Providing Recommendations for Clinical Staff Delineating Scope of Practice in Outpatient Practices using a Collaborative Decision-Making Approach

Purpose: Our large academic medical center is an enterprise covering both community outpatient practices and hospital-based outpatient departments (HOPD). Although we share regulations with Centers for Medicare and Medicaid Services (CMS), HOPD’s are driven by the Joint Commission (JC) Standards. With the understanding of both CMS and JC standards along with hospital policy and community standards, a council comprised of clinical educators and ambulatory care clinical program coordinators was to developed to review activities, interventions, and roles for nurses and other clinical staff to ensure they can safely perform under their specific scope of practice.

Learning outcome: Identify strategies and tools to support delineation of scope of practice for outpatient departments.

Description: The scope of practice (SOP) council is a collaborative decision-making group developed to provide clarity and evidence-based recommendations for tasks constituting the practice of medicine, independent professional judgement, or the making of clinical assessment centered on community and regulatory standards not outlined in organizational policies. The SOP council developed education providing guidance and detailed requirements for SOP request submissions.

Evaluation/outcome: Any clinical role, including staff and/or leaders, are able to submit a request. A new request should be considered if there is a question regarding a new clinical skill, process, procedure, or equipment or there is a skill already listed on the SOP index and a new department would like to be added. Each submission requires evidence or research supporting the request. When a request is submitted, council members are notified and perform a separate search using Vizient, AAACN, ANA, professional organizations, and hospital policy. The request is discussed and is either approved, denied, or pended for additional details. Once a recommendation is made, the decision is presented to the director of ambulatory care clinical programs and the ambulatory chief nursing officer (ACNO) for review and approval. The submitter, along with the clinical educator for the department, are then notified to ensure competency training is validated, if necessary. The approved request is added to the SOP index. Since the inception of the SOP council in 2021, there has been an overall increase in the queries related to scope of practice, with 28 official requests. Of those requests, there were fifteen approvals, four denials, and nine requests that were escalated to operational leadership for further review.