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    Josh Anderson, MS

    Who is the most important person in your clinic? The doctor, the administrator or the nurse? While all these roles help your clinic function, there is one group that has a tremendous impact on your patients: your front desk staff. If you have not spent time with your front desk, you need to dedicate an eight-hour day to seeing what they do each day. It is amazing to watch them juggle scheduling, phone calls, patient questions, follow-ups, patient cases, etc.

    First impressions set the tone for the patient’s entire encounter. This downstream effect on the clinic staff and providers can start with a positive or negative interaction when the patient calls to make an appointment. Although patients are starting to migrate to online scheduling, most of our patients still schedule their appointments via the phone. When assessing access for your clinics you need to follow the natural flow of your patients. The first step in patient access is their ability to contact that clinic to schedule an appointment or ask questions. If your patients cannot effectively contact the front office, leakage will occur within your organization.

    Lesson 1. We cannot change what we cannot measure

    Valley View started to notice that our clinics had stagnant or declining schedule utilization rates. Schedule utilization was calculated by assessing the percentage of hours filled divided by the number of available hours in a day for each provider. For example, if a provider filled eight hours out of their 10 total clinic hours, they had an 80% utilization. After some discovery we found that our clinics were struggling with their missed call rates. Missed calls were calculated as the number of calls that went to voicemail divided by the total number of calls. We were shocked to find that some clinics had more than 50% of their incoming calls going to voicemail. Determining what your current state is for schedule utilization and your rate of missed calls is a simple way to measure patient access. When you start to look at the number of missed calls evaluate the following aspects:

    • What time of the day are the calls being missed?
    • What days of the week are they being missed?
    • Where are the calls being transferred?
    • How long are those calls?

    Our organizational goal was to have a missed call rate of 10% or lower. It took almost a year to do this, but the impacts it has had on patient access and staff burnout was worth the effort.

    Lesson 2. Understanding your gaps and patient behaviors 

    Figure 1 is an example of our Internal Medicine Clinic percentage of missed calls by hour each day. Regardless of the day, the greatest number of missed calls occurred at 10 a.m. each day. When we looked at the total number of calls coming into the clinic, we saw that 10 a.m. each day saw the greatest volume of all calls as well. The missed call percentage could be due to multiple factors, such as peak check-in times, convenient times for the patient to call, or staff assigned to other tasks. Regardless of the factors, the data showed we had to focus on the phones during these times to improve access. Interventions included strategies such as upstaffing, pausing other tasks that can be done later or simply making the back office aware that the front office’s attention would be focused on the phones during these peak hours.

    As we continued to measure other aspects of the phones, we found that a large portion of the incoming phone calls to the front desk were not meant for the front desk staff at all. For example, our highest transfer rates from the front desk were due to issues outside of their scope such as prescription refills, clinical questions, billing or medical records.

    This prompted us to create a phone tree (Figure 2) for our clinics with a uniform experience and common list of selection options for patients. Drawing inspiration from two studies,1,2 our phone tree was customized to fit Valley View’s needs and implemented at all the clinics to create a uniformed patient experience, regardless of which location the patient called. This phone tree allowed patients to determine for themselves the subject or which department they would like to speak with regarding their issue, thus freeing up our clinic staff to handle check-in and scheduling. We also noticed an opportunity for keepage within our phone tree, which allowed patients to be connected directly with our pharmacy for their prescription refills. Our introductory message made patients aware of online scheduling options and upcoming events at the hospital. Additionally, we provided a Spanish option to expand access for Spanish-speaking patients.

    Lesson 3. People, process and then technology — in that order

    As we continued to conduct a root cause analysis as to why our missed calls were occurring, Valley View found that we had a perception issue and a process issue with staff. Staff had the perception that the patient in front of them needed their attention more than the one calling in. The front desk would let the phone call go to voicemail and then return the call when it was convenient for them. The issue with this method was when the front desk would call back, it would not be convenient for the patient, thus the patient would send the call to voicemail and the cycle would start all over again. We taught our front desk staff to kindly ask the patient in front of them if they would mind if we took the call and, if necessary, place the caller on hold for a minute while finishing the other task. The goal was to avoid that vicious cycle of phone tag. Following is a brief outline showing how to place a patient on hold and how to transfer them.

    Scenario 1:  you are checking a patient out and the phone starts to ring, and you need to put the person calling on hold.

    • “Good morning/Good afternoon – thank you for calling XXXXX. My name is XXXX and your care is our top priority. May I place you on a brief hold?
      • Wait for the answer.
      • “Thank you we will be right back with you.”
        • Reassure him or her that you will be back with them as quickly as possible.
        • Try not to place the caller on hold for more than 60 seconds.
          • If you must place someone on hold for more than 60 seconds, check back with them and let them know you are almost finished with your other patient. Also, if possible, try to have another staff member cover the call for you.
      • Once you return to the call, pick up the phone and thank the patient for holding.

    Scenario 2: Transferring a caller from the front desk to another department or team member.

    • Tell the caller that you are transferring him or her to another department or team member and explain why.
    • Tell the caller the specific person or department you are transferring to.
    • Make sure you have the caller’s name and phone number in case the transfer fails.
    • Ask for permission to transfer the call.
    • Wait for the answer.
    • Thank the caller and proceed with the transfer.

    We also explained to staff that fewer phone calls going to voicemail meant a smaller number of phone exchanges they would have. Figure 3 illustrates this reduction in overall calls to the Internal Medicine Clinic. By doing so our staff was free to work on other projects or tasks. In addition, we calculated our time on the phone with patients was roughly 95 seconds per call. By answering the phone and preventing the return call and voicemail review, we were able to reduce the time on the phone or checking voicemails by 48 hours per month. Technology improvements for the phones included headsets, longer ring times and “hot keys.” Training was required for new and current staff.

    As administrators we cannot assume front desk staff know all the functions of these phones. Figure 4 shows a direct relationship between missed calls decreasing (orange line graph) and percent utilization increasing (blue line graph). The vertical red line shows when this project started. Valley View conducted a correlation coefficient calculation on this inverse relationship and found the increase in schedule utilization to be strongly associated with the phone interventions and reduction in missed calls (correlation coefficient -0.6899). In addition to the improvements in schedule utilization, we also found an organization increase of 17% in work RVUs (wRVUs). This wRVU increase was correlated to the reduction in missed phone calls (correlation coefficient -0.6670) as a result of increased patient access leading to more referrals, better coordination of labs/images and increased procedures.

    Summary: Phones are the life line for clinics and patients

    Phones play a crucial role in patient care acting as a lifeline for both clinics and patients, facilitating efficient communication and promoting access to healthcare services. It is important to offer other ways to reregister for appointments, like online scheduling, but in the end calling a clinic may still be the best option for most patients. These three easy lessons will help to improve many aspects of your clinic including increased schedule utilization, improved patient care and increased revenue for your clinics. All of these strategies took little to no financial investments and resulted in a major interventional change for our organization with years of added benefits. Right now, opportunity is calling your clinic — did you answer, or did you let it go to voicemail?

    Notes:

    1. Hussain S, Thomas, S. “Answering the Call: Improving Telephone Management in Your Practice” ACG GI practice toolbox. Available from: https://t.ly/5sdjs.
    2. O’Brien L, et al. “Improving Responsiveness to Patient Phone Calls: A Pilot Study” Journal of Patient Experience, 2017, Vol. 4(3) 101-107. Available from: https://doi.org/10.1177/2374373517706611.

    Written By

    Josh Anderson, MS

    Josh Anderson, MS, director of strategic growth, Valley View Hospital, Glenwood Springs, Colorado, can be reached at josh.anderson@vvh.org.


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