Issue link: https://nnumagazine.uberflip.com/i/956820
people present their stories is a recipe for disaster. "[The TSRs are] good people in a really bad situation." One of the main indications to call center nurses that TSRs are encroaching on nursing scope is the common refrain by callers: "I just explained that to the other nurse." Patients are under the mis- conception that they had been talking to a registered nurse all along. Some actually become irritated and angry when they have to retell their health story and answer all the same questions again, which can make it hard to establish good rapport and get cooperation when callers finally do connect with an RN. Kaiser has, in the past, run into trouble with healthcare regula- tory authorities for their usage of TSRs. In the early 2000s, the California Nurses Association filed suit against Kaiser for mis- leading its members into thinking that they were talking to regis- tered nurses and was found culpable by the California Department of Corporations for violating the nursing practice act. As a result of that suit and bargaining provisions won in 2015, nurses now have the right to review and correct TSR scripts three times a year, but Kaiser makes it extremely difficult for them to do so. For one thing, Kaiser will not even provide RNs a complete list of scripts with names and descriptions, arguing that the scripts are "proprietary information." RNs have to guess, based on what they know about the highest volume medical issues, the most common scripts TSRs are using. During their meetings, RNs are allowed to take notes but not allowed to remove them from the room or take them home. Nurses know there are mysterious "alternate workflow scripts," but have been unable to see them; they suspect these are additional scripts that direct patients away from registered nurses. "Whenever we bring up this issue of TSRs assessing, the man- agers say, 'Oh, no, no! They never assess. They do active listening,'" said Roth, who adds that in talking with individual TSRs, some are uncomfortable with the role they have taken. "They say, 'We are very comfortable with the data. We are not seeing any problems.' Well, we nurses see the problems. They're in our PSACs." In 2017, AACC nurses at the three call centers filed a combined total of 4,600 PSAC reports. * * * A teleservice representative whom we'll call David has worked in the Vallejo call center for just over a year and is considered by his managers to be an above-average employee. David, who doesn't want his real name used for fear of near-certain retaliation at work, offers an insider's perspective on what TSRs do daily and the expec- tations and pressures put on them by Kaiser management. He used to work in retail sales at a call center, but calls working in the AACC "intense, complex, and a totally different animal." Talking to David, the overriding imperative of his work is time: keeping AACC calls as short as possible. Like RNs, TSRs are timed from the moment the call begins to the end, and that time is broken into four segments: from taking the call to choosing a script, from script to deciding on an outcome, how long it takes to process that outcome, and then wrapping up the call. "Everything is based on time," said David. "That's the most pressure." He said that he was told by managers that the call center wants to keep the average handle time per call down to about four minutes, and that they are always pushing the workers to shave times even more and "beat" previous averages. He is not allowed much personal time between calls, even after difficult calls. "At some point, what numbers are they trying to hit?" he wonders. "At some point, the numbers become unreachable." Calls about common colds are easy, said David, but calls from patients with multiple health issues, many symptoms, and the elderly are very complicated and confusing. For example, if someone calls complaining of neck, back, and leg pain, he is not sure which script to assign. He knows he is not an RN and shouldn't be assessing the patient, but says that he has no choice. "I just ask, 'Which hurts more?' At that point, we assess. We have to pick a script," said David. "I know that I don't assess. Sometimes I feel like I am. But I try my best not to." In addition to time, David is judged by managers on how often he refers patients to the advice nurses. "They want our transfer rates at the call center to average between 18 to 22 percent," he said. Kaiser has claimed that there is no "maximum quota" or penalty for TSRs to forward to advice nurses, but David's experience clearly shows that they are at risk of being counseled or disciplined by management for failing to conform to the type of workflow that Kaiser wants. As a result of these pressures, David constantly worries about mak- ing a mistake and says he is often stressed out by his job. "If I get a bad call, it sits with me, and I keep turning it over in my mind for a week," said David. "You're graded on everything and you're told, constantly, as a whole, that we're not doing well. That we need to do better." Like the advice nurses, David has ideas for how the workflow can be changed and improved. He said that patients often call already wanting to book an office appointment, but Kaiser makes him first act as gatekeeper and ask 20 questions from the script, offering the patient to speak to an advice nurse, offering to message the doctor, offering a video appointment. "It just frustrates the member. They're 28 N A T I O N A L N U R S E 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 J A N U A R Y | F E B R U A R Y 2 0 1 8 Above and opposite: Advice RNs Jeri Martinez and Jamesina Prater at their desks in the call center.