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
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.
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.
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.
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 10th 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.
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.
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.
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.
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.
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.
