Utilizing Peer Review to Minimize Risk in a Medical Call Center
By: Mark Dwyer, Chief Operations Officer, LVM Systems, Inc.
Peer review examines the quality of nursing care in terms of structure, process, and outcome. The American Nurses Association (ANA) describes peer review as the process by which practicing registered nurses systematically assess, monitor, make judgments, and provide feedback to peers by comparing the actual practice to established standards. In the context of a professional nursing practice model, the expected outcomes of this process include increased professionalism, accountability, autonomy, retention, improved communication skills, and quality outcomes.
Let’s look at how this applies to assessing nurse triage calls in a medical call center. The process begins with selecting triage call records from a date range for peer review based on various triage data elements. Data points such as the triage date, triage nurse, guideline used, and disposition level are some of the standard selection criteria. Once the appropriate records are selected for review, they are typically assigned to a queue for an immediate review or later when time permits. (Note: when conducting the peer review, the nurse reviewer must have access to both the written and, if available, audio call record.)
As the nurse conducting the peer review begins the process, she accesses the original triage call record to identify the nurse who handled the call, the patient’s birthdate and age, the date and time of the call, and the guideline used. This is also when the nurse reviews the original triage details, specifies the review type and may indicate if the call is part of a quality improvement (QI) project. Having reviewed the triage details, the nurse reviewer identifies the disposition selected during the original triage call. Suppose the reviewer believes the disposition was under-referred or over-referred. In that case, the call is passed to QI management for the QI manager to determine the reason for the inappropriate referral. Some of the common reasons resulting in an under or over-referral are:
Incomplete assessment or not enough objective data
- The nurse did not recognize a serious symptom
- Wrong guideline used
- The nurse did not adhere to the guideline
- Inadequate interventions tried at home
If the call includes an audio recording, a separate set of questions is used to evaluate the triage assessment. These include, did the nurse:
- Use two patient identifiers
- Review the patient’s health history
- Identify the main or most serious complaint
- Assess the severity of all symptoms
- Evaluate the guideline questions sequentially until reaching a positive response
- Ask the caller if they understand the instructions
A thorough peer review of the audio recording must also include questions to assess the nurse’s level of communication and customer service, time management, and written documentation. Assessing the nurse’s level of communication and customer service is done using a 3-point scale (3 = excellent, 2 = good, and 1 = room for improvement). The nurse should:
- Develop a rapport with the caller
- Demonstrate advocacy for the patient and family
- Use open-ended questions throughout most of the interview
Additional considerations evaluate time management. These include:
- Time progression of the call
- Maintained control of the call
- Redirected the caller as needed
The nurse reviewer then assesses the written documentation to determine if it aligns with the audio recording and is complete and whether, in the reviewer’s opinion, the triage nurse selected the most appropriate guideline and disposition. Again, if the reviewer believes the disposition was under-referred or over-referred, the call is passed to QI management for the QI manager to determine the reason for the inappropriate referral. Finally, to assess the outcome of any emergency department (ED) or urgent care center (UCC) referral, if the referral, in the reviewer’s opinion, was an under or over-referral, a unique set of questions enable a QI review by the medical director. For example:
- Did the patient’s overall clinical picture suggest the need for an urgent visit to rule out serious differentials?
- Was the patient seen within the appropriate time frame?
- Did the patient receive interventions that couldn’t have been done at home?
- What was the patient’s most significant diagnosis?
If the medical director agrees that the call resulted in an under or over-referral to the ED or UCC, she tracks the appropriate disposition and indicates the reason for the incorrect disposition. After completing the assessments, monthly results are shared with the reviewed nurses providing feedback on ways to offer better telephone triage services. The manager also runs reports to quantify departmental results. Using this information enables the manager to conduct remedial training as appropriate. An effective peer review program allows for a formal approach to performance analysis and the systematic and continuous actions that lead to measurable improvement. Following a nurse review process like this one enables the medical call center to minimize its overall risk.