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Describe advanced rooming and discharge protocols
Identify how to involve team members in advanced rooming and discharge activities
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 tasks2,4- 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 tasks4,6,8:
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.
Identify Current Workflows
Create an Advanced Rooming Checklist
Create an Advanced Discharge Checklist
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.
Can advanced rooming and discharge work in a teaching practice?
Yes. In fact, nurses and MAs can be an important source of cohesion in teaching practices where there are different physicians in session each day. Additionally, the standardized process of advanced rooming ensures that medical students or residents don't miss necessary elements of patient care, such as immunizations or diabetic foot exams.
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.
How can I trust my team to do these new tasks reliably?
Investing in training will save time in the long run. Well-trained clinical team members may do their work more effectively and with greater purpose if they understand the rationale behind the process and the benefits to the patient. A few hours of training will pay off with a more efficient practice and a happier work environment.4,7
I work with a different MA each day. What is the best way to train everyone?
Having teams of people work together every day is ideal. Sometimes this isn't possible, which underscores the need to develop standard workflows for all team members in your practice.
Will the rooming checklist vary by specialty?
Yes. For example, in a primary care practice the staff may be trained to perform a diabetic foot exam as part of the rooming process for patients with diabetes. In a pulmonary practice, the clinical team may be trained to teach the proper inhalation technique using a handheld nebulizer. In a palliative care practice, the clinical team may be trained to complete a detailed pain assessment prior to the physician portion of the visit.
Which parts of a visit note can a nonphysician documentation assistant write as part of a team documentation process?
Under Medicare payment rules for new and established office or outpatient E/M visits, a documentation assistant can enter:
History of Present Illness (HPI)
Past Family Social History (PFSH)
Review of Systems (ROS)
Medication list (eg, perform medication reconciliation)
The information does not need to be re-documented by the billing practitioner. Billing physicians simply review, update, and verify the information, sign, and date the note.
The physician must still personally perform the physical exam and medical decision-making activities of the E/M service being billed. For more information on the 2021 E/M CPT coding and documentation changes, please visit the AMA website on E/M coding here. The AMA's Debunking Regulatory Myths site also discusses this topic in depth. The STEPS Forward Team Documentation toolkit also contains information about how team members can help with this task.
Our electronic health record (EHR) doesn't include pop-ups that remind the clinical team about a patient's preventive care needs. Can the team still help bring patients up to date?
Some practices create a visit prep checklist and place it in each room and at the nurse or MA workstation for ease of reference.
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
“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; Pediatrics, Fairview Health Services
“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.”
Should the patient rooming and/or discharge process be standardized across all practices in our organization?
There is no right answer. Standard processes can add to reliability and efficiency; at the same time, standardization is best balanced with the ability to customize to the unique needs of an individual practice or specialty. An organization can develop a standard rooming and/or discharge template that individual practices can then use as a starting point in creating their own local protocols.
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
To estimate the amount of time and money you can save by implementing advanced 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. Calculations are for demonstration purposes only. Actual savings may vary.
Prioritize 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 or MA can help avoid this problem by clarifying the patient's objectives for the visit (eg, “How can we help you today?” or “What are you hoping to accomplish today?”). If the list is long, the nurse or MA can help patients prioritize their agenda by asking clarifying questions, such as, “What are the 3 issues that are most important for you today?”
If possible, place a printer in every room.
Having a printer in every room dramatically increases efficiency. For example, team members can print the updated medication list while in the exam room with the patient. One clinic found that this saved 20 minutes of physician time every day. Reducing the need for multiple trips in and out of the room can decrease the likelihood that the MA, nurse, or physician will be interrupted while processing their thoughts on the patient. Minimizing distractions and disruptions enables practices to deliver safer care.
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
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Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.
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