Telephone triage: Can your staff answer the call?

Medical Economics, February 1st, 2007

Just as the front desk is the public face of your practice, the people answering your phones are its public voice.

Given that key role, these employees should not only be intelligent, flexible, and cool under pressure; they should also have a clear and thorough sense of their mission. But that understanding is lacking in too many practices, say experts, often through no fault of the staff members themselves.

"There's a lack of clarity as to what's expected of nonclinical people when they answer the phones," says Houston gastroenterologist Gary A. Glober, who consults with practices on developing leadership and communication skills. "Office managers, nurses, and the doctors themselves aren't making it clear what they want these individuals to say."

Consultant Judy Bee, of La Jolla, CA, agrees, adding, "When people handling the phones listen to patients, they don't know what's important and what isn't." And because of this, she says, their conversations take longer than they should. Worse, if the call is urgent and a nurse or medical assistant has to call back to determine what's really going on, precious time has been wasted.

The solution, say experts, is to provide nonclinical staff with written guidelines on how to handle both urgent and routine calls. This can take any number of forms, ranging from posted phone and appointment grids, to decision trees, to triage manuals. But however you manage the task, the point is to communicate as efficiently as possible how you want incoming calls handled.

Here's a step-by-step process for getting that job done.

Three steps to creating a phone protocol

What doctors shouldn't do, says Glober, is to hand down phone procedures from "on high" without first collaborating with their staff. Here's how to carry out a collaborative effort:

Step 1: Gather information. The key here is to define the nature and scope of the problem you face. Holding an office-wide brainstorming session is one way to conduct this research. Another way, says Glober, is to have staff track calls as they come in, noting the type of call, the time of day, and how they were handled. "Do this until patterns emerge," he says.

He also advises polling new and established patients (in person or by mail) to find out if urgent calls are being handled satisfactorily. If not, discuss with staff members how they can be handled more efficiently. What about the handling of more routine calls, such as appointment requests, billing or insurance questions, or requests for lab results? Can these calls be answered more efficiently? If so, how?

As part of the information gathering step, each physician in a group practice needs to spell out how she wants different types of calls handled. For example, some doctors want all calls from referring doctors to be transferred to them immediately and the patient's chart brought in. Others don't. Similarly, how does each doctor want her personal calls handled? Should the operator ask the caller whether the physician should be interrupted, even if she's with a patient? Or should the caller be told that all nonemergency personal calls will be returned at the end of the day?

Doctors also need to spell out how they want different types of appointments scheduled. In a four-member primary care group, for instance, each member may want same-day appointments for any patient who calls in complaining of mild chest pain, but only two of the four doctors may want to see that patient for a long appointment. "If doctors don't tell people handling the phones what they want, the only feedback these staffers get is when things go wrong—and things will go wrong a lot," says Bee.

Step 2: Draft written guidance. This can take any number of forms, ranging from the simple to the elaborately complex. If you're detail-oriented, you can draft your own telephone protocol manual, with guidance from one of several resources like Telephone Triage Protocols for Nurses, 3rd ed., by Julie K. Briggs (Lippincott Williams & Wilkins, 2006).

If, on the other hand, you prefer something simpler, consider the telephone and appointment grids that consultant Judy Bee offers to her own clients. (To view two sample grids. You'll find blank versions you can download at www.memag.com/phonetips|~ .) "When doctors are presented with a tool like this, a light goes on and they realize how efficient their telephone operation and appointment scheduling can become," says Bee.

Step 3: Practice actual scripts. Glober recommends holding periodic meetings to check how your new telephone protocol is going. At these meetings, he says, the telephone staff should re-enact specific call scenarios, both urgent and routine.

While nonclinical staff should neither offer nor respond to requests for medical advice, they can be trained to ask broadly helpful questions, he says. "If the situation is urgent, doctors and nurses need to know what the caller's major signs and symptoms are. Typically, a telephone clerk needn't go any deeper than this, unless the doctor specifically wants more information."

After eliciting the necessary information, says Glober, the telephone clerk's duty is to be empathetic and reassuring. That means acknowledging the caller's concern and telling her what the plan of action is.

Glober describes one script a telephone clerk might follow in dealing with a distraught caller: "It's obvious that you're really concerned, and I'm going to make sure that the nurse or, if necessary, the doctor hears about this immediately. So let me put you on hold, talk to the nurse (or doctor), and get back to you quickly." But for such a scenario to work, he cautions, clerks must be able to communicate with clinical staff almost instantaneously, whether through an intra-office hotline or some other way.

Tips for making your phone handling first-rate

Once you've developed a set of phone procedures, focus on other aspects of your telephone and scheduling routine that may be hampering efficiency. Here are some ideas: Keep your office open during lunch. Practices that close and switch incoming calls over to an answering service lose a certain amount of quality control, says Glober. He suggests rotating staff during lunch periods so there's always a seasoned professional handling the phones. Answer all calls by a real person, within four rings. This is easier said than done, Glober acknowledges, but it's crucial to the growing emphasis within healthcare on high-quality customer service. His suggestion for getting it done: After ring four, have the call automatically transferred to the back office. Another suggestion: Hire retired staff or those on maternity leave to field "overflow" calls at home. Teach courtesy. For some employees, a courteous, inviting telephone manner is almost second nature, even during stressful times. For those who require more training in this art, experts suggest a scripted greeting and some coaching in how to listen for verbal and nonverbal cues. Spell out priorities. If there's a patient by the window and one on the phone, whom should the receptionist attend to first? "If the receptionist has almost finished with the caller, she ought to signal that fact to the patient in front of her, perhaps through body language," says Bee. If, on the other hand, the call promises to be a long one, she says, the receptionist should be trained to excuse herself, place the caller on hold with a thank you, and attend to the patient standing in front of her. Don't rush to fill empty appointment slots. "In most practices, if there's an open space in the schedule and someone calls in requesting a well-woman visit, yearly physical, or some other routine appointment, the receptionist or scheduler will fit them in on an empty day," says Bee. "But that squeezes out room for sick patients who call later on and really need to be seen." The better method, she says, is to ration the routine slots, scheduling the nonurgent calls at some point in the near future.

No practice handles incoming calls perfectly all the time, of course. But if you do things the right way, your telephone staff will not only be happier, your patients will give you high marks for courtesy and efficiency.