Wake-up Call

Advice nurses who work at Kaiser Permanente’s call centers struggle to keep their patients safe despite onerous working conditions and the corporation fighting them at every turn. If you are a Kaiser member, this is a must read. Just whom exactly are you talking to when you call the advice hotline?

National Nurses United
24 min readMar 23, 2018


By Lucia Hwang

We’ve all been there. It’s 2 a.m. and your two-month-old baby is wailing with a 102 fever. You’ve tried everything and are on the verge of panic. Should you take him to the ER now? Should you wait until the morning? Are you overreacting? But what if it’s something serious?

Kaiser Permanente members, however, need not face these health quandaries alone. As a Kaiser patient, you can call 24 hours a day, seven days a week, for any reason and speak to an advice nurse over the telephone who can help you assess the problem, determine what course of action to take, and access medical services. Speaking as a Kaiser member who has called the advice line on a number of occasions (And, yes, once for our toddler who would not stop vomiting!), the advice nurses are a godsend and a trusted, professional resource that is not only much appreciated among Kaiser patients, but considered one of the unique benefits of being a Kaiser member.

That is, if you ever actually get to talk to an advice nurse.

The ugly truth is that Kaiser’s entire care model depends on restricting, as much as possible, member access to advice nurses through the use of unlicensed teleservice representatives (TSRs) who act as gatekeepers to nurses by interacting with patients via conversation scripts. For nurses who actually do get connected to patients, Kaiser pushes them to work as quickly and intensely as they are humanly capable through common call center management techniques that nurses say are wholly inappropriate when applied to their profession of caring for and ensuring the safety of live human beings: patients. These methods include heavy micromanagement, timing for efficiency every segment of the process, and counseling and discipline for performance that doesn’t meet their benchmarks. Under these onerous working conditions, approximately 950 registered nurses who work at Kaiser’s three major Northern California call centers struggle and fight to provide the best patient care they possibly can.

The numbers tell the story: Out of nearly 14 million calls Kaiser received in 2015, only close to 3.5 million — about a quarter — were referred to registered nurses, according to Kaiser’s own statistics as presented via video monitors at the Vallejo call center. Kaiser claims that the 75 percent of calls the Appointment and Advice Call Center, often referred to by nurses as the AACC, receives that don’t get routed to a registered nurse are “routine,” non-urgent calls for appointments and other administrative needs, but the RNs aren’t buying it.

“That’s totally not true. They’re getting stopped at the teleservice representative,” said Mary Magtanong-Sigua, RN and chair of the professional practice committee for the call center located in Vallejo, Calif. “And we know the people calling are sicker and sicker than ever before.” Multiple nurses noted that Kaiser hospitals are discharging patients too soon, earlier and faster than ever, meaning that patients are developing serious complications at home and turning to the advice nurses for help by phone. “We end up with those calls.”

As Mary Roth, an 18-year call center RN who also holds one of two Kaiser Quality Liaison positions representing the call centers, notes, “The people who are not that sick, who have means, who know how to navigate the system, they’re all going to go online [to Kaiser’s website]. The ones who are sickest, who are elderly, who may have English as a second language, are going to call us.” In other words, the call center fields inquiries from the most vulnerable of patients. While nurses say there have always been issues with the way Kaiser’s call centers operated, the problems have accelerated and compounded within the last five years.

To protect their patients, call center nurses are fighting for reforms that they say are desperately needed to keep members safe and ensure they receive the care they deserve and are paying for. To protect their profession and their practice, call center nurses are also championing changes needed to improve their working conditions, safeguard nursing judgment and the assessment process, prevent injuries among call center RNs, and attract and retain experienced call center nurses. They demanded improvements as part of this current round of 2017–2018 bargaining for the master contract covering 19,000 Kaiser Permanente registered nurses and nurse practitioners.

“All registered nurses should understand and care about what we call center nurses are facing because our experience foreshadows what to expect in nursing and healthcare in the years to come as corporate healthcare shifts toward telemedicine or virtual care,” said Melinda Billings, a Kaiser call center RN in Sacramento for 16 years and also a quality liaison. “It’s up to us nurses to fight back and make sure we make Kaiser prioritize patients over profits.”

This ad, posted in a Kaiser pediatric medical office building, leads members to believe they will have easy access to an RN for medical questions and help though Kaiser’s own statistics show 75 percent of calls never reach a registered nurse.

Why this use, or rather, misuse of call centers? Billings homed in on the motive: profit. Just for 2017 alone, Kaiser added more than 1.1 million new members to its rolls and posted astounding profits of $3.8 billion, according to its financial statements. Kaiser nurses throughout the system say that the giant healthcare corporation has only been able to achieve these financial gains through a variety of cost-cutting measures: lowering labor costs by short staffing on registered nurses and substituting in lesser-qualified and more inexpensive staff; keeping patients away from the hospital or in-person appointments by directing them to online and telehealth services; and by discharging or processing as quickly as possible the patient members who do make contact with the system.

Kaiser has long envisioned a future where most patient care is provided virtually, and it has not been shy about promoting that model. By whittling away at the standards and routinizing the care provided by call centers, AACC nurses are worried that Kaiser is only a hop, skip, and jump away from automating the call centers and eliminating a live registered nurse — or human, for that matter — at the other end of the line entirely. In this brave new world, patients would only get to “talk” to a computerized phone menu: Press 1 for chest pain and press 2 for abdominal pain.

So why do call center nurses keep on doing what they do even though they feel disrespected by Kaiser, are under so much enormous stress and management pressure to work harder, faster, longer, and are in danger every passing year of being replaced or superseded by lesser skilled staff or even automation? The answer is simple: They love helping their patients.

RN leaders in Vallejo, Calif. call center professional practice committee

“Here at the call center, we touch many lives every single day,” said Magtanong-Sigua. “It’s the ultimate problem solving job because we get everything. And you can get right to the person that wants the help and fix it right there and then. When I get a mom and baby with fever, I can educate her and tell them what they need to worry about and not worry about versus waiting until the morning for an appointment. They feel good afterward.”

Roth feels similarly. “You have to be really creative. You can’t see, touch, smell the patient, but talking to them can paint an incredible picture. It’s an incredibly intellectual and challenging job. Their ethnicity, culture, age all come into play,” said Roth. “You can help them.”

RN leaders in Sacramento, Calif. call center professional practice committee

Kaiser’s call centers came about as a result of consolidation of existing nursing advice services provided via telephone from various departments, clinics, and doctors’ offices. Back in the day, patients would call these settings directly and a secretary would line up calls for patients needing to speak to a registered nurse. The system was pretty unwieldy, though, and Kaiser in 1997 opened up call centers staffed by RNs where it could route calls from all members. There are currently three main call centers in Northern California: one in Vallejo, one in Sacramento, and one in San Jose. Vallejo is the largest, with approximately 400 RNs; Sacramento is next, with about 375 RNs; and San Jose has about 140 RNs, for a total of more than 900 RNs. There are call centers in Colorado, Maryland, and Southern California as well, though newspapers recently reported that there will be a total of some 700 layoffs of employees between its Baldwin Park, Woodland Hills, and Los Angeles call centers — likely teleservice representatives.

RN leaders in San Jose, Calif. call center professional practice committee

The main reason a Feb. 19, 2018 San Gabriel Valley Tribune article stated for layoffs at the Southern California facilities is to save labor costs by moving the positions to lower-paying areas within California. Because TSRs in Southern California are represented by different unions that have bargained different wages, these workers in effect have tiered wages depending on where they live — what’s known as regional wages. This is a model that Kaiser has proposed in this current round of bargaining with Kaiser nurses, but one that CNA rejects for its members.

At the same time, Kaiser is establishing additional call centers in other states such as Georgia; in October 2016 Kaiser opened a 150,000 square foot center in Duluth, Ga. that houses up to 1,000 employees. “The move to the new center is part of a national initiative to operate all Member Service Contact Centers as a shared service organization to continually advance service to KP members and drive operating efficiencies,” reads an Oct. 20, 2016 press release.

The Duluth center was integrated with the Southern California-based Kaiser on-call operation “to allow for process and service standardization, common management, and call sharing capabilities. Nurse advice operations in two time zones increases our capacity to provide telephone advice during peak calling times on the east and west coasts, quicker call responsiveness for members, and increased member satisfaction.” Kaiser call center nurses dryly note, however, that shifting work to other states where nurses are not unionized and where the state’s nursing practice acts are not as strong as in California allows Kaiser to more easily control these workforces, erode nursing practice and judgment, and potentially use these out-of-state nurses are strikebreakers during labor disputes.

Kaiser has also pushed to have call center RNs work remotely from home, and some TSRs already do. The advice nurses say the idea sounds attractive at first glance, but poses serious risks to RNs and patients. Not only would working remotely destroy unity among advice nurses who at least see one another frequently and can compare notes about issues, it would put nurses, their licenses, and their patients in untenable situations. Michelle Berry, an AACC RN for 11 years, chief nurse representative at the Sacramento call center, and a National Quality Forum cochair, recounted that in fall 2017, one of the nurses at her call center received a suicide call. She needed to alert a manager and get additional help, but obviously could not put the caller on hold. There was no way in the system for her to flag anyone down, so she resorted to scribbling a note on a piece of paper and waving it over her head, waiting for somebody to see her. Berry finally noticed her, then had to put her patient on hold and run to help. “Imagine a nurse working at home: How is she supposed to get help? She can’t put them on hold to call 9–1–1.” Berry also pointed out that once you move jobs to people’s homes, you might as well move the positions to “Timbuktu” and anywhere nurses get paid less.

After the call centers were established, Kaiser quickly figured out ways to cut labor costs by relying heavily on the usage of teleservice representatives with scripts that prompted the TSR to ask patients questions in order to screen which callers could or could not access an advice nurse or advice physician, which callers could or could not book an appointment. Kaiser claims that the scripts are developed by their physicians and that TSRs are not assessing and triaging patients in violation of the California Nursing Practice Act, but the RNs, who often can overhear TSR conversations with patients, know this is not true. While some TSRs are more diligent about sticking to the script and not venturing into nursing practice territory, many more are not — simply because they are uneducated about scope, because they are under enormous pressure by their managers to avoid transferring calls to the advice nurses, and because nurses’ review of the scripts that they have been allowed to see read almost identically to the nurses’ own triage protocols. “The fact is that unlicensed assistive personnel are caring for the majority of our patients,” said Billings. “About 70 percent of all callers never make it to an RN.”

From the advice nurses’ viewpoint, Kaiser’s call center workflow is actually backwards: Callers should always be first connected to a registered nurse who can determine if they are symptomatic and perform triage. If the caller’s issue is administrative in nature, the RN can then pass that call onto a TSR who can help book appointments, refill a prescription, and so on. In addition, nurses stress that TSRs should clearly identify themselves not by an ambiguous title that the healthcare corporation devised, such as “teleservice representative,” but by a commonly understood title such as “clerk” which clearly signals to callers that they are not speaking to a medical provider. Not only is Kaiser’s practice of using TSRs as the first point of contact potentially unsafe for patients, it is inefficient; Billings had many examples of TSRs booking patients for appointments that they don’t need, and not booking appointments when needed.

“Initial triage by an unlicensed clerk is an error in system design and a case of the organization attempting to increase their profits,” wrote Roth in a Sept. 29, 2017 response to JoAnn Glover, the AACC director of nursing practice, during contract bargaining when call center issues arose. “Nurses report hearing clerks ask questions such as ‘How much bleeding?’ or ‘Is there a lot of pain?’ There are many ways that potentially serious symptoms can be missed by an untrained clerk.” Roth gives examples: Women have called in complaining of breast pain, when they are really experiencing chest pain. The TSR books an appointment with the ob-gyn, which proves futile, then calls back for an appointment with medicine. Or an asthmatic patient calls in for an inhaler refill, which the TSR dutifully processes, but the patient should have also received a respiratory assessment by an RN. As it turns out, the caller is in acute distress and ends up needing to go to the emergency department.

Many callers who happen to be pregnant get sent by TSRs to ob-gyn for everything, even though their problem may have nothing to do with their pregnancy. Or patients with abdominal pain frequently also get sent by TSRs to the ob-gyn clinic because they are unable to distinguish abdominal pain from pelvic pain. These are all real examples that nurses have documented in their assignment despite objection (ADO) forms, which in the AACC are called patient safety and advice concerns (PSAC).

Billings remembers one time she picked up a caller who had been placed on hold by the TSR in the pediatric queue. It was a mom whose child had sustained a head injury and had been bleeding. With just a few quick questions, Billings figured out that the child was unconscious in the back seat of the mom’s car and should have been directed to the ER right away, never mind being put on hold! “But the TSR hears ‘laceration’ and that the bleeding is controlled and immediately puts her in the queue,” said Billings, explaining how the script restrictions combined with the non-linear way that 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 misconception 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 regulatory authorities for their usage of TSRs. In the early 2000s, the California Nurses Association filed suit against Kaiser for misleading its members into thinking that they were talking to registered 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 managers 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 more than 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 expectations 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 making 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 like, ‘Didn’t you hear me? I want an appointment.’ It’s a waste of time.” Patients don’t understand that Kaiser requires the TSR to ask these questions because it is trying to direct them to these options instead of an in-person appointment.

Because of job stress and working conditions, David reports that “90 percent of TSRs are not happy there. The morale is very low. A lot of people use the term ‘prison.’”

It was after midnight on a Friday night when Mary Roth picked up the call. Her computer monitor is telling her the patient in question is a newborn and the quavering, teary voice on the other end of the line is the new, young mom. “I am calling about my baby. I don’t know what’s wrong, my baby won’t stop crying.”

Over the next minutes, Roth becomes the ultimate multitasking nurse detective: using her powerful conversational skills to establish trust and rapport with the new mother as well as reassure her and calm her down, listening carefully through her headset to not only the mom, but the sounds the baby is making and other background noises, scrolling through the patient’s medical record to glean as much information and history as possible, and drawing upon her decades of nursing experience and knowledge to pull everything together into a treatment plan for this woman. Even though it was harder to hear the mom while the baby was crying, Roth senses the importance of the mother-baby bond at that moment and does not ask the mom to put the baby down — something a less experienced RN might have done.

The upshot? Roth not only educated the new mom about the causes and solutions of crying babies and determined this particular baby was fine, but assessed that the mom likely had mastitis and was able to arrange a prescription for her. She further taught the mom about breast infections and how to avoid them in the future, as well as offering the mom additional resources about breastfeeding and postpartum depression and emotional changes. The call ended with a grateful and more empowered patient on the road to health and a nurse who felt confident that mother and baby had received the best possible care. These types of stories are why Roth is a call center advice nurse.

“All calls require us to use our critical thinking skills, employ the nursing process, use the resources provided judiciously, and practice as professionals within our scope as described in the nursing practice act,” wrote Roth in this exemplar on her work. “As registered nurses we are required to consistently advocate for the safest outcome for our patients and it is gratifying when all the components come together to make that possible.”

If it were up to Kaiser, Roth might never have taken the time to triage the mother (in order to keep the call time short) or been experienced enough to consider the mother-baby pair, which could have led to call backs and a delay of treatment for the mother. “It is important to manage each call thoroughly and completely,” wrote Roth.

Sadly, Kaiser AACC nurses report that management does not provide them the conditions they need to do their best work; RNs are struggling to provide the kind of quality care Roth describes in her scenario despite Kaiser, not because of Kaiser.

Like the TSRs, the Kaiser nurses’ main complaint is that Kaiser management believes that minimizing the call handle time and maximizing the volume of calls trump all other concerns, including patient safety and the well-being of the registered nurse. “In the call center, the pressure is to move faster with taking care of the patients, but we’re not having the proper tools and not having the staffing,” said Berry. “There is high surveillance and micromanaging of any and everything we do. The encouragement is to speed up instead of spending the appropriate amount of time at that moment to properly assess that patient.”

Jamesina Prater, an experienced call center advice RN, at her desk

The call center nurses describe management that treats them like automatons undeserving of respect, down time, and adequate bathroom breaks, and working conditions that cause undue emotional and psychological stress and physical injury. Sometimes nurses show up for work and don’t even have an assigned desk because the staffing software wrongly calculated two 0.5 full time employees as only one person! Nurses are timed and judged on every aspect of their call by customer service standards developed for the retail, banking, and hospitality industries — even though they are literally handling matters of life and death. “There is a general sense among nurses that Kaiser has no respect for our practice,” said Billings.

Every month, nurses are scored according to the AACC “Quality Listening Key,” a 30-page document that details Kaiser’s expectations and guidelines for every aspect of each call, from triaging proficiency to appropriateness of clinical advice given to whether the RN made enough caring and empathetic statements during the call. Nurses object to being constantly measured against this scoring key, which attempts to micromanage RN behavior. For example, the document states that, “’Good luck’ is not considered a sympathetic/empathetic expression” and that “’Take care’ is an acceptable expression but will not be counted as an expression of empathy if it is the only empathetic expression verbalized.” As Roth illustrates in her story about the crying baby, advice nurses must be free to complete the entire nursing process using their nursing judgment, knowledge, and skills to determine the best plan for each patient on the other end of the line.

“There is a certain number of times I have to say the phrase ‘I’m sorry,’” said Billings, “but when I’m dealing with a person with chest pains or trying to determine if they have clear airways, that’s more important at the moment. The tone of your voice conveys that you are sorry.”

Kaiser management routinely harps on advice nurses who do not meet their benchmarks for time. In one “Verbal warning — Workflow Optimization” memo to an RN, the RN team manager criticizes her average call handle times as being too long and calls per hour average as being too low compared to regional averages. The clinical outcomes of this nurses’ patients were never mentioned or considered; it’s clear management only cares about times.

Berry said that managers are also pushing the nurses to work faster, to beat the previous regional averages, but the more experienced advice nurses know better than to take the bait and are not intimidated by managers. “We don’t fall for it,” said Berry. “The older nurses are not going to speed up.”

Jeri Martinez, also an experienced call center advice RN, at her work desk

Roth echoed the others when she explained her approach to calls. “I don’t ever try to work faster,” said Roth. “I take my time. Every single patient needs as much time as they need. You can’t compromise patient care.” If managers hassle her about her call times, she responds, “Are you asking me to standardize my care? To limit my patient care?” Or she points out the many ways that understaffing in other departments is causing her calls to be prolonged.

Unfortunately, the AACCs are employing fewer and fewer experienced call center advice nurses. The environment is so “harsh,” say nurses, that attrition rates are high. Many RNs quit from the stress, medical conditions related to call center work, or have taken early retirement. According to new hire and termination numbers received through a CNA information request, the three Northern California call centers for the period 2010 to 2016 hired 782 RNs but lost 846, for a deficit of 64 RNs even as patient membership numbers have grown by millions. In 2016, the call centers hired only 92 nurses while 191 left. Billings said that she has witnessed entire new hire classes leave within 90 days.

Roth says the call centers are also hiring RNs with less and less experience. When she started, AACC nurses needed a minimum of five years of clinical experience. That requirement went down to three to five years, and now it is six months to a year. “When we began, the nurses had decades of experience that they could bring to our call center practice,” said Roth. “You need to be able to visualize and extrapolate based on experience. If you can’t connect symptoms to a living person at the bedside, you’re in big trouble.”

Trish Gonzalez, a call center RN who worked for many years in pediatrics, said that some nurses believe that call center nursing is an easy job, and they’d be very wrong. “I can’t tell you what a high level of care patients receive because of the wealth and breadth of experience that each individual nurse comes with,” Gonzalez said. “We’re taking care of people with blindfolds and hands tied behind our backs. For anybody who thinks the nurses at the call center are going out to pasture, it’s not true. Nurses from every background are all working together and really, really taking good care of our patients.”

To throw another wrench into an already dysfunctional workflow, nurses say that Kaiser’s Internet-based call management system, KPATHS, is a disaster. Nurses previously used a system called STARGATE which, while not perfect, was more reliable. In November 2016, the call centers switched over to KPATHS without notifying or discussing the union or nurses. The results were not pretty.

The most distressing KPATHS malfunction happened on May 16, 2017, when the entire system crashed at 9:20 a.m. and normal operations did not resume until 5:05 p.m. According to a report prepared by the nurses, the service disruption resulted in advice nurses losing contact with symptomatic patients, patients stuck in long waits to speak to TSRs as well as RNs, loss of access to interpreter services, and advice nurses forced to handle calls without their protocols and without charting — among a host of other issues. Despite Kaiser’s statement, “the crash/outage directly affected Kaiser’s ability to deliver care,” read the report. “The AACC was unable to book appointments, provide telephone prescriptions (TTP), or give advice.”

Besides the major systemwide crashes and inconveniences of the system, advice nurses are most worried about the extremely long (more than 30, 40, 50 minutes) wait times some callers experience and random crashes or freezes during individual calls, which happen daily. Patient safety is jeopardized when callers get put on hold for such a long time or get disconnected from nurses. “The worst part is when you are in the middle of a conversation and you’re not even through the emergent part, and it will freeze and kick the patient off the call,” said Berry. “And during interpreter calls, it will freeze up or kick off callers. Each time they do an upgrade, it breaks what was fixed. If we had one straight week without system flaws, we would do cartwheels down the hallway.”

More than a year later, KPATHS is still crashing. On Jan. 2, the system crashed in the middle of the day. TSRs were unable to transfer calls to advice nurses, so managers instructed the RNs to pick up their chairs and go sit next to TSRs and take over the headset if a patient called with emergent symptoms. “It’s pathetic,” said Roth. “They still have no backup plan for crashes.”

When you consider the entirety of Kaiser’s Appointment and Advice Call Centers — the way the workflow is improperly designed between TSRs and nurses; the organization’s profit motive for relying on call centers; the mentality and mindset of managers who measure AACC employees against typical call center standards and work pacing in other industries; the lack of proper tools, equipment, and nurse staffing; and the enormous mental and physical stress the work puts on RNs, it’s no wonder that many call center nurses are unhappy about their work environments and their ability to provide safe patient care.

In 2016, CNA nurse leaders conducted a survey of RNs at Kaiser’s three Northern California call centers. The results showed, among other things, that more than 66 percent felt pressure to avoid making appointments for patients in violation of their professional judgment; more than 50 percent felt they could not consistently apply the nursing process to their patients, give advice, or advocate; more than 85 percent of their patients believed that the TSR was a health professional; more than 66 percent of nurses had to revise actions or instructions given by a TSR; and almost 50 percent of RNs felt bullied in their monthly coaching sessions by managers. In other words, Kaiser prevents them from doing their jobs.

“I like my job. I hate the environment,” said Berry matter of factly. “Let people do their job. Stop super micromanaging.”

RNs created signs to show managers who often interrupted their calls with patients

Of course, the call center nurses are organizing and fighting back. The quality liaisons and nurse leaders have been meeting regularly to discuss ways of addressing issues. One example of a solution to the problem of supervisors interrupting nurses while they are on the phone with patients was development of small placards reading, “Please do not distract me when I am providing patient care.” that nurses can hold up. The reverse side includes some important phrases for advice nurses to use in establishing their role as RNs with patients.

In addition, CNA’s nursing education department last year hosted a series of well-attended continuing education courses focused solely on call center nurses’ workplace and practice issues. The professional practice committees at the various call centers have also been occasionally successful in modifying TSR scripts to make them safer.

Call center registered nurses protest during a Kaiser day of action

And as part of current contract negotiations, the call center nurses put three specific proposals on the table. The first was to be able to document and keep notes during their reviews of TSR scripts. The second was to reinstitute regional professional practice committee meetings among the three call centers so that nurses are able to share information and better understand AACC issues on a systemwide level — which they won. And the third was to establish a standing committee to examine on a quarterly basis technology and its use at the call centers.

The advice nurses are determined to win improvements so that they can do what they love best: take care of their patients. “I know I am an asset to Kaiser,” said Berry. “I get satisfaction every day on a regular basis from patients who tell me, ‘Thank you. You’ve calmed me down. You’ve helped me so much.’ I’m there for the patients.”



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