Purpose: The diversion of controlled substances, particularly narcotics, remains a significant concern in health care. To address this, the pharmacy department is revising the controlled substances and high-diversion drug management policy for ambulatory care clinics, aiming to improve medication safety and compliance with best practices. A key revision is the creation of a standardized log to prevent diversion, ensure accountability, and enhance patient safety. The ASHP Guidelines on Preventing Diversion emphasize the importance of tracking systems, monitoring, documentation, and staff training to reduce misuse and protect patient care.
Description: A rapidly expanding ambulatory care health system, now encompassing over 250 clinics, is acquiring a diverse range of healthcare facilities, each with unique processes for managing controlled substances. These variations create challenges in achieving a consistent, compliant, and efficient approach to tracking. As the system grows, standardizing procedures across clinics is essential to mitigate risks related to regulatory compliance, patient safety, and operational efficiency.
The lack of a standardized system complicates regulatory compliance, quality control, and risk management as the organization grows. Variations in tracking protocols increase the risk of non-compliance with DEA regulations, leading to potential legal and financial consequences. Inconsistent tracking also hinders inventory management, misuse prevention, and waste identification, affecting patient safety and reputation. To address these issues, the health system must implement a standardized controlled substance tracking framework that aligns with regulations, integrates across clinics, and enables centralized monitoring and compliant management.
The policy update aims to improve communication, reinforce security, and create a safer, more accountable environment for patients and providers. The log will support these goals while the health system works to implement Pyxis systems in all 250+ clinics, enhancing management of high-theft medications. A pilot program was launched in select clinics to ensure the log meets policy and evidence-based standards. The ambulatory care nursing department developed multiple log versions, collaborating with clinic staff to assess functionality and alignment with the policy. Feedback from the pilot refined the log and improved integration into daily workflows.
After the pilot, feedback was reviewed to refine the narcotic log. Research shows that iterative feedback and collaboration are crucial for successful healthcare tool implementation. The final log was submitted to the pharmacy department for inclusion in the revised policy, which will be presented to the policy committee for approval. This evidence-based approach ensures the log aligns with best practices and supports regulatory compliance.
Evaluation/outcome: By employing evidence-based methods, the pilot will help refine the narcotic log and ensure it meets both operational needs and regulatory standards. Ultimately, the goal is to roll out the log across all ambulatory care clinics, improving oversight, reducing risks associated with controlled substance misuse, and enhancing overall patient safety.
Learning outcome: Upon completion, participants will be able to evaluate and refine substance tracking systems, ensuring they align with regulatory standards and best practices, and apply these improvements to enhance safety and reduce diversion in clinical settings.

Purpose: The educational training program was meticulously and thoughtfully designed to establish and evaluate a targeted curriculum for medical assistants (MAs) practicing in the ambulatory care setting. This training aligns with the MA certification standards and was developed specifically for primary and multi-specialty clinics within a large academic healthcare facility. The initiative catered to existing patient care assistants (PCAs) who had achieved MA certification and newly hired MAs. Upon completing the ambulatory care training program, MAs reported significant increases in confidence, skills, and critical thinking abilities. Integrating MAs into ambulatory care clinical practice has transformed team-based workflows and fostered innovation, thereby enhancing the overall delivery of care.
Description: Medical assistant training programs offer certification education; however, the absence of a nationally recognized or widely implemented curriculum often results in many MAs feeling underprepared for new and expanded roles. A new orientation education program was developed to address this challenge and enhance the readiness of MAs practicing in the ambulatory care setting. Recognizing that the scope of practice for MAs is more comprehensive than that for PCAs, our executive nursing leadership played a crucial role in encouraging PCAs to achieve certification and transition into the MA role. This program aimed to increase MAs’ confidence, skills development, and critical-thinking abilities that would contribute to reshaping the ambulatory patient care delivery model. The program encompassed a comprehensive 16-hour didactic course, medication and calculation training, point-of-care testing, clinic workflow orientation, and education on specific clinic diagnoses. The curriculum provided opportunities to improve provider interaction and support to promote care coordination. Each phase of the program incorporated a nursing preceptor, critical-thinking exercises, and interactions with clinical nurse educators to help MAs comprehend the complex needs of their patient populations and foster interdisciplinary communication.
Evaluation/outcome: Of the 151 MAs enrolled, 149 completed the training program by applying acquired knowledge, passing the required medication exam with a 90% or higher score, and participating in clinical observation and vaccine injection practice. Nurse managers’ feedback was overwhelmingly positive, describing the MAs as positive, flexible, and valuable assets to the teams. Positive participant course evaluations revealed that over 95% of MAs improved their medical knowledge and understanding of ambulatory care practice. Medical assistants have coordinated pre-visit planning, rooming, discharge activities, and patient education. This integrated approach enables physicians to dedicate their attention to patient care, improving team collaboration and clinic workflow efficiency.

Purpose: Our outpatient oncology clinic reported 3 patient falls in Q4 of 2023. Falls can lead to physical and emotional injury, hospitalization, and the delay of chemotherapy treatment, or research participation. A multidisciplinary fall prevention task force was established to implement a standardized process in Q1 of 2024. Fall prevention was addressed on a patient basis lacking identification or communication methods of the risk between departments and infusion floors to prevent falls. A tool addressing our specific patient population was not developed, based on literature search results. One source, the CDC STEADI questionnaire, suggests 3 key questions that could be used to assess fall risk in an outpatient setting.
Description: A Fall risk assessment questionnaire titled “Check Your Balance,” based on the CDC 3 key questions, is used for every patient upon check-in to clinic. The patient receives a yellow wrist band, in addition to an ID band, for a “yes” response to any screening question. A secure message is sent to trained staff members that the patient is wearing a yellow band and needs assistance. The patient is then assisted while moving/walking within the clinic by a trained staff member.
Fall prevention interventions include signs for patients, pull cords in the bathrooms and patient rooms changed to red, and fall prevention signs posted in the bathrooms. Gait belts and walkers were purchased and placed on both floors of the clinic. Education and training for staff who have direct patient care was conducted on safe mobility, gait belt use, and fall prevention techniques with competency demonstrations.
Evaluation: Data was collected through staff and patient surveys at two months and six months during the pilot. We tracked fall occurrences through the electronic incident reporting system. The number of total yellow bands was counted to track how many patients were identified as increased risk for fall. Communication of the at-risk patient for fall in the clinic has improved with the secure messaging platform. Incident tracking during the 6-month pilot shows no falls in the clinic. 95-100% of staff feel the workflow made a difference in patient safety; 95-96% of staff feel the workflow is efficient. At the six-month evaluation, 85% of patients who received a yellow band reported increased perception of safety.

Purpose: Nurse residencies largely consist of inpatient-based programs with some emerging primary care programs. The growth of our ambulatory specialty care service line-ased practices, in combination with ongoing regional expansion, has increased the requests for RNs. Still, the number of applications wasn’t meeting the demand. For specialty clinics that historically only hired experienced RNs, reconsidering past hiring norms and investigating the acceptance of new graduates was imperative. This project applied the evidence-based practices of other successful nurse residencies and developed a program to meet the increased staffing demands.
Description: From Novice to Expert and “tiered skills acquisition model” (TSAM) were integrated into some of the foundational content of the AAACN ambulatory care registered nurse residency program to create an ambulatory care multispecialty service nurse residency program to meet our needs. A TSAM orientation template was designed for departments to utilize as they restructured their current orientation into tiers or phases and added content for onboarding a new graduate RN. “New graduate” was defined as having one year or less of experience.
Our current RN transition-to-ambulatory care practice lectures were restructured and expanded to provide professional content for the nurse residents, and peer group sessions were implemented monthly. Clinical orientation and educational content were determined to be the responsibility of the hiring departments due to the wide variety of clinical skills needed for each specialty area.
The professional lecture topics were selected using the Ambulatory Care Registered Nurse Residency Program Professional Topics Guide. Topics covered in the first two large introductory classes include ambulatory care nursing, scope of practice, health literacy, HIPAA, patient safety, staff safety, and workplace safety. Nursing contact hours are offered for these two classes. The shorter, more focused lectures include topics such as nursing professional development, regulatory considerations, resilience, care management, population health, diversity, equity, and inclusion.
A pilot program was initiated with two specialties and expanded to include ten specialties. Data are collected throughout the program, beginning with demographic information and then pre- and post-program self-evaluations, lecture evaluations, preceptor evaluations, and end-of-residency program evaluations.
Evaluation/outcome: Among the 15 questions asked in the end-of-residency evaluation survey, the range of scores was 4.00-4.60 on a 5-point scale. The question with the lowest score was “I was given sufficient information about the residency program before it started,” which was rated 4.00+0.67. The highest scoring questions were “I understand my accountability when delegating patient care to others” (4.60+0.70) and “I feel confident and competent in assuring a safe patient care environment” (4.60+0.70).

Purpose: This research study explored the use of a lead apron as a non-pharmacological tool to reduce anxiety in patients and improve sustainability efforts in an interventional radiology department.
Relevance significance: Environmental sustainability has become a great concern in health care. Global climate change has also become a global health threat which can negatively impact public health and well-being. Health care contributes significantly to the global carbon footprint because it is energy and resource intensive and produces substantial amounts of waste. Hospitals produce more than 7,000 tons of solid waste a day with operating/procedural rooms contributing up to 20% of total hospital waste.
Anxiety can be found in almost 80% of patients undergoing surgical procedures, endovascular procedures, and dental procedures, resulting in delayed procedures, prolonged wound healing, decreased feelings of well-being, and prolonged discharge times. Given the high incidence of pre-procedural anxiety amongst patients, it is evident there is a need to explore other non-pharmacological adjuncts to reduce anxiety and comfort patients awaiting their procedures. This research project's aim was to investigate the effects of using a weighted blanket in the form of a lead apron on a patient awaiting a procedure in an outpatient radiology unit. This project hypothesizes that the use of a lead apron will reduce state anxiety levels in patients awaiting an interventional radiology procedure.
Strategy: This research study utilized a mixed methods design to gather quantitative and qualitative data. A convenience sample of 60 patients was recruited from an outpatient ambulatory unit. Participants were then randomly assigned using an online computer- generated randomizer program with 30 participants randomized to a control (standard hospital blanket) and an intervention group (15-pound lead apron within hospital blanket). Vital signs were taken and STAI-6 inventory scale was performed pre- and post-blanket application.
Evaluation: All study variables were analyzed using descriptive statistics. A significant statistical difference was noted in the post blanket STAI-6 inventory score between the control group and intervention group. Control group n=30, mean 44.30, standard deviation 14.77. Intervention group: n=30, mean 30.40, standard deviation 7.828. The control group reported little difference in their anxiety levels, whereas the intervention group dropped approximately 15 points in their inventory score. An independent t-test was performed on the post-blanket STAI -6 scores (p= 0.002) which showed a significant statistical difference in anxiety scores between the groups.
Conclusions: Based on the STAI-6 inventory scores, anxiety levels were significantly reduced after using a 15-pound lead apron to simulate a weighted blanket. The results of this study indicated that recycling lead aprons into weighted blankets is a viable option to improve environmental sustainability. Retired lead aprons could provide an inexpensive, non-invasive, and non-pharmacological tool that expands nurses’ ability to provide adjunct therapeutic care.

In 2019, the OHSU ambulatory care nursing cluster leadership created a one-day ambulatory care-specific nursing conference to meet professional development needs specific to the ambulatory care RN role and to foster collaboration and community. This conference has been built upon each year and was switched to a virtual format in 2021 due to COVID restrictions and the growing number of nurses working remotely.
In preparation for the 2024 conference, we surveyed all ambulatory care RNs to assess learning gaps, interest, and educational needs. This survey data was used to guide speaker and content curation. Previous conference participant feedback prompted the development of a conference website that included registration, speaker bios, and presentation descriptions and allowed for efficient navigation between sessions. Small group discussion sessions were added to several presentations to increase engagement. New in 2024, sessions were recorded for asynchronous viewing to allow participants to receive maximum NCPD contact hours. The leadership planning committee for the conference focused on using Magnet standards to guide our conference planning. Our goals were to provide advocacy for resources and strengthen communication and visibility between leaders and clinical nurses. Professional development with educational achievement are an important part of our ambulatory care nurse cluster charter and annual goals. This is in line with OHSU's professional practice model. The conference planning committee also conducted a post-conference survey to better understand the impact of the conference. 100% of attendees report that the conference content will change their nursing practice. There was also a 100% increase in the number of attendees from 2019 to 2024. The number of speakers, sessions, and NCPD contact hours have grown to meet the needs of our participants. There was also a significant portion of the participants who chose to watch the recordings and complete the education activities. The goal of the ambulatory care nursing cluster is to continue to provide an ambulatory care-specific conference each year with new and emerging topics and continue to connect ambulatory care nurses to one another and to lifelong learning.

Background: At a major academic medical center, the specialty ambulatory care clinics were experiencing a shortage of credentialed medical assistants. A unique program was developed to transition clerical staff in ambulatory care clinics to certified clinical medical assistants (CCMAs). This initiative aimed to enhance the skill set of clerical staff, improve patient care, and support career advancement.
Program description: The program spanned 12 months, with participants attending 4-hour lectures every Friday. Collaborating with a certifying organization, the program provided comprehensive study materials and facilitated 150 hours of externship experience within the clinics where participants held their clerical roles. This hands-on experience was crucial in bridging theoretical knowledge with practical application.
Outcomes: Two cohorts, each consisting of 20 students, successfully completed the program with a 100% pass rate, resulting in 40 newly certified CCMAs. The program's success underscores the effectiveness of structured educational support and practical training in achieving certification goals.
Conclusion: This program not only empowered clerical staff by providing them with valuable clinical skills but also contributed to the diversity and capability of the medical assistant workforce. The organization's investment in covering the program costs highlights its commitment to staff development and patient care excellence.

Purpose: The purpose of the quality improvement project was to develop an interprofessional consultation committee (ICC) to address high-utilizer patients in primary care.
Description: Interprofessional committees are commonly used in inpatient settings to create care plans for their high-utilizer patients. However, committees like these are seldom found in outpatient settings. Qualitative research studies suggest that multidisciplinary committees provide mitigation to patient's social needs while increasing interprofessional communications and care planning. The term “high utilizer” refers to patients who impose a disproportionately high burden on the healthcare system due to elevated resource use.
ICC is beneficial in inpatient and consists of the following disciplines: social work, case management, behavioral health providers, providers, medical assistants, registered nurses, and clinic leadership. ICC goals were achieved by allocating time to collaborate on creating care plans with the various disciplines listed above.
An ICC pre-survey consisting of 20 mixed methodology questions was sent to providers and staff at a primary care location in June 2023 with a 1-week return. The survey was completed before the ICC was established to determine the need for a committee specialized in the care of high-utilizer patients. The committee was approved by organizational and clinical leadership. It was led by one registered nurse and one care coordinator. This committee's workflow included identifying high-utilizer patients, scheduling a meeting, creating a care plan, and planning any follow-up as needed. A focused post-survey of 10 mixed methodology questions was given in April 2024 to the same population to determine if the clinic benefitted from this committee.
Evaluation/outcome: The survey in June 2023 had 31 participants out of 60. The survey in April 2024 had 41 participants out of 60. When asked “how are you at keeping boundaries with high-utilizer patients once boundaries have been established?”, nearly 26% of participants answered either “good” or “excellent.” In April 2024, 68% of participants responded with “good” or “excellent.” This reflects a 42% increase within a 10-month period. When asked “how effective is our team at meeting high-utilizer patient goals?”, 19% of participants indicated “very,” in comparison to 49% of participants in April 2024, representing a 30% increase. Post-survey data shows an increase in staff and provider engagement and confidence in the ability to care for patients both on an individual and clinical level.
Limitations included staff participation, which fluctuated between data collections. Additionally, data was limited to self-reporting.

Objective/purpose: To standardize practices and improve quality of patient care across immediate care clinics (IC) by reducing unwanted variations in workflows and promoting efficient and effective utilization of services provided by registered nurses (RNs).
Background/description: Health care is a field that is constantly evolving and there has been a steady increase in numbers of immediate care clinics within our organization to help decongest the emergency departments. There is, however, a lack of standardization of staffing, services, and care provided in the IC clinics, specifically related to the scope of practice of registered nurses (RNs). The variability in RN practices has led to uncertainties regarding the extent of responsibilities, often resulting in inconsistencies and inefficiencies in patient care. The goal of this project is to standardize the RN practice in IC settings, empower RNs to work at the top of their licensure, and ensure all clinics follow a unified approach to patient care. By aligning practices, we aim to promote consistency and streamlining of services across all ICs, reduce variation, adopt efficient workflows, and optimize patient care.
Implementation: In efforts to address above mentioned variations in practice, we have initiated the development of standardized protocols, including smart phrases and order sets for electronic health records (EHR). These templates serve as quick references for RNs, particularly in scenarios involving IV infusions, medication administration, and standardized clinic procedures. This approach provides clear guidance, helping RNs become more familiar with their independent, dependent, and interdependent functions, thus reducing uncertainty and variability in clinical decision-making. Additional benefits of a standardized scope of practice for RNs in immediate care settings include improved patient safety by reducing errors and ensuring consistent, high-quality care. For RNs, it provides clarity, promotes professional growth, reduces stress, facilitates scalability across clinics, and ensures care quality remains high as operations grow. Overall, standardization enhances both patient outcomes and staff experiences.
To advance this strategy, we are in a process of implementing the following initiatives: 1) identify and designate RN preceptors and super users within each clinic to support training and promote ongoing adherence to best practices; 2) conduct comprehensive training sessions for RNs to reinforce standardized protocols and ensure consistent application across all clinics; 3) implement a feedback loop to continuously assess and refine the standard practices, allowing for adjustments based on clinic needs and patient care data; 4) collaborate with multidisciplinary teams in regular workshops to address any emerging concerns, clarify protocols, and encourage best practice sharing; and 5) enhance EHR tools by expanding the use of smart phrases and order sets in the EHR, covering a broader range of scenarios beyond IV infusions, medication administration, and clinic procedures, to provide comprehensive support to RNs.
Desired outcome: Standardizing the scope of practice of RNs in immediate care settings can enhance patient care, streamline operations, and foster a supportive environment for both patients and nursing staff. Furthermore, it will allow for a wider adoption of efficient workflows and more predictable patient experience.
Implications: Using TVs in waiting rooms can be an easy and cost-effective way to engage patients in their health care, convey important information, and has the potential to improve health literacy.

Purpose: Engaging in continuous professional development is essential for all members of the healthcare team, as it enables them to effectively incorporate peer-to-peer feedback into clinical practice. This ongoing process fosters a culture of constructive self-reflection, improves communication, and supports refinement of clinical skills that can lead to reduction of medical errors and improved clinical outcomes. The purpose of this project was to design, pilot and evaluate a comprehensive support framework for the ambulatory care float team. The framework aimed to integrate educational elements with targeted clinical remediation, ensure staff adherence to protocols, enhance clinical competency, and promote successful integration into diverse clinical environments.
Description: The ambulatory care float team is responsible for staffing various clinic practices with nurses and medical assistants across a broad geographical area encompassing over 250 clinics. Clinical staff frequently face significant challenges adhering to clinical policies, procedures, and protocols. A key factor contributing to these difficulties is the absence of dedicated float team clinical leadership to guide their transition to practice. This gap in support impacts their ability to consistently meet organization standards and efficiently provide safe patient care.
The pilot phase utilized the plan-do-check-act (PDCA) model to implement several strategic initiatives: 1) assign ambulatory care nursing leaders as mentors to oversee new staff clinical competency validation; 2) conduct observational assessments of current orientation procedures to identify strengths and weaknesses; 3) developed and enhanced clinical skills validation plan with competency checklists, including the review of policies, procedures, and clinical skills; 4) review and refine the plan based on feedback from ambulatory care nursing and float team administrative leaderships; 5) assess and coordinate training sites across the pool of 250 clinic sites; 6) deploy a training calendar and facilitate staff registration via Qualtrics links/QR codes; and 7) collect post-training evaluations to assess the impact on staff knowledge and confidence.
Evaluation/outcomes: The pilot phase highlighted several successes, including 100 % participant consensus that supportive feedback improved their understanding of training material and scope of practice, increased self-confidence during care delivery, and recommended the expansion of trainings to all back-office staff. Opportunities for improvement presented as low completion rates (16%) and high training session cancellations (70%), largely due to logistical and engagement barriers. Nevertheless, staff feedback was overwhelmingly positive regarding the impact of training on teamwork and heightened patient safety awareness in clinical settings. Based on the results, it is recommended that a dedicated nurse leader be added to the float team to enhance leadership, alongside the establishment of a comprehensive clinical remediation program. The restructuring of the new hire orientation process to incorporate float team skills training will also be prioritized, with a focus on creating a centralized training facility to improve accessibility and consistency.