By Wendy Thomas and Ann M. Hurst
Historically, patients in need of medical advice call their physician’s office or the emergency department and, if they’re lucky, speak to a veteran nurse who can provide some basic advice based on his or her years of nursing experience. Over the years, telephone triage has evolved from relying on the nurse’s experience as the source of information to newer, more efficient computer programs that walk the triage nurse through a series of algorithms in determining the best course of action for the patient. As stated by the Scope and Standards of Practice for Professional Telehealth Nursing from AAACN, “Telehealth nurses have a rational, systematic method of planning and providing nursing care via telecommunication.”
Just as triage methods have evolved to meet the needs of an ever-changing healthcare environment, so have the locations of triage delivery. One of those trends is the emergence of a work-at-home option. Issues like office space availability, staffing, and cost-efficiency are all reasons call centers consider moving their departments to a work-at-home arrangement.
Whatever the reason, moving a hospital- or office-based triage department to a home-based environment requires careful planning. Considerations include coordination of services, policy writing and revision, training on the use of technology, and assistance from Human Resources on change management. IT training and troubleshooting tools are vital for the staff when they work alone at home.
The decision to move the telephone triage department at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware, to a home-based unit came in February 2012 after close examination of our space challenges. A meeting to discuss viability was held with the heads of all departments that would be affected by our move. Once the decision was made, a project manager was assigned to help us organize the work. A project charter was developed that outlined the role of each stakeholder, department, and unit involved, along with setting a timeline of three months from planning to implementation. Major considerations such as technology, cost, staff education, and staff expectations were also explored.
Technology: Each associate was given a Nemours desktop computer with Internet protocol (IP communicator) software installed that replaced the desktop telephone. Each computer was configured with Jabber instant messaging software so nurses would have direct communication with each other that would not interfere with their calls. Call recording software from Calabrio was installed to allow for monitoring and recording incoming patient calls. Staff was issued either single or binaural headsets according to their preference.
Our electronic medical record contains the Barton Schmitt protocols, so documentation occurs at the point of call. In addition, a copy of the Barton Schmitt protocols were loaded on the individual nurses’ computer desktop in case of system downtime. Telephone triage associates are connected through virtual private network (VPN), which gives them access to all of the software programs used by the hospital on a daily basis. Associates were also granted administrators’ rights, allowing them to receive software upgrade pushes from the IT department. Help desk personnel access associates’ computers to remotely fix most issues through Web-Ex online conferencing. At times, associates find it necessary to bring their computer back to the hospital information systems area for upgrade assistance.
In order to support the technology demands and connect to the hospital’s VPN, associates are required to meet certain technology criteria. They need to have hardwired Internet access – not wireless – with minimum bandwidths of 1.1 to 3 Mbps download speed and 384 Kbps upload speed installed in their homes.
Cost: Originally, the estimated cost for the purchase of desktop computers, monitors, headsets, and work-at-home software licenses for twenty-one associates was approximately $20,000. The final cost of the equipment was actually $24,507, with computers, monitors, and headsets costing approximately $18,000, and software licenses approximately $6,500.
While installing and maintaining Internet connection is the associate’s responsibility, Nemours reimburses a portion of their Internet provider bill each month. Minimal cost was incurred in paying associates to attend training and transition meetings and for their time to pick up their computer from information systems, where they learned the basics of connecting the equipment at home.
Staff Education and Support: The associates had varying degrees of computer competence, making training classes on basic computer setup and troubleshooting a necessity. Associates experiencing technical difficulty first check their Internet connection before calling the information systems helpdesk. At times, the problem lies with the Internet service provider. Otherwise, the Nemours help desk stands ready to help them solve their problem via the phone. Originally, some staff had limited knowledge on even connecting a computer; now they can troubleshoot and reboot their own systems. Staff has become very savvy at identifying the root of problems.
Additional education included the use of Teamshare, a collaboration website at Nemours, where all process documents, procedures, schedules, and other resources can be immediately accessed by all staff. This is a virtual file cabinet of information.
Also important, the nurse manager has found innovative ways to bring the team together as a cohesive unit. She conducts staff meetings virtually, uses the instant messaging chat function to keep communication open, and provides the ability for the staff to meet in person several times per year.
Policy Changes: All of the telephone triage department policies have been rewritten to address a work-at-home environment rather than a hospital-based office environment. These policies included workspace setup, attendance, and service-level requirements. Policies outline workflow processes and steps to take if an associate’s home systems are not functioning, thus preventing her from working at home. A back-up space has been identified within the main hospital that provides the team with equipment for orientation and emergency purposes, such as loss of power at the associate’s home. All of these standards and policies are located on the Teamshare site and are always available for staff reference.
Staff Expectations: The staff is expected to provide a private, quiet workspace in their home that is free of distractions. Ideally, there should be a door separating this area from the rest of the home to preserve confidentiality during calls. Each associate provides the manager with a picture of his or her home office. If the associate encounters a problem working from home, such as a loss of power, they are given a thirty-minute window to correct the problem. If they are unable to resolve the issue in that time, they are expected to come into the hospital and work from the back-up space.
Incoming calls are recorded and monitored by the nurse manager, and a sampling of call scores is reviewed each month with the associate. New telehealth nursing and clerical competencies were written and reviewed with staff to set basic customer service and quality standards for calls.
The Results: As a result of this move home, the majority of incoming patient calls are now answered live. Associates report a high degree of satisfaction with their work arrangement. Their work location is transparent to patients, as the staff is proficient at providing a high level of service, telephonically. This is the first total telecommuting department at Nemours, and it has been accomplished through partnerships and collaboration with a number of departments within the organization. The results have been well worth the journey.
Ann M. Hurst, BSN RN CNML, is the director of nursing at Nemours Ambulatory Services. Wendy Thomas, RN, is the nurse manager for Nemours Kids Health On Call. Wendy has presented this topic at National Conferences across the US. If you are interested in having her speak at your conference, please contact wendy.thomas@nemours.org.