Empower staff to make patient visits more meaningful and efficient.

Expanded rooming and discharge protocols

  • Christine Sinsky, MD AMA, Medical Associates Clinic and Health Plans
CME Credits: 0.5

How will this module help me implement expanded rooming and discharge protocols?

  1. Five ways to involve staff
  2. Answers to questions about adopting protocols
  3. Case vignettes describing practices using new protocols
  4. Rooming and discharge checklist to help with implementation

CME accreditation information 

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduces the amount of time physicians spend delivering care. By implementing expanded rooming and discharge protocols, physician practices can increase operational efficiency by leveraging the skills and training of staff to perform additional tasks and responsibilities associated with a patient visit. Such workflow adjustments will allow physicians to spend more time interacting with patients.

Expanded Rooming and Discharge Protocols
Release Date: October 2014
End Date: October 2018

Objectives

At the end of this activity, participants will be able to:

  1. Learn how to effectively implement expanded rooming and discharge protocols
  2. Assess their current rooming and discharge process
  3. Develop a comprehensive rooming checklist
  4. Develop a comprehensive discharge checklist
  5. Manage process improvements after implementing expanded rooming and discharge protocols

Target Audience

This activity is designed to meet the educational needs of practicing physicians.

Statement of Need

Preparing the necessary clinical information for a patient visit is time consuming. Without a clear process for delegating tasks such as gathering, retrieving and reviewing patient information, physicians spend more time completing administrative tasks than focusing on complex clinical issues and engaging with patients in the exam room. At the end of the visit, patient treatment adherence can also be a challenging task for physicians and staff. Some patients may have difficulty remembering and/or understanding medical instructions prescribed by physicians, which can affect health care outcomes.

This expanded rooming and discharge protocols module is one of several practice transformation strategies aimed at reducing or eliminating onerous administrative tasks. It leverages the skills and training of staff and empowers them to take on additional responsibilities that will make patient visits more seamless and meaningful.

Statement of Competency

This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.

Accreditation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Association designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claiming Your CME Credit

After viewing the webinar, in order to claim AMA PRA Category 1 Credit™, you must; 1) view the webinar in its entirety, 2) successfully complete the quiz answering 4 out of 5 questions correctly and 3) complete the module.

Planning Committee

  • Kevin Heffernan, MA – AMA CME Program Committee
  • Ellie Rajcevich, MPA – Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA – AMA Director, Professional Satisfaction and Practice Sustainability
  • Christine Sinsky, MD – Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
  • Rhoby Tio, MPPA – AMA Senior Policy Analyst, Professional Satisfaction and Practice Sustainability

Author(s)

  • Christine Sinsky, MD – Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

Faculty

  • Amireh Ghorob, MPH – Director of Practice Coaching and Training, Center for Excellence in Primary Care, University of California–San Francisco
  • Michael Glasstetter – AMA, VP Advocacy Operations, Advocacy Planning & Management
  • Chris Goerdt, MD, MPH – General Internist, University of Iowa
  • Thomas Healy, JD – AMA, Vice President and Deputy General Counsel
  • Douglas Olson, MD – Chief Medical Officer, Norwalk Community Health Center
  • Jeffrey Panzer, MD – Medical Director, Oak Street Health
  • Ellie Rajcevich, MPA – Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA – AMA Director, Professional Satisfaction and Practice Sustainability
  • Christine Sinsky, MD – Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
  • Rhoby Tio, MPPA – AMA, Senior Policy Analyst, Professional Satisfaction and Practice Sustainability
  • Rachel Willard-Grace, MPH – Research Manager, Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California–San Francisco

About the Professional Satisfaction, Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement

The content of this activity does not relate to any product of a commercial interest as defined by the ACGME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Hardware/software Requirements

Adobe Flash 9.0.115 or above
Audio speakers or headphones
Screen resolution of 800X600 or higher
MS Internet Explorer 8.0 or higher, Firefox, Opera, Safari, etc.
Adobe Reader 5.0 or higher

Introduction

What are expanded rooming and discharge protocols?

Physicians alone cannot do all of the work needed for most office visits. With expanded rooming and discharge protocols, the nurse, medical assistant (MA) or other clinical support staff are able to fully use their skills to create a smooth visit for the patient and a satisfying clinic session for the entire team. Creating standard work routines enables staff to take on additional responsibilities that give physicians more time to spend on work for which they were uniquely trained.

Expanded rooming and discharge protocols introduction

How much time and money will implementing expanded rooming and discharge protocols save my practice?

This calculator allows you to estimate the amount of time and money you can save by implementing expanded rooming and discharge protocols in your practice. Enter the number of patient visits per day and physician time spent on rooming and discharge tasks per day.

Your practice

$
/min

Cost of physician's time

days/year

Clinic days per year

Estimate savings

/day

Total visits per day

x
min/visit

Physician time on standard
tasks/visit More info

=

Time

1h 40m
/day

Time saved

=

Money

$66,000

Annual savings with
expanded rooming
and discharge

Source: AMA. Practice transformation series: expanded rooming and discharge protocols.. 2014.

As part of the expanded rooming protocol, the nurse or MA can complete the following tasks:

  • Identify the reason for the visit and help the patient set the visit agenda
  • Perform medication reconciliation
  • Screen for conditions based on protocols
  • Update past medical, family and social history
  • Provide immunizations based on standing orders
  • Arrange for preventive services based on standing orders
  • Assemble medical equipment, if needed, before the physician enters the exam room

Conducting these activities during patient rooming will enable the physician to spend more time directly interacting with the patient and family, rather than focusing on these elements of the visit.

As part of the expanded patient discharge protocol, the nurse or MA can complete the following tasks:

  • Print and review an updated medication list and visit summary
  • Reiterate to patients the medical instructions prescribed by the physician
  • Coordinate the next steps of care

This augmented patient discharge process will ensure that patients understand and remember their discharge instructions, leading to improved treatment adherence.

A lot of the work has already been done for me, so I can spend more time with the patient and less time looking at the computer.

Mary Wild Crea, MD

Mary Wild Crea, MD
Pediatrics, Fairview Health Services, Rosemount, MN

Five steps for involving staff in rooming and discharge activities:

  1. Identify current workflows
  2. Create a rooming checklist
  3. Refine the rooming checklist
  4. Create a discharge checklist
  5. Provide ongoing staff training
  1. 1

    Identify current workflows

    Write down the tasks that the nurse/MA currently completes during rooming, such as obtaining vital signs and documenting the reason for the visit as well as tasks completed after the visit.

  1. 2

    Create a rooming checklist

    Create a wish list of tasks that the clinical support staff could do before and after the physician component of the visit to improve care and reduce physician time on routine functions. Your list might include reconciling medications or identifying the patient's agenda for the visit. Next, pick one or two of these tasks and try them out for a week. Then pick two more and continue to refine the list. Encourage feedback and suggestions during team meetings or morning huddles to ensure that the new process is working for physicians, staff and patients.

  2. Sample rooming checklist Download See all downloadable tools
Patient rooming
Medication reconciliation
Patient education & follow-up care
Future orders
Select a step to see more details Take vital signs, determine chief complaint, update past, family and/or social history, update immunizations, etc. Review and reconcile the patient's medication(s) Reinforce next steps of care as well as provide immunizations, patient education and health coaching Order laboratory tests, screenings, etc. before the next visit
Sample patient visit workflow diagram

Source: AMA. Practice transformation series: expanded rooming and discharge protocols.. 2014.

  1. 3

    Refine the rooming checklist

    Over a period of several weeks, refine the rooming checklist based on team feedback and post it close to where the work is done. For example, the checklist can be placed in workstations and exam rooms so that the care team can easily access and refer to it. Making the checklist easily accessible will help the team gain confidence and consistency in performing their new responsibilities.

  2. Refine the rooming checklist
    Beverly Loudin, MD, MPH

    We developed a greater role for our medical assistants so the physicians don't have to shoulder all of the work.

    Beverly Loudin, MD, MPH, Medical Director, Patient Safety & Risk Management, Atrius Health, Boston, MA
  3. 4

    Create a discharge checklist

    Similar to how the rooming checklist was developed, create, refine and post a list of tasks that nurses or MAs will do after the physician leaves the exam room. (Note: not all patients or practices will need a discharge step. This step can be used as needed.)

  4. Patient discharge checklist Download See all downloadable tools
  5. 5

    Provide ongoing staff training

    Training often occurs on the spot. For example, the physician can explain a new task or provide feedback regarding the way the support team documents particular elements of the patient rooming or discharge process. Regular team meetings provide another opportunity for ongoing education. Some organizations may create skills assessments to formally sign off on an employee's acquisition of new skills, such as performing a diabetic foot exam. The more comfortable nurses and MAs become with their new responsibilities and enhanced roles, the greater the contribution they will make and the more they will enjoy their work.

  6. Empower staff to take on more responsibilities. #STEPSforward

    ;

Dealing with the “list”

Some patients come to their appointments with multiple issues on their minds, and the most important one may not surface until the time allotted for the appointment is nearly past. The nurse/MA can help avoid this problem by clarifying the patient's objectives for the visit (e.g., “How can we help you today?” or “What are you hoping to accomplish today?”). If the list is long, the nurse/MA can help the patient prioritize their agenda by asking clarifying questions, such as, “What are the three issues that are most important for you today?” A pre-appointment questionnaire given to the patient before the visit and reviewed by the staff during rooming is also useful.

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Conclusion

Expanded rooming and discharge protocols address inefficient workflows by organizing and standardizing common tasks that practice staff perform during patient visits. The strategies in this module will enable practices to create personalized patient rooming and discharge checklists to increase patient and staff satisfaction with the care being provided.

Expanded rooming and discharge protocols conclusion

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References

  1. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15(7):35-40. http://www.aafp.org/fpm/2008/0700/p35.html. Accessed April 2, 2014.
  2. Blash L, Dower C, Chapman S. High Plains Community Health Center—Redesign expands medical assistant roles. San Francisco, CA: Center for the Health Professions at the University of California, San Francisco; November 2010. Revised November 2011. https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/8.1%202010-11_High_Plains_Community_Health_Center_Redesign_Expands_Medical_Assistant_Roles.pdf. Accessed April 2, 2014.
  3. Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5(5):457-61.
  4. Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the roles of medical assistants: who does what in primary care? JAMA Intern Med. 2014;174(7):1025-1026. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1868539?utm_source=silverchair%20information%20systems&utm_medium=email&utm_campaign=archivesofinternalmedicine%3Aonlinefirst05%2F12%2F2014. Accessed April 2, 2014.
  5. Herzberg F. One more time: how do you motivate employees? Harvard Business Review. January 2003. https://hbr.org/2003/01/one-more-time-how-do-you-motivate-employees. Accessed April 2, 2014.
  6. McCarthy BD, Yood MU, Bolton MB, Boohaker EA, MacWilliam CH, Young MJ. Redesigning primary care processes to improve the offering of mammography. The use of clinical protocols by nonphysicians. J Gen Intern Med. 1997;12(6):357-363.
  7. Patel MS, Arron MJ, MD, Sinsky TA, Green EH, Baker DW, Bowen JL, Day S. Estimating the staffing infrastructure for a patient-centered medical home. Am J Manag Care. 2013;19(6):509-516.
  8. Sinsky CA, Sinsky TA, Althaus D, Tranel J, Thiltgen M. 'Core teams': nurse-physician artnerships provide patient-centered care at an Iowa practice. Health Aff. 2010;29(5):966-968.
  9. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278. http://annfammed.org/content/11/3/272.full. Accessed April 2, 2014.
  10. Yarnall KS, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders: “time” to share the care. Prev Chronic Dis. 2009;6(2):A59.
  11. Elevating the role of the medical/clinical assistant: maximizing team-based care in the patient-centered medical home. Seattle, WA: Safety Net Medical Home Initiative, a project of The Commonwealth Fund, Qualis Health and MacColl Institute at the Group Health Cooperative; August 2011. http://www.mainequalitycounts.org/image_upload/PCMH%20Pilot%20Expansion%20Launch_Elevating%20The%20Role%20Of%20The%20Medical%20and%20Clinical%20Assistant_Safety%20Net%20Medical%20Home%20Initiative_2011.pdf. Accessed April 2, 2014.

STEPS in practice

Case 1

How's it working in Boston, MA?

In 2008, North Shore Physicians Group (NSPG)—a 365-provider, 20-site organization—began a system-wide change from a traditional physician-centric delivery model, where the physician is responsible for all elements of care, to a team-based care delivery model, where the care is shared among a group of closely aligned professionals.

The model is based on an expanded role for MAs, “so that the physicians wouldn't have to shoulder all of the work,” said Beverly Loudin, MD, MPH, former NSPG Director of Patient Safety and Quality and director of the initiative. She began by interviewing physicians regarding the skills and responsibilities they would want in a highly functional MA.

Once the role was designed, NSPG developed a week-long training program to assure that all MAs in the system would have the same skill set, which aligned with their new responsibilities.

During the summer of 2009, NSPG trained 80 MAs in the new model of care. They were taught basic clinical skills, critical thinking, health coaching, patient self-management techniques and population management. Because improving work while doing the work is seen as an essential strategy going forward, MAs are also trained in process improvement.

The MA role was transformed from someone who generally answers phones, escorts patients and obtains vitals to a partner capable of team-based care. Each day, the MA, physician, scheduler and nurse start with a morning huddle to review the day's work and plan for a smooth workflow. What was previously a three-minute rooming process has been expanded to an eight-minute process, and now includes recording current medications and allergies, agenda setting, form completion and closing gaps in care (also known as “in-reach”). For example, the MAs review all health monitoring reminders, give immunizations and proactively book appointments for mammograms and bone density scans. The goal is to meet all of the patient needs while in the exam room, rather than leaving time-consuming loose ends to be addressed after the patient leaves.

The MA also assumes responsibility for entering a greater portion of visit note data. As one NSPG leader reports, “a huge part of the change has been having the MA put extensive information into the EHR.” The MA starts the note and performs most of the structured text data entry components of the visit. The provider will later edit these entries for accuracy and document the narrative portion of the note.

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Case 2

How's it working in Rosemount, MN?

At Fairview Health Services in Rosemount, MN, MAs are prompted by the EHR to obtain the relevant information or perform the appropriate condition-specific tasks for preventive care for adults, diabetes and cardiovascular disease, low back pain, asthma and migraines, in addition to standard rooming tasks and medication reconciliation.

For example, during a visit an elderly woman presented with a rash and blood pressure issues. During rooming the MA checked the date of the last bone density scan (it had been more than three years so the MA scheduled another bone density test), reviewed advance directives, colonoscopy, diabetic metrics, lipids and pneumococcal vaccine status. Because the patient's brief depression screen was positive during rooming, the MA administered a longer depression survey to more thoroughly assess the patient's status. The MA then uploaded all of the answers from the new survey into the EHR and communicated the results to the physician. This allowed the physician more time to address the depression uncovered by the MA while ensuring that all other acute and preventive measures were managed.

At the conclusion of the visit, the MA or physician used the exam room's printer and provided the patient with a printed summary of the visit, including instructions for behavioral change, medication adjustment and next appointments.

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Downloadable tools

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The tools and resources here can offer implementation support for your practice. You can download and modify them to fit your specific needs.

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Module Completion

Individual tools

  • Expanded rooming and discharge protocols module

    Download a printable PDF version of this module.

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    PDF, 553 KB

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  • Expanded rooming and discharge protocols PowerPoint

    Use this PowerPoint presentation to review this module with your team.

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    PPT, 62 MB

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  • Sample rooming checklist

    A checklist of tasks for the clinical support staff to complete before and after the physician component of the visit, to improve care and reduce physician time on routine functions.

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    MS WORD, 37 KB

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  • Patient discharge checklist

    A checklist to help create a list of tasks that nurses or MAs should complete after the physician leaves the exam room.

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    MS WORD, 34 KB

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  • Visit prep checklist

    A checklist that allows the clinical team to compile a list of the patient's screening and immunization needs to be addressed during the upcoming visit.

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    MS WORD, 52 KB

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  • Pre-appointment questionnaire

    Set the agenda for the patient's next appointment and save time during the clinic session by having patients fill out this questionnaire over the phone or by email.

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    MS WORD, 57 KB

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  • Competency assessment for diabetic foot exam

    A form to help assess that all the elements of a diabetic foot exam have been completed. Can be used for training purposes or practice needs.

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    MS WORD, 49 KB

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  • Expanded rooming and discharge protocols implementation checklist

    A checklist to help assess, improve and reassess the implementation process of expanded rooming and discharge protocols in your practice.

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    MS WORD, 37 KB

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  • Expanded rooming and discharge protocols metrics

    Measure the impact of expanded rooming and discharge protocols.

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    MS WORD, 98 KB

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If you would like to learn about available resources for implementing the strategies presented in this module, please call us at (800) 987‑1106 or send us a message.

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AMA PRA Category 1 Credit™ will be available for the activity. Physicians should claim only the credit commensurate with the extent of their participation in the activity. In order to claim AMA PRA Category 1 Credit™, you must: 1) view the module in its entirety, 2) successfully complete the quiz by answering 4 out of 5 questions correctly and 3) complete the evaluation.

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