I am glad the one you reported is excellent. Seems all are not the same as these RNs and patients report:
Posted on Sat, Aug. 09, 2003
CRITICS HUNG UP OVER KAISER'S CALL CENTER
By Judy Silber
CONTRA COSTA TIMES
Kaiser Permanente's system for handling member phone calls threatens patient care by giving too much responsibility to operators who are unqualified to evaluate medical needs, critics of the health care provider say.
"They (operators) are practicing nursing without a license in some instances," said Jim Ryder, Kaiser division director for the California Nurses Association.
The call centers Kaiser uses to answer about 1 million calls a month have improved patient care by reducing the amount of time members wait on hold, said Tom Driscoll, regional operations director for Northern California's call centers.
Driscoll admits the centers are imperfect. But he points out that in recent years, the number of complaints about the call centers has declined. An investigation by the California Department of Managed Health Care also found no obvious problems and cited Kaiser's call centers as possible models for the industry.
Critics contend the call centers still have major flaws. Most glaring, they say, is that operators are only required to have a high school education and have little medical training, not even in medical terminology. Yet members must speak to them and answer questions about their conditions if they want to make an appointment, connect with their doctor, receive advice from a nurse or get directions to a Kaiser facility.
Three Northern California call centers -- in Vallejo, San Jose and Sacramento -- serve most of the region's 3.2 million members. With the exception of patients receiving specialty care and those at some Kaiser facilities, members are connected to a call center when they phone a number listed at the front of Kaiser's patient guide book. By the end of the year, all of Kaiser's facilities will use the call centers.
Callers are given several options on a voice mail menu when they phone the centers. But other than by calling after hours or booking appointments online, there's no way to bypass the operators.
The voice mail menu that greets callers does offer an option to speak to an advice nurse. But except between 10 p.m. and 6 a.m. when nurses pick up all calls, operators always answer those calls first, asking questions before transferring callers.
Operators' questions are more than a mere nuisance; they amount to practicing medicine without a license, Ryder and others said.
Prompted by a computer program called a script, operators query patients about their injury or illness, checking "yes" or "no" boxes as they go. The script instructs operators on what to do with a patient -- whether to book an appointment, take a message for the doctor, or transfer the call to an advice nurse.
The scripts are written by doctors, but the operators put them into action. For each caller, operators must choose the appropriate script. However, if a member mentions one of 15 emergency symptoms such as chest pain, operators immediately transfer the patient to the front of the waiting line for a nurse.
The California Nurses Association argues that registered nurses should answer all incoming calls. That way patients will receive the most appropriate and timely care, it says. That will mean more nurses at the call centers and an increase in membership for the CNA.
"That person who answers the phone, in a roundabout way they're making medical decisions," said Gayle Moore, a former Vallejo Call Center advice nurse. "That's my beef. They should be making no medical decisions whatsoever."
The critics also object to Kaiser's title for operators: health care contact specialist. It's deceptive and suggests operators are professionals who can give medical advice, Woods said.
Kaiser makes no apologies about the titles and its use of operators. The three call centers were set up in 1997 and 1998 to improve phone service and they've done just that, Driscoll said.
For one thing, he says, they're convenient. By phoning one number, members can book an appointment, connect to the pharmacy or ask advice from a nurse on the most mundane or serious of medical problems, any time of day or night.
"Minimally, members want appropriate care in a timely manner," Driscoll said. "A better way is to work through the (call centers)."
And the title, he said, describes the job.
Before Kaiser started the call centers, patients complained of long wait times. Now, operators -- whose pay averages from $14 to $16 per hour -- generally answer the phones in 45 seconds on average, he said.
As an added benefit, the call centers can monitor infectious disease outbreaks and alert Kaiser doctors, sometimes faster than county public health departments.
It's just not practical to have nurses answer all calls, he said. More than 1,200 operators and 800 advice nurses work at the three call centers. It's already hard finding nurses to fill those available positions.
Besides, Driscoll said, most calls don't require a medical professional. Often members simply need directions, or already know they want an appointment. Operators can easily deal with these calls and pass on all others.
And if operators don't deliver what a patient wants, patients can always ask for an appointment or to speak with an advice nurse, Driscoll said. He insists the system increases efficiency.
An unscientific survey of Kaiser members in Walnut Creek found some who are satisfied with the call centers. "I love everything about Kaiser," said William Francis, a Walnut Creek resident and a Kaiser member for nearly 47 years. He and his wife have always received the care they needed, he said.
Other Kaiser members are less complimentary.
They say they don't like relaying their personal information to operators. Some say they've been hung up on when they refused to answer operators' questions. Messages to doctors went unanswered. Wait times for nurses on busy days during peak operating hours can also be long. And they complain the system can obstruct their access to care.
Suffering from a chronic pain condition called fibromyalgia, Sheila Ganey at one point phoned the call centers nearly every other day.
She left messages for her doctor with operators, who sent them to him. Sometimes, he called back. Other times, he didn't, forcing Ganey to call again.
Ganey resented operators' questions. For example, when she had pneumonia and was coughing blood, they asked, "How much?"
Nurses, who look at the script an operator has chosen once calls are transferred, complain that operators often pull up the wrong scripts, asking inappropriate questions.
So nurses have to start all over again. Tired of answering questions, patients grow impatient.
Nurses have a more sophisticated perspective on patient problems than operators, said Moore, the former call center nurse. That can lead to different outcomes for patients.
She gives an example: Say an 80-year-old requests an appointment because he has a really bad cold. The operator will make the appointment for the following day if that's what's available. Nurses will do a more careful evaluation, Moore said. They will take into account the patient's age, their medical history, if anyone is at home to help take care of them, and then decide how soon the patient needs an appointment, she said.
Some operators agree with the nurses' criticisms.
"In my opinion, when the nurses say the (operators) are making medical decisions, they are," said Ellen Weaver, a former operator who quit the Vallejo call center in May 2002.
Arriving at the correct outcome for a patient required some medical knowledge because it wasn't always clear which script to pick, Weaver said. "Sometimes the thing they're talking about is not in the place you first think to look," she said.
In addition, callers sometimes ask for medical advice because they assume operators are nurses.
Driscoll emphatically denies that operators place patients at risk. Computer scripts -- not operators -- assess patient needs, he said. Operators may receive only a few weeks of computer training. But because the call centers receive so many calls per month, operators quickly learn through experience which scripts best fit a caller's conditions, he said. To make sure they're doing a good job, Kaiser randomly screens a few thousand calls per month.
Driscoll is the first to say the call centers are a work in progress. In 2000, Kaiser recorded 2,482 complaints. Patients grumbled about discourteous staff, too much time on hold and a lack of appointments. By 2002, the number of complaints had decreased to 335.
However, even today, about 20 percent of the time, patients can't get appointments when they want them, Driscoll said. As a result, operators must send computer messages to doctors, flagging more critical cases so that doctors can squeeze patients into their schedules, if necessary.
A bonus program for operators also provoked outrage. The program, in place from January 2000 to December 2001, rewarded operators who kept calls to a minimum time, transferred less than 50 percent of calls to nurses and booked appointments for only 15 percent to 35 percent of patients. Kaiser discontinued the program because it didn't improve service, Driscoll said.
Even with the improvements, nurses say there are still problems.
They complain the call centers overemphasize efficiency. Each call is timed. Supervisors reprimand operators whose averages exceed about 4 minutes, or nurses whose averages are more than 81/2 minutes.
Nurses and operators are segregated, prohibiting any possibility for team work. Nurses aren't allowed to speak in any language other than English, even if they're bilingual. In addition, Kaiser strongly discourages nurses from calling patients back to make sure they're all right.
"I know a lot of these problems are not the fault of the call center. It has to be done in a systematic way, otherwise there's chaos. But these are the areas that cause nurses to feel depressed and helpless, and they really need to fix those," Moore said.
Driscoll said nurses must speak in English because right now there's no way to assess competency in other languages. As for callbacks, he said it's the physician's responsibility to follow up on cases.
However, this policy is in contrast with those at other call centers. For example, nurse advice lines run by McKesson Health Solutions for some of the country's largest HMOs allow nurses to check on patients in certain cases.
Concerned about operators' roles in Kaiser's delivery of care, state Sen. Debra Bowen, D-Redondo Beach, has introduced a bill aimed at limiting operators' duties.
The bill states that operators may gather information about patients' conditions, but must give it to a licensed professional for assessment. It has cleared the Senate and will be heard by the Assembly Appropriations Committee on Aug. 20.
The bill follows another passed by the California Legislature in 1999 explicitly stating that only licensed medical professionals can give telephone advice.
The roots of both bills lie in part with the case of Margaret Utterback, who died in 1996.
It was before Kaiser had set up the call centers. Medical assistants, who have some medical training, answered the phones at Kaiser Hayward's facility when Utterback called at least five times on Jan. 26, 1996.
Terry Preston attributes her mother's death to the delay in care that resulted because medical assistants didn't realize the severity of her mother's condition.
Utterback, too, didn't recognize the severity of the crisis. Medical assistants didn't tell her to head to an emergency room. And she couldn't get an appointment with her doctor until late in the day. Thirty-six hours later, an abdominal aortic aneurysm ruptured and Utterback, 74, a Kaiser member for more than 50 years, died.
Kaiser never admitted medical wrongdoing. However, the HMO paid a $1 million fine to the Department of Managed Health Care in November for the Utterback case.
Preston is angry that rather than fixing the problem, Kaiser has instead given more responsibility to operators who have even less training than the medical assistants who answered her mother's calls.
"I keep shaking my head," Preston said. "We get a law passed, and then they establish this program that doesn't even have medical assistants. It's high school graduates."
Kaiser says it has no problem with either the present law or the pending bill. Again, the HMO insists that nurses and doctors, not operators, evaluate patients' needs.
"We're providing superior service," Driscoll said. "With our call centers, I think we make less mistakes."
BY THE NUMBERS
Kaiser's three call centers:
* Handle 1 million calls a month;
* Employ 1,200 operators and 800 nurses;
* Serve 3.2 million Northern California members;
* Received 2,482 complaints in 2000
* Received 335 complaints in 2002
* Operate 24 hours a day, 7 days a week;
* Generally answer calls in under 45 seconds.