In 2018, Nemours Children’s Health System in Florida realized it had a phone system problem. When attempting to schedule an appointment, patient families were experiencing long hold times, incorrect call routing and dropped connections.
Families were growing frustrated with failed attempts to reach the hospital, and they were sharing their feedback directly and through social media.
The organization heard multiple stories from parents who, after painfully long hold times, decided to drive to one of the facilities to schedule in person rather than continue to wait on the phone. Schedulers, physicians and even the CEO were fielding complaints, and the need for change was evident.
Over the course of six months, a cross-functional team began a significant improvement process to stabilize the phone trees, standardize work across the scheduling teams, and create an integrated call center infrastructure.
Identifying the issue
Nemours Children’s Health System serves over 400,000 children with two freestanding hospitals and more than 70 primary, specialty and urgent care sites across six states.
The past decade has yielded significant growth and expansion across the system, especially in Florida where Nemours Children’s Hospital Orlando opened in 2012. And as the organization grew rapidly, so did the complexity of the phone system.
In August 2018, a specific patient family complaint about the phone system surfaced at a frontline huddle and, given the service impact of the problem, it escalated to the Florida leadership huddle.
The Florida practice administrator, who had reporting line oversight of the scheduling teams in Pensacola, Jacksonville and Orlando, took ownership of the problem.
In partnership with the Continuous Improvement Resource Office, he convened a small team with representatives from each site to investigate the situation. This group documented the current state by mapping out the patient flow through the phone system, capturing problems at each step and looking at data from each site.
Abandonment rate is a standard call center metric that captures how often callers hang up and abandon the call prior to reaching an agent in relation to total calls. The call center industry benchmark abandonment rate is 5%; Nemours was seeing spikes in the 30% range.
This concerning data, in combination with the process issues that surfaced during the current-state documentation, prompted the need for swift action.
Understanding the problem
The project took the form of a kaizen improvement event, and the team was pulled offline from regular duties for multiple days to focus on rapid problem solving and process improvement.
A successful event requires significant up-front investment to ensure the team will have resources in place to achieve their targets, as well as developing a well-formed, cross-functional team.
The core project team consisted of the scheduling team managers from three sites, the switchboard manager, the telecommunications manager, and a Lean facilitator. A management guidance team of senior leaders supported this core team and provided guidance and removed barriers for the project.
A "tiger team" from marketing, physician relations, enterprise intelligence (data), EMR scheduling and IT also supported the work. The team completed a two-and-a-half-day assessment and planning session to understand the current state, perform a root cause analysis, define a vision and targets and make a game plan for the event.
Two weeks later, they completed a four-day improvement event, followed by six months of intensive implementation, including checks on results every two weeks and numerous adjustments until the new system stabilized.
To better understand the current state, the team completed observations and interviews with schedulers and switchboard operators, spoke with patient families, and listened to dozens of recorded calls. They generated a list of scenarios and performed secret-shopper calls to navigate the phone systems. What they experienced was remarkable:
- Dead-end calls, dropped calls and extended hold times.
- Confusing prompts and scripting.
- Multiple transfers and incorrect routing.
- Options “timing out” if a caller didn't make a selection within three seconds.
The team aggregated a list of the phone numbers documented on marketing materials. A decade ago, the Nemours footprint in Florida consisted of three specialty clinics in Jacksonville, Pensacola and Orlando.
Over the last 10 years, the system grew to include a freestanding children’s hospital, multiple satellite clinics, and 18 primary care and urgent care sites. Each time a new location opened, or a new specialty was onboarded, multiple phone numbers were generated to support the site or service.
The assumption was patients and families wanted a more direct way to reach their provider.
But the system was made up of multiple phone numbers leading, in a complex way, to the same scheduling call centers. At the time of assessment, there were over 75 phone numbers in use across the state, each with its own phone tree, set of prompts and voice talent.
The team documented the problems they found on Post-it notes. By the end of the second day, there were over 100 problems captured. To drill down on root causes, they went through a categorization exercise and uncovered three themes:
- PROCESS. Variation in standard work and processes to handle, route and escalate calls.
- TECHNOLOGY. Widespread software issues, varying phone setups, broken scripts, and inconsistent tools and resources.
- REPORTING. Variation in metric definitions, inconsistent performance targets and lack of visibility.
When envisioning the future state of how patients schedule an appointment, the team knew it would require multiple phases of improvement. They developed a vision with three phases:
First, the organization needed to stabilize the current system to solve the immediate problem.
The target: Improve the abandonment rate by 50%. Second, to further streamline the phone system, the organization would need to standardize how it schedules appointments to allow for cross coverage.
Without standardization, calls would never be level-loaded across all specialties causing potential for spikes in the abandonment rate. Third, the team envisioned an integrated call center for patients and families with an innovative interface and world-class patient experience.
The team was also charged with creating a future-state design, implementation plan and communication plan. To determine how the new system would look, they completed a facilitated exercise to brainstorm solutions to the phone tree problem.
Each idea the team generated was shared, grouped and ranked based on two filters: ease and impact.
After the initial round, they spent 10 minutes further developing each of the top ideas in teams of two before re-ranking. It took three rounds to generate the top four ideas.
Engaging with consumers
Improvement does not happen in a vacuum—hospitals can’t make assumptions about what families want. At Nemours, the team collaborated with the internal market research department to create a survey targeting the catchment area in Jacksonville, Orlando and Pensacola.
The survey did not mention Nemours, which allowed the survey to gain feedback from a broader demographic, capturing patients using the health system and its competitors.
The team took the ideas they generated during the facilitated exercise and created eight product offerings for respondents to rank.
The survey received over 400 responses, which produced definitive results. The team was able to incorporate this feedback into the short-term countermeasure and long-term vision. For example, remember those 75 phone numbers the organization thought families wanted? It turns out they overwhelmingly prefer a single phone number.
Understanding this was about progress, not perfection, the team designed and implemented a new phone tree structure that would stabilize, standardize and incorporate as much family preference as possible. They mapped out a phone tree that was identical across the three sites, reducing the total prompt options from 96 to 24.
They established one local scheduling phone number per site and planned with marketing and telecommunications to phase out the additional numbers over a year. The team hired a single voice actor to record the new prompts.
They standardized onboarding training, phone system settings and performance metrics, and created a call center dashboard to serve as the single source of truth.
A better system for families
Throughout the implementation, the team weathered high turnover and countless technology issues with the system infrastructure, but their hard work and resolve paid dividends.
The streamlined phone tree provided desperately needed relief to the abandonment rate. Rates steadily dropped from peaks above 30% to maintaining below 10% and continued to progress toward industry standard at 5%.
The relief was palpable from employees, patient families and community providers. In a patient satisfaction survey, one family said, “The new phone system has made a huge difference. It’s much easier to get through and is saving us a lot of time.”
During the crisis period, outbound scheduling staff were often being deployed to cover inbound calls to contain the abandonment rate. With the system stabilized, the organization realized significant improvement in referral work queues.
Before this project, it would take almost nine days to contact a family to schedule an appointment after receiving a referral.
The team was able to decrease time to scheduling contact to within 24 hours of referral, all while clinics were realizing record volumes. In addition to improvement in performance metrics, the teams also reported higher job satisfaction scores and reduced employee turnover.
The initial stabilization work completed at the end of 2018, and the team has sustained improvement to the abandonment rate since. In 2019, abandonment maintained an average of 8%, and in 2020 the organization hovered around 3%.
Nemours maintains progress through a change control process, as well as a daily management system. The core team began huddling daily at the start of this project and continues to do so today under the leadership of the new Florida Access Center director, a member of the project team who was promoted.
Upon learning of the successes in Florida, counterparts from the Access Center at Nemours Alfred I. duPont Hospital for Children in Wilmington, Delaware, were able to spread and scale the project model to standardize phone trees and prompts in the region through a facilitated improvement event.
Additionally, the two teams came together for a system-wide approach to standardizing the operations. During observations, a variation in scheduling guidelines and processes between specialties became evident.
The complexity of these processes prevented the possibility of cross coverage and level-loading of incoming calls, as schedulers needed to be deeply trained in nuances for each provider. Standard scheduling work opens the door to a truly centralized call center model.
Next, the team began implementing decision trees, which provide a standard scheduling algorithm that guides the scheduler to the right appointment and prevents errors. Nemours’ approach to decision trees involves a two- to three-day, in-person session where a physician representative from each location, clinic staff, schedulers and operations hash out standard scheduling rules for their specialty by diagnosis.
It’s a tedious process with tremendous payoff. The organization currently has a handful of specialties live, with more in progress. Nemours is on its way to the ideal future state: an integrated call center with a world-class patient experience.
Taiichi Ohno, the father of the Toyota Production System, which inspired lean manufacturing in the U.S., is credited with saying, “Where there is no standard, there can be no kaizen (improvement).” It took a dedicated team six long months, overcoming multiple setbacks to create stability for the organization's phone systems. And they have continued improving ever since.
