Implementing standing orders to meet the Quadruple Aim

By Lauren Robinson, DO, family medicine resident, Augusta University, Medical College of Georgia, Augusta, Ga., laurobinson@augusta.edu; Juliana Van Alstine, certified nursing assistant, jvanalstine602@gmail.com; James Mayers, MD, family medicine resident, Augusta University, Medical College of Georgia, Augusta, Ga., jmayers@augusta.edu; Carla Duffie, DNP, MHSA, PCMH-CCE, NEBC, nurse manager, family medicine clinic, Augusta University, Medical College of Georgia, cduffie@augusta.edu; and Janis Coffin, DO, FAAFP, FACMPE, MGMA member, chief transformation officer, Augusta University Health, Augusta, Ga., jcoffin@augusta.edu.

The healthcare industry is in the process of transitioning from a fee-for-service (FFS) model to a value-based care model to improve healthcare outcomes and lower overall medical costs. With this goal in mind, the Quadruple Aim framework outlines four important components: improving population health, reducing cost of care, enhancing patient experience and improving provider satisfaction.1

While the transition to value is a widely accepted concept to optimize provider performance nationwide, clinicians report increasing levels of burnout and stress related to the increasing levels of administrative burden.

The prevalence of physician burnout has been reported near or exceeding 50% in physicians-in-training as well as practicing physicians in the United States.2 Work factors are noted to contribute to high levels of physician burnout, including inefficient work processes and computerized provider order entry (CPOE).3 Some solutions to physician burnout include appropriate distribution of job roles, optimizing the EHR, reducing redundant data entry and using support staff to offload clerical burdens.

Implementing standing orders have shown to increase efficiency, patient satisfaction and care, as well as patient quality care, which helps healthcare provider organizations address the Quadruple Aim and reduce physician burnout.

Redistributing the workload

Standing orders are care directive protocols approved by an authorized provider such as a physician, dentist, physician assistant (PA) or nurse practitioner (NP). The authorized provider defines the circumstances and parameters in which a nurse, medical assistant (MA) or other medical support staff can place a medical order.4 The staff are able to submit orders based on the protocol without the physician or clinician examining the patient. Standing orders may be specific to patients or conditions/diseases following healthcare needs. Condition-specific standing orders are not dependent on the relationship between provider and patient but to the protocols of care directives for specific conditions and diseases. Patient-specific standing orders allow patients to be serviced in a more efficient and timely manner regardless of the provider’s location.5

Examples of standing orders include immunization administration, health screening activities, preventive care measures, ordering lab tests or treatments for certain categories, diabetes measures, prescription refills, and pre-/post-operative orders. Therefore, standing orders delineate the specific type of medical practice and the protocols the nurse must follow. They also identify the related specific patient population served and designate the level of supervision and the locations of which the patient population may be served.6

The Centers for Medicare & Medicaid Services (CMS) requires that standing orders be based on evidence-based guidelines and recommendations. Neither state nor federal law are required to allow institutions the ability to implement standing orders, thus the scope of practice should be considered when writing the standing order.

Standing orders should be reviewed and revised at minimum annually. Carefully formulating standing orders with supervision will reduce the risk of errors. These orders should be formulated and approved by committees or group reviewers with respect to available resources and these guidelines and recommendations. All providers — nurses, MAs and other staff members — are responsible for the care they provide, which includes carrying out standing orders. CMS also requires standing orders to be dated, timed and validated by the ordering provider responsible for the care of the patient. The ordering provider must be authorized to write standing orders by the institution’s policy according to state law.

Recommendations for nurses implementing standing orders based on patient-specific, condition-specific or verbal orders include:

• Nursing leadership involvement
• Basing standing orders on nationally recognized and evidence-based guidelines and recommendations
• Following institutional policies
• Additional review and revising of standing orders (any changes should be effectively communicated to nursing staff for review)
• Working to the top of licenses and abilities.

Training staff to make medical decisions when implementing standing orders is important so they can initiate them without confirming with the authorized provider first.

Standing orders to meet quality measures

Practices have improved performance and increased quality after implementing standing orders. One study showed that all practices implementing electronic standing orders significantly improved on at least three of the 14 measures based on health maintenance templates and performances over 21 months.7 The use of standing orders has proven to increase performance in the control of diabetes and immunization.8

Mitigating physician burnout

Burnout is commonly defined as chronic emotional exhaustion or depersonalization. Work-related stressors contribute to physician burnout. These stressors include inefficient work processes and environments; for example, physician-entered documentation, electronic communication, computerized physician order entry, etc. Studies estimate physicians would need more than 21 hours a day to provide all recommended acute, preventative and chronic care for a panel of 2,500 patients,9 and computerized order entry by physicians is associated with a 29% greater rate of physician burnout. Implementing standing orders could significantly reduce this risk10 and can help to redistribute physician workload across the healthcare team. Physicians are able to focus on more complex medical decisions while delegating routine patients’ needs to others on the healthcare team.11

Challenges

Challenges that can arise from implementing standing orders can include limited patient-provider continuity, high staff turnover or limited staff, and residents/students learning team-based care.

Using a step-by-step approach can also limit challenges when designing and executing standing orders. These steps include:

• Support of all healthcare team members (providing education if necessary)
• Carefully selecting/formulating standing orders
• Cultivating ownership during the process
• Clearly stating tasks and responsibilities of the healthcare team
• Additional review before implementing the standing order
• Periodic reassessment after the standing order is in place
• Periodic review.12

 
Educating the staff on implementing standing orders will limit challenges. Initial standing orders should be carefully chosen so they have little potential to cause patient harm. It is also important to avoid overloading a member of the healthcare team who could potentially slow workflow.

Standing orders have the potential to lower costs for the physician and the patients, by improving efficiency. This can also reduce length of stay of patients by reducing time to treatment and diagnostic tests. Actively implementing standing orders can reduce processing costs while streamlining the ordering process. Implementing standing orders can improve patient health, practice productivity and efficiency, revenue, overall satisfaction and retention.

Key takeaways

• Benefits: Decrease in physician burnout; increase in efficiency, patient and provider satisfaction, patient quality care; and lower patient and physician cost
• Improvement of population health and patient experience is also a benefit of implementing standing orders. (Reaching the goal of the Quadruple Aim)
• Challenges: Limited patient-provider continuity, educated staff, proper oversight, reduced learning for residents/students of team-based care, high turnover or limited staff
• Important steps to follow: Gathering support from healthcare team, carefully selecting standing orders (little potential for patient harm; guidelines/evidence for support), cultivate ownership, comparing standing orders to already developed ones for guidelines, review with healthcare team for questions and clearly stating responsibilities, periodically review effectiveness as well as any updates on the latest recommendations and regulations.

Notes:

1. “Quadruple Aim.” Strategies for Quality Care. Available from: bit.ly/3IrA7mt.
2. West CP, Dyrbye LN, Shanafelt TD. “Physician burnout: contributors, consequences and solutions.” J Intern Med. 2018; 283(6): 516– 529. doi: 10.1111/joim.12752.
3. Ibid.
4. Carlson D. “Standing Orders and Verbal Orders.” Washington State Department of Health Nursing Care Quality Assurance Commission. Sept. 12, 2014. NCAO 6.0: 1-4.
5. Ibid.
6. Ibid.
7. Nemeth LS, Ornstein SM, Jenkins RG, Wessell AM, Nietert PJ. “Implementing and evaluating electronic standing orders in primary care practice: a PPRNet study.” J Am Board Fam Med. 2012 Sep-Oct;25(5):594-604. doi: 10.3122/jabfm.2012.05.110214. PMID: 22956695.
8. Ibid.
9. Leubner J, Wild S. “Developing standing orders to help your team work to the highest level.” Fam Pract Manag. 2018 May-June; 25(3):13-16.
10. West, et al.
11. Leubner, Wild.
12. Ibid.