Updated: 04/22/25
Updated: 04/22/25
Purpose: The purpose of this randomized controlled trial was to evaluate the impact of a post-hospitalization phone call on the self-administered parent asthma management self-efficacy (PAMSE) scale, attendance at post-hospitalization follow-up appointments, and re-presentation to the admitting hospital.
Background/significance: Transitioning from the hospital to home is vulnerable time for patients and caregivers as they are under stress which can hinder their ability to comprehend discharge instructions and, ultimately, their adherence to the discharge plan once home. Post-discharge phone calls are an intervention aimed at decreasing preventable readmissions by allowing providers to address any care gaps and reinforce discharge instructions in the period after discharge. Asthma is the most common chronic disease in pediatrics, affecting about 8.3% of children in the United States. Many adult care transition programs exist, but there is a paucity of literature to support implementation of follow-up phone calls and subsequent effect on positive outcomes in the pediatric asthma population.
Methods: The parents of 174 patients (86 in the intervention group and 88 in the control group) aged 2 years and older admitted to the hospital with status asthmaticus were enrolled. All patients received standard discharge education. The intervention group also received a 48–72-hour post-hospitalization phone call evaluating patient status, reinforcing asthma education and follow-up appointment(s). A PAMSE score was evaluated at discharge and 2 weeks post-discharge. Alpha significance level was set to 10% to identify relationships within the instrument analysis.
Results: Both groups demonstrated a statistically significant change in PAMSE scale total score post-discharge (N=174). However, the intervention group demonstrated improved PAMSE scores specific to confidence in their children taking medication (p = 0.029) and helping their child stay calm during a serious breathing problem (p
Background/significance: Transitioning from the hospital to home is vulnerable time for patients and caregivers as they are under stress which can hinder their ability to comprehend discharge instructions and, ultimately, their adherence to the discharge plan once home. Post-discharge phone calls are an intervention aimed at decreasing preventable readmissions by allowing providers to address any care gaps and reinforce discharge instructions in the period after discharge. Asthma is the most common chronic disease in pediatrics, affecting about 8.3% of children in the United States. Many adult care transition programs exist, but there is a paucity of literature to support implementation of follow-up phone calls and subsequent effect on positive outcomes in the pediatric asthma population.
Methods: The parents of 174 patients (86 in the intervention group and 88 in the control group) aged 2 years and older admitted to the hospital with status asthmaticus were enrolled. All patients received standard discharge education. The intervention group also received a 48–72-hour post-hospitalization phone call evaluating patient status, reinforcing asthma education and follow-up appointment(s). A PAMSE score was evaluated at discharge and 2 weeks post-discharge. Alpha significance level was set to 10% to identify relationships within the instrument analysis.
Results: Both groups demonstrated a statistically significant change in PAMSE scale total score post-discharge (N=174). However, the intervention group demonstrated improved PAMSE scores specific to confidence in their children taking medication (p = 0.029) and helping their child stay calm during a serious breathing problem (p
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 04/22/25
Updated: 04/22/25
Patient-centered medical home model of care was developed in an effort to serve more people and improve chronic disease care. Using interdisciplinary team-based care, PCMH uses a system-based approach to improve access and quality of care in the primary care environment. Increased demand for primary care services can be traced to the passage of the Patient Protection and Affordable Care Act.
As the patient centered medical home (PCMH) care model continues to evolve at Nebraska Medicine, the role of registered nurses (RNs), the largest healthcare workforce, is seen as a valuable asset in providing patient education and prevention strategies. In addition to chronic conditions like diabetes, hypertension, and hyperlipidemia, Nebraska Medicine developed clinical protocols for acute symptom management and healthcare screenings. An interdisciplinary committee developed these protocols using nationally recognized evidence-based guidelines for the following conditions: group a streptococcal pharyngitis (GAS) care screening, urinary tract infection (UTI) care screening, breast cancer screening, colorectal cancer, and nonpregnant adult diabetes in ambulatory care.
The nurse care coordinators (NCC) are registered nurses hired specifically to coordinate care, address care gaps, and invite patients to be full participants in their care. Using care registries and between patient visit outreaches, these protocols enable nurses practicing at the top of their license and skill set to enter orders on behalf of the PCMH medical providers. These protocols can expedite diagnostic test results and facilitate the implementation of therapeutic strategies. Following RN education, this work rolled out to 15 PCMH clinics in May of 2024.
Nebraska Medicine PCMH teams continue to work together to use clinical best practices, technology tools, and provider skills sets to promote strategies to improve patient care. Ambulatory care nurses find their ability to provide quality patient care rewarding and a source of pride.
This session will share the five protocols, review the workflows needed to achieve organizational approval and staff acceptance, and outline next steps to evaluate effectiveness and satisfaction.
As the patient centered medical home (PCMH) care model continues to evolve at Nebraska Medicine, the role of registered nurses (RNs), the largest healthcare workforce, is seen as a valuable asset in providing patient education and prevention strategies. In addition to chronic conditions like diabetes, hypertension, and hyperlipidemia, Nebraska Medicine developed clinical protocols for acute symptom management and healthcare screenings. An interdisciplinary committee developed these protocols using nationally recognized evidence-based guidelines for the following conditions: group a streptococcal pharyngitis (GAS) care screening, urinary tract infection (UTI) care screening, breast cancer screening, colorectal cancer, and nonpregnant adult diabetes in ambulatory care.
The nurse care coordinators (NCC) are registered nurses hired specifically to coordinate care, address care gaps, and invite patients to be full participants in their care. Using care registries and between patient visit outreaches, these protocols enable nurses practicing at the top of their license and skill set to enter orders on behalf of the PCMH medical providers. These protocols can expedite diagnostic test results and facilitate the implementation of therapeutic strategies. Following RN education, this work rolled out to 15 PCMH clinics in May of 2024.
Nebraska Medicine PCMH teams continue to work together to use clinical best practices, technology tools, and provider skills sets to promote strategies to improve patient care. Ambulatory care nurses find their ability to provide quality patient care rewarding and a source of pride.
This session will share the five protocols, review the workflows needed to achieve organizational approval and staff acceptance, and outline next steps to evaluate effectiveness and satisfaction.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 05/18/25
Updated: 05/18/25
Purpose: To describe the development of our innovative asthma nurse education telemedicine program, which provides patient/family-centered asthma education while generating volume and productivity for pediatric primary care nursing in a safety net hospital setting.
Background/significance: Boston Medical Center’s pediatric primary care implemented a comprehensive asthma quality improvement program to enhance guideline-based care, address barriers to home management, and improve outcomes for children in an urban safety net population. A pivotal member of the pediatric asthma team is the asthma nurse champion, who received specialized asthma educator training at the American Lung Association Asthma Educator Institute. In 2022, the nurse champion initiated asthma education telemedicine sessions to educate newly diagnosed patients and families, provide detailed guidance on treatment plan changes to SMART therapy (a major change to chronic asthma management in accordance with the 2020 NIH asthma guideline update), ensure access to home medications, and facilitate communication among families, providers, and pharmacies. These telemedicine visits not only expand nursing’s role in managing chronic illnesses through care coordination but also generate billable encounters, contributing to ambulatory care productivity and revenue. This innovative approach bridges gaps in care and strengthens support for pediatric asthma patients and their families.
Methods: This is a retrospective study of telemedicine encounters for asthma-led nurse education. Data from the asthma nurse champion’s program evaluation tracking database and billing data were reviewed. Descriptive statistics were used to describe the types of and indications for referrals received and the asthma education themes that are most discussed during those encounters. Encounter data were aggregated to tally the numbers of visits and describe overall program revenue-generating potential. We also describe asthma education interventions in relation to patient treatment adherence and understanding of treatment plan.
Results: From July 29, 2022, to May 31, 2024, 254 referrals were made for asthma nurse telemedicine education. 116 were directly requested by physicians and 128 were identified by the asthma program coordinator because of low asthma control test (ACT) scores identified during routine symptom surveillance screening which were not addressed by the provider during clinic visits. Of 254 referrals, the asthma nurse successfully contacted 246 patients (97%), scheduled 177 asthma education telehealth appointments (71%), and completed 174 asthma education sessions (70%) with parents and patients and caregivers. Billing data show that $20,880 was generated from these encounters.
Conclusions: The pediatric primary care asthma nurse champion provided 174 individualized, patient/family-centered telemedicine encounters, which presented new opportunities to optimize high-quality, guideline-adherent asthma care and demonstrate volume and obtain revenue for our safety net hospital practice. Future directions include expansion of billable encounters to a larger number of nursing colleagues both through telemedicine and in-person visits and evaluating clinical outcomes (i.e., reductions in asthma-related ED visits) in association with asthma nursing encounters.
Background/significance: Boston Medical Center’s pediatric primary care implemented a comprehensive asthma quality improvement program to enhance guideline-based care, address barriers to home management, and improve outcomes for children in an urban safety net population. A pivotal member of the pediatric asthma team is the asthma nurse champion, who received specialized asthma educator training at the American Lung Association Asthma Educator Institute. In 2022, the nurse champion initiated asthma education telemedicine sessions to educate newly diagnosed patients and families, provide detailed guidance on treatment plan changes to SMART therapy (a major change to chronic asthma management in accordance with the 2020 NIH asthma guideline update), ensure access to home medications, and facilitate communication among families, providers, and pharmacies. These telemedicine visits not only expand nursing’s role in managing chronic illnesses through care coordination but also generate billable encounters, contributing to ambulatory care productivity and revenue. This innovative approach bridges gaps in care and strengthens support for pediatric asthma patients and their families.
Methods: This is a retrospective study of telemedicine encounters for asthma-led nurse education. Data from the asthma nurse champion’s program evaluation tracking database and billing data were reviewed. Descriptive statistics were used to describe the types of and indications for referrals received and the asthma education themes that are most discussed during those encounters. Encounter data were aggregated to tally the numbers of visits and describe overall program revenue-generating potential. We also describe asthma education interventions in relation to patient treatment adherence and understanding of treatment plan.
Results: From July 29, 2022, to May 31, 2024, 254 referrals were made for asthma nurse telemedicine education. 116 were directly requested by physicians and 128 were identified by the asthma program coordinator because of low asthma control test (ACT) scores identified during routine symptom surveillance screening which were not addressed by the provider during clinic visits. Of 254 referrals, the asthma nurse successfully contacted 246 patients (97%), scheduled 177 asthma education telehealth appointments (71%), and completed 174 asthma education sessions (70%) with parents and patients and caregivers. Billing data show that $20,880 was generated from these encounters.
Conclusions: The pediatric primary care asthma nurse champion provided 174 individualized, patient/family-centered telemedicine encounters, which presented new opportunities to optimize high-quality, guideline-adherent asthma care and demonstrate volume and obtain revenue for our safety net hospital practice. Future directions include expansion of billable encounters to a larger number of nursing colleagues both through telemedicine and in-person visits and evaluating clinical outcomes (i.e., reductions in asthma-related ED visits) in association with asthma nursing encounters.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 04/22/25
Colorectal cancer (CRC) is the second leading cause of cancer-related death among men and women in the US. CRC is now the number one cause of cancer death for men under 50 and the second cause of cancer death for women in that age group, although it may be prevented through screening. When colorectal cancer is found in early stages, nine out of ten people have no evidence of their cancer five years later. Regular screenings are recommended starting at age 45.
Colonoscopy was once widely regarded as the gold standard for CRC screening since precancerous growths can be removed during the procedure. However, patients at one of the health system’s major medical centers were facing an 18-month wait for a screening colonoscopy. Like many organizations across the nation, multiple factors such as specialist shortages, guidelines lowering the recommended screening age to 45 from 50, increased prioritization of screening, and other influences have contributed to a growing delay to procedure access. While colonoscopy is the sole screening option for patients with traditional risk factors, those without factors (average risk) have three options at our organization: colonoscopy or the stool-based tests called fecal immunochemical test (FIT) or sDNA-FIT (Cologuard).
Objective: To increase colonoscopy access for patients who require timeliness by removing at least 30% of targeted average-risk patients from the colonoscopy waiting queue through alternate testing, using an opt-out mailed stool test outreach model.
Methodology: The performance improvement project team created a report to identify patients meeting agreed-upon eligibility criteria as determined by physician leaders and other relevant experts. Over seven weeks, eligible patients were sent a primer communication through their patient portal or mail, per preference settings in the electronic medical record (EMR). The communication explained a pre-determined test (FIT or Cologuard) would be mailed to their home in the coming weeks unless the patient opted out by notifying the centralized project team via one of three methods: website, call center, or PCP clinic. Patients who appeared as self-pay in the EMR were called by the team. They were screened for eligibility and had test options reviewed, and if they confirmed self-pay, they were offered a referral to a trained financial advocate, regardless of modality chosen.
Two weeks after the communications were sent, a bulk order was placed by a nurse with the test vendor who prepared and mailed the tests.
Results: After sending 1,248 patient (intent to treat (ITT) population) primer communications, bulk orders were placed for 1,183 (94.8%) kits over the course of seven weeks. Opted out notifications were received for 314 patients (25.2%), with most reported they had a change in personal health (121 patients) which met heightened risk criteria, or they prefer colonoscopies (120 patients). Valid results were received for 457 patients (36.6% of ITT), with 42 positive results (9.2% positive rate) requiring a follow-up colonoscopy. The project removed 415 patients (33.3% of ITT) from the waiting queue, reducing the wait by approximately two months.
Colonoscopy was once widely regarded as the gold standard for CRC screening since precancerous growths can be removed during the procedure. However, patients at one of the health system’s major medical centers were facing an 18-month wait for a screening colonoscopy. Like many organizations across the nation, multiple factors such as specialist shortages, guidelines lowering the recommended screening age to 45 from 50, increased prioritization of screening, and other influences have contributed to a growing delay to procedure access. While colonoscopy is the sole screening option for patients with traditional risk factors, those without factors (average risk) have three options at our organization: colonoscopy or the stool-based tests called fecal immunochemical test (FIT) or sDNA-FIT (Cologuard).
Objective: To increase colonoscopy access for patients who require timeliness by removing at least 30% of targeted average-risk patients from the colonoscopy waiting queue through alternate testing, using an opt-out mailed stool test outreach model.
Methodology: The performance improvement project team created a report to identify patients meeting agreed-upon eligibility criteria as determined by physician leaders and other relevant experts. Over seven weeks, eligible patients were sent a primer communication through their patient portal or mail, per preference settings in the electronic medical record (EMR). The communication explained a pre-determined test (FIT or Cologuard) would be mailed to their home in the coming weeks unless the patient opted out by notifying the centralized project team via one of three methods: website, call center, or PCP clinic. Patients who appeared as self-pay in the EMR were called by the team. They were screened for eligibility and had test options reviewed, and if they confirmed self-pay, they were offered a referral to a trained financial advocate, regardless of modality chosen.
Two weeks after the communications were sent, a bulk order was placed by a nurse with the test vendor who prepared and mailed the tests.
Results: After sending 1,248 patient (intent to treat (ITT) population) primer communications, bulk orders were placed for 1,183 (94.8%) kits over the course of seven weeks. Opted out notifications were received for 314 patients (25.2%), with most reported they had a change in personal health (121 patients) which met heightened risk criteria, or they prefer colonoscopies (120 patients). Valid results were received for 457 patients (36.6% of ITT), with 42 positive results (9.2% positive rate) requiring a follow-up colonoscopy. The project removed 415 patients (33.3% of ITT) from the waiting queue, reducing the wait by approximately two months.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 04/22/25
Updated: 04/22/25
Introduction: To address unacceptable and aggressive behaviors in patients and visitors, could implementation of a behavior escalation readiness and response process improve an ambulatory care clinic’s culture of safety? Healthcare workers are five times more likely to sustain a workplace violence injury than other professions, and workplace violence incidents are underreported. Incivility, though less severe than other types of mistreatments, may still result in significant impacts on healthcare worker well-being and patient care. Both incivility and workplace violence in healthcare can pose great physical and psychological safety risks for patients and healthcare workers. The American Academy of Ambulatory Care Nursing (AAACN) recognizes the need for a behavior escalation readiness and response process to enhance safety in ambulatory care settings.
Methods: Data was collected from a freestanding pediatric ambulatory care clinic with 23 specialty divisions, serving nearly 1000 patients daily and employing 500 associates across four locations. A multidisciplinary continuous improvement event in December 2023 utilized results from a voluntary survey of associates to assess their knowledge of resources and reporting related to behavior escalations. Multiple perspectives were considered, including feedback from the youth advisory council, the patient experience team, associate interviews, and data from another healthcare system. A tiered process for behavior escalation readiness and response was developed, including a patient and visitor escalation (PAVE) response team to address escalating behaviors. Educational sessions, stress first aid training, and mock scenarios were conducted with the newly formed PAVE response team. After PAVE team training was completed, all patient and visitor facing associates were offered a two-hour training to recognize escalating behaviors, empower them to apply de-escalation skills, and request PAVE team support.
Results: Post-training evaluations revealed positive feedback from associates, emphasizing feeling supported, heard, and confidence in de-escalation. Post-implementation survey data showed an increase in knowledge regarding resource utilization, response processes, and event reporting specific to behavior escalations. Weekly audits of escalation events ensure appropriate utilization of the process further supporting and empowering associates. This includes debriefing with associate wellness resources and verifying event report documentation is appropriately entered.
Discussion: Challenges included protected time for training and variable staffing ratios at other sites. Training was adapted to accommodate providers’ limited opportunities to attend the two-hour training. An abbreviated process is being created for smaller sites with less leadership support. Ongoing leadership commitment and awareness are essential to sustain progress. Future educational sessions will refresh current associates and capture new ones. The goal is to make the process portable across all locations, reducing variability in processes, language, and training. In summary, implementing a behavioral response process significantly enhances safety and well-being for both patients and associates in a pediatric ambulatory care setting.
Methods: Data was collected from a freestanding pediatric ambulatory care clinic with 23 specialty divisions, serving nearly 1000 patients daily and employing 500 associates across four locations. A multidisciplinary continuous improvement event in December 2023 utilized results from a voluntary survey of associates to assess their knowledge of resources and reporting related to behavior escalations. Multiple perspectives were considered, including feedback from the youth advisory council, the patient experience team, associate interviews, and data from another healthcare system. A tiered process for behavior escalation readiness and response was developed, including a patient and visitor escalation (PAVE) response team to address escalating behaviors. Educational sessions, stress first aid training, and mock scenarios were conducted with the newly formed PAVE response team. After PAVE team training was completed, all patient and visitor facing associates were offered a two-hour training to recognize escalating behaviors, empower them to apply de-escalation skills, and request PAVE team support.
Results: Post-training evaluations revealed positive feedback from associates, emphasizing feeling supported, heard, and confidence in de-escalation. Post-implementation survey data showed an increase in knowledge regarding resource utilization, response processes, and event reporting specific to behavior escalations. Weekly audits of escalation events ensure appropriate utilization of the process further supporting and empowering associates. This includes debriefing with associate wellness resources and verifying event report documentation is appropriately entered.
Discussion: Challenges included protected time for training and variable staffing ratios at other sites. Training was adapted to accommodate providers’ limited opportunities to attend the two-hour training. An abbreviated process is being created for smaller sites with less leadership support. Ongoing leadership commitment and awareness are essential to sustain progress. Future educational sessions will refresh current associates and capture new ones. The goal is to make the process portable across all locations, reducing variability in processes, language, and training. In summary, implementing a behavioral response process significantly enhances safety and well-being for both patients and associates in a pediatric ambulatory care setting.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Jim Woodard, DNP, MBA, RN, Chief Operating Officer, TRU Community Care
Updated: 04/22/25
Updated: 04/22/25
The world has experienced an increase in disasters, both natural and caused by humans. Earthquakes, wildfires, tsunamis, and terrorist attacks have all occurred over the last decade. Responding to these events requires tremendous resources, including trained healthcare providers. One solution to adding resources is enlisting nurses, who make up the largest discipline in health care. This project focused on improving ambulatory care nurse emergency preparedness knowledge, willingness to deploy to disasters, and willingness to teach patients about disaster preparedness. A quasi-experimental design was used in this pre- and post-educational intervention project. The theoretical frameworks used were the San Diego 8A’s change model and Orem’s theory of self-care. Two validated assessment tools, the emergency preparedness information questionnaire (EPIQ) and the readiness estimate & deployability index (READI), were used to measure changes in nurse knowledge. Project data was reviewed using a paired two-sample t-test and Cohen’s d effect size measure. A convenience sample of n = 41 nurses completed the pre-and-post EPIQ and READI surveys and the educational intervention. The paired t-test showed 37 of 44 EPIQ questions had p values of p < .05. The remaining six questions had p values exceeding p > .05. All 33 READI question sets had p values of p < .05, indicating a statistically significant difference between pre-and post-education responses. All but one EPIQ question had Cohen’s effect scores of d =.05 or higher, indicating a medium to strong post-education intervention effect. READI Cohen’sd analysis showed that 12 of 33 questions had scores of d = .02 or less, indicating a slight effect from the educational intervention. The remaining questions showed a medium to strong effect with Cohen’s dscores of d = .05 or higher. The paired t test result for question 32 was a p < .001. The Cohen’s d effect measure analysis for question 32 was d =1.176, indicating an improvement in nurses’ willingness to educate patients on disaster preparedness. The results of this project confirmed that the introduction of evidence-based disaster education improved ambulatory care nurse knowledge, willingness to deploy to a disaster, and willingness to educate others.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 04/22/25
Updated: 04/22/25
Over the last decade, the cardiology clinic has experienced exponential growth in patient volumes and an increase in the complexity of patients. Cardiology clinic visits often entail performance of multiple diagnostic studies and multiple hand-off points between providers. Because of these complexities, it is challenging to move patients through their visit in a timely and efficient manner.
In Spring 2023, a team of multidisciplinary key stakeholders set out to redesign clinic flow to decrease patient wait times and increase team satisfaction. Baseline time studies indicated patients were spending 40% of their visit waiting and discussions with staff revealed they felt siloed with strained team communication.
Focusing on improving team dynamics, relationships, and communication were a top priority of this new workflow, with an outcome measure being reduction of patient wait time by 46% from a baseline median wait time of 37 minutes. It was anticipated that the implications of improving efficiencies in clinic would allow better utilization of resources, which would increase patient volumes and improve team culture. A standardized and simplified workflow was developed providing clarification of roles, prioritizing face-to-face handoff, and relocating teams for proximity. Addition of a “navigator” staff position allowed for improved patient experience and flow. This role is responsible for regulating visit starts, escorting patients to the next phase of their visit, and facilitating face-to-face handoff with the next caregiver. Care teams were relocated to sit in closer proximity to promote communication and aid in discussions for planning patient needs.
This new workflow was implemented in Summer 2023. Data from the first year shows a significant reduction in patient wait time, with a median wait time of 11 minutes (decrease of 70.2% from baseline median wait time). Patient throughput has increased because of efficiency, with volumes up 10.7% year to date compared to 2023 and access to next available appointment time improved from 103 days to 27 days. Staff, providers, and families reported positive feedback including increased face-to-face handoff communication, team camaraderie, and awareness of patient needs. Prioritizing team dynamics amongst the multidisciplinary leadership team had significant impact in building a model that is sustainable and in support of each individual team. Additionally, modeling and encouraging these behaviors amongst the larger team has facilitated a shift in the team culture.
Lessons learned from the design and application of this model include identifying and including key stakeholders in the process, ensuring active change management occurs, and meeting frequently to assess progress and make adjustments as necessary. Additional takeaways include creating forums to receive timely feedback from staff and providing transparency to team members, including results of data collection and modifications made based on feedback received.
At the end of the session, the learner will be able to discuss this innovative care model implemented to decrease patient wait times and improve the patient/family experience. This structured workflow process change has allowed flexibility with multiple diagnostic services within one visit while increasing predictability for team members, improving communication across job roles, improving the patient/family experience, and increasing patient throughput.
In Spring 2023, a team of multidisciplinary key stakeholders set out to redesign clinic flow to decrease patient wait times and increase team satisfaction. Baseline time studies indicated patients were spending 40% of their visit waiting and discussions with staff revealed they felt siloed with strained team communication.
Focusing on improving team dynamics, relationships, and communication were a top priority of this new workflow, with an outcome measure being reduction of patient wait time by 46% from a baseline median wait time of 37 minutes. It was anticipated that the implications of improving efficiencies in clinic would allow better utilization of resources, which would increase patient volumes and improve team culture. A standardized and simplified workflow was developed providing clarification of roles, prioritizing face-to-face handoff, and relocating teams for proximity. Addition of a “navigator” staff position allowed for improved patient experience and flow. This role is responsible for regulating visit starts, escorting patients to the next phase of their visit, and facilitating face-to-face handoff with the next caregiver. Care teams were relocated to sit in closer proximity to promote communication and aid in discussions for planning patient needs.
This new workflow was implemented in Summer 2023. Data from the first year shows a significant reduction in patient wait time, with a median wait time of 11 minutes (decrease of 70.2% from baseline median wait time). Patient throughput has increased because of efficiency, with volumes up 10.7% year to date compared to 2023 and access to next available appointment time improved from 103 days to 27 days. Staff, providers, and families reported positive feedback including increased face-to-face handoff communication, team camaraderie, and awareness of patient needs. Prioritizing team dynamics amongst the multidisciplinary leadership team had significant impact in building a model that is sustainable and in support of each individual team. Additionally, modeling and encouraging these behaviors amongst the larger team has facilitated a shift in the team culture.
Lessons learned from the design and application of this model include identifying and including key stakeholders in the process, ensuring active change management occurs, and meeting frequently to assess progress and make adjustments as necessary. Additional takeaways include creating forums to receive timely feedback from staff and providing transparency to team members, including results of data collection and modifications made based on feedback received.
At the end of the session, the learner will be able to discuss this innovative care model implemented to decrease patient wait times and improve the patient/family experience. This structured workflow process change has allowed flexibility with multiple diagnostic services within one visit while increasing predictability for team members, improving communication across job roles, improving the patient/family experience, and increasing patient throughput.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 04/22/25
Updated: 04/22/25
In a large academic medical center with over 90 ambulatory care clinics, obstetrical care accounts for approximately 24,000 visits annually. Historically, gestational diabetics were managed without any consistent education or standard algorithm of screening among obstetrical/gynecological and maternal fetal medicine clinics. Having dedicated services providing co-management of care for pregnant diabetic patients or newly diagnosed gestational diabetics before 2018 was identified as a gap in care.
Mothers who were diagnosed with gestational diabetes giving birth in the United States rose from an estimated 6% in 2016 to 8.3% in 2021. This highlighted the need for improved awareness and screening efforts in prenatal care settings. The importance of improving the standard of care was further underlined in 2017 with the American College of Obstetricians and Gynecologists (ACOG) collaboration with the American Diabetes Association development a screening strategy in detecting gestational diabetes or pre-diabetes.
One of the OB/GYN and MFM clinics took the lead, transitioning a registered nurse to the role of diabetic educator in 2018. Over five years with services aimed at closing the gap and under new leadership, in 2022, a registered dietitian holding a diabetic care and education specialist (CDCES) certification was hired. To improve education and compliance with appropriate screening, the CDCES interventions started with following patients from diagnosis through delivery. The biweekly appointments with the CDCES offered education, including basic pathophysiology of gestational diabetes and individualized diet modifications based on gestational age. Glucose monitoring via glucometer or a continuous glucose monitoring (CGM) device analyzed by the CDCES provided insulin recommendations to the provider. This collaborative model encouraged a personalized approach to the management of gestational diabetes.
Once referred to the CDCES, the cadence of follow-up visits is determined based on insulin requirements. For diet-controlled gestational diabetics (A1DM), glucose logs were reviewed weekly, with a telehealth visit every two weeks. For insulin-dependent gestational diabetics (A2DM), blood glucose was reviewed, and the patients were seen weekly. To provide ongoing continuity of care, all patients received individualized post-delivery guidelines one week before delivery, as well as a diabetes prevention visit at six weeks postpartum.
The intent of the CDCES role and implementation of the algorithm would reflect an improved compliance percentage in alignment with ACOG and ADA-recommended screenings. To determine compliance, a review of charts from delivered patients in September with a diagnosis of gestational diabetes were compared starting in 2019 at 2-year intervals until the 2023 implementation of the algorithm, then compared with the patients for the month of September the following year. The compliance percentage doubled in one year post-implementation of the algorithm for 2024.
Mothers who were diagnosed with gestational diabetes giving birth in the United States rose from an estimated 6% in 2016 to 8.3% in 2021. This highlighted the need for improved awareness and screening efforts in prenatal care settings. The importance of improving the standard of care was further underlined in 2017 with the American College of Obstetricians and Gynecologists (ACOG) collaboration with the American Diabetes Association development a screening strategy in detecting gestational diabetes or pre-diabetes.
One of the OB/GYN and MFM clinics took the lead, transitioning a registered nurse to the role of diabetic educator in 2018. Over five years with services aimed at closing the gap and under new leadership, in 2022, a registered dietitian holding a diabetic care and education specialist (CDCES) certification was hired. To improve education and compliance with appropriate screening, the CDCES interventions started with following patients from diagnosis through delivery. The biweekly appointments with the CDCES offered education, including basic pathophysiology of gestational diabetes and individualized diet modifications based on gestational age. Glucose monitoring via glucometer or a continuous glucose monitoring (CGM) device analyzed by the CDCES provided insulin recommendations to the provider. This collaborative model encouraged a personalized approach to the management of gestational diabetes.
Once referred to the CDCES, the cadence of follow-up visits is determined based on insulin requirements. For diet-controlled gestational diabetics (A1DM), glucose logs were reviewed weekly, with a telehealth visit every two weeks. For insulin-dependent gestational diabetics (A2DM), blood glucose was reviewed, and the patients were seen weekly. To provide ongoing continuity of care, all patients received individualized post-delivery guidelines one week before delivery, as well as a diabetes prevention visit at six weeks postpartum.
The intent of the CDCES role and implementation of the algorithm would reflect an improved compliance percentage in alignment with ACOG and ADA-recommended screenings. To determine compliance, a review of charts from delivered patients in September with a diagnosis of gestational diabetes were compared starting in 2019 at 2-year intervals until the 2023 implementation of the algorithm, then compared with the patients for the month of September the following year. The compliance percentage doubled in one year post-implementation of the algorithm for 2024.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Monica Banes, MSN, RN, CPN, Director for Ambulatory Care Services, Texas Children's Hospital | Kimberly Holt, MHA, BSN, RN, CPN | Courtney Prewitt, MBA, BSN, RN
Updated: 04/22/25
Updated: 04/22/25
Background: The “healthcare worker (HCW) as hand hygiene (HH) observer” model, created by the Joint Commission Center for Transforming Healthcare, works well in inpatient settings but presents challenges in ambulatory care settings. This model, using the targeted solutions tool (TST) for HH, evaluates compliance based on the World Health Organization’s (WHO) moments of HH: before and after contact with a patient and their surroundings. HH observations performed by HCWs in ambulatory care settings interrupt patient care and do not maintain anonymity of the observer. HH observations performed by HCWs showed a compliance of ≥ 95%; however, parent feedback and leader rounding observations suggested lower compliance. This resulted in concerns with the reliability of HCW HH compliance data and a need to evaluate other methodologies. Although adult studies show that patient observations are a valid method for determining HCW HH compliance, there is limited research on parent HCW HH observations in pediatric ambulatory care settings.
Aim: This quality improvement (QI) project aimed to implement HCW HH compliance using parent observations in pediatric ambulatory care settings by September 30, 2023.
Methods: A benchmark survey was conducted through the American Academy of Ambulatory Care Nursing to assess HCW HH observation practices in ambulatory care settings. In March 2023, the Associates in Process Improvement’s model for improvement framework was used to identify goals and measures of change. HCW HH compliance was measured utilizing direct parent observation during their scheduled visit in ambulatory care services across the system. The QI project defined HCW HH compliance as correct HH performed before and after contact with the patient or their surroundings. The ambulatory care quality workgroup created the parent observation process by obtaining HCW feedback regarding the current process, created a parent survey and QR code, and established a communication plan for stakeholders. A QR code linked to an organization approved survey software captured data. After implementation in April 2023, a member of the ambulatory care quality workgroup analyzed data bimonthly to ensure metric compliance. The ambulatory care quality practice council, representing over 100 clinics, met to analyze the data and disperse findings to their respective areas.
Results: In April 2023, the pediatric ambulatory care clinics successfully implemented a system-wide parent observation process for HCW HH compliance. Prior to implementation, HCW HH scores averaged 99.2% but contradicted parent feedback and leader rounding observations. Although, post-implementation HCW HH scores decreased to 90.3%, the team met the organization standard of ≥ 90% HCW HH compliance. However, post-implementation of PDSA cycle number 3 reflected an increase in HCW HH compliance to 96.4%.
Conclusion: Healthcare systems rely on HCW HH compliance data to drive infection prevention practices. Due to workflows in ambulatory care settings, HCW observations can affect data reliability. This QI project implemented a system-wide parent observation process in pediatric ambulatory care settings and achieved HH compliance ≥ 90%. Project limitations included setting goals for the target number of parent observations, data surrounding HCW feedback, and parent participation in the planning phase. Future QI initiatives should focus on parent engagement, empowerment, education, and survey submission targets.
Aim: This quality improvement (QI) project aimed to implement HCW HH compliance using parent observations in pediatric ambulatory care settings by September 30, 2023.
Methods: A benchmark survey was conducted through the American Academy of Ambulatory Care Nursing to assess HCW HH observation practices in ambulatory care settings. In March 2023, the Associates in Process Improvement’s model for improvement framework was used to identify goals and measures of change. HCW HH compliance was measured utilizing direct parent observation during their scheduled visit in ambulatory care services across the system. The QI project defined HCW HH compliance as correct HH performed before and after contact with the patient or their surroundings. The ambulatory care quality workgroup created the parent observation process by obtaining HCW feedback regarding the current process, created a parent survey and QR code, and established a communication plan for stakeholders. A QR code linked to an organization approved survey software captured data. After implementation in April 2023, a member of the ambulatory care quality workgroup analyzed data bimonthly to ensure metric compliance. The ambulatory care quality practice council, representing over 100 clinics, met to analyze the data and disperse findings to their respective areas.
Results: In April 2023, the pediatric ambulatory care clinics successfully implemented a system-wide parent observation process for HCW HH compliance. Prior to implementation, HCW HH scores averaged 99.2% but contradicted parent feedback and leader rounding observations. Although, post-implementation HCW HH scores decreased to 90.3%, the team met the organization standard of ≥ 90% HCW HH compliance. However, post-implementation of PDSA cycle number 3 reflected an increase in HCW HH compliance to 96.4%.
Conclusion: Healthcare systems rely on HCW HH compliance data to drive infection prevention practices. Due to workflows in ambulatory care settings, HCW observations can affect data reliability. This QI project implemented a system-wide parent observation process in pediatric ambulatory care settings and achieved HH compliance ≥ 90%. Project limitations included setting goals for the target number of parent observations, data surrounding HCW feedback, and parent participation in the planning phase. Future QI initiatives should focus on parent engagement, empowerment, education, and survey submission targets.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 04/22/25
Updated: 04/22/25
Electronic health records (EHR) have demonstrated their effectiveness in minimizing medical errors. However, the use of workarounds can introduce significant safety risks. A carveout in the hospital-based clinic (HBC) policy allowed cancer center nursing staff to sign orders under “transcribed/internal” mode. Non-providers use this order mode when entering orders into Epic on behalf of a provider. Orders entered this way are active immediately before the provider signs it and are subject to interpretation and transcription errors. Concerns related to physicians and nurses practicing outside of scope encouraged executive leadership to look at improvement opportunities to ensure patient safety and protect our medical staff by ensuring all were practicing within scope of their licensure.
This initiative aims to provide the safest care possible to our medical oncology patients by eliminating the gap in unsigned orders. The process of pending orders to providers was developed to ensure orders are reviewed for accuracy and signed by the provider before they are executed. Key stakeholders, including cancer center leadership, clinicians, nurse educators, workflow informaticists, and project management, met to develop an individualized, collaborative plan for each disease-oriented team (DOT).
Initially, executive health system leadership met with cancer center leadership, including project management, to assess compliance and patient safety concerns, review data, and partner to develop an action plan. Before each DOT go-live, the project team met to develop an implementation strategy with respective clinic leadership, including physician leaders. Education was then provided to each nursing team which included required Elsevier training to be completed before go-live. An Epic “pend and send” workflow was created allowing nurses to directly pend orders for signature to the provider via an Epic in-basket message.
Genitourinary (GU) medical oncology was the first DOT to go live in April 2024. A phased approach was utilized to implement the workflow in the remaining DOTs, with planned completion by November 2024. Before implementation in April, the cancer center averaged over 3,000 transcribed orders entered weekly. As of the end of September, the cancer center decreased transcribed internal orders by 50%. The partnership between the project team, physician leadership, and clinical team was critical to this project's success. A tailored approach to each DOT while focusing on the patient's safety and care was integral in the rollout of this initiative and helped increase buy-in from clinicians.
This initiative aims to provide the safest care possible to our medical oncology patients by eliminating the gap in unsigned orders. The process of pending orders to providers was developed to ensure orders are reviewed for accuracy and signed by the provider before they are executed. Key stakeholders, including cancer center leadership, clinicians, nurse educators, workflow informaticists, and project management, met to develop an individualized, collaborative plan for each disease-oriented team (DOT).
Initially, executive health system leadership met with cancer center leadership, including project management, to assess compliance and patient safety concerns, review data, and partner to develop an action plan. Before each DOT go-live, the project team met to develop an implementation strategy with respective clinic leadership, including physician leaders. Education was then provided to each nursing team which included required Elsevier training to be completed before go-live. An Epic “pend and send” workflow was created allowing nurses to directly pend orders for signature to the provider via an Epic in-basket message.
Genitourinary (GU) medical oncology was the first DOT to go live in April 2024. A phased approach was utilized to implement the workflow in the remaining DOTs, with planned completion by November 2024. Before implementation in April, the cancer center averaged over 3,000 transcribed orders entered weekly. As of the end of September, the cancer center decreased transcribed internal orders by 50%. The partnership between the project team, physician leadership, and clinical team was critical to this project's success. A tailored approach to each DOT while focusing on the patient's safety and care was integral in the rollout of this initiative and helped increase buy-in from clinicians.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
