Learn how Stanford Health Care reduced after-hours calls to physicians by creating the Clinical Advice Services and involving other trained team members.
Physicians at Stanford were required to serve as “first call,” which consisted of answering patient calls after-hours (nights and weekends). Many of these physicians were also rounding in the hospital or performing surgery while on call. In some specialties, such as primary care, attending physicians who served as first call would receive numerous calls during nights and weekends, forcing them not to schedule any personal activities and often awakening them at nighttime. The call system was causing delays in patient call backs, fragmented patient care, and physician burnout. Poor documentation, inadequate resolution of concerns and subsequent follow-up, and poor patient satisfaction were also noted.
Developing the Intervention
To address these issues, SHC launched Clinical Advice Services (CAS), a call center where clinical assistants (non-licensed personnel) and experienced registered nurses are co-located and trained in utilizing triage protocols to best address the entire enterprise's after-hours patient calls.
The CAS operations team built the SHC triage call center from the ground up with close attention to Lean methodologies. Prior to CAS, there were no standards for documentation or clinical protocols for after-hours calls. After researching how other health organizations run call centers, the department partnered with IT, business analytics, administrative leaders, patient/family advisors, and physician leaders throughout the institution in every clinical specialty to develop a documentation and triage process. Together they developed customized nurse triage protocols for all specialties and identified metrics to ensure a high-quality service. The Stanford leadership team fully supported and funded the CAS intervention.
It was important for the call center to develop a strong operational team to run CAS. They hired a medical director, nurse director, clinical operations manager, nurse educators, and an administrative leader. In addition to the leadership team, they hired seasoned nurses and clinical assistants, and trained them to use the new customized protocols. With a dedicated call center, the team set their sights on standardizing the process for addressing patient after-hours needs and reducing physician call volume by 90%.
The greatest barrier was inadequate staffing to meet high call volumes during the rapid expansion across all services. CAS was deployed across more than 100 specialties within SHC and reached over 1 million patient encounters within 4 years. The team struggled to obtain the appropriate funding to support this rapid growth. Currently, they are working with leadership to quantify hard ROI, demonstrate value, and convey the importance of expanding the team to meet their call volume. They are also partnering with specialists to obtain information on how to improve the “upstream” daytime patient support to reduce the need for after-hours calls. For example, the most common reason patients call after-hours is for medication refills and medication questions.
CAS is now fully deployed across the SHC enterprise. Based on current data, approximately 40% of calls are entirely addressed by clinical assistants and another 60% are managed between the clinical assistants and nurses. Primary care patients are the top utilizers of the after-hours service. Less than 10% of primary care calls require escalation to physicians and less than 5% of all calls require triage to the Emergency Department (ED). Ninety-two percent of patients had all their needs met during interactions with CAS. Patient satisfaction is consistently above 95%, and over 35% of patients who call CAS said they would have gone to the ED if they did not have access to the after-hours service. A physician satisfaction survey performed in January 2019 showed qualitative and quantitative improvement in physician satisfaction with the after-hours call experience.
For organizations exploring their own clinical advice services options, Nawal Johansen, MD, FACP, Medical Director of SHC's CAS, suggests covering these program features that were key to CAS's success:
Form a strong operational team comprising a medical director, nurse director, experienced clinical operations manager, nurse educators, and a hospital administrative leader to run the health call center.
Consider adopting Lean and/or standard work methodologies to ensure adoption, adherence, and a commitment to quality improvement.
Purchase evidence-based nurse triage protocols for physicians and health care teams to validate, modify, and approve for areas of medicine where such protocols are available, and partner with representative practitioners in specialties to create customized nurse triage protocols for areas of medicine where there are not.
Work closely with provider and administrative champions across all specialties to ensure smooth and successful onboarding of each specialty and communicate regularly with the champions for ongoing feedback.
Create a feedback mechanism to enable efficient communication between providers and CAS and establish a formal process for case reviews initiated by provider and patient feedback.
Engage in constant Plan-Do-Check-Act/Lean quality improvement methods.
Create a robust Quality Committee to review quality data and trends, develop ongoing quality improvement projects, review and update protocols, and review staff performance and case reviews.
Work with IT early on to create and review automated reports on utilization and triage data to optimize service and ensure quality (nurse call back times, top protocols used, triage dispositions, escalations to physicians, escalations to the ED, patient and provider satisfaction, etc.).
The CAS operational team meets frequently to review quality and triage data and partners with CAS staff and specialty champions to optimize triage protocols, nurse education, and upstream daytime work. Important information that they continue to collect includes nurse call back times, top protocols used, triage dispositions, escalations to physicians, and escalations to the ED. They plan to expand the service to affiliated clinical centers, leverage technology to help the triage process and patient care coordination, support population health priorities, engage the caregiver, leverage education, and optimize and scale medication management, which continues to be the main reason patients call after hours.
Stanford Health Care (SHC) is an academic medical center in California that offers comprehensive services from primary to tertiary care.
Dr Johansen thanks Eric Lee Escobedo-Wu, MS, RN, and Fouzel Dhebar, MPA/HSA, MSc. for their contributions and review of this article.