Telephone Triage – The Missing Link? Sally-Anne Pygall Consultant MSc RGN RM 1

What are the issues? Telephone triage is a clinical subspecialty and requires appropriate training We need clarity on clinical audit OOHs We must improve the audit we do by training the auditors appropriately With better triage and audit we can change the face of health care - THE MISSING LINK! 2

Telephone Triage/Consultation Why is telephone triage important ? Crucial to health care today First point of contact for many 20-25% of all consultations take place over the phone Used in huge variety of health care settings Great implications for managing patient care 3

The current situation Not many people are trained Not well monitored (in and out of hours) Not given enough credence Not used to the best advantage – impacts on patient journey; could save resources Patient’s lives are at risk and staff are vulnerable We need more training and more audit 4

What is telephone triage? – “Prioritising client’s health problems according to their urgency, education and advising clients and making safe, effective and appropriate decisions” (Coleman 1997) – “... Decision making under conditions of uncertainty and urgency” (Patel 1995) Can be compared to work done by air traffic controllers and emergency service operators 5

What is telephone triage used for? It can be used to : – Prioritise – Assess – Signpost – Review – Provide on going treatment – Support patients and carers – Reduce need for face to face care 6

So why is it used so commonly? Benefits are: – Quicker, easier access and patients like the immediacy – Fewer face to face consultations required (appointment/ workload management) – More cost effective services, resource management – Useful in times of high demand (Swine Flu!) – Patient education and empowerment 7

What training do people have? Not a lot - given the many uses and prevalence of telephone triage and telephone consultations!!! One study from US estimates only 6% of people are trained Generally not recognised as specialist skill 8

GPs (in and out of hours) No mandatory training for GPs Training only as good as their supervisor Many GPs dislike telephone work or lack confidence (Hallam 1998, Foster 1999) Does being a doctor make you proficient in telephone triage? 9

Nurses No mandatory training for nurses in general – NHS Direct nurses train for 6-8 weeks – most other nurses little or no training – does being an experienced nurse make you proficient in telephone triage?? 10

Other Roles Increasingly carried out by numerous professions including: – Pharmacists, OTs, Physiotherapists, Intermediate Care Teams, Mental Health Teams etc Little if any training 11

Call handlers and receptionists Out of Hours NQR standards stipulate call handlers should be monitored as part of ‘clinical performance’ i.e. delivering clinical care Receptionists - many not trained in identifying emergencies ( Primary Care Foundation Trust Urgent Care Report June 2009 ) 12

Why is telephone triage so risky?  Lack of visual clues  Lack of patient medical history (OOHs)  Delay or denial of care  Poor interactions as a result of poor communication (dissatisfied caller)  Reduced access for some patients or can lengthen patient journey  Disliked by some patients, have to repeat history to multiple people 13

Risks cont.  Can perpetuate culture of seeking help for minor conditions if seeing unnecessarily  Time constraints – less time allocated commonly  Face to face appointments given inappropriately  Inadequate training! 14

Do we really need training, is it that difficult? Many calls only just ‘adequate’ Inadequate assessment due to poor technique (not just about clinical skills) Not the same as face to face examination skills Lack of training therefore lack of understanding about what makes a good triage 15

Why do we need training? How can we expect a safe and cost effective level of care to be provided if we don’t equip people involved in telephone triage with the skills to deliver this? Improve telephone triage and we can achieve so much – the MISSING LINK! 16

Who’s better at telephone triage? Nurses considered more cost effective but take longer (Perrin and Goodman 1978) Need more research Only way to find out who’s best is listen to the calls! 17

Listening to calls – quality assurance Some GP surgeries now record their calls, but not mandatory – should it be? Voice recordings more likely to support clinician than condemn them in complaints No quality assurance for ‘in hours’, mainly done OOHs for audit/NQR purposes 18

Clinical Audit - OOHs Three documents to support audit – OOHs National Quality Requirements (NQRs), introduced Jan 2005 and reviewed in July 2006 – Supported by document ‘Commentary on the National out of hours Quality Requirements’ – RCGP Out of Hours Toolkit provides audit tool Standard 4 and 5 in NQR interpreted differently ? 19

Audit cont. Variation in – Who is audited – What is audited – How often audit is done – What is used to do audit – What training is provided for auditors – How and what is reported back to individuals – How and what is reported back to PCTs Why all the variation when we have NQRs??? 20

NQR Standard 4 – audit of individuals “Providers must regularly audit a random sample of patient contacts and appropriate action will be taken on the results of those audits. Regular reports of these audits will be made available to the contracting PCT. The sample must be defined in such a way that it will provide sufficient data to review the clinical performance of each individual working within the service”. 21

NQR Standard 4 Clarified in 2006: – Quality Requirement 4 requires providers regularly audit the clinical quality of the service they provide by auditing the work of each and every individual working within the organisation who contributes to clinical care. 22

Commentary Document “.. other members of staff (most importantly call handlers) make their own important contributions (to clinical performance )as well” “..the (audit) sample is constructed in such a way that it reviews the clinical performance of all those working in the service”. 23

NQR Standard 4 and Commentary Document together These documents don’t clarify : – what ‘audit regularly’ means – what type of audit should be done – how many calls/consultations should be audited or provide a minimum number What they do suggest is: – that audit be done by peer review groups, led by clinician experienced in this field 24

NQR Standard 5 – audit of patient experiences Providers must regularly audit a random sample of patients’ experiences of the service (e.g.1% per quarter) and appropriate action must be taken on the results of those audits. Regular reports of these audits must be made available to the contracting PCT. 25

Commentary Document “..is just as important to audit the patient experience across the network as a whole” “..they (PCTs)of course commission an OOH provider to discharge this responsibility (for whole systems audit) on their behalf.” 26

NQR Standard 5 and Commentary Document together These documents don’t clarify: – what ‘regularly’ means in terms of reports to PCTs i.e. does not say report quarterly These documents do clarify : – that ‘regular’ audit of patient experience means quarterly – suggest 1% of patient experiences be audited ACROSS WHOLE SYSTEMS 27

RCGP OOHs Toolkit RCGP commissioned by DoH to develop a tool kit to support NQR Standard 4 Published March 2007 Provides audit tool for whole systems audit across OOHs provider Recommends audit report includes information on productivity and outcome data, records, complaints/compliments- Excellent sample reports in Appendices 28

RCGP Toolkit cont. Suggests “at least 1% or 4 examples (whichever is the larger) of each individual’s calls/consultations” are audited as a baseline If ‘concerns’ then further audit done of 4% Suggest individuals and PCTS receive reports on performance quarterly 29

Confused??? Is it me?? RCGP suggest 1% or 4 calls/consultations audited. Is this 4 in total or 4 of each?? NQR 4 & 5 may have got ‘muddled’ with RCGP suggestion – i.e. 1% audit of patient experiences became audit of 1% of care episodes for each individual RCGP and NQR both appear to suggest a mixture of calls and consultations be audited 30

We need clarity! We need clarity on : – How much audit of individuals needs to be done – Do we audit telephone triage or face to face/documentation or both (is audit of documentation an appropriate substitute for face to face consultations) – How often audit of individuals needs to be done – How often we report back to individuals AND PCTs 31

What about the auditors? “... a peer review of cases with individuals is the most appropriate learning vehicle. This should be led by a senior clinician experienced in this field” (Commentary Document 2004) Variation in ‘auditors’ Variation in audit results 32

Auditors cont. Variation in experience and training May not use any audit tools May not be involved in reporting back to individuals Lack of resources at times 33

Auditors cont. May be a good time to review RCGP audit tool kit BUT – do we need to develop separate tools for telephone and face to face/documentation – do we need a specific tool for non clinicians OR have one tool which is more adaptable to different roles Sample reports are strongest element of current tool (in my view!) 34

So what needs to be done? Commissioners – Ensure providers are training staff and carrying out audit across whole systems in agreed way Providers – Ensure staff carrying out telephone care are trained or have access to training and are audited Individuals – Request access to training in order to be proficient and that audited by trained auditors DoH - Provide clarity and ensure training is mandatory 35

Telephone Triage and Audit Must go hand in hand – train, audit, retrain, reaudit By acknowledging that these are specialist skills which require the appropriate training and tools, we can improve the quality of the clinician and patient experience, save thousands of pounds, educate and empower patients and carers to manage their own health care for non urgent conditions thereby reducing the culture of accessing unscheduled care unnecessarily, but most importantly - we may even save lives. 36

Thank You Sally-Anne Pygall Tel: