Background: Nurses play a critical role in the delivery of telehealth services, also known as virtual health care. Approximately 45 RNs perform the primary care telephone triage for 200 primary care offices within the 7-state region and manage 120,000 calls per year at a pediatric Magnet facility.

A telephone triage quality improvement committee was formed to increase the quality of audio and documentation reviews though multiple activities, including but not limited to identifying a group of clinical nurses in the department to perform audits, establishing a program to reach a degree of agreement among RN auditors (inter-rater reliability or IRR), auditing both documentation and audio reviews, and auditing the use of established telephone triage guidelines. The goal of the QI program is to provide autonomy in the RN role, improve high-quality care in performing telephone triage, and communicate RN best practices as well as opportunities for improvement.

Staff role/program development: The QI process was established by completing a needs assessment on the current state of the quality improvement processes. The clinical department leadership team identified the need to increase the number of call recordings/audio reviews for all RNs and establish a consistent program to perform audits. All RNs within the department were informed of the proposed plan and encouraged to apply to be a part of the auditing team. Five RNs were chosen from those who applied, each RN having variable triage experience- ranging from two to ten or more years performing telephone triage. The clinical management team within the department also joined alongside the RN auditors to establish inter-rater reliability.
The group meets once a month and used the meeting venue to elicit feedback to continually improve auditing processes, including, but not limited to, establishing auditor resources, setting time to applying and discussing the auditing process, escalation of concerns during auditing, and data entry. The committee member role is to advocate anticipated challenges and barriers to the auditing process, act as a liaison to all team members regarding auditing processes, and perform audits as assigned.

Next steps: The committee’s quality improvement goal is to reach 90% IRR prior to performing audits independently. Once IRR is established, the number of audits performed will increase from reviewing 180 documentation call review per year to a total of 960 documentation and audio reviews per year.

Ongoing re-evaluation of all quality improvement processes will continue for the entirety of the program, which will ensure high reliability with the updated QI process. Consistent process for auditing will lead to data-driven process improvements to clinical practice within the department, ensuring patient safety and optimizing value-based care and the patient/family experience. Ongoing quality assurance and quality improvement will increase the RN’s autonomy by supporting application of the RN’s expertise and ensuring that RNs are working to the full extent of their education and training, also known as working to the top of the RN scope of practice.

Sara Nudd BSN, RN, CPN

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