Thomas Isaac, M.D., M.B.A, M.P.H., is Senior Medical Director of Quality, Safety, and Patient Experience at Atrius Health in Boston, Massachusetts.

What is Atrius Health doing differently to manage incoming calls from patients during the coronavirus epidemic?

Dr. Isaac: We’ve created both a new triage system and a dedicated COVID-19 resource center. A new phone option connects patient callers directly to the resource center. Those calls, plus any that our staff consider to be possible COVID-19 calls, are handled first by medical secretaries using a detailed interview protocol we developed. Patients with concerning symptoms are transferred to a nurse who evaluates their condition and recommends care, which can range from managing mild symptoms at home to scheduling a video visit with a physician or seeking emergency care. Some patients, especially first responders, health care workers, and residents in communal living, may be referred for drive-through COVID-19 testing. Our chief nursing safety officer leads the call center. In the three weeks between the end of March and the middle of April, they triaged almost 11,000 patients and fewer than 100 of them were sent to the ED.

How do you train staff to manage a system that’s evolving so rapidly?

Dr. Isaac: Our medical secretaries and nurses are very effective under normal circumstances, but this situation certainly called for specialized training. The center ramped up to include a total of 80 people, mostly nurses. Initially, we had to do some in-person training, though now nearly everyone is working remotely from home. We use rapid Plan-Do-Study-Act (PDSA) cycles to make sure what we learn each day is folded into the work we do the next. We learn what issues come up from the medical secretaries and nurses and take that information to our clinical leaders, infectious disease specialists, and infection control and nursing operations colleagues. If they decide we need new updates to the algorithm, we execute the changes in Epic that evening. The next day, we train our staff on the changes. That cycle continues daily, and virtually all of it happens remotely.

We sometimes question whether a certain change is too disruptive to consider doing overnight. You don’t want to cause confusion. If we feel we don’t have something quite figured out, we may hold on it, think about it, and decide the following day. It took us a little while to learn that. The first two weeks involved many late nights! People are still working incredibly hard, but we’ve settled into more of a steady state.

What advice do you have for physician practices that want to improve their response to patient calls?

Dr. Isaac: The usual best practices of safety still apply. You still need to think in terms of maintaining a culture of safety. You want to build a high-functioning team and listen to the frontline. Continue to explore how to improve every day and use rapid PDSA cycles to test and revise changes as you go. Don’t forget to collect data and think about which metrics to use; what do you need to know for planning future improvements?

This interview took place by phone on April 14, 2020. The Betsy Lehman Center thanks Paula Griswold, Executive Director of the Massachusetts Coalition for the Prevention of Medical Errors, for initiating the conversation.