Improving Performance of an Out-Patient Call Center in a General Internal Medicine, Academic Physician Practice

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1 Improving Performance of an Out- Call Center in a General Internal Medicine, Academic Physician Practice Deborah M. Simak, RN, M.N.Ed. Research Administrator/QI Facilitator Wishwa N Kapoor, MD, MPH. Falk Professor of Medicine; Chief, Division of General Internal Medicine; Vice Chairman, Department of Medicine; Director, Center for Research in Health Care; University of Pittsburgh, School of Medicine Gary Fischer, MD. Assistant Professor of Medicine; Medical Director, Ambulatory Services, General Internal Medicine; University of Pittsburgh, School of Medicine Mark Roberts, MD, MPP, FACP. Associate Professor of Medicine and Health Services Administration Chief, Section of Decision Sciences and Clinical Systems Modeling University of Pittsburgh School of Medicine Key Contact Person simakd@msx.upmc.edu Background: The UPP, GIM is an academic practice of 35 faculty and 42 resident physicians. Its outpatient facility is located on the 9 th floor of Montefiore University Hospital, University of Pittsburgh Medical Center. The practice receives a mean of 552 calls per day (range ) and sees an average of 180 patients per day. Satisfaction survey results and objective performance data indicated significant problems with patient access through call center (telephone) service, i.e., average speed of answer (wait time) of 144 seconds, only 55% of calls answered live, 19% of calls abandoned, and 24% rolled over to voice mail. F OCUS on the Customer F ind a Problem to Solve Press Ganey Measures Satisfaction Access to care (score 80.1) Ease of scheduling appointments (score 78.8) Helpfulness on phone (score 75) Many patient c/o long hold, voice mail, no response Hello? Anybody there? Is it done yet? News Media Reflects Customer Woes Telephone technologies great for seller, but Pity the ever-patient customer You just keep me hanging on, Jane Blotzer, Post-Gazette,

2 Purpose of the Study: Improve call center performance and responsiveness to customers by decreasing wait time to less than 20 seconds, increasing calls answered live to 90%, and decreasing abandoned calls and voice mail calls to less than 5%. Methods: A multidisciplinary team used the FOCUS: PDCA, quality improvement methodology and traditional quality improvement tools (e.g., flow-charts, run charts, cause and effect diagrams) to analyze the problem and identify root causes. Changes addressed priority concerns regarding misuse of technology and inadequate coordination of staff and physicians. FOCUS on Process:Clarify Current Flow P atie n ts P h y s ic ia n s H o m e C a r e In s u ra n c e C o m p a n ie s P h a rm a c ie s M a in P h o n e N u m b e r O p tio n M e n u E m e rg e n c y D i a l O I m m e d i a t e C o n n e c t t o A p p o in t m e n t L i n e P a t ie n t A p p o in t m e n t D i a l 1 H M O R e fe rra l/ A u t h o ri z a t i o n D i a l 2 P re s c ri p t io n D i a l 3 P h y sicia n C a ll in g G I M M D D ia l 4 O t h e r C a ll s S t a y o n l in e C o o r d in a t o r I m m ed i a t e A n s w e r Ans w ering M a c h i ne H o ld a n d W a it A n s w e ri n g H o l d a n d T ra n s f e r A n s w e ri n g L e a v e L o n g m e s s a g e a n d Ex it A n s w e r in g M a c h in e H o ld a n d W a it A n s w e rin g M a c h in e H o l d a n d W a it R e a l E m e rg e n c y? Yes N O A p p o in t m e n t C o o rd i n a t o r s A n o t h e r A n s w e r in g L e a v e L o n g M e s s a g e a n d E x it If N e ed R x in H r s L e a v e M e s s a g e as A b o v e a n d C a ll M a in # D i a l 1 C o o r d in a t o rs C o o r d in a t o rs N u r s e E m e rg e n c y L in e I m m e d ia t e A n s w e r M a n a g e C al l s Triage Call Back Main Number 11Th Caller Goes to Audix Leave Message and Exit Voice Mail O t h e r N u r s e R e f e rra l S p e c i a li s t M e d i c a l S e c re t a r y FOCUS on Process:Clarify from 's View Technology (Voice Mail; E-Message) Causes Rework and Delay Go To Angry View EpicCare Info and Resources Available Yes Is it Done Yet?! C all Goes Into Reception/ Calls Appointment Voice M ail S tudent or Secretary Retrieves Messages C alls P atient for More Information Writes Message for Staff No Calls for More Information Action Rework Delay Leaves Message Behind the Scenes C:\winnt\profiles\brownd5\personal\Debbie Simak\ Scenario 3 36

3 The team s recommendations for improvement were finalized with input of GIM faculty physicians and administrators. Using existing staff, the team completely redesigned the process. They reorganized the Academic GIM Division into four Firms of primary care faculty and resident physicians. They dissolved the RN and Secretary Pools and reassigned staff into RN-Secretary teams, each of which supported a physician Firm. Call center technology was limited to the reception function. All other personnel were place in traditional call pickup groups. Each team answered live calls transferred from reception staff. To reduce rework and delays, electronic medical record messages and voice mail messages were eliminated and the automated menu was simplified. Changes are best described with graphic representation of Old Way Vs New Way. PDCA:Plan to Change from Old Way Calls go to Appt Staff, Voice Mail or EpicCare E-message Rx Refills Referrals All calls Voice Mail Menu Selection Appointments Sick Calls All Other Calls Type Electronic Message to RN pool or Secretary 12th caller in queue Appt Coord Answer calls PDCA:Plan the Change to New Way Calls go to RN-Sec Team who Support MD/Resident Firm Receptionist Make Appt Triage Calls to Firm of s MD Firm1 Firm2 Coverage Group Firm3 Firm4 Coverage Group 37

4 Quantifiable Results: Changes made to processes, technology and staffing resulted in significant improvements. (See charts below). Objective data demonstrate that 97% of the calls are answered live, less than 2.5% are abandoned, and the average wait time is 13 seconds. Although process improvements were achieved very quickly following extensive system changes, a statistically significant improvement in Press Ganey, patient satisfaction scores was not realized for 6 months. In May 2002, scores improved in three key areas: Access to Care from 80.1 to 84.9; Ease of Scheduling Appointments from 78.8 to 86.8, and Courtesy of Appointment (reception) Staff from 84.0 to PDCA:Check the Change for Results Average Speed of Answered Calls Time Intervention Implemented Nov 16, 2001 Baseline 144 Seconds Post Intervention 13 Seconds 0.00 Baseline 12/03/01 12/21/01 01/14/02 02/04/02 02/22/02 03/14/02 04/03/02 Date Number of Calls PDCA:Check the Change for Results Close Performance Gap: Total Calls vs. Answered Calls Intervention Implemented Nov 16, 2001 Total Calls Answered Calls Baseline 12/03/01 12/21/01 01/14/02 02/04/02 02/22/02 03/14/02 04/03/02 Date 38

5 PDCA:Check the Change for Results Responsiveness to Customers Number of Calls Calls Audix Calls Abandoned Calls Answered Baseline June' 02 July'02 Months Conclusions and Implications: The team evaluated the QI project and QI process with the following conclusions: To improve the outcome of a patient care system, improve the system More staff is not always the answer Technology used improperly can hinder A team approach with careful analysis leads to unexpected solutions Doing it right the first time improves performance Sustain performance over time to improve patient satisfaction 39