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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
0.5 Credit CME
How Will This Toolkit Help Me?

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

Introduction

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.27 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 tasks2,46,8:

  • 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.

Four STEPS to Adopt Advanced Rooming and Discharge Protocols:

  1. Identify Current Workflows

  2. Create an Advanced Rooming Checklist

  3. Create an Advanced Discharge Checklist

  4. Provide Ongoing Team Training

STEP 1 Identify Current Workflows

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.

Box Section Ref ID

Q&A

STEP 2 Create an Advanced Rooming Checklist

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.

Figure 1. Sample Advanced Rooming and Discharge Workflow
Box Section Ref ID

Q&A

STEP 3 Create an Advanced Discharge Checklist

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.

STEP 4 Provide Ongoing Team Training

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

quote

“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
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Q&A

Conclusion

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

How Much Time and Money Will Implementing Advanced Rooming and Discharge Protocols Save My Practice?

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.

Box Section Ref ID
Graphic Jump Location
AMA Pearls

AMA Pearls

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.

Further Reading

Journal Articles and Other Publications

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AMA STEPS Forward® presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

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

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Credit Renewal Dates: February 2, 2018, April 25, 2019, April 24, 2022

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.

About the AMA Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group is committed to making the patient–physician relationship more valued than paperwork, technology an asset and not a burden, and physician burnout a thing of the past. We are focused on improving—and setting a positive future path for—the operational, financial, and technological aspects of a physician's practice. To learn more, visit https://www.ama-assn.org/practice-management.

References:
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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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2687865/Google Scholar
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Bodenheimer  T, Laing  BY.  The teamlet model of primary care.  Ann Fam Med. 2007;5(5):457–461. doi:10.1370/afm.731Google Scholar
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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. doi:10.1001/jamainternmed.2014.1319Google Scholar
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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 clinic protocols by nonphysicians.  J Gen Intern Med. 1997;12(6):357–363. doi:10.1046/j.1525-1497.1997.00060.xGoogle Scholar
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Sinsky  CA, Sinsky  TA, Althaus  D, Tranel  J, Thiltgen  M.  Practice profile. 'Core teams': nurse-physician partnerships provide patient-centered care at an Iowa practice.  Health Aff (Millwood). 2010;29(5):966–968. doi:10.1377/hlthaff.2010.0356Google Scholar
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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. doi:10.1370/afm.1531Google Scholar
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Blash  L, Dower  C, Chapman  S, for the Center for the Health Professions at UCSF.  High Plains Community Health Center—Redesign expands medical assistant roles.  Center for the Health Professions at the University of California, San Francisco. November 2011. Accessed March 9, 2022. 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
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Herzberg  F.  One more time: how do you motivate employees?  Harvard Business Review. January 2003. Accessed March 9, 2022. https://hbr.org/2003/01/one-more-time-how-do-you-motivate-employeesGoogle Scholar

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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