Running head: LEADERSHIP STRATEGY ANALYSIS

Nursing Leadership and Innovation: Introducing a Telephone Triage System

Ronda Mott
Ferris State University

LEADERSHIP STRATEGY ANALYSIS

Nursing Leadership and Innovation: Introducing a Telephone Triage System

Nursing practice as a profession has been lifted far beyond its antecedent roots at the
bedside not only as a consequence of the development of formal nursing research and design but
perhaps more so from the advent and focus on quality improvement and patient safety. In the
same ways that clinical excellence and patient advocacy are bedrocks of the nursing profession,
the commitment of nursing leaders, administrators and practitioners to an environment of quality
and safety is now an established pillar and critical underpinning of what defines contemporary
nursing practice. These conclusions harmonize with the Quality and Safety Education for Nurses
(QSEN) educational mainstays of promoting: 1) quality and safety, (Cronenwett et al., 2007)
and American Nurses Association (ANA) standard No. 8 (American Nurses Association, 2010, p.
49) and 2) incorporation and use of infomatics to administrate care and evaluate performance
(Cronenwett et al., 2007) and ANA standard No. 14 Professional Practice Evaluation where the
nurse is responsible for attaining and maintaining the knowledge, certifications and skills within
the defined scope of care and to evaluate professional practice in regard to constructive feedback
from non-nurse colleagues, individual decision making, in order to promote patient safety and
ethical practice (American Nurses Association, 2010, p. 59).
Clinical Need
The clinical problem identified that deserves a nursing researched, evidence-based
solution is that our radiation oncology practice lacks an effective telephone process for managing
the daily needs of a diverse patient population. Currently, clinic calls are screened by front desk
secretaries, who lack the clinical knowledge and assessment expertise to ascertain the needs of
patients and how to manage the issues that arise. Frustration develops, patient safety may be
compromised and time is wasted due to the inefficiency in connecting patients to office resources

LEADERSHIP STRATEGY ANALYSIS

or the appropriate office personnel (physician, therapist, nurse) to meet their needs. Therefore, a
need exists to establish a single, standard, effective phone triage practice to maximize
communication, save time, enhance the continuity of care, assure patient safety and improve
outcomes and satisfaction. The clinical question to be answered from this problem is: Would a
standardized registered nurse (RN) telephone triage process maximize intra-office
communication and improve patient outcomes, safety and satisfaction for a diverse, outpatient,
radiation oncology patient population?
To address this clinical problem, the nursing literature pertaining to the question was
examined. The database search engine supported sites of CINAHL, PUBMED, AHRQ and
Cochrane Reviews were queried with the input terms oncology telephone triage and nursing
telephone triage ambulatory oncology clinic. In order to tailor the research results to the
clinical question specifically, several inclusion criteria were applied to the query results
consistent with those endorsed by Nieswiadomy (2012) for uncovering question specific nursing
literature.
According to Nieswiadomy (2012) preferred literature results constraints included those
sources which are 1) published within ten years, 2) specific to ambulatory or oncology nursing
scope of practice, 3) authored by nurses or other professionals with credentials in oncology
practice administration and management, 4) published in peer reviewed nursing resources, 5)
sources that could offer a turn-key approach to protocol implementation that supports a proven
system or theory of phone triage already prevalent within the scope of care (i.e. the nursing
process.)
The literature results in general defined telephone triage as the safe, effective, proven and
appropriate method for the disposition of health related problems via telephone by experienced

LEADERSHIP STRATEGY ANALYSIS

RNs using approved guidelines and protocols. In specific, the Flannery, Phillips, and Lyons
(2009) study defined telephone call volume and distribution in an active ambulatory oncology
practice; described patient phone caller type and reason for the call; examined differences in call
volume by practice characteristics and validated investigator developed tools used to collect data
on telephone call content and patient demographics. Finally, this study data demonstrated the
impact of telephone calls on ambulatory oncology practice such as time required to satisfy
patients, RN workload, the actions required to manage phone calls and the characteristics of a
patient subgroup whose needs can be met by repeat calls, rather than home and clinic visits
(Flannery, Phillips, & Lyons, 2009). According to Gleason, Brennan O'Neill, Goldschmitt,
Horigan, and Moriarty (2013) work identified a reliable ratio between clinic appointments and
the number of call and the average time spent on triage calls. Further this study concluded that
despite the enhanced communication and patient satisfaction, a triage process geared to high
volume practices requires an additional 16.4 hours per day of nursing time. This work further
identified the educational needs of RNs who do phone triage, while designing strategies to
educate on phone triage skills, particularly, nursing comfort, critical thinking and triage decision
making. A study was done where Gleason et al. (2013) clarified the need to standardize phone
triage practice and insure effectiveness through tailored RN education. According to Hickey and
Newton (2013) the textbook, a general guide for oncology nurses using telephone triage includes
a treatise on the history and development of phone triage as a patient management tool, its
importance in current practice and how to instruction on phone assessment, communication and
documentation. It serves as a primer for developing a formal working practice model for
oncology outpatient practices. On the other hand, Bunn, Byrne, and Kendall (2005) work
assessed the effects of telephone triage on patient safety, service and patient satisfaction. They

LEADERSHIP STRATEGY ANALYSIS

documented that half of clinical matters could be handled by phone, still satisfying patients with
no evidence of an increase in adverse effects or need to use other services. Lastly, Towle (2009)
editorial review assumes oncology practices must have phone triage processes and comments on
the logistics of phone triage methods and styles. The author offered views on key metrics in
critiquing a phone triage process (time spent per call, time to return a call, chart retrieval and
relay to appropriate patient responder, etc.) and the pros and cons of using different types of
triage interfaces (live operator versus electronic voicemail) and values of each (Towle, 2009).
In summary, the current nursing literature provides scientific and evidence-based support
for oncology practice telephone triage guidelines and protocols. The literature also provides
navigation through the challenges, educational requirements, implementation strategies,
assessment tools, metrics, benefits and stakeholders pertinent to the development and
administration of a telephone triage system for outpatient oncology practices.
Interdisciplinary Team
Consideration from an interdisciplinary team of vested stakeholders would be necessary
for the study and ultimate implementation of a new telephone triage process. According to
Hickey and Newton (2013) and Towle (2009) speak to the staff role interdependence that creates
efficiencies for the various office roles involved (nurse, clerical, records retriever, patient
responder, etc.) and results for the most important stakeholder, the patient. Because our practice
takes a considerable number of daily calls (average 30-40 per day in an 8 hour day) and qualifies
as a high-volume practice (Gleason et al., 2013) an effective telephone triage process would
not only impact but require the buy in of patients, physicians, nurses, therapists, practice
managers and the clerical staff. Patients, as the end consumers of the services, are immediately
influenced by phone triage quality of care and communication and arguably will be a new

LEADERSHIP STRATEGY ANALYSIS

systems most valued critics. Nurses, who remain the physical interface between the practice and
patients, share directly in a new systems promise to better stratify workflow and solve the
growing nursing dilemma of increasing nursing demands with unpredictable workload. As well,
nurses will be the chief change agents facilitating the new process for the practice. Physicians,
who are directly charged with the ultimate responsibility for patient outcomes, should support a
triage platform that steers them toward physician essential patient interactions. Further,
physicians would likely value the ability to effectively manage patients by phone with no adverse
effects and equal if not improved satisfaction, in lieu of a clinic visit. Therapists, who in our
practice are charged with administering radiation treatment, should experience fewer scheduling
conflicts and office interruptions during treatment due to better management by phone of
patients peripheral issues. Finally, clerical staff should be relieved from the current burden of
having to provide responses to patients that are outside of their areas of expertise and the task of
choosing the correct patient responder (i.e. nurse, physician, therapist, office manager) for a
specific call, which dilutes their clerical focus. In summary, with all staff stakeholders currently
unified in a desire to provide top tier care for the most vital stakeholder (the patient) and each
motivated by the individual benefits just outlined, no clinical obstacle toward guideline driven
telephone triage appears to exist.
Data Collection Method
The best method supported by the literature for collecting telephone call volume and
distribution data for our practice is the descriptive retrospective design method. According to
Flannery et al. (2009) supported this method for accurately analyzing oncology practice phone
calls over a four month time frame suitable to obtain a representative sample of typical practice
calls. However, high volume practice settings (thirty or more calls per day) might achieve a

LEADERSHIP STRATEGY ANALYSIS

sufficient sample in a shorter period. Data collection would be facilitated using Flannery et al.
(2009) two validated, investigator developed tools (telephone call recording instrument and
demographic or medical data instrument) to measure current practice metrics including: total
volume of patient calls received per day; distribution of calls over the time of day; type of caller;
reason for the call; time spent per call; time to return a call; time spent retrieving a record and
assigning appropriate patient responder (nurse, physician, etc.); method and time to document
the call, number of hours and types of action required for RN phone management. Staff
requirements to facilitate data collection would include at least one RN using investigation tools,
one clerical staff as timer or recorder and one staff person from the institutional quality or
information technology (IT) departments to collate or graph data per day. Each person on this
team would function in the data collection capacity on their respective day of normally scheduled
work, ensuring that all staff within these roles is involved in the process. In this process, the
nurse acts as the change process agent, responsible for supervising, monitoring and encouraging
the data collection work of clerical, quality and IT staff efforts while anticipating and removing
barriers that might hinder progress (i.e. push back from staff for adding the data collection duties
to other routine work load.) Further, physicians and therapists who may initially find themselves
burdened by the data collection period as a short term challenge to daily efficiency, should be
encouraged and challenged by nurse facilitators to refreeze their attitudes (Yoder-Wise, 2014,
p. 327) by integrating the process into their thinking and daily routines in preparation for the
long term gain expected from a future working telephone triage process. An applicable
leadership theory to employ for staff both during data collection and after phone triage
implementation is Organizational Behavioral Modification, in which the nurse leader seeks
feedback and uses positive reinforcement to motivate constructive behaviors and negative

LEADERSHIP STRATEGY ANALYSIS

reinforcement to dissuade negative behaviors and attitudes during the process (Yoder-Wise,
2014, p. 11).
Established Outcomes
The current literature touts many evidence supported outcomes as a consequence of a
telephone triage system in the areas of office efficiency, patient safety, nursing readiness and lack
of adverse events related to phone management. The chief standard of care goal for
improvement for our practice would be to reduce the total time (sum of the time to receive,
process, chart review, assign to responder, answer and document) of a patient initiated call to
under twelve minutes. According to Flannery et al. (2009) demonstrated that the average time
spent on a triage call is twelve minutes per call. Despite the enhanced communication and
increased satisfaction, a triage process geared to high volume practices like ours (30-40 calls per
day) may require as much as 6 to 7.5 hours of additional RN nursing hours for current needs
using a twelve minute benchmark in an 8 hour clinic day (Gleason et al., 2013). Given the
unlikely scenario of adding an additional RN to the team just to handle phone triage, reducing
this benchmark without sacrificing other valuable outcomes is the most efficient, immediate
strategic goal based in evidence-based practice, for our phone triage process.
Implementation Strategy
An applicable and potentially effective linear theory or process for planned change and
implementation of a telephone triage process in our office setting is Havelocks Six Phases of
Planned Change (Yoder-Wise, 2014). According to Yoder-Wise (2014, p. 328) the theory
assumes that change can be planned and implemented in six stages, as a rational problem solving
process, particularly useful for low level, low-complexity change. In that the proposed
implementation of a phone triage process proposes change in a single office departmental setting;

LEADERSHIP STRATEGY ANALYSIS

among not more than twelve employees; involving a process for which the rudiments are
currently being practiced; between a group of individuals in close relationship and already
sharing a commitment to top tier care of clinic patients, this model gives direction for the low
level, incremental transition envisioned. Further, according to Yoder-Wise (2014) the model
emphasizes the importance of effective change agents (in this case the RN staff) in successfully
establishing a new innovation to solve an identified problem. Stages 1 and 2 have been
addressed in that a close knit group of professionals, already with established working
relationships have already acknowledged and diagnosed the significant disadvantages that the
lack of a nurse driven phone triage process holds for the practice now and in a future of planned
clinic growth. Stage 3 requires the acquisition of relevant sources pertinent to the diagnosed
problem, followed by Stage 4 which requires choosing a solution. Having already framed the
clinical question, researched the literature, identified the evidence to pilot a phone triage process
and shared it with the team of stakeholders, stages 3 and 4 are completed. Unlike any other time
in nursing practice, is the growing need to bring the nursing viewpoint in defining and solving
clinical problems in the practice setting (Yoder-Wise, 2014). Previously, a seasoned nurse
clinician with years of clinical experience could often be a potent change agent for the nursing
point of view based on experience alone. With Yoder-Wise (2014, p. 328) the model hinging on
the strength of the change agent a research qualified nursing perspective is not only the most
persuasive in winning agreement with peers and coworkers but is most welcome when
collaboration is necessary for innovation. Finally, stages 5 and 6; gaining acceptance of the
triage process and stabilizing the new innovation; in practice pivot on nursing staffs ongoing
efforts under Organizational Behavior Modification principles to identify the positive results for
patients and team stakeholders, seek stakeholder feedback, monitor for and employ necessary

LEADERSHIP STRATEGY ANALYSIS

10

adjustments, dissuade negative attitudes and reinforce individual team member buy in, until
change becomes standard practice (Yoder-Wise, 2014).
Evaluation and Measuring Improvement
Evaluating and measuring improvement is an essential function in change management
(Yoder-Wise, 2014, p. 330). The evaluation and monitoring of the benchmark metrics in the
phone triage process are elucidated in the work of Flannery et al. (2009) and serve as a ready
guide to how effective the actual exercise in triage is or is not. However, evaluating the
transition to this new practice requires that as many affected stakeholders as possible should
remain involved in the evaluation process. According to Yoder-Wise (2014, p. 331) evaluation
includes continually assessing the change process to determine whether progress toward defined
goals is acceptable or needs revision. In evaluating the implementation and effectiveness of the
phone triage process, the RN staff as change agents continue to monitor and collect data on the
desired metrics agreed to for the practice. These data would be publically posted in our practice
for all stakeholders on a weekly basis for general review and to assist the nursing staff in
recognizing and making necessary changes more immediately. According to Yoder-Wise (2014,
p. 332) public posting of data reinforces that the change is underway and communicates a vested
interest in the groups effort, which is consistent with Hirschhorns military campaign approach
to change evaluation, where a public space for information and resources about the change
symbolizes to all that the telephone triage process is moving forward. Further, according to
Yoder-Wise (2014, p. 331) effective change requires continuous feedback about the progress of
the change process. The setup of an anonymous feedback board for staff maximizes obtaining
untainted, accurate and actionable criticism on the progress of the utilization of the phone triage
process. Although discussions on the change process will likely be the subject of staff meetings

LEADERSHIP STRATEGY ANALYSIS

11

and day to day discussions, the feedback board capitalizes on cybernetic theory to access
negative feedback which can drive course corrections in the change process (Yoder-Wise, 2014,
p. 331). Finally, requesting patient and family feedback on the triage process through survey or
direct interview can be used to reemphasize the values that underpin the change (i.e. patient
satisfaction, higher care quality, safety) and the benefit for staff stakeholders, all consistent with
marketing campaign change theory.
Conclusion
It has been disappointing to realize that addressing the lack of a formal phone triage
process in our practice had not taken on more importance in the past. To realize that for years,
our patients have been managed without the value and effectiveness of a triage process is
sobering. Within the new context of nursing leadership theory, the complete process of moving
our staff and practice in the direction of a positive change by introducing a nursing evidencebased innovation is much clearer.

LEADERSHIP STRATEGY ANALYSIS

12
References

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Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., & Mitchell, P.,...Warren, J.
(2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131.
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Flannery, M., Phillips, S., & Lyons, C. (2009). Examining telephone calls in ambulatory
oncology. Journal of Oncology Practice, 5(2), 57-60. doi:10.1200/JOP.0922002

Gleason, K., Brennan O'Neill, E., Goldschmitt, J., Horigan, J., & Moriarty, L. (2013).
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Yoder-Wise, P. S. (2014). Leading and managing in nursing (5th ed.). St. Louis, MO: Elsevier
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