By Rebecca Anwar, Ph.D. & Judy Capko
The pressure is on for physicians and staff to meet the new demands of managed care without compromising patient services. These new demands create frustration and confusion. Staff feels less in control than ever before and, unfortunately, patients can feel this. They get jockeyed around on the telephone and in the office as they try to maneuver through the system to get their questions answered and care given.
Implementing an effective triage system will improve communication, confidence and service. Triage systems also help reduce emergency office visits for minor complaints while ensuring there is access to the appropriate level of care when necessary. Clinical triage is particularly useful in primary medicine and specialties such as cardiology, ob/gyn and pediatrics. In general, triaging from a central unit and within departments, such as scheduling, billing and nursing is important. But where do you start?
Who handles the incoming calls and how are they routed within the office? Does one person assume the responsibility and serve as the triage point, or is there a voice mail system to direct the callers to the right department? If someone in the practice is routing calls, be sure they have a specific protocol that specifies what questions to ask so the caller can be directed to the proper source without delay. Record pertinent information and transfer it to the next person so the caller will not have to repeat him/herself. In developing a telephone triage system, you will want to flowchart the process to see if perhaps there are steps that are redundant or of no value.
Once you have identified the essential steps, put it in an algorithm or written protocol format and review it with the entire staff to see if it needs to be debugged. The final draft should be clear and precise. Now it’s time to have an implementation meeting to make sure everyone is on the same page and to minimize confusion. The physicians need to participate in this meeting as well. Everyone in the office needs to know how information flows and how patients are served.
Patient Encounter Triage
Track the steps patients go through from the time they enter your office until they leave. Remove any stumbling blocks along the way. Some of the most common problems for patients are:
• Getting through the paper work at the front desk.
• Being ignored in the reception area.
• Knowing what to do and where to go when the doctor leaves the exam room.
Once a patient enters the office it is essential that they are recognized and welcomed. As they approach the front desk, have the required paperwork ready for them to complete. It is too late to search for separate forms and clipboards or pencils once the patient is standing in front of you. For specialty practices, most managed care plans require a referral form from the primary care physician. Have a protocol in place to manage patients that have forgotten their referral form or failed to get one. This happens more times than not, and knowing how to handle the situation smoothly will not only reinforce the importance of the referral form to the patient, but will endear you to them for getting things straightened-out without a great deal of fuss.
You can avoid having patients ignored in the reception area by creating a triage point in the nursing station that includes a copy of the daily schedule, indicating patients that have arrived. It is critical that someone assume responsibility for making sure the schedule is accurate, that charts put up for arrival do not get removed unless a patient has been escorted to an exam room, and checking with the front office when it “appears” there is a no-show. It may be that the chart simply didn’t get put up for arrival. This sets you up for failure—it puts you behind and you have at least one unhappy patient.
Often when the physician has completed the office exam he or she leaves the room without telling the patient what happens next. If you do not have a specific clinical office procedure for triaging at this point, you will have delays and more confusion. Your nursing staff needs to know what happens next in order to triage properly. For example, the patient encounter triage process should include:
• Discharging the patient from the exam room.
• Instructing patients on ancillary studies to be performed in the office.
• Scheduling ancillary studies outside the office.
• Instructing patients about their next visits.
• Routing the patient to the scheduler.
• Routing the patient to the cashier.
It is important to clearly define your triage process in the clinical system to save the patient and the clinical staff steps and to make the patient visit go smoothly. This improves communication, saves time and increases patient satisfaction.
Advice Nurse Triage
Patients often call in to discuss signs and symptoms they or a member of their family are having. With a nurse triage system in place, patients are often able to care for themselves or be directed to an appropriate level of care within the practice.
Triage systems also help to identify patients that are ill but reluctant to seek medical care or are too busy to make an appointment. Top priority, life threatening calls may include allergic reactions, chest pain, eye injuries, burns and shortness of breath/wheezing, among others. Each of these symptoms requires an emergency protocol that might be as straight forward as instructing the patient to call 911, with the triage nurse calling 911 in 2-3 minutes to verify that the patient made contact. Other clinical protocols used in telephone triage are generally developed by both the nurse and physician staff so that the triage nurse can provide clear and appropriate instructions.
In the end, it is important to recognize that triage systems belong to the entire staff. Setting them up will improve productivity and patient flow at a time when practices feel the pressure to too much with too little time. You can learn by checking with practices similar in size and service mix that have been successful in implementing effective triage systems. An objective third party can sometimes play a key role in getting staff buy-in and guiding you through the implementation process.
Rebecca Anwar, Ph.D., is based in Philadelphia, PA and Judy Capko is based in Newbury Park, CA. They are senior consultants with The Sage Group, Inc., a national consulting firm.