FY24 Caring Wisely Project Proposal Phase I

• PROPOSAL TITLE:  Transforming Ambulatory Care Nursing Through Interprofessional Collaborative Practice
• PROJECT LEAD(S):  Rachelle Althaus,RN; Zaineh Khalil,NP; Jeannette Lager, MD; & Heidi Willsher,RN

• EXECUTIVE SPONSOR(S):  Anais Ryken, Erica Rajabi
• ABSTRACT - One paragraph summary of your proposed initiative – Limit 1500 characters (with spaces)

Establishing formalized protocols would create an atmosphere where Registered Nurses would be part of the bigger picture and promote Interprofessional Collaborative Practice (IPCP).  Nurses would have more of an impact for our aggregates in the moment, without delays, thus creating a stronger nurse-patient relationship and stream-lined processes with more consistency, efficiency, and an increase in safety net protecting licensures, leading to high-quality patient care and improved outcomes.  Formalizing protocols would strengthen and elevate nursing’s presence and provide an opportunity for nursing to continue a journey where roles expand, deepen, and provide more sustainable relationships in IPCP, moving towards practice at top of scope.  To sustain and scale this project, additional resources would be needed to walk the protocols through intensive processes to formalization. Frequent monitoring would be required to ensure protocols are being followed and are within scope.  Monitoring would require additional resources that are not accounted for in most, if any, of the varying ambulatory practices. Additional resources, such as Schmitt-Thompson Software, would potentially open opportunities to scale this throughout the organization and possibly statewide. These protocols are considered gold standard, trusted, and provide standardization, quality, efficiency, focus, decision support, and are recommended by the AAACN (American Academy Ambulatory Care Nursing). (2)

• TEAM - Core implementation team members and titles
• Rachelle Althaus, RN Clinical Nurse II (Triage Nurse)
• Zaineh Khalil, MSN-FNP Nurse Practitioner II
• Jeannette Lager, MD Interim Chief MIGS/UROGYN Division & Medical Director MIGS/UROGYN
• Tiffany Louie, OBGYN Administrative Director
• Anais Ryken, Women’s Health Director
• Abigail Shatkin-Margolis, MD, Urogynecologist
• Heidi Willsher, RN, MSN, MBA/HCM, Nurse Manager

• PROBLEM - Background of the problem.  What is the cost associated with this problem?  Why address this problem now? What is the current condition?

• Background of the problem:

Nursing practice has transformed over the years to what we see and know. Most organizations have limitations that do not allow nursing to practice at the top of their scope. These varying lines of practice can be better solidified thru intense protocols that organizations can develop under scrutiny and an extremely tight monitoring process to ensure that the protocols are being following and Registered Nurses continue to practice within their respective scopes of practice.

Minimally Invasive Gynecological Surgery & Urogynecology division (A.K.A. – GYN Surgical Specialties) sits under the umbrella of Women’s Health. The GYN Surgical Specialties clinic is heavily procedural and surgically based, which requires the triage nurse to have the acumen to critically think on their toes, respond rapidly to telephone triage assessments without the ability to perform hands-on/visual physical assessments, and the ability to manage conditions remotely for specific treatment modalities targeted to their specific treatment, procedure, or surgery type, and provide further guidance for treatment at home or seeking higher-level care (e.g., Emergency Room).

• What is the current condition?

We currently have approximately three protocols that have been formalized and approved by the Ambulatory Care Nursing for practicing Registered Nurses to follow in our clinic. This places unnecessary hardships on our triage nurse(s) to use their critical thinking, assessment skills, clinical acumen, and places barriers and sometimes significant delays when they are not able to get in touch with providers.  This can be for things as simple as over-the-counter medications to assist with defecating, topical anti-itch relief creams, sleep aids, non-narcotic remedies, and more. Many of our providers have agreed to similar, if not identical, post-operative care instructions, pre-operative prep work and labs, constipation remedies status post-surgery, etc.

• Why address this problem now?

There is a big push within our organization for everyone to practice at top-of-scope.  This drive is correlated with changes in APeX in-basket initiatives and management that are focusing on work-life balance for all stakeholders, specifically providers.  These initiatives are encouraging supporting team members (e.g., practice coordinators, patient navigators, LVNs, RNs, etc.) to practice at top-of-their respective scopes and decrease/limit the amount of in-basket traffic to physician providers.  This encompasses staff pools where patient messages, requests, results, etc., are handled at lower levels and only escalated to physician providers when Advanced Practice Providers (e.g., NP’s and PA’s) are not able to resolve those messages.  For this to come to fruition, it will require lot of work and support at many levels so patients can be taken care of timely, within scope, and promote higher quality patient care and improved outcomes. 

• What is the cost associated with this problem?

It is challenging to determine potential cost for this identified problem.  There is cost involved in increased workload for our providers that would take away time they could be seeing patients or in the operating room.  There is cost associated with delayed care, poor outcomes, decreased patient satisfaction, and reputation.  Then there are the costs of labor to make this a reality with decreased bandwidth of the individual players, expectations of doing more with less, and limited resources.  Not doing this can be costly in all the ways mentioned above and then some.  Mostly, having organizational buy-in to purchasing the Schmitt-Thompson software to utilize our electronic medical record to its fullest potential while impacting patient care.

• TARGET - What is the goal?  What are the expected benefits, both qualitative and quantitative?
  • What is the goal?

Implementation of formalized nursing protocols to allow nurses to practice at top-of-scope and promote an Interprofessional Collaborative Practice that allows for high-quality patient care and improved outcomes. 

• What are the expected benefits, both qualitative and quantitative?
  • Qualitative

1)      High-quality Patient Care

2)      Improved Outcomes

3)      Increase in Faculty/Staff Work-Life Balance

4)      Increase Patient Satisfaction

5)      Increase Faculty & Staff Engagement

6)      Stronger Interprofessional Collaborative Practice

7)      Professional Growth, Development, & Empowerment

8)      Team Building

9)      Increase in Opportunities for Patient Education (e.g., EMMI, Internal, etc.)

10)  Promotion of Shared Governance

11)  Better Reputation

12)  Reduction of Delays in Care

• Quantitative

1)      Increase Patient Satisfaction thru Press Ganey & NRC

2)      Increase Staff Engagement thru Gallup

3)      Improved Retention/Decreased Turnover Rates

4)      Decrease is Adverse Outcomes

5)      Decrease in Turn-Around-Times (TAT)/Response Rates:

• Patient Advice Messages
• CRMs (Call Center Relayed Messages)
• Prescription Requests
• Appointment Requests
• Outgoing Referrals
• Requests from Providers for Patient Actions

6)      Increase Revenue Stream from Increased Ratings/Patient Satisfaction Scores, & Incentive Programs

7)      Decrease in Surgical Site Infections

8)      For Some Specialties, potential for Remote Patient Monitoring which is at-home monitoring of chronically ill patients through the use of wearable devices. These typically track essential vital signs and can be used to alert doctors to any significant health changes so they can intervene before their patients require immediate care. CMS has approved reimbursements of approximately $120 per patient per month. If 50 patients are enrolled, that’s $72,000 in revenue per year.

• GAPS - Why does the problem exist?  Describe system issues; technological gaps; education

• Why does the problem exist?
  • Absence of Nursing Protocols to allow practice at top-of-scope
  • Health System not prioritizing ambulatory care best practice
• Describe:
  • System Issues

1)      Lack of Insight and/or understanding of issue

2)      Not prioritizing ambulatory best practice

3)      Limited resources

4)      Organizational structure

5)      Limited presence of Ambulatory Care in Shared Governance Model

6)      Operating in silos

7)      Lack of understanding liability, urgency, and potential cost to individual licensures and organization in ambulatory care nursing triage

8)      Inaccurate staffing models in nursing triage

9)      No formal guidelines on nursing caseloads in triage setting

10)  No formal support to analyze, provide input, get feedback, and promote organizational changes in structure

11)  Staffing models (e.g., number of staff to support number of providers, especially in highly complex specialties)

• Technological Gaps

1)      APeX [EPIC] very powerful tool, but limited resources available to aid in using the tool to its fullest potential

2)      Lack of proper software (Schmitt-Thompson or others) that helps drive decision trees, promote high-quality, safe patient care, and provide a safety net to our Registered Nurses

3)      Analysts that are experts in explaining the date, etc.

4)      Not all clinics are set up the same (e.g., urgent lines, designated call centers, referral centers, back office support, etc.)

• Education

1)      Interprofessional Collaborative Practice

2)      Scope-of-Practice

3)      Role Clarity

4)      Triage Process

5)      Staff Education within Subspecialties

6)      Importance of timely interventions at appropriate levels

• INTERVENTION - Describe your proposed intervention and rationale for approach. Describe your practice setting and target population (e.g. department, unit, clinic, patient characteristics, diagnosis group, procedural group, provider characteristics, staff characteristics, etc.). Describe potential barriers to implementation. What are the possible adverse outcomes that may occur that may affect quality of care and patient safety because of your proposed intervention?

Implementation of formalized nursing protocols to allow nurses to practice at top-of-scope and promote an Interprofessional Collaborative Practice that allows for high-quality patient care and improved outcomes.  What would be fundamentally different would be our nurses practicing at the top of their scope, having a layer of protection with formalized nursing protocols to protect our licenses, and have a significant impact on decreasing workloads of our providers by providing advanced support and freeing them up to see more patients or perform more surgeries. This innovation of adopting nurse protocols will have an impact toward organizational growth and expansion, while having an impact on an individual nurse’s worth, contributions, and overall job satisfaction. “Protocols are rules and/or procedures to be followed when performing a clinical function or service authorized by a policy.” ” In addition, protocols need to be reviewed at least once a year and revised as necessary.” “Protocols mean that everyone handling the telephones gives consistent information. This helps avoid conflicting advice…they help defend against charges that they are practicing medicine without a license.”(1)

By leveling the playing field, raising the ceiling of where nurses can practice within scope, and involving them in the process, this will increase their engagement, perceived worth of their own profession for self and their organization, and promote involvement in continuous process improvement. This promotes Interprofessional Collaborative Practice (IPCP) and in turn helps to propel nursing forward, continue innovating, trialing, and adapting to changes that encourage thinking outside of the box, and encouraging nurses, regardless of tenure, to come to the table and promote changes in our workforce for today, tomorrow, and years to come. (2)

Minimally Invasive Gynecological Surgery & Urogynecology division (A.K.A. – GYN Surgical Specialties) sits under the umbrella of Women’s Health. The GYN Surgical Specialties clinic is heavily procedural and surgically based, which requires the triage nurse to have the acumen to critically think on their toes, respond rapidly to telephone triage assessments without the ability to perform hands-on/visual physical assessments, and the ability to manage conditions remotely for specific treatment modalities targeted to their specific treatment, procedure, or surgery type, and provide further guidance for treatment at home or seeking higher-level care (e.g., Emergency Room).  Some of the procedures performed in clinic are urodynamic procedures, cystoscopies w/wo BOTOX, hysteroscopies, Ablation procedures, and more.  Surgical cases include, but are not limited to, the following:  robotic-assisted laparoscopic hysterectomies, myomectomies, excision/ablation endometriosis, open abdominal procedures, Urogynecological surgeries, and more.  Physician providers are all surgeons.  Advanced Practice Providers include Nurse Practitioners.  Staff include Registered Nurses, Licensed Vocational Nurses, Practice Coordinators, and Patient Navigator.

Potential barriers to implementation are cost, resources, organizational structure and processes, and time.  Possible adverse outcomes that may occur that could potentially affect quality of care and patient outcomes because of the proposed intervention are negligible.  It’s more the opposite where the proposed intervention will improve quality of care and patient outcomes by reducing barriers, preventing delays in care, and allowing nurses to practice at the top of scope.

• PROPOSED EHR MODIFICATIONS Note: EHR modifications are NOT required for a winning proposal
• What are the clinical problems you are hoping to solve with APeX?
• Streamlined processes
• Consistent documentation practices
• Improved efficiencies
• Decision Trees to assist in clinical pathways
• Reduction in Delays of Care
• Nurses Practicing at Top-of-Scope
• Improved Patient Outcomes and High-Quality Care
• Promotion of Interprofessional Collaborative Practice
• What APeX tools (patient lists, reports) or workflows (orders, documentation, alerts) are you using now to achieve this goal? How would you want these modified? 
• “Per Protocol – Cosign Required”
• Modifications would come with software acquisition and implementation of nursing protocols
• What new APeX tools/workflows do you think you need to achieve the goals of your project?
• Purchase and Interface with Schmitt-Thompson Protocols
• Clinical Decision Trees
• Report Automation
• Development of Tools to Monitor Compliance with Protocol Usage & Reports
• COST - Estimated baseline costs to the health system and projected savings from the proposed project
• Baseline Costs to Health System
• Initial purchase of Schmitt-Thompson Protocols and an approximate $650/year/user licensing fee
• Development of Protocols (will fall to individual service lines and cost of resources)
• Projected Savings
• Would be in the form of items listed under TARGET section with qualitative and quantitative measures
• SUSTAINABILITY –
• If successful, how will this intervention be sustained beyond the funding year?
• Maintenance of protocols with updates
• Budgeted into cost centers that utilize the software and have triage nurses
• Who are the key UCSF process owners?
• Stakeholders (e.g., Ambulatory Care Nursing, Individual Departments that utilize triage nurses)
• UCSF Executive Leadership
• BUDGET - Line-item budget up to $50,000 - Briefly identify key areas of the project that will require funding, e.g., salaries, software, printing, etc.

References:

1. Long, Vicki E. and McMullen, Patricia C. (2003). “Telephone Triage for Obstetrics & Gynecology.” Lippincott Williams & Wilkins, Philadelphia, PA 19106.

2. Schmitt-Thompson Clinical Content. “Gold-Standard Nurse telehealth Triage Guidelines.” Retrieved 01/31/2023, from: www.stcc-triage.com