections may need to be eliminated due to a small number of responses which would effectively expose one or two participants. The results, often along with an analysis and commentary, are distributed to all who submitted data.

Although conducting a benchmarking study once is valuable, the real benefit comes from repeated studies over the course of time. Therefore, it is important to follow-up with those who participated to determine any problem areas needing correction or additional data to be collected. These changes must be made before the survey is repeated. Depending on the nature of the information, the survey should be repeated at least annually, possibly quarterly, or even monthly.

Some examples of benchmarking metrics:

Operational

Percent of calls answered
Average time to answer
Percent of calls placed on hold
Average hold time
Occupancy (percent of time spent working)
Average call duration
Average wrap up time
Number of calls answered per month
Amount of time spent on calls per month
Schedule adherence

Sales and Marketing

Number of sales made
Sales per hour
Average revenue per sale
Number of inquiries
Closing ratios
Source of leads

Human Resource

Annual turnover rate
Average employee (CSR) tenure
Cost to hire one new employee
Cost to train one new employee
Starting pay per hour
Average hourly rate

Financial

Percent of revenue spent on labor
Percent of revenue spent on marketing promotions
Percent of revenue spent on all sales and marketing efforts
Number of clients
Average revenue per client
Cost per sale
Profit margin

Conclusion: Benchmarking is a valuable mechanism to bring outside experience, information, and knowledge into a business. With this input, business goals become more defined and realistic; direction, clearer; and focus, sharper. It is an opportunity for improvement that should be seized.

Read more in Peter Lyle DeHaan’s Healthcare Call Center Essentials, available in hardcover, paperback, and e-book.

Tags operations management, Peter Lyle DeHaan's Vital Signs