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organization to continually advance service to KP members and drive operating efficiencies," reads an Oct. 20, 2016 press release. The Duluth center was integrated with the Southern California- based Kaiser on-call operation "to allow for process and service standardization, common management, and call sharing capabili- ties. Nurse advice operations in two time zones increases our capaci- ty to provide telephone advice during peak calling times on the east and west coasts, quicker call responsiveness for members, and increased member satisfaction." Kaiser call center nurses dryly note, however, that shifting work to other states where nurses are not unionized and where the state's nursing practice acts are not as strong as in California allows Kaiser to more easily control these workforces, erode nursing practice and judgment, and potentially use these out-of-state nurses are strikebreakers during labor dis- putes. Kaiser has also pushed to have call center RNs work remotely from home, and some TSRs already do. The advice nurses say the idea sounds attractive at first glance, but poses serious risks to RNs and patients. Not only would working remotely destroy unity among advice nurses who at least see one another frequently and can com- pare notes about issues, it would put nurses, their licenses, and their patients in untenable situations. Michelle Berry, an AACC RN for 11 years, chief nurse representative at the Sacramento call center, and a National Quality Forum cochair, recounted that in fall 2017, one of the nurses at her call center received a suicide call. She needed to alert a manager and get additional help, but obviously could not put the caller on hold. There was no way in the system for her to flag anyone down, so she resorted to scribbling a note on a piece of paper and waving it over her head, waiting for somebody to see her. Berry finally noticed her, then had to put her patient on hold and run to help. "Imagine a nurse working at home: How is she supposed to get help? She can't put them on hold to call 9-1-1." Berry also pointed out that once you move jobs to people's homes, you might as well move the positions to "Timbuktu" and anywhere nurses get paid less. After the call centers were established, Kaiser quickly figured out ways to cut labor costs by relying heavily on the usage of teleservice representatives with scripts that prompted the TSR to ask patients questions in order to screen which callers could or could not access an advice nurse or advice physician, which callers could or could not book an appointment. Kaiser claims that the scripts are developed by their physicians and that TSRs are not assessing and triaging patients in violation of the California Nursing Practice Act, but the RNs, who often can overhear TSR conversations with patients, know this is not true. While some TSRs are more diligent about sticking to the script and not venturing into nursing practice territo- ry, many more are not—simply because they are uneducated about scope, because they are under enormous pressure by their managers to avoid transferring calls to the advice nurses, and because nurses' review of the scripts that they have been allowed to see read almost identically to the nurses' own triage protocols. "The fact is that unlicensed assistive personnel are caring for the majority of our patients," said Billings. "About 70 percent of all callers never make it to an RN." From the advice nurses' viewpoint, Kaiser's call center workflow is actually backwards: Callers should always be first connected to a registered nurse who can determine if they are symptomatic and perform triage. If the caller's issue is administrative in nature, the RN can then pass that call onto a TSR who can help book appoint- ments, refill a prescription, and so on. In addition, nurses stress that TSRs should clearly identify themselves not by an ambiguous title that the healthcare corporation devised, such as "teleservice repre- sentative," but by a commonly understood title such as "clerk" which clearly signals to callers that they are not speaking to a medical provider. Not only is Kaiser's practice of using TSRs as the first point of contact potentially unsafe for patients, it is inefficient; Billings had many examples of TSRs booking patients for appointments that they don't need, and not booking appointments when needed. "Initial triage by an unlicensed clerk is an error in system design and a case of the organization attempting to increase their profits," wrote Roth in a Sept. 29, 2017 response to JoAnn Glover, the AACC director of nursing practice, during contract bargaining when call center issues arose. "Nurses report hearing clerks ask questions such as 'How much bleeding?' or 'Is there a lot of pain?' There are many ways that potentially serious symptoms can be missed by an untrained clerk." Roth gives examples: Women have called in com- plaining of breast pain, when they are really experiencing chest pain. The TSR books an appointment with the ob-gyn, which proves futile, then calls back for an appointment with medicine. Or an asth- matic patient calls in for an inhaler refill, which the TSR dutifully processes, but the patient should have also received a respiratory assessment by an RN. As it turns out, the caller is in acute distress and ends up needing to go to the emergency department. Many callers who happen to be pregnant get sent by TSRs to ob- gyn for everything, even though their problem may have nothing to do with their pregnancy. Or patients with abdominal pain frequent- ly also get sent by TSRs to the ob-gyn clinic because they are unable to distinguish abdominal pain from pelvic pain. These are all real examples that nurses have documented in their assignment despite objection (ADO) forms, which in the AACC are called patient safety and advice concerns (PSAC). Billings remembers one time she picked up a caller who had been placed on hold by the TSR in the pediatric queue. It was a mom whose child had sustained a head injury and had been bleeding. With just a few quick questions, Billings figured out that the child was unconscious in the back seat of the mom's car and should have been directed to the ER right away, never mind being put on hold! "But the TSR hears 'laceration' and that the bleeding is controlled and immediately puts her in the queue," said Billings, explaining how the script restrictions combined with the non-linear way that J A N U A R Y | F E B R U A R Y 2 0 1 8 W W W . N A T I O N A L N U R S E S U N I T E D . O R G N A T I O N A L N U R S E 27 From far left: Professional practice committees for the Sacramento, Vallejo, and San Jose call centers.