Advanced Rooming and DischargeOptimize Team-Based Visit Workflows

Learning Objectives

1. Describe advanced rooming and discharge protocols

2. Identify how to involve team members in advanced rooming and discharge activities

3. Explain key steps to implement advanced rooming and discharge protocols in your practice

Physicians alone cannot do all the work needed for most office visits.¹ Advanced rooming and discharge protocols are standardized workflows that enable nonphysician team members to take on additional responsibilities. Quiz Ref IDWith advanced rooming and discharge protocols, the nurse, medical assistant (MA), or other clinical support team member can use their unique skills to create a more efficient, higher quality, and more satisfying visit for the patient and the entire team.^2- 7 This in turn saves physicians time and reduces costs for practices.

As part of the advanced rooming protocol, the nurse or MA can complete the following tasks^2,4- 6,8:

• 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

• Administer immunizations based on standing orders

• Pend or order 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, rather than focusing on these elements of the visit.

Quiz Ref IDAs part of the advanced discharge protocol, the nurse or MA can complete the following tasks^4,6,8:

• Print and review an updated medication list and visit summary

• Review other after-visit instructions, such as home blood pressure monitoring or referrals to subspecialists

• Coordinate the next steps of care, such as scheduling future appointments and labs

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

1. Identify Current Workflows

2. Create an Advanced Rooming Checklist

3. Create an Advanced Discharge Checklist

4. Provide Ongoing Team Training

Write down the tasks and workflows that the nurse or MA currently completes during the rooming process, such as obtaining vital signs and documenting the reason for the visit, and tasks completed after the visit. Documentation of tasks and workflows may seem overly simplistic, yet it is an essential starting point to achieve a comprehensive understanding of each team member's role within the clinical workflow. The process of mapping out tasks and workflows enables clinical teams to accurately assess current state, gaps in clinical care skills, and future needs.

Quiz Ref IDCreate a list of tasks that clinical support team members could complete before the physician component of the visit to improve care and reduce physician time on routine functions.^1,6 Your list might include reconciling medications or identifying the patient's agenda for the visit. A health maintenance checklist can be useful for establishing your list. Next, pick 1 or 2 of these tasks and try them out for a week. Then pick 2 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 patients, physicians, and team members.

The example workflow depicted in Figure 1 may help you to design your advanced rooming and discharge protocols.

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 responsibilities.

After advanced rooming protocols are refined, create an advanced discharge checklist that includes a list of tasks that nurses or MAs will do after the physician leaves the exam room. Continue to refine and adapt this list with feedback from your team.

Quiz Ref IDWe suggest starting with the advanced rooming protocol because in some practices, MAs won't have time to go back into the exam room after the physician is finished with their portion of the visit. After advanced rooming becomes an established routine, as staffing level allows, you can add the advanced discharge protocol for a subset of your patients, such as those with more complex care.

Quiz Ref IDTraining 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.² Regular team meetings provide another opportunity for ongoing education.⁴ 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.^8,9

Advanced rooming and discharge protocols enable physicians to focus directly on patient care through optimizing inefficient workflows and by organizing and standardizing common tasks that the care team performs during patient visits.^1,6 The strategies in this toolkit will enable practices to create personalized patient rooming and discharge checklists that increase patient and staff satisfaction and improve overall patient care.^2,5

Journal Articles and Other Publications

• Sinsky CA, Jerzak J, Hopkins K. Telemedicine and team-based care: the perils and the promise. Mayo Clin Proc. 2020;96(2):429-437. doi:10.1016/j.mayocp.2020.11.020

• Jin J, Reimer J, Brown M, Sinsky C. Saving Time Playbook. American Medical Association; 2021. AMA STEPS Forward™ Playbook Series. Accessed March 9, 2022. https://www.ama-assn.org/system/files/ama-steps-forward-saving-time-playbook.pdf

• Patel MS, Arron MJ, Sinsky TA, et al. Estimating the staffing infrastructure for a patient-centered medical home. Am J Manag Care. 2013;19(6):509 516. https://www.ajmc.com/pubMed.php?pii=85113