Tag Archives: Peter Lyle DeHaan’s Vital Signs

Dr. Barton Schmitt Interview: Telephone Triage Protocols

By Peter Lyle DeHaan, Ph.D.

Peter DeHaan, Publisher and Editor of AnswerStat

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.

Thank you

Peter Lyle DeHaan, PhD, is the publisher and editor-in-chief of AnswerStat. He’s a passionate wordsmith whose goal is to change the world one word at a time.


[From the Fall 2003 issue of AnswerStat magazine]

Welcome To AnswerStat Magazine!

By Peter Lyle DeHaan, Ph.D.

Author Peter Lyle DeHaan

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. They can sign up for a free subscription. 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. Next, email your ideas to dehaan@answerstat.com. 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.

Contact Us: AnswerStat has a lean and efficient structure, this makes us accessible and easy to reach:

  • Subscriptions, article guidelines, and other on-line resources at AnswerStat.com
  • Advertising: Contact Valerie Port at 866-668-6694 or Valerie@AnswerStat.com
  • Articles, advisory board, letters to the editor, and all other issues: Contact Peter DeHaan at 616-284-1305 or dehaan@AnswerStat.com

Peter Lyle DeHaan, PhD, is the publisher and editor-in-chief of AnswerStat. He’s a passionate wordsmith whose goal is to change the world one word at a time.

[From the Summer 2003 issue of AnswerStat magazine]

Benchmarking Your Call Center

By Peter Lyle DeHaan, Ph.D.

Peter DeHaan, Publisher and Editor of AnswerStat

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. He’s a passionate wordsmith whose goal is to change the world one word at a time.

[From the Summer 2003 issue of AnswerStat magazine]