Risk Management

Telephone Screening as a Risk-Reduction Tool

Anne M. Menke, RN, PhD

OMIC Risk Manager

Digest, Winter 2004

Each day, countless patients call ophthalmologists to report problems and seek advice. During these telephone conversations, the health care team does not have access to the wealth of information obtained from face-to-face communication and physical examination of the patient. After hours, the patient may be unknown to the ophthalmologist and the chart unavailable. OMIC claims experience confirms that making medical decisions on the basis of the limited information obtained over the telephone is a risky – albeit necessary – aspect of ophthalmic practice.

To promote both the continuity and defensibility of telephone care, OMIC has developed sample telephone contact forms and screening guidelines, which are available online at www.omic.com or by calling (800) 562-6642, ext. 652. This article provides risk management recommendations on how to develop and implement a screening protocol based on using these contact forms and guidelines.

First and foremost is to exercise the same care when treating a patient over the telephone as you would during an office visit: (1) gather the information necessary to assess the situation and determine the treatment plan; (2) communicate the assessment and treatment plan to the patient; and (3) document the encounter and decision-making process in the medical record. To safely enlist your staff’s assistance in gathering information, develop and implement written protocols for telephone screening and treatment that are specific to your patient population, subspecialty, and staff. Supervise staff members who screen calls. In addition to developing and approving written protocols, effective supervision includes: (1) training and verification of competency; (2) willingly accepting questions from staff members unsure of how to handle specific calls; (3) daily review of telephone calls; and (4) periodic review of the screening protocols themselves.

Staff Scope of Practice, Qualifications, Training

Ophthalmologists are fortunate to employ staff members with detailed knowledge about ophthalmology who have undergone extensive training and certification; however, patient safety concerns and the laws governing the practice of medicine place limits on the tasks non- physicians can perform. The role of non-physicians in screening ophthalmic problems consists of gathering information in order to assign an appointment category. They cannot diagnose or treat a condition or provide medical advice; all medical decisions must be made by the ophthalmologist.

Instruct staff members not to minimize patient complaints or provide false reassurance. Handle with care patients who are concerned about their condition and are not satisfied with the type of appointment given. Juries are not sympathetic when a patient with significant vision loss testifies that she begged the receptionist to be seen right away but was told that nothing serious was wrong. Encourage staff to consult with you any time questions arise. Examples include complaints that are not listed in the screening guide, complaints that fall into more than one appointment category, and patients with routine complaints who want to be seen the day they call. In general, err on the side of patient safety when assigning an appointment category.

Take into account the language spoken by the majority of your patients. It might seem obvious, but only authorize staff members with the necessary language and communication skills to screen ophthalmic problems over the phone. Such skills include patience, cheerfulness, compassion, clarity of enunciation, and professionalism, as well as a willingness to abide by the guidelines and seek help whenever needed. Ensure that telephone screening is included as a job responsibility in the employee’s job description. Provide training to staff members who handle patient calls, and evaluate their competency in applying screening guidelines before allowing them to implement the screening protocols.

Customize Protocols to Your Practice

OMIC sample telephone contact forms and call screening guidelines do not cover all possible patient complaints and may not apply to every situation. Customize them for your practice and subspecialty; approve the final, written version; and implement them only after extensive staff training. Review the protocols regularly (annually or when there are practice changes) to assure that they still meet the needs of your patients and practice. Include in the protocol how you want staff to address two common situations that have led to delay in diagnosis claims: same day appointment requests and new patients. Ask your staff members to inform you of a patient’s desire to be seen the same day, and make every effort to accommodate the patient’s wish. If you cannot see the patient when the patient wants to be seen, speak to the patient and carefully screen the call to determine the cause of the patient’s symptoms and concern. Suggest alternative sources of care. Remind patients of their right to seek emergency care at a hospital if they feel they have an emergency medical condition. Keep in mind, however, that many emergency departments may not be equipped to carefully evaluate ophthalmic complaints. Direct the patient to a source of care that is likely to prove beneficial.

Indicate in the protocol whether or not your practice accepts new patients and how to handle calls from new patients if it does not. For example, have staff members first ask callers if they are a current patient. If the answer is no, have staff members inform the caller that the practice does not accept new patients, and offer them the names of ophthalmologists in the area who do. Do not discuss callers’ conditions or complaints if you are not available to accept them as patients. Once adapted to the individual practice and approved by you, post the guidelines by the phones of all staff members who answer calls. When guidelines are updated, note the new revised date and keep a copy of all former versions in case prior care and screening are ever called into question.

Indicate in the protocol whether you want to be notified of emergent appointments, and what to do if the patient asks to speak with you. Address how you will supervise non- physicians who assist in telephone screening.

Screening, Documenting Calls During Office Hours

The OMIC sample telephone contact form (Figure 1) prompts staff members to gather information that will be used to determine the timing of the appointment: emergent, urgent, or routine. On the sample screening guideline (Figure 2), patients with emergent conditions are told to come in or go to the ER immediately. Urgent patients are seen within 24 hours in this guideline, but you may wish to see these patients the same day. Patients assigned a routine category are given the next available routine appointment.

If the patient’s complaints fall into more than one appointment category, assign the quickest category. For example, if the patient complains of discharge that causes the eyelids to stick together (urgent appointment) and mild ocular irritation, itching, and burning (routine), give the patient an urgent appointment. If the patient has any complaint that falls into the emergent category, give an emergent appointment.

Document all patient care-related calls in the patient’s medical record. Some practices may want to use a telephone contact form that prompts staff members to ask questions and documents the answers on the same form (the sample provided is designed for ease and speed of documentation by allowing staff members to circle answers instead of writing them out). Other practices may choose to provide staff with a list of questions to ask (such as the ones on the sample contact form) but chart only the pertinent information, either in the progress notes or on a phone message slip that is taped into the medical record (e.g., “10/1/03 11:15 am. Mary Smith called to report sudden onset of ‘flashing lights’ and ‘floating things’ OD. Had cataract surgery OD on 8/15/03. Given emergent appointment for today at 1 pm. AMP, receptionist”).

Staff members will understandably be concerned about the time required to screen calls using these suggestions. Not every phone call will require asking every question. Rather, the patient’s complaint will determine the extent of the screening process. For example, as soon as enough information is obtained to categorize the appointment as emergent, no more information needs to be obtained since the patient will be asked to come in immediately. Differentiating urgent from routine problems will take more staff time and effort and may require asking all or nearly all of the questions. The time spent carefully screening calls is time well spent, however, if it preserves a patient’s vision.

Review, date, and initial all calls on a daily basis. This provides a safety net for patients and documents the supervision of your staff. Regardless of the type of appointment, file all telephone contact forms in the patient’s medical record.

Screening, Documenting Calls After Hours

While these guidelines are designed for use during office hours, your after- hours and on-call telephone contacts with patients or other caregivers also need to be carefully screened, handled, and documented. OMIC claims experience includes multiple cases where the ophthalmologist’s only involvement in a patient’s care was an undocumented after-hours contact or prescription refill.

A sample after-hours form is included on the web site that prompts you to ask about recent procedures or surgeries and whether the patient has contacted other health care providers about the same or related problems. Compact Patient Care Phone Call Record pads also can be obtained from OMIC and kept in your car, purse, briefcase, or locker. Once you return to your office, place the contact form in the patient’s medical record. If you provide on-call coverage for a physician in another practice, fax a copy of your contact form and records to the other physician and retain the original in a file designated On-call Coverage Contacts.