Transcript
25 Years of Nurse Triage Practice Keona Health Transcript
STEPHEN DEAN
My name is Stephen. I’m the COO and co-founder of Keona Health. Telehealth nurse triage 20-years-ago versus today. So, this is the conversation about the historical practice of nurse
triage. And I'm joined by two very experienced individuals for whom I have tremendous respect. I love reminiscing. I love stories, especially stories about the practice of patient care.
And over the course of any discussion about the past, there are explicit lessons for the practice today. But implicitly, there are also a trajectory starts getting painted of practice into the future. And so I hope this ends up being valuable for everyone and our audience.
So, Gina. Gina Tabone, I'm going to start with you. I’m going to ask you three things. First for our audience, could you just give a quick recap of what Nurse Triage is? Second, then tell us a little bit about your background with Nurse Triage. And finally, we’ll kick off the 20-years-ago discussion with training and orientation. What was training and orientation of triage nurses like 20-years-ago versus today?
GINA TABONE
Thank you so much, Stephen. And like Stephen said, my name is Gina Tabone. And I have been involved with nurse traige for over 25 years now. And just to go back to the roots of triage triage itself, the word comes from the military. And triage was a way in the battlefields for medics to sort of determine the acuity of the injury that the different soldiers were experiencing.
Is the patient a priority? Can the patient just be assisted with first aid? So, it was rating the acuity and then prioritizing care based on the acuity by the medic. So, that's just a little bit of background to triage. Fast forward to American health care, actually, worldwide health care triage became a way of assisting people who are experiencing different types of symptoms or medical conditions initially to determine actually what care they needed.
So, we sort of took the concept of triage, and at that time it was only telephone to caring for patients when they were in separatelocations from the nurses. My background with triage started in the late 1990s. I was working for Cleveland Clinic and actually had a bone marrow transplant and after being off work for a few years, I could go back to work as a nurse, but had to be very careful with direct patient care because I was still a bit compromised.
So, Cleveland Clinic at that time had a department called Nurse on Call, which was at that time telephone triage and Nurse On Call at Cleveland Clinic evolved out of Cleveland Clinic's commitment to serving the underserved community in Northeastern Ohio. So, they published this number, created this number, easy to remember. 444-1234 Put it on billboards and all sorts of community resources. Handed it out in the United Way's 211 resource guide for if you're experiencing any problems, call these nurses and they will help you.
So, it started out, it was extremely successful. And what's sort of happened that I'm jumping ahead a little bit here was the physicians, primarily primary care within Cleveland Clinic began to realize, “Hey, these nurses are doing a great job. How can they help us?” As I mentioned, I started there in the late 90s and I started out as a staff nurse, a triage nurse.
And I've got to tell you, Stephen you asked about our orientation and training. When I started back there, it was an absolute dream. Training for Nurse On Call was so fantastic. It was six months. Six months until you were actually signed off and approved to take care of patients independently. I can tell you that it was in the beginning overwhelming, it was expensive, and it was tedious.
I say it was overwhelming. You got these huge six-inch binders. I don't even know if they make them any more filled with pages and pages of instructions and customized advice for how to handle each different area, each different practice. When I tell you it was expensive for probably the first four months, you were one-on-one with your preceptor. Meaning, your preceptor only took calls as a way for you to observe what she was doing. So, it slowed her down, she explained after every call. It started out with an overview of what you'd be working with our tools back then.
And remember, this was the 90s I had gotten my first and I'm dating myself Gateway computer and hunt and pack the keys with two fingers. And that was the extent of my computer experience. So, for myself and a lot of other nurses were not experienced in operating or using a computer. It was a phenomenal training. When you went on the phones independently, you were prepared. You were constantly monitored, you were coached, and it was a phenomenal training.
I thank them for it at the time and we'll talk about this as we go on. But it was sort of a traditional nursing background. There was not a lot of evidence about telephone triage or caring for patients when you were not in the same room as them. So, we really had the opportunity at Cleveland Clinic to grow with the specialty as things like the AAACN, American Academy of
Ambulatory Care Nursing began to take telephone triage under its wing and really develop it into a specialty of nursing that is today respected and understood and greatly utilized.
And we were very fortunate at Cleveland Clinic that our manager was for a couple years the president of AAACN. So, she was really committed to not having this be a practice of assumptions and traditions, but truly evidence based. I'll let Tim share some of his experiences now.
STEPHEN DEAN
So, Tim, your background is a bit different than Gina's. You didn't start in a large, respected contact center. You ended up with that experience, but you started small. So, could you first tell us a little bit about your background and follow that up with commentary?
TIM OGRENTZ
Sure. When I first went to college, I was into science and I was a physics major, and an astronomy major and had to leave school for family reasons. And when I got married, I needed a good career. So, I went to nursing school. So, I've been a nurse for 27 years. I started out in the emergency room. I worked in the E.R. for 8 years, got burned out a little bit, and was kind of missing my, you know, background in science and such.
So, stumbled upon through a friend telephone triage, saw an ad in a paper, and she called me and let me know about it. I thought, “Wow, what a cool way to incorporate kind of computers and science, you know, with my new career of nursing.” And so I’ve been doing that ever since.
The first day I sat down, I knew I was going to retire out of nurse triage in some, some form or fashion. I've been doing that ever since I helped stand up a large contact center here in Chicago. After 10, 10 or more years of experience, just answering phone calls with patients. So, thousands of phone calls over the decade. So, I had a lot of experience. So, I helped stand up the Contact Center for Advocate Health Care here in Chicago.
I had various roles for advocates, first advocate health centers and advocate medical group, Clinical Analyst, Trainer. Finally left as clinical manager where we had 60 nurses,150,000 nurse triage phone calls per year. During that time, I finished my Bachelor's in Nursing and then I took a Master's in Business Analytics. And then moved to Keona Health, where I'm Director of Services and Analytics and I lead the customer success team and kind of bring all that business and science and computers and all that stuff together, kind of act as business translator. When I first got trained as a triage nurse, like Gina said, there was no theory involved.
It was just nursing like you did at the bedside. But over the phone. So, there's a little bit of a shocker because you couldn't see the patient, you couldn't hear or talk to the patient, touch, all those things that you used in nursing school or when you were trained, it was like you're working with a blindfold on. And so it's quite a difference from the tools you're used to using when you're assessing patients.
I sat there one-on-one with a more experienced nurse for many months, Gina said six months. I don't think mine was six months. I think it was more, along the lines of three or four. But right, that nurse was taken out of circulation and just took phone calls and taught me what went on during the phone call and how to document.
A lot of the training was learning four or five different pieces of software and that was a pain, right? And the patients got frustrated and I got frustrated having to jump from one software system to the next, trying to do all the things that were involved in doing a nurse training phone call. Keeping notes on procedures and changes was also painful because it was, kind of Post-it notes and everything all over the place.
And people had their own notebooks. They were interpreting things as they understood them to be for kind of the rules that made sense for them to do their triage phone calls. So, anyway, after a few months, I was finally able to take phone calls with my preceptor. And we switched roles.
First, I was listening and then, I was listening and she was triaging, then I was triaging, she was listening.
And we did a post-conference, we called it after every phone call and just talk about what went on, what we could have done better. I think my first triage phone call took 45 minutes. the patient was so patient. You know, the same thing you tell people, my computer’s running very slowly. Sorry about the delay. All the scripting stuff that you learn when you're new.
Stephen training was kind of ongoing. Nursing is a practice right? And so we never stop learning. And so in the large on premises contact centers, we'd listen to our colleagues, especially the more experienced colleagues, kind of pick up what they were laying down to their patients and using what they said, the phrases and stuff, assessment techniques, and that type of thing during our own triage practice.
STEPHEN DEAN
So, two things strike me that are kind of similar, though, to both of your stories. One is how different telehealth triage was to your traditional practice of nursing. Right? Two, the organizations were heavily invested in training you for that like for even three months,
even though it's less than six months, right? We've got a three month and we've got six months. They're paying you to do nothing but get trained and then they're paying this experienced preceptor the productivity is probably cut in third, right? While they go through those months
of working with you for that.
GINA TABONE
One thing to keep in mind for myself, a good 25-years-ago, clinical had not necessarily been accountable to the business side of health care. When I started with Nurse On Call, it was so far under the radar. Cleveland Clinic wanted to do a good thing for the community, the underserved, because they had to. They were for a nonprofit organization. There had to be some sort of offerings to indigent populations to maintain their nonprofit status. I mention that because we were sort of at that time kind of rogue. Nobody knew what was going on in our department.
We did have quality monitoring, but it was just our phone summary with how many calls per month we handled, and then we would monitor the quality of the phone call. It was not like it is today. Even for myself as a nurse, evolving in my roles. I started out as a staff nurse and I did some little precepting, and then orientation training, then I was the Education Specialist, and then the Manager, and then finally the Administrator.
And I had to sort of teach myself, I never went to business school. I was dumb in those types of things. I still can't even balance my checkbook to be honest. But it was an evolution, so we were not held to the higher ups or as we refer to them as the bean counters. We did not have that in our department. What really got us popular and on the radar of the higher ups was in 2009 when H1N1 hit. So, not nearly as dramatic as COVID and certainly not as great of an uptick, but certainly it rattled health care for a season.
So, we had sort of the operators for all the calls that were coming to the Cleveland Clinic, did not know what to do with these H1N1 calls. So, of course, “Oh, we've got this department, we'll let them handle it.” And we took it on, but we streamlined the processes. We had IVR options, you know, you want to know about H1N1. So, our handling of H1N1 by this crazy little department located in the basement of some practically ready to collapse building, really came out as a very good solution and handled it very well.
So, we were really recognized within the organization and at that point it was good and it was bad. So, then we started to capture the attention of the higher ups and they wanted to know what we were doing and how we were doing it. And I can remember at one time I was not the Administrator, but I was the Education Specialist and after H1N1, oh, they came and you know, “What do you guys need?” Well, we needed twelvemore nurses. Boom. We got an approval for twelve nurses, which any nurse or nurse manager knows. That is unheard of. We really rose in popularity and that was really the start of the growth and the commitment to Nurse On Call and actually the valuation of it.
TIM OGRENTZ
The business impact to the specialty is very apparent now with the structure, the training takes, with learning, telephone triage theory, then scenarios using triage theory plus maybe Schmitt- Thompson, learning the application. Nowadays we have instead of five different softwares, we have one software, if you're lucky, right? If you're in a contact center that has a unified platform and then the software training is pretty intuitive now. So, training is minimal. So, the focus is more, I find, on patient care, efficiency from a business perspective, from a patient journey, patient care perspective.
TIM OGRENTZ
But we still take time to develop those interview skills over time and we still continue to learn, no matter how long we've been on the phones. I think.
GINA TABONE
Going back to what Tim was just mentioning about the technology and it still kind of boggles my mind. When I first started at Cleveland Clinic’s Nurse On Call, we were handling patients after hours for our primary care practices. And the record of our work, there was no electronic medical record. Patients would talk to Nurse On Call after hours, but the office had no record that we had spoken to their patients. So, patients themselves, “Oh I talked to the nurse.” And we'd say, “Well, you didn't talk to us.” And the office would say, “Well, you didn't talk to us.” It was truly the blind leading the blind in a lot of different scenarios.
STEPHEN DEAN
Well, I mean, I'm just kind of wondering today who would pay for that kind of extensive training that you guys got back then?
TIM OGRENTZ
Nobody.
STEPHEN DEAN
I don't think anyone would, especially with staffing shortages and everything else, right? On the flip side, it has pushed some efficiency and some gains in training process and technology.
Right?
GINA TABONE
There's not as much to teach anymore because so much of it was dedicated to the equipment. When we started, it was paper charts. Nursing itself the whole profession underwent sort of a technological revolution and we resisted it. It's so fortunate for us because I think that the background that we have in nurse triage understanding where all of the practices or procedures come from. There's still the great debate should you triage a patient who's not present.
Someone calls in and about their brother or their mother, but they just left their house and they're not with them. We can discuss both sides, the pros and cons, advising a patient to go to the emergency department. Are you going to actually call 911 for them, or are you going to tell the patient to call 911? So, I think that we're able to reflect back on the discussions and sort of the turmoil of what different practices should do and the rationale behind it. So, we do come with a very good, solid foundation that enables us to problem solve issues when they come up in our specialty.
TIM OGRENTZ
For that scenario, we used to at first stay on the line with them while we called 911, and then later we switched to have the patients if they can and if they want to have the family call 911, whoever that was. and then call them back five minutes later to check to make sure that it happened.
GINA TABONE
And Tim, that's even sort of an evolution of the software and the technological tools. I mean, we were in a big call center with 100 nurses. If a nurse called 911 from our phone in the early days, it would go to the 911 number in the municipality where the call center was. Certainly things worked out. Technology and telephony worked out those kinks. But we did have some dilemmas that we sort of work through and we grew up with it.
TIM OGRENTZ
You mean having to find the 911 center for the location where the patient lives versus where you're calling from. Yeah.
GINA TABONE
Exactly.
Yeah. Yeah.
TIM OGRENTZ
A lot of knots to untie in the early days, right?
STEPHEN DEAN
How about the standard operating procedures? I'll start with you this time. Tim, right? Standard operating procedures. 20-years-ago. Just tell me they didn't happen to involve Post-it notes.
TIM OGRENTZ
No, they absolutely 100% did. Nobody was working remote back then. So, everyone got brought into the on prem contact center and it was just a whole bunch of cubicles. Oftentimes you had to share a cubicle with somebody else. Each person understands or is organized differently. Their mind thinks in different ways as far as how to organize information. So, some people had binders, very organized with binder tabs and all that stuff. And some people just had papers tacked to their cubicle walls with a whole bunch of Post-it notes and little notes and stuff that's not really standardized, right?
It's just paper that maybe two-years-old sitting up there on your wall, hard to keep it updated, hard to access the information that you need in the moment. You kind of have to remember where it was on the wall to get to the right thing. And then the computers would go down. The company decided at one point to print out binders of the top ten most frequently used guidelines. And I think we had two copies. They would be in use for the entire time.
So, you had to fight over them, so to speak, to take care of your patients. Sometimes you just had to wait for the binder and then we were just chatting with the patient. So, it was horrible for the patient, for the nurse, super time consuming, frustrating, created delay of care. So, sometimes patients just got frustrated and hung up. It's a lot better now.
GINA TABONE
Yeah, it is. Yeah.
TIM OGRENTZ
I don't know if we want to talk about that yet, but that's how it was.
STEPHEN DEAN
Oh, we can. Yeah. Let’s bounce over to Gina and then we’ll talk about what it’s like today.
GINA TABONE
Looking through the questions and preparing for this, I swear, I thought they're going to think I’m a psych case because I have so many flight of ideas when I was thinking about 20-years-ago.
Because I really loved nurse triage, I was so into it and standard operating procedures we knew how to handle a call. I go back and I think, “What's the patient calling for?
Is it a symptom based call? Is it a health information call? Is it a physician referral call?” We learn how to handle that process and managing the call and that sort of information. But when I think back to standard operating procedures, as I mentioned earlier, we became popular very fast. That partnered with the fact that at that time Cleveland Clinic was growing and they were acquiring practices all over the place and they were opening these family health centers all throughout Ohio. Whenever a new practice or they would acquire a new physician group from the outside came on and it involved primary care, we were sort of used as a lure.
They wanted to satisfy these different practices and these doctors. So, whatever they wanted we did. It was so overwhelming and so specialized. And we had a doctor that I could remember primary care doctor. He played an instrument for the Cleveland Orchestra. Okay, so these were the days where doctors were on call a lot. So, when he was on call, he'd call us and say, “I'm going on stage for 90 minutes. Call me after.” Oh, okay. Thank you.
We had another doctor, a husband and wife who, unbeknownst to the nurses, had split up or were separated. So, the doctor, the husband would be on call. We call the number we had for him. The wife would answer, “He doesn't live here anymore.” Click. Cleveland Clinic acquired a physician practice in a county called Medina County, which is maybe 75 miles south of Cleveland. Okay? And there was a practice there that they acquired. Well, this practice they helped out the coroner for Medina County.
So, we acquired the practice Nurse On Call was covering for them. We would get calls from police departments, the highway patrol, when people had to speak to the Medina County Coroner. Doctor Grabenstetter I'll never forget it. So, we were venturing into areas that just to satisfy our new customers until finally we could not do it anymore. And they finally started to realize. But that probably did not happen until I would say 2010, 2012, when we really started to look at centralizing what we were doing, really bonding our work with the appointment center, hospital transfer, the operators. For a good ten years, we were sort of, “We’ll do anything.” Most of our procedures in the early days did not really revolve around nursing practices, but mostly satisfying the physicians so we could get there buy ins so we could survive.
TIM OGRENTZ
Well, in that regard, I think it was good that the business side of things started wanting to make things more efficient and standardized and realize that nursing is an expensive resource and we should have them working at the fullest extent of their license instead of doing work that
non-professionals could do.
STEPHEN DEAN
So, that for ten years, right? I mean, you're talking about basically no standard operating procedures or minimal, right? I mean, your standard is the term that is actually not the case when you're following the directors of each individual physician.
GINA TABONE
Yeah, right.
STEPHEN DEAN
And how you guys kept that straight, I would have no idea.
GINA TABONE
It was a tough job. I think that nurse triage is probably the most cerebral job in nursing there is. All you're relying on is your ears. You can't see, you can't touch, you can't smell. It's very cerebral. And we've talked about this, the skill of truly listening, not hearing, but listening, absorbing processing is essential because we are relying on the patient to help us so that we can in turn help them. Standard operating procedures. No, we didn't. We thought we had them, but we didn't.
TIM OGRENTZ
I'm just glad all the pieces of paper and post-it notes that were hanging on the cubicle, all that stuff can be digitized now and we show it right in the triage software. And we don't show it all. We show the nurses what they need to see in the moment as it applies to their triage process when it needs to apply. So, anywhere from calendars, time calls, schedules, special instructions by practice site, physician paging, even appointment scheduling when it's appropriate. There's still an argument about should the nurse schedule the appointment?
GINA TABONE
Tim, I remember Oakkar, who is our CEO, and I'm not trying to plug our company, but just a little information. He's our CEO and I first met him when I was at Cleveland Clinic because he had developed, along with Stephen and Jimmy. I don't even know what it was called then this platform or app. And it was essentially the patient being able to sort of not self-diagnose but
self-triage and then come up with a disposition. It was gaining in popularity at that time. As I remember it, it was like time WebMD was around, so people were exploring and investigating their own health and stuff like that.
Fast forward years later when Keona had continued to develop the platform so that it could do more and more. And I remember at a conference Oakkar showed me and I honestly thought, “Oh my goodness, this is like magic.” I can remember like you said, Tim, we had to sign on seven different applications and we had different passwords and everything like that. And I remember one time when we first started to gain some interest or attention from kind of the bean counters, we determined that in an average eight-hour shift, a triage nurse probably was
clicking back and forth about 1,100 times in an eight hour shift. And then we were able to identify, copying and pasting in an eight-hour shift almost 150 times.
It was just sort of this patient's information's right there. Wow. You can look at the electronic medical records and you just press click and it transfers there. Now, of course, I'm fast forwarding here because we're including the electronic medical record, but I remember seeing Care Desk not in its entirety because we've grown a lot since but in its capabilities. And I remember and I said to Oakkar, “This is like magic.”
TIM OGRENTZ
I'm a pretty technical guy. And I build computers and I was into computers and a lot of different software, but had never seen anything in health care that was like the software that I was seeing outside of health care. So, I was like, “It's about time, where has this been all my triage life?” I fell in love with it from the first.
STEPHEN DEAN
Yeah, yeah. You don't have to guess on what to do next. Well, and then also the thing that strikes me listening to this is what type of nurse can even do triage nursing 20-years-ago versus what kind of nurse can even do triage nursing today. You talked about how cerebral it was, right? You have to focus, you’re just listening. On top of that, you have operating procedures, non-standardized. You got to figure that out. On top of that, you don't have the evidence-based guidance that helps you through it. On top of that, how about the documentation? Talk about cerebral. Oh my goodness. And how many nurses could actually handle that? That's crazy to think about.
GINA TABONE
It in the early days, without a good understanding of it or just even for myself, I was physically compromised. I couldn't do direct patient care. Well, for a while we went through this sort of send us your lanes, send us your latex allergy, send us your bad knees, your bad back. About to retire. We were sort of the island of misfit nurses for a while. It was, you know, nothing bad myself being one of them. But we sort of went through, at least for myself. And I'm sure Tim has his own memories and experiences too. But we went through a time where, oh, the ED nurses loved it. They were all over it. They could do it with their eyes closed.
And we brought on ED nurses and probably have the same success rate as any other type of nurse. But what we found was the ED nurses or the critical care nurses was they had been in the trenches. They had seen bleeding, no breathing, heart attacks. So, when they were talking to someone over a phone, chest pain, oh is it this? “They're not having a heart attack. I know that.” So, there was a tendency to sort of I don't want to say minimize, but because where they had been,
TIM OGRENTZ
It’s a culture thing.
GINA TABONE
We couldn't have that either. It was not so much background as it was the nursing qualities, at least for me. We sort of started to experience, to identify qualities that we wanted to see in
people. At that time, employment records were not that protected. You could call someone and they could tell you, “Oh man, she's always late. She has break ups with their boyfriend. She can't be at work.” You can't say that kind of stuff anymore, but we'd want to know that and we want to know attendance. Attendance and tardiness, and all those things. And today we're not quite as investigative shall I say, as we used to be. But we've learned.
STEPHEN DEAN
You do have, I think even as being from outside, I personally have seen what I think is a trajectory from hiring for the critical thinking to hiring for the smile and the patient service. With the critical thinking kind of like, we'll help coach you and guide you through that. So, has that been your guys’s experience?
TIM OGRENTZ
Yeah, I think the critical thinking is super important. But we want somebody who offers and is able to provide a great customer experience you can hear if someone's smiling over the phone, on a phone call. You can hear the exact opposite of somebody who’s very impatient with, It's like the patient is bothering them. You know, “How dare you call me?” I'd rather have a balance of both of those things when hiring new nurses, but I'd prefer to have somebody else who's got the assessment background that an ER nurse does without the cynicism that comes with that sometimes. And I think we've come a long way.
We've gone from just paper clunky, inefficient to more efficient process with some of the tools we have nowadays, I think we still have more work to do. I think we need AI recommenders in some aspects of the triage process like guideline selection, what's most frequently selected, that type of thing to allow nurse focus more on the triage process and the interaction between nurse and patient and less worrying about typing and that type of thing. Yeah, but we've come a long way.
GINA TABONE
And you know what else is really important too, and I think that this is a very vital part of training is that we need to capitalize on the fact that year after year nurses are voted the number one most trusted profession in the world. Year after year, after year. So, we want them to understand that despite the fact that you're not in the room with the patient, no pain meds, no anesthesia, no procedures, you still, and especially today, are very vital in the continuum of care.
Telephone triage is no longer an option for health systems. It is an absolute essential. When nurses are caring for patients over the phone or over the computer video, whatever it is, we want to really make sure that they understand that you have used to say thirty-second window of opportunity. Now it's even less you have a fifteen-second window of opportunity to win that patient over and begin that trusting relationship so that they believe what you say. They're convinced that you're there to help them. And if they recognize that and they believe it, their tendency to comply with the advice that you're giving them is increased compliance leads to better outcomes, which leads to better revenue for your organization and and everybody's happy.
So, those first fifteen-seconds, we don't want people answering the phone. “Hi, my name is Gina I’m a registered nurse speaking on a recorded line how may I help you?” People are going to be like, “What?” Start from the first second, “Good morning. My name is Gina. I'm a registered nurse. How may I help you?” So, it's the equivalent of an open question or sort of, hello, enter my office or enter the room. And some of this people just have it naturally. Other people, you can coach them and the best coaching tool is to let them listen to how they sound when it is undesirable or unacceptable, and then listen to what it sounds like when someone else does it differently or better.
TIM OGRENTZ
During training, we had a little module on word choice. So, say for instance, you have a mom calling about a baby that has a fever. For example, if the nurse would say, “So, does the kid have a fever?” Versus, “Does your child have a fever?”
GINA TABONE
That takes me back to a memory, paeds. I have no children, so I was terrified of triaging paeds patients. When I first started a very popular word was lethargic, so parents would, “Oh, he's very lethargic.” “Well what is he doing right now?” “He's riding his bike up and down the driveway.” Oh okay, he's not lethargic.
TIM OGRENTZ
Professional jargon versus…
GINA TABONE
Yeah, yeah. Or just wording. We’re nurses, we're licensed. We're professional. We know that we went to school, but you just sort of learned as we went. And like you mentioned earlier, Tim, there were some awesome nurses that we learned from that just knew how to handle difficult situations or even mundane situations. So, we were great teachers. We shared a lot of knowledge with each other.
STEPHEN DEAN
We're dealing with training the nurses, Q&A, and reporting afterwards. Right? Back when you started, Tim, you were side-by-side. You too Gina, you guys were side-by-side with preceptors for a long time. But after you're on your own, how was reporting in QA handled back then?
TIM OGRENTZ
We didn't see reporting when I first started. It was, if you weren't producing X amount of encounters per hour, then you got brought in and maybe you were shown a report. In QA, the same thing. You didn't really hear about it unless there was some coaching item. Yeah, I didn't know if it was present when I first started those many years ago, but eventually they just recorded all the phone calls. The manager was playing dual roles we couldn't afford a separate position, so the manager just had to listen to a certain amount maybe somebody who was new got more attention than somebody who was more experienced. But theoretically, everyone had their phone calls, listened to, if there was some coaching item, they got brought in. How about you, Gina? Was it pretty much your experience in the beginning?
GINA TABONE
We received every month a report of our phone activity. And I can remember Red Circle just said average calls per hour and it was always expected to be around four. You knew who was getting 4.8 or in the fives and anything in a three was bad. So we got that they were sticklers about monitoring our calls. So we had a senior nurse, and the senior nurse would be the one responsible for our quality. So, it was a very time consuming process because we had the audio and the written. So again, two separate applications. It was so crazy back then.
We recorded every call back to the 90s and I can remember we had like a server room and in the server room there were reel to reel recordings and at the start of every shift it had your assignment where you were sitting and there was a person it was assigned to to go in and make sure that the green lights were on the recorders and the green lights were on the server and it wasn’t then we let people know. But I remember the call recordings going from reel to reel and then to cassettes, and I remember if I became manager having contract with Iron Mountain.
Iron Mountain would come in I don't know, every three months or six months and pick all of these things up and they were stored indefinitely because at that time, from the minute a child is born until whenever they want to sue if something goes wrong, you have to have those records. So, I do remember those telephone records. They would review symptom based calls and then they decide, are we going to do health information or physician referrals calls? And then they would do specific protocol evaluations and monitoring just to see what was going on. It was a wonderful practice it was very personalized and truly a learning experience. Back then, I appreciated it and I think the nurses did too.
TIM OGRENTZ
Yeah, you bring up part of the QA process was to compare what was written in the records versus what was on the phone call. It reminds me of one nurse who had great documentation and she had great productivity metrics and handle times and such. Just so happened that nurses kept hearing this nurse refer patients no matter what. Like every call, refer the patient to the urgent care. They pull the the call recordings versus all the documentation. And that nurse was no longer a part of the team.
GINA TABONE
Tim We had a nurse and she was a very seasoned nurse. She was not a young woman, came from the E.R. We found her putting out a page to a physician for every single call, practically. I mean, you need some ownership. We provided you tools to use that are specifically for nurses to use in this type of practice. You really uncover a lot of interesting practices or habits when you do call monitoring. Some are great and you want to pass them on to the other nurses, but others not so good. And you really want people to avoid that.
And in those days we worked so closely together in the cubicles that overhearing what other people were doing, good and bad, it really had to be monitored closely. That's why as we had roles that sort of advanced up the ladder, people were always located in the call center. To me, that is the best way to understand and hear what really is going on.
TIM OGRENTZ
Yeah, I don't think people should be released to work remotely from the call center until they have some years of experience in the call center. Listening to their colleagues and taking calls among a bunch of other nurses who are seasoned or whatever.
GINA TABONE
When I was doing consulting, the first thing I wanted to do was get dual headsets, and let me just sit in and listen where the nurses are working. Let me start there. I wonder often with remote practices how that has been replaced or if it has, because it was really a very valuable learning experience. Although I do know that with some of the telephony systems, you can listen in real time with your nurses. So, maybe that's become the new mechanism for hearing what's going on. I hope so.
STEPHEN DEAN
Let's fast forward. How's QA and reporting now compared to what it used to be?
TIM OGRENTZ
While we were talking about standardization earlier. Right? So, for instance, when we used to train new nurses, we titrated the audit. So, as soon as they got out of training, we do five calls a week and then for five weeks drop it down to four for four weeks. That was very structured and we caught things and coached right from the get go, right off the bat. So, we used reports as well along with that reports from their traige software. We didn't have many reports.
You know, I went from using a product called Center Max then to McKesson's Relay Care. After Relay Care, We had decent reports, but they were all just kind of tabular reports that use the plug in called Crystal Reports, if you might be familiar with that. So, no data visualizations back then. The reports were canned. You couldn't ask questions of the data that you had that weren't inside one of those canned reports.
STEPHEN DEAN
Right.
TIM OGRENTZ
And you couldn't get deeper insights because you were just stuck with what you had. And nowadays we can do self-service reporting. We have nothing but dashboard visualizations. I work with the reports here at Keona, so we create a bunch of standard reports, and that's usually enough. But if we don't provide something that answers the question that they might have or we come up with a product that needs a new set of reports, then we just create them or customer. If they're savvy enough, they can create them themselves. So it's quite a different world, some of the behaviors that people do. We can gain insight on some of that as well.
STEPHEN DEAN
Well, what do you mean by that?
TIM OGRENTZ
The call avoidance stuff.
STEPHEN DEAN
The metrics will give you some insight.
GINA TABONE
Yeah, extended wrap time, not ready for call. You know, unfortunately, we kind of look for punitive things or things that are going wrong
TIM OGRENTZ
Yeah squeaky wheel, I guess. Right?
GINA TABONE
Yeah, we can. Back to reporting, there was not any interest in what we were doing until really Cleveland Clinic made the commitment to centralize. So, they leased this huge building that housed like 750 people. And like I said, we had the appointment center, hospital transfer, physician referral. We were all located in the same area and we all had the telephony, and fortunately for us we had a dedicated IT team.
So, back then and this is even going back fifteen years, which is the prehistoric ages practically now. But unlike Tim, I am not a technical or computer person as everyone probably already knows. But I knew what I wanted to see. I knew what I wanted to see from the reports and all of the data that was in there. I didn't know how to get it. So, I can remember sitting down with our IT people and i felt they were talking Greek to me. It was sort of an evolution of learning how to communicate with each other. Mostly I had to evolve.
Nonetheless, we were able to get what we needed from them, knowing what the higher ups wanted to see from us. So, we were able to get the data from them to impact our practices and improve them. To me, in addition to helping the patient, helping the physicians, helping the practices, the data that we collect is so rich. It makes telephone triage wealthy, but we don't get credit for it. The data that we collect is evidence of the value we are providing. We can track this is how many ED dispositions we reach from our triage.
However, because we reached out to a provider on call based on the nurse using her clinical, critical thinking and nursing judgment, we reached out to a physician, had a one minute encounter, downgraded that recommendation. So this is how many ED re-appropriations we can claim in organizations like Cleveland Clinic who was at the time self-insured. When we triage your patients and we reach out to a physician for a one minute phone call, we boom right off the bat, save the health plan $600 by them not having to go into the ED.
So, knowing what potential the data has and being able to think through all the components, the nurse's skill level, the protocols used, the dispositions, we really look at things at a very granular level and can apply them to very global solutions that nurse triage is, which doesn't often get credit for it.
TIM OGRENTZ
I like tailoring some of those questions that we ask the data around behaviors. So, for instance, if we have the group reaches a certain amount of ED referrals over time, but individuals within that team reach a different percentage of ED referrals for the same time period. Then that's a conversation you need to have with that person. It’s a confidence issue. Yeah.
GINA TABONE
And Tim, you know what that’s so true. Schmitt and Thompson guidelines, historically, the highest level of acuity is, say, a priority recommendation. You need to call 911 immediately. On average, Schmidt and Thompson’s been between 8-10% of total encounters results in call 911. In my experiences at least we tend to see that much higher in new hires.
TIM OGRENTZ
Sure.
GINA TABONE
They're apprehensive. They're going to be extra cautious about…
TIM OGRENTZ
erring on the side of caution right? Be safe.
GINA TABONE
It takes me back to the early days I remember my first AAACN conference hearing, Dr. Andrew Hertz. He heads up one of our biggest clients at Keona, Rainbow Babies and Children's. I remember Dr. Hertz saying that when they have new nurses come on the rainbow triage line, they equate it to being a new graduate, despite the experience they bring to the job. It's a total new skill. It's understandable that they are cautious. It says something good about them. They're not practicing cavalierly. It's just interesting when you know what you're looking for and you have some understanding of why this nurse's ED immediate referral is higher than the average. We have an explanation for it.
TIM OGRENTZ
Well, I like my role here at Keona. You were talking about meeting with the IT people and they were speaking Greek to you, and you were speaking Greek to them. And I'm the kind of guy here in the middle who understands both worlds. I could be the translator. That’s fun for me.
GINA TABONE
I think that's really something that sets us apart from a lot of the other triage or call center platforms or software or whatever you're going to call them is the fact that since day one, Keona has ingrained nurses into their technology. And this goes all the way back to right back before when Oakkar and and Stephen, and Jimmy released the first product. Before they released it, Oakkar came to Cleveland Clinic.
I remember sitting in Panera with him the first time I met him and then going through it and sitting with him in our conference room. So, they have you, Tim, your technology, your implementation, you deal with the go lives. I mean, not a lot of platforms have a like person that these nurse managers or clinical leaders can reach out to. And we do. And I've always thought that that is reflected in our software. And a lot of software has gotten down to a lot of just clicks. We're efficient like everybody else, but we have great intuition and valuable experiences built into the software and I think that when skilled people start to use it or when we demo it,
that's what sets us apart because people are able to recognize it.
TIM OGRENTZ
One of the things that brought me to Keona and one of the things that keeps me Keona is that Keona does the right things for the right reasons. And they put patients first and nurses first.
STEPHEN DEAN
I was thinking the other day about this is actually a couple of months back. But you know, when you think of how nursing got started, it was patients in the battlefield primarily, but it ended up being actually more than just a battlefield. The wounded were being left behind because the doctors couldn't always be where they were. And so you have Florence Nightingale, who is medically trained but then also is taking the best of science and statistics at the time, training people to be where the patients are, and applying the science to the patients.It's transformed health care. Right?
I think there's still some analogies, though, to that today where post-COVID people are not as trusting of their providers, and becoming less trusting of the doctors, and they're not where the doctors are. Now, we’re not in as dire circumstances as at war. Of course. But still you've got health concerns that aren't being properly addressed. And honestly, I think if Florence Nightingale were an American alive today, when people aren't trying to avoid their doctors, she would be applying the latest cutting edge statistics, techniques, and technology to help reach the patients.
GINA TABONE
How health care just sort of had to respond immediately because in essence, health care shut patients out. Don't come into the office, drive through COVID testing. They had to.
STEPHEN DEAN
And if you're thinking about it, I'm going to scare you to not doing that.
GINA TABONE
Yeah. Don't come in, stay away. Like big yellow tape across the ED doors and everything. But they were quick to provide alternatives. And what we had been doing, Tim and I for decades really catapulted more than it did with H1N1 or even with the evolution in the ten years since 2009, it really put us front and center in what we did. And I still don't think that in the world of now is telemedicine and telehealth. Wow, big deal. We've been doing it for almost 30-years now. And I think that in a lot of ways they reinvented the wheel and didn't take opportunities to learn from what telephone triage nurses were doing.
Certainly gotten better, but we could have helped them. The main thing that we could have helped them with, how do you communicate with people when you're not with them? That communication skills, that ability to establish that immediate rapport and really move on from there, I think that telemedicine could have learned a bit more from nursing.
STEPHEN DEAN
Yeah, and there's been some kind of pushback on telemedicine. I think it’ll even out and come back. It was implemented quickly without training. Right? This was not six-months. While we help you figure this out, right? Use the right terminology, as Tim was saying earlier, follow the right processes. This is your home here,now have a camera.
TIM OGRENTZ
Right, that's about it.
GINA TABONE
And it was also sort of forced on a group that historically physicians don't respond well to mandates. Don't tell them what to do, don't tell them how to practice. I could remember when we first went live with Epic at Cleveland Clinic, we had a doctor who’s wife would transcribe for him every night at home. He was not going to do this crazy computer documentation, so it was sprung on them. It was probably not the best mechanism. But again, we were in a crisis and many, many of them rose to the occasion. Hopefully in medical school and in nursing school, alternate mechanisms or methods of caring for patients are introduced and taught a little bit.
TIM OGRENTZ
Yeah, communication skills is a big piece of it. I hope so too, Gina.
STEPHEN DEAN
Okay, escalation procedures. How did you escalate? Who did you escalate to? What were the processes for it 20-years ago?
TIM OGRENTZ
Yeah, in the first contact center. So, we had a calendar of on call physicians. There was just a small group of them, maybe five or six and each one they just rotated. Each one was on call per day and in the box with their name on the calendar day we had their direct cell phone number. So, we call the docs and we did that in a couple of cases. So, when the nurse just wanted a collegial consult, depending on who was on call, right?
TIM OGRENTZ
We didn't want to call if so-and-so was on call because it was a crappy person, other docs, or they were able to teach the nurses who called them. Oftentimes they take the time to do that. So, that was really nice. The other time we would call them, outside of a collegial consult was if we had an ED disposition. So, this was required. So if we had an easy disposition, we had to call and present the case. Sometimes the provider would want to talk with the patient, but we just take the physician's recommendation.
And sometimes, depending on how you presented the case, what was going on, they would just agree with the Schmitt-Thompson disposition and we'd send the patient along to the ED. Sometimes when it was appropriate, we would do the downgrade according to their instructions, sometimes depending on provider. You know, there was Doc who invariably would call in Tylenol three for everyone we called. That was 20-years ago. So, that isn’t happening today, but that was back then. How about you, Gina?
GINA TABONE
We were so conscientious. We had to be prepared for everything. We'd get in, we'd see there'd be a list where we were sitting and every day, I'm not kidding. We had a legal size page of on call. We had to know who we were going to reach out to. At that time, we were not covering for that many specialties. We had at that time 13 different sites. We had family medicine, internal medicine, Peads, Med Peads. So, we had this very involved call sheet. Inevitably, there was something on it that was not right. We relied on the practices or the sites to tell us if there were any changes.
We also relied on them to provide an on call schedule for us so we could get it out the week, the month before. And there were always issues with it and that was until it was automated. And then we went to a platform or whatever it's called called AM Com, but still no matter how sophisticated it had gotten, it still relied on some human being entering the information and changing it as needed. But for us, we had escalation procedures for if a patient refused 911. Cleveland Clinic started out as that community line for the underserved, so they were our public callers.
We really had no relationship with them. We had no doctors information, no medication information. So, if a public caller, our community caller called and they refused 911 there was really nothing we could do. You have very bad chest pain and you're short of breath. If you don't go to the emergency room and call 911 right now, you could die.
STEPHEN DEAN
Use that word, die.
GINA TABONE
And so, if it was an established patient that was the patient of Cleveland Clinic, we'd say, “You know what? I just want you to know, do you understand that?” And then we'd call the doctor. And sometimes the doctor would be like, “So? He doesn't want to go.” But most of the time they'd be like, “Conference me over to the caller.” The caller would talk to the patient and sometimes it was merited. Patients with long history of COPD who are on oxygen at home and hear them gasping over the phone. But this is their baseline.
TIM OGRENTZ
That's their baseline. Yeah. Well, it was different.
GINA TABONE
A lot of times when we would escalate was when we would triage the patient and based on the guideline, her nursing judgment led her to believe this guy could be seen tomorrow at the office and it would be fine. But nursing practice does not allow nurses to downgrade any recommendation within the guidelines. So, she would reach out to the physician, run it by him, give him a report, answer his questions, and then ultimately the decision was up to him.
However, if he did offer an agreement about a downgrade, we want that documented.
Our escalation process again, one of our standard operating procedures. We’d page the on call doctor, page him again after fifteen minutes, page him again after another fifteen minutes. He didn't respond? Then we’d page the primary care doctor who was not on call, who would get very angry that the on call doctor didn't pick up the phone. And anyways, he took it over. And this would be like we fill out a special call report that would go to our manager if a provider did not answer our pages. But this escalation went on.
Suppose the primary care doctor didn't answer. Then we would call the medical director of the site. Medical director would be like, “I can't believe they didn't answer.” There were historically providers who were less reliable than other providers, shall we say. But our escalation process It was very documented and we had a medical director for the call center. And when we would have those issues where we didn't get any responses, even if we didn't get the Medical Director to respond, then our Medical Director of Nurse On Call would take it over. But it was up to the medical director to reach out to the physicians, and handle that. In those days, we sort of had a place we didn't confront a physician about anything, even if it was something they weren't doing right.
So, escalation, very big deal. We also had escalation policies for we got after ours all of the critical results. Any Coumadin results, any critical x-ray results. After hours, all the critical results for outpatient came to us. So again, this is Jaco. You have timestamps on things. I can't remember off the top of my head, but I think it was you had sixty minutes, I believe, from the time you received the critical results, the lab, they wanted to get rid of it. So, as soon as it came up, they would call us and we had a special line like a hotline for incoming critical results, along with incoming physician calls. The lab, or the radiology, the imaging department.
They wanted to get their off their plates. So they call us. They documented it was no longer their responsibility, it was ours. So, that would begin the timestamp of when we reached out to the physician, did they answer? I think at that time, Jaco, it was sixty minutes from receiving the critical result to action. Go to the ED or sometimes tests had to be redone. Someone's glucose
might have been 12. Well, the guy would have been dead already if that were really the case. So, the doctor would say, “Okay, I'll just put another order in, call the patient, and tell them to go tomorrow and get a redraw.”
Escalation was a big part of what we wanted to make sure that we had down pat and also, like I mentioned before, we did so many different things for so many different groups. That trial and error, when something happened That's a great apology for how they handle it better the next time.
TIM OGRENTZ
That escalation procedure you just described sounds kind of long. I would be concerned about creating a delay of care for the patient. So for us, at some point, if we weren't able to reach an on call provider, we just follow the Schmitt-Thompson recommended disposition and downgrade will be damned.
STEPHEN DEAN
You did have some different escalation procedures based on who it was, right? So yeah, I mean, you had a peds specialty, I remember that had different escalation procedures. Right?
GINA TABONE
And Stephen, not clinical, probably the most concrete escalation procedures revolved around the technology. Like Tim said, if there was a phone outage, oh man, it was like happy days. You know, those were the days I can remember like 8 hours the phones were down. People were polishing their nails, setting their hair, reading. Outages happened a lot, but it would be like, Yahoo!
TIM OGRENTZ
Yeah, we didn’t mind those at all.
GINA TABONE
We actually had alternate site that we rented, paid monthly years, and years, and years. It was like an hour and a half south of where we were. We would go down there every six months to bring new paper protocol books, make sure we had enough headphones for nurses, enough supplies I could remember driving. It was like a field trip day. There were written escalation procedures for the nurses to try at their death stop. Before we reached out and reported it to IT or phone. I think that at that time probably many more of our issues now you can call AT&T or whoever and most of the things are managed remotely. But at that time I can remember phone guys coming in with their tool belts on and it was all physical, present activity, getting things back up and running.
TIM OGRENTZ
Really come a long way, it sure has. You still had to staff nurses during the after hours because that was your agreement you had to have a 24-hour contact center but call volume was much lower and maybe you had certain populations would call more frequently in the evening and maybe take a little bit longer on the phone like the elderly population, for instance. But we had after hours utilization management, prescription refills, critical labs reporting, that type of thing, just like you did because somebody had to take them. And there were timeframes associated with all those things and the work had to be done. And you were paying these really expensive nurses to basically sit around and wait for a phone call. So, that makes sense.
GINA TABONE
I was saying how we just grew, grew, grew more, and more, and more, and more. Everything was different until there was a certain point where we felt like we were a dumping ground. “Oh would give it to them. They're there. They can do it. They can do this. They can do that.” And what I remember most specifically was somehow Cleveland Clinic at one point got dinged by JCO because the credentialing office was not open 24/7. And Stephen, for someone non-clinical, the credentialing office would be like the nurse was working on a med search. And in July all the new residents come on. And the new resident comes on and sees the patient, the new residents says, “I want you to set up the patient in bed 304 I'm going to do frontal lobotomy on them.”
And that's an exaggeration, of course. But the nurse needed to be able to verify somewhere that the resident had the permission to conduct this procedure at the bedside if she had any doubt. So, that was the credentialing office. At Cleveland Clinic It was Monday through Friday, 8-5. So they got dinged by JCO. “Oh, who can do credentialing? Nurse On Call.” We began to take on the credentialing line and it was just like one thing after another after another. That was just another interesting absorption that we took. And again, and it wasn't until that centralization effort came about in 2011, we had a real advocate over the contact center who listened to what we had to say and said, “This is kind of B.S. Why are we doing this? Why doesn't a physician have access after hours and they can check it remotely?” Because at that time, we started to see things sort of appearing electronically.
STEPHEN DEAN
I mean, this is something that is medically needed, but it's mostly logistical. Right? And going back to the way that how cerebral practice is, you’ve got your triage nurses not only had to keep track of all the things we mentioned before, but also look up, keep track of, and or remember, oftentimes proper escalation. So, today you have well, I mean, software can tell you who's on call without you having to look it up and do on call with the click of a button if you're going to upgrade, it prompts you for your justification, you're going to downgrade. There's only two justifications available or you shouldn't be downgrading, right? It's all kind of like taking the logistical mental space out of what has to be in their heads and putting it in front of them.
TIM OGRENTZ
I think it's important to hire the right staff who will in the time where they can't reach a physician that they won't just stay on a program of, “Oh, man, I got to get hold of this doctor.” They're kind of locked into a program of behavior versus just using their clinical judgment in the critical thinking and saying, “Okay, can't get a hold of doc, let's just send the patient to the ER.”
GINA TABONE
In my experience, the beginning of triage, the nurses were very much so generalists. We focused on primary care for most of the time at Cleveland Clinic, our biggest users of nurse triage were pediatric patients. The parents. These are our parents now that I started triaging their symptoms 20-some years ago. We have become wiser and try to eliminate external escalations because they're so time consuming. And what really makes me think about this are the specialties. Say blood and urine.
GINA TABONE
Using the Schmitt-Thompson guidelines for blood and urine for a established urology patient might be too conservative. So, I think that as we branch out and triage more and more specialties, being able to customize the guidelines for specific patients to treat them where they are in their health status right now is very important. And that is why we see and we know the value of customizing guidelines to the population you're serving and really meeting them where they are, but also helping your nurses, freeing up their time, so that the next patient that's waiting to talk to them is going to be able to be served as quickly as possible.
STEPHEN DEAN
You know, as you think back for 20-years ago to today, we're coming out of COVID. We've always had a nursing shortage. But let me tell you, it is like at another level right now, where do you see telehealth triage going in the future?
GINA TABONE
You can see I'm I'm old, I'm 65 and I was considering retiring. Oakkarr had approached me, Keona had approached me about joining their team a couple of years ago. And I had second thoughts about stepping back. Aside from believing in our product, I was finally feeling like what I had spent 20 some years doing was being recognized and validated and valued and utilized, and I can remember interviewing at one point when I was at Nurse On Call for a job in another department in an outpatient clinic at the Cleveland Clinic.
And I remember doctor saying, “So why did you leave nursing?” I remember those days when nobody had any idea what we did. It was not official nursing. I feel so positive and hopeful that it is really going to get its due. It already has its due. It's recognized, it's valued. People that have a good experience don't hesitate to call back the next time and it's just making sure that it's a good experience for the patient. They're talking to someone that they feel is caring about them. They don't have to repeat the same information over, and over, and over again.
Eliminate the frustration of this modality of care and really give them a solution. To be able to provide for every need that that patient may have at that particular time, I think in some organizations it's already here with the proper training, nurses, technology, support from above and valuation. And I think the future is just absolutely bright and hopeful for nurse triage.
TIM OGRENTZ
I would agree with that last thing you said. I think it's bright and hopeful for nurse triage. We work here and we talk with different contact centers and ops folks throughout day to day, and we do our daily work and we make little contributions, meaningful contributions. As those contributions stack up here and in other companies that eventually telephone triage will get to the place where it's just like working at the bedside, all the technical hurdles that we face in today's world, it's better than it was 20-years ago, and 20-years from now it's going to be even better so that we can focus on the patient, and the nurse patient interaction and provide excellent care. That's where I’m at.
STEPHEN DEAN
Fewer barriers. And the population of nurses that can do that grows. The population of nurses who wants to do that grows. Right?
GINA TABONE
This was so enjoyable. Yeah. We should have had a drink first.
TIM OGRENTZ
Gina, you know the old joke. I'd rather have a bottle in front of me than a frontal lobotomy.
GINA TABONE
I love that. I never heard that.
STEPHEN DEAN
Oh, fantastic. Okay, next time. Thank you again.
