Background: It is challenging for patients to navigate through complex healthcare systems after-hours. This leads to delays in patient care, patient/provider dissatisfaction, inappropriate resource utilization, readmissions, and higher healthcare costs. Prior to August 2015, non-medical staff at external call centers with invalidated standard work, poor work cell co-location, and inadequate active daily management addressed the after-hour patient calls at our institution.

Purpose: We established a patient-centric Clinical Advice Service (CAS) at our institution to deliver coordinated care to our established patients after-hours. CAS utilizes key Lean principles such as value stream mapping, empathy mapping, waste walk, takt time calculations, plan-do-check-act cycles, standard work, and active daily management.

Description: CAS is currently live in 26 specialties (medical and surgical), and has accepted 228,990 calls since August 2015. CAS has 21 registered nurses (RNs), 10 clinical assistants, 2 assistant patient care managers, 1 nursing director, and 3 part-time medical directors on staff.

Clinical Assistants manage the non-clinical calls that include directions, appointments, and general information. 40% of the calls to CAS have been non-clinical. The RNs manage the clinical calls utilizing over 390 standard protocols based on patient’s symptoms. These protocols specify what questions the nurses should ask the patient based on the chief complaint, how to appropriately triage the patient to 911, emergency department, urgent care, when to escalate to the on-call physician, or route a non-urgent message to the outpatient clinic for follow-up in the daytime, and what advice to give.

The phone lines from the outpatient clinics, and any calls from the patients to our hospital’s page operator (for the services active with CAS) are routed to CAS between 4 PM and 8 AM on weekdays, and for 24 hours on holidays and weekends.

The highest call volumes to CAS come from Primary Care, Orthopedic Surgery, and Hematology/Oncology. With a strong quality assurance program, CAS nurses have protocol adherence rate of 92%. CAS has also improved resource utilization with 91% reduction in after-hour calls to on-call physicians, and an average referral rate of 6% patients to the emergency department.

Conclusions: A shared seamless connectivity vision, cascading, multidisciplinary ownership of the problem, synergistic enterprise improvements, and a stable institutional operating system have contributed to the success of CAS. With CAS, we aim to optimize connectivity, and improve the patient/provider experience after-hours, along with efficient resource utilization.