Sally Anne Pygall gives a detailed guide about how to go about auditing a telephone triage service.
Although clinical audit is compulsory for out-of-hours services as part of the National Quality Standards [1], it's very uncommon amongst GP surgeries.
However, an audit of telephone consultation services can improve patient care and safety and provide feedback and learning for clinicians; therefore improving their skill and confidence. Audit can also show who is best at telephone triage and therefore who should be triaging most often.
This article looks at the questions you should ask yourself before auditing your service.
What information should we audit?
A simple paper based audit and check of telephone records for each clinician can give a snapshot of outcomes and how long most consultations take as part of the overall performance picture.
Compare this with accepted averages – for instance the average length of a telephone consult in surgeries is expected to be around 7.1 minutes [2]. Information on outcomes may reveal who is more likely to refer patients to a face-to-face consult - a rate of around 80% of triages results in a follow up appointment for some clinicians, whilst others may have a referral rate of less than 50%.
A review of this type of information can help provide an all round view of performance, but it is not an accurate method for assessing the quality of calls. To do this, it is worth assessing retrospective voice recordings or listening to live calls using a clinical audit tool.
Despite initial reservations about having their calls listened to, GPs and nurses usually find they learn a great deal from listening to each other's calls. Recordings can also be used in clinical practice meetings, where examples of good and not so good calls are discussed openly.
The more accomplished triagers can support their colleagues in improving their skills and the use of audit will continue to reveal any additional training needs for both nurses and GPs.
What clinical audit tools should we use?
One of the dangers of ‘informal feedback' (e.g. listening to each other's calls and offering an opinion) is a lack of standardisation of results and a poor evidence base for suggested improvements or ongoing performance monitoring. It can also lead to subjectivity as a result of differing priorities amongst the team.
A clinical audit tool removes the subjectivity and can provide a good benchmark for development purposes. At present there are no clinical audit tools for GP surgeries; except perhaps from those developed by independent consultants.
However, the RCGP ‘Out of Hours Clinical Audit Toolkit [3] designed for out of hours work could be adapted for use within GP surgeries and is certainly better than not using any tool at all. With the help of an external consultant, you may be able to develop a tool specific for your own needs and to provide information on everything from communication skills to clinical decision making.
Who will carry out the audit activity?
It's a good idea to use both GPs and nurses if both staff groups are triaging, with named individuals responsible and accountable for audit who have adequate time set aside for audit work.
Although GPs commonly feel they are best placed to assess the quality of other GP calls, as long as a good audit tool is used in the right way a nurse could assess a GP and vice versa with both roles learning from each other's calls.
Having specific responsibility for audit reduces the chances of poor inter-rater reliability and having protected time to do audit reduces the likelihood of it becoming less of a priority and therefore not done at all.
What training do we require?
Before beginning your audit, auditors should be adequately trained in telephone triage so they have an understanding of what to assess, how to evaluate fairly and how to strike a balance between individual decision making and best practice as agreed by the practice team as a whole. This may require external support initially.
If the auditors are not trained appropriately, it can result in a huge variation between them, making feedback less credible and ill received, which may therefore lead to fewer of the required improvements.
Sally-Anne Pygall is a nurse and director of training company Telephone Consultation Services. For more information go to www.telephoneconsultationservices.co.uk
Sally Anne Pygall
