SironaHealth's Medical Call Center Blog

A service typically bundled as part of a nurse advice line, Audio Health Library Directories provide patients with 3-to-5 minute pre-recorded messages that cover general health information on topics like allergies, diabetes, back pain and over 400 other ailments.

Generally, health plans and hospitals will provide access to these audio health topics via an option on their nurse line’s Interactive Voice Response (IVR) menu. The idea being that when patients call into the telephone triage service, they will have an opportunity to receive general information about a health topic prior to asking the nurse their specific questions.

What we’ve found, however, is that while the information provided in these recorded messages is valuable, a very low percentage of callers will choose to listen to them – and here’s why:

1. Your patients aren’t aware of the directory and/or don’t understand how to use it.
2. Callers can’t easily navigate the directory without a topic list right in front of them.
3. Consumers call your nurse advice line looking to speak with a nurse, NOT a recording.

You’ll notice that the reasons above have little to do with content, and everything to do with how the service is being offered. There’s no doubt that there is value in offering patients access to an audio health library, but when we take a hard look at utilization rates, the 'standard' approach to offering this service is in desperate need of an overhaul.  

When launching your Audio Health Library, here are some tactics that will help you improve the effectiveness of the directory and encourage higher utilization:

• Adequate Promotions - When offering your Audio Health Library as a component of your nurse advice line, just having it as an option off of your IVR isn't enough. Similar to the way you promote your nurse triage service, you need to provide clear, consistent reminders that the directory is available. The importance of this is compounded by the fact that to successfully navigate the directory over the telephone, callers require a topic list that contains the appropriate numerical code for the topic they are interested in. Without easy access to your directory guide, callers will have a very difficult (if not impossible) time navigating the system.   
   
  
• Website Modules - Audio directories are ideally suited for the Web. In contrast to your telephone directory, website versions of the Audio Health Library are inherently easier to navigate and fit in very well with other health related content already offered on your website – allowing users to quickly navigate and listen to the 400+ health topics at their convenience.  
  
  
• Smart Phone Friendly - With smart phones having more in common with a computer than a telephone, consumers are spending more time doing Internet research over their mobile devices. Creating a mobile friendly version of your on-line Audio Health Library will allow your consumers to access your pre-recorded health messages directly from their mobile phone.
  
  
• Easy Escalation to a Nurse - Remember, behavior change begins with information but rarely occurs without one-on-one guidance. Your Audio Health Library will have the most impact on patient behavior when it is used in conjunction with your nurse advice line. Whether you are offering the directory over the phone or the web, make sure there is always a clear and easy way for patients to access your nurse advice line and speak with a registered nurse. 

As your organization ramps up its nurse advice line or enhances its current program with value-added content, remember to focus on creating services that engage your consumers both over the telephone and the Internet. Not all healthcare consumers will want to interact with you in the same way, and sometimes older services will perform better when adapted to newer media. 

How can you make sure your website visitors find up-to-date information on hospital sponsored community events, health classes, and seminars?

Provide Clear Navigation – In a previous article focused on increasing referrals to in-network physicians, one of my first recommendations was to focus on making it as easy, and intuitive as possible for your website visitors to navigate to your “Find a Doctor” section. The same goes for your health classes and events. If your visitors can’t find your available seminars, they can’t register – and don’t assume they will dig through your site to find them, because chances are they won’t.

Ideally, your visitors should be able to access your classes and events section within two clicks (one click is better) wherever they are on your website. The best way to do this is to place a link on your website's main navigation menu.

Make It Easy for Users to Search for Classes and Events – Many hospitals offer dozens, if not hundreds of classes to choose from. We recommend implementing a simple way for users to search through your list to find the classes and events that apply to them. At minimum, you should allow users to search by location, topic, and date.  Depending on your community’s demographics, you may also want to offer users the ability to search for classes offered in languages other than English.

Promote Classes & Events on Your Homepage – The homepage of your hospital’s website usually receives the most traffic, thus it is one of the best places to promote your hospital-sponsored classes and events. By dedicating a small piece of webpage real estate to promoting three or four of your newest classes, you greatly increase the likelihood visitors will review and register for the event. This list should be updated as often as possible to encourage users to revisit your site.

Allow Your Patients to Subscribe via Email or RSS – People are inundated with an overwhelming amount of information every day through the Internet, TV, radio, and their smart phones. And while they may be interested in participating in your events, they may not remember to check back to your website regularly to see what’s available. Help your community stay up-to-date on what you have to offer by allowing them to receive automated updates through email or RSS (Really Simple Syndication).  

For example: Now that you have a regularly updated list of new classes and events on your homepage, offer a link to your RSS feed or a field where they can submit their email address for future updates. 

Provide an Easy Way for Visitors to Register – It’s critical that you provide a clear call-to-action that directs visitors on how to enroll in your classes or events. This should either be a toll-free 1-800 number into your hospital contact center or a web form that allows users to provide their information, submit payment (if applicable), and confirm their registration.

Note: If you choose to offer your visitors a choice between calling your call center or registering through your website, it’s a good idea to have your contact center manage the entire class and event registation process. This ensures rosters are consolidated, eliminating the chance for double-bookings and inaccurate reporting.

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By following these simple guidelines, you can significantly increase registration rates for your hospital-sponsored programs. The key to success is to continually test new ways to engage your patients through your website and to build off of the strategies that are the most effective. 

What other website changes have you made to improve registration rates?  

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This is the fourth article in a series about Clinical Service Quality Management in Health Call Centers.

Most organizations that are concerned with quality will conduct periodic reviews of their own work.  Quality experts pan the concept of inspectors, for good reason: reliability should be built into processes. However, to build reliability into processes, techniques are needed to measure process characteristics.

Why 'Standard' Sampling Methods Miss the Target

In the clinical contact center world, a sample point is the patient interaction. The interaction consists of transaction data, a call recording and the patient’s experience.  Often the sampling starts with the transaction data. This can be segmented and profiled in many different ways – by guideline, disposition, or call times to name a few.

Typically, the sampling methodology ranges from “let’s look at a bunch of stuff from some time period, group of people, type of work, or some combination thereof, to taking a random sample using a 95% confidence interval.

Intuitively, we lean toward getting a “representative” sample to audit an operation. A random sampling technique may be employed, pulling enough interactions to achieve a 95% confidence interval based on an estimated error rate.  The sample audit “set” gets assigned to someone to pull every month, review the data, listen to the recording, and maybe call the patient.  Problems are then reported back and corrective actions are taken.

This strategy may be more work and not as effective as we would like. Let’s state our intent and test it against our methods. For most of us, the intent is to find the problems and correct them before patient safety is impacted.

A confidence interval sampling strategy will produce a representative sample, given a normal distribution in the base data. The chance of getting samples that are “okay” is very high and the chance of finding “errors” is very low.  In this instance, we really don’t want a representative sample, because the sample produces a low probability of answering the question: “Where are the problems that impact patient safety?”  

Utilizing Control Charts to Identify Samples that Need Attention

One of the best tools to answer our question is the control chart. There are over a dozen types of control charts. Your measurement goals and data drive your chart selection. Control charts can be used on the full set of data for any period and category. For example, “disposition frequency” by nurse, time of day, or customer can be analyzed.

Generally, control charts segment data into four zones: one, two, and three standard deviations (sigma) from the mean and then everything else (the outliers). The chart is informing us about the variability of the process. The more variability (the larger the three zone) means less consistency. Low process consistency means a higher error rate. We assume the mean of the process is in compliance. Given this logic, we start analyzing the interactions furthest from the mean, which have the highest probability of being non-conforming. This methodology increases the probability of addressing our original question: “Where are the problems?”

In today’s world of high volume healthcare call centers, quality programs need to be highly focused. The sheer volume can be daunting: techniques are needed to see emerging problems in order take corrective action quickly and effectively. The control chart accomplishes this and is one of the many tools SironaHealth employs to ensure patient safety.

SironaHealth is committed to offering quality healthcare contact center services, and therefore constantly monitors all business processes. In the following article by SironaHealth statistician, Allison Levesque, we review how Statistical Process Control techniques are among the tools used to determine appropriate areas of focus, and how SironaHealth uses them to ensure guideline adoption.

This year the country and the world have been hit with the devastating H1N1 Virus.  With this new pandemic, a new telephone triage guideline was created in order to properly triage those affected.  To ensure that nurses were well versed in the new guideline and utilizing it properly, SironaHealth's quality team provided updated training to the nursing staff, followed by control chart analysis to determine compliance and training effectiveness. Control charts illustrate variation in a process and put limits on that variation, which are considered statistically acceptable. Instances that extend beyond the acceptable limits indicate that processes are out of statistical control. Anything outside the control limits needs investigating.

As a statistician, I wanted to see the proportion of H1N1 guideline usage compared to all other guideline usage for each nurse relative to volume. The H1N1 guideline was new in 2009.  As with anything new, adoption takes time. However, we did not want to leave this up to time. So, we rolled out the latest H1N1 guidelines and began tracking their use against traditional flu guidelines and symptomatic guidelines (fever, diarrhea, vomiting, headache, sore throat, cold, and cough).  Control charts were used to detect slow adopters very early.

Appropriate use of guidelines is critical to patient safety. Positive triage statements and care advice vary with each guideline. So it is imperative that quality programs detect process issues before a break down occurs.

Statistical methods allow us to see processes “creep” toward non-compliance.  In this sense, we were able to measure H1N1 guideline adoption from the moment the guideline was released – on any interval necessary. This early detection trigger allowed SironaHealth to take corrective actions such as refreshing and retraining staff and management almost immediately.  The measurement is continuous, so the corrective actions are measured and adjusted if necessary as well.

Applications of statistical process control within the healthcare industry are needed to establish the foundation of quality, which drives patient safety. At SironaHealth, it has repeatedly proven to be effective in improving the quality of our healthcare services.  We continue to implement and refine statistical techniques to reduce process variability, ultimately ensuring that only the highest quality and safest services are being offered.

This is the third article in a series about Clinical Service Quality Management in Health Call Centers.

Fee-for-Service is a common re-imbursement mechanism in healthcare that is increasingly criticized because it focuses on services and not outcomes. Allowing a fee-for-service mentality into your quality program can produce adverse, unintended consequences.

In the world of telephone triage, a worst-case scenario is to reimburse clinicians for the number of calls completed. Piecework incentives remove the focus from the patient onto the clinician.  This is not to say the clinician is bad in some way – however, the organization is telling the clinician, in fact requiring the clinician, to focus on their own self interests (and the organization’s) over all else.

The amount of time and energy spent on the patient will not be determined by medical need. So, the odds of an adverse outcome increase with each encounter.

Is there another way? Yes. In manufacturing, it has been demonstrated over the past 60 years that a focus on quality increases throughput while a focus on throughput reduces quality and throughput.  It may sound a bit counter-intuitive. But, if we remove all the waste in a process, we are left with what is necessary. This shortens cycle time - for doing things right actually takes less time.

The incentives must be aligned with interests of the patient.  This means no “calls per hour” or “pay per call” metric. Instead, we ensure the clinician is available, the disposition is appropriate, the disposition is arrived at in a timely manner (no delay in care), and the patient is treated with courtesy and compassion.  If these and other quality metrics are met, we will see reasonable throughput.

At SironaHealth, we see wildly different encounter times – from chest pain to suicide calls. Each requires a different response. We do not incent our clinicians to hurry through a call so that they can get that 4th or 5th call done that hour. The nurse spends the appropriate amount of time to address the patient's concern, whether it be a suicide call or a hangnail. We recognize variation in the form of a “call distribution profile” metric. This is one of many metrics that allows us to focus on quality and patient safety. And not surprisingly, the byproduct is increased throughput.

The most critical question to ask when shopping for triage services is: How does your triage vendor's process keep patients safe and how are incentives aligned to meet process safety goals?

This is the second article in a series about Clinical Service Quality Management in Health Call Centers.

Most organizations mention quality as an important part of clinical service delivery. The depth of this commitment ranges from “we strive to do better…” to “quality is imbedded in our processes and management philosophy.”  Few organizations understand the science of quality and how an organization’s immune system undermines quality:  “Our people are wonderful and anyone who says different …”

Organizations, departments, and workgroups first react to quality measurement by closing ranks and resisting scrutiny. This is normal. A group’s instinct is self-preservation. This is especially true of clinical teams who have historically been under siege. The challenge is to separate the problem from the people. A good place to start is with Edwards Deming.

Deming believed people fail because:

•    The process is designed for failure
•    The training process fails to train
•    The recruitment fails to match people with work

Usually all three work in concert to create havoc. However, rarely, do you have someone come to work and say, “Gee, how can I fail today?” or “What can I intentionally do to destroy my credibility?”  Most people want to do meaningful work successfully.  So, when “Wonderful” people are put into no-win situations driven by poor process design, training, and skills, they are no less wonderful; however, they may do less than wonderfully. Breaking down self-preservation barriers requires involving everyone in the solution. This begins with explaining what drives success and failure, then asking team members: “At the end of the day, how do you know you have been successful?”  And, “What are the barriers to your success?”

Do not be surprised if few people cannot answer the first question but unload a torrent on the second. This is the first step in externalizing the problem: get a read on everyone’s standard of good and bad. Next, work to identify and measure ways to overcome these barriers as a team.

A word of caution: Be careful what you ask for. Once a team opens up, the infrastructure must be capable of acting on the concerns. Re-engineering for quality requires, among other things, a mandate from the top, and most importantly, a capacity to evolve – resources, software, and knowledge.

While the peak of reported H1N1 cases in the U.S. may be behind us, consumer demand for flu related heath advice remains high. Hospitals, health insurers, and employers have relied heavily on their healthcare call centers this season to provide updated health information and advice from licensed professionals.

URAC, the leading healthcare accreditation organization for medical call centers, recently published a news release focused on the benefit of utilizing accredited health call centers to respond to public health concerns like H1N1 and the seasonal flu.

URAC News Release: Consumer Demand for H1N1 Information Highlights Importance of Accreditation for Health Call Centers

Key Takeaways

URAC Accredited Health Call Centers:

• Have policies and procedures in place to effectively respond to public health concerns.
• Offer access to licensed Registered Nurses 24 hours a day; seven days a week.
• Utilize physician authored clinical guidelines to ensure consistent and up-to-date advice.
• Adhere to clear benchmarks for medical call center service level standards, ensuring healthcare consumers receive responses to their health issues quickly.
• Provide assurance that health line services are adhering to strict quality standards.

SironaHealth is a URAC accredited health call center that provides 24 x 7 nurse advice line services on behalf of health plans and hospitals nationwide. For more information on our accreditation, please read our official news release. 

Offering a nurse advice line service is one of the best ways to help consumers make smart decisions on where to seek care. But to ensure program success, it's important that you make it as convenient as possible for your consumers to get in touch with the nurse advice line service. The key is to educate your consumers on the existence of the service and remind them of its availability as often as possible.

Your website provides you with a unique opportunity to do more than just promote the service and its toll-free number. By offering a "nurse call-back" option, you're providing an easy way for website visitors to speak with a nurse -- increasing the likelihood they will choose to use the service.

Nurse Advice Line Call-Back Requests

Offered on a health plan or hospital's website, these secure call-back request forms capture (at minimum) the consumer's name, age, gender, telephone number, location, and health question or concern. Once the consumer submits his or her information, the call-back request is processed and placed into the contact center's outbound queue, prompting a call from a nurse.

Here's an example of a SironaHealth call-back request form:

Providing Consumers with Health Information & Advice via Email

Similar to the process for nurse call-backs, consumers can request that health information be sent to them via email. When a consumer submits a request for e-mailed health information, the request is forwarded to a nurse, who researches the member's question using trusted content sources -- ensuring that the information provided is accurate, up-to-date, and applies to their specific situation. 

The nurse then compiles the necessary information and e-mails that content to the patient's personal e-mail account. At any time the patient can choose to speak to a nurse to clarify questions, or obtain more information or advice.

Website Requests Should Be a Standard Component of Your Nurse Line Service

Each day, more and more healthcare consumers are turning to the Internet (and your website) for answers to their health questions. While health information is widely available online, effective healthcare support -- and behavior change -- comes from the one-on-one guidance consumers receive when speaking with a healthcare professional. Your job is to make sure your consumers have easy access to those professionals, whether they call you on the phone or visit your website.

Consumers make smarter healthcare decisions when they can consult with a clinician. By providing access to a registered nurse, you ensure consumers will receive the support and guidance they need to make informed decisions about their health and where to seek care -- whether that means a trip to the ED, a follow up with their doctor, or treating themselves at home.