Practice Tips

Ambulatory settings such as physician office practices have various levels of telephone triage that occur. Some offices have pre-recorded algorithms that direct patients directly to a licensed clinical triage staff member, while others have non-clinical staff that answer each call. No matter how your telephone systems are organized, setting up strong protocols and policies to effectively mitigate risks is a good proactive risk management approach.

Telephone triage, when done safely and effectively, improves patient access to the appropriate level of care, increases practice efficiency, improves patient satisfaction, and optimizes patient and provider communication. It is important to remember that telephone triage systems do not replace a provider's physical exam and independent professional judgment.

Develop a Clinical Triage Policy

Developing a triage policy will help ensure your processes are safe and take into consideration any scope of practice issues. Here is a sample template you could use as a guide: Telephone Triage Sample Policy. When creating your policy, at a minimum, ensure the following is addressed:

• Scope: You can choose to create a separate or one combined policy to address all the different kinds of calls that may come in that would require some level of triage. Some examples include prescription refills, appointments, recommendations on clinical follow-up, seeking medical advice, and medical emergencies.
• Purpose: Detail what the intent of the policy is for, such as improving accessibility, and prioritizing phone calls.
• Personnel:Who will be involved in telephone triage. Remember to include all staff types that may have applicability. Define qualifications by role.
• Procedures:Address on and off-hours, and any algorithms and/or protocols that should be followed.
• Documentation: Detail how and where the documentation should occur for each staff member involved, from the front office staff to the provider.
• Compliance: Remember to include quality improvement activities so the telephone triage process is measured appropriately for outcomes and opportunities for improvement.

Develop Clinical Triage Protocols and Algorithms

There is much to consider when putting together telephone algorithms and triage protocols.  Here are some guiding principles:

• Develop a visual algorithm that follows a call from start to finish to aid all disciplines in understanding their role and expectations. Here is a sample you could use as a guide: Telephone Triage Algorithm
• The staff who obtains the clinical data during the interview, if not licensed, must have a yes/no algorithm and always be able to engage the provider for assistance.
• Triage systems that involve screening of patient symptoms and subsequent clinical advice should utilize a licensed staff member, such as a registered nurse, with the appropriate background, training, and clinical experience. The nurse should utilize written clinical protocols to guide this process.
• Triage systems for offices that staff only unlicensed medical assistants, with no licensed clinician other than the provider staff, should have protocols in place that guide how clinical and non-clinical questions are addressed. The role of the medical assistant in the office practice setting has expanded, so established protocols should be specific to this role and scope of practice.
• Because the physician is ultimately responsible for any information staff provide to patients, written triage protocols must be reviewed and approved annually by the physicians. Retain a copy of the approvals and protocols.

Other Considerations

• Educate patients regarding your telephone triage practices so they know which topics can be handled via triage (such as refills and follow-up questions), what requires an appointment (new symptoms), and what is considered a medical emergency (911 phone call in place of calling the office).
• Provide staff training and education upon hire and annually (or more often if needed). Education should include a competency specific to telephone triage. All competencies should be documented and retained within the staff’s HR files.
• Standardize documentation through the use of templated telephone encounter note types.
• Monitor all triage practices on a regular basis. Complete documentation audits, seek feedback from patients, and look for opportunities for improvement.

When opportunities for improvement are identified, utilize a structured method, such as Plan-Do-Study-Act (PDSA) to implement and monitor system/process changes.

Minimize Professional Liability

A telephone consultation poses the same level of professional liability risk as a physician office visit. The duty to provide care is legally established from the moment the patient seeks advice. Minimize professional liability by practicing the following:

• Utilize written protocols as an adjunct to, not a replacement for, critical thinking and clinical decision-making.
• Return patient calls in a timely manner according to defined parameters and inform patients when to expect a call back.
• Require provider review of triage documentation as defined by policy, including time, date of the review, and provider signature. In the EMR, ensure the system reflects the provider's acknowledgment of the triage documentation.
• Advise the patient when to call back or when they should seek emergency care, such as calling 911 or presenting to the emergency department.
• Use a standard format, such as teach back, to ensure the patient understands the advice given. This should be part of the standard documentation for all triage encounters.
• Document all telephone communications immediately.
• Document an when deviation from written protocols occurs.

Resources

ECRI. (2023, December 19).  Triage, Resource Collection.ECRI.

Last updated: 2/22/24