1. Standing Orders as a System Change
Creating and Implementing Standing Orders

2. What is a Standing Order
It is a written instruction/document containing orders, rules, regulations or procedures prepared by a physician for the conduct of patient care.
Standing Order (SO) authorizes certain medical staff to carry out medical orders per practice-approved protocol.
SO usually apply to a certain patient population.

3. Review what is the need:
Taking steps to improve patient’s health and longevity.
Early detection of disease.
Meet and exceed screening protocols.
Standing Orders are about improving patient’s health and keeping patients healthy by doing prevention screening on a timely basis. Standing Orders can also help you improve your performance measures to meet and/or exceed your screening protocols.

4. Standing Orders
What are some common screenings or routine/seasonal immunizations you may consider for SO:
Breast and Cervical Cancer
Colorectal Cancer
Diabetes
Immunizations
Flu Shots
SO can be used for routine care or immunizations for both children and adults (zoster for shingles). Some SO can be seasonal such as flu shots. Many SO also offer the opportunity to education patients on screening, when screening should start and their frequency. SO can also be used to monitor patients diagnose; as example you may have a patient who is having problems keep the blood glucose level at the desire level. With a SO the patient can come and be checked without seeing the provider. If the level is good it is documented in the patient’s chart; if it is high then the patient can see the provider.

5. Who does the SO affect? Patients
Education about health screening and their frequency
Financial impacts
Some patients may not know what screenings they need to do, when the screenings should start and how often they need to be repeated. SO can assist with this while - the nursing staff is taking the patient’s vitals they can review what screenings need to be done and move forward by discussing and giving the patient information on the screenings as well as ordering the screenings.
You may have patients who are not symptomatic and through a screening and because of early detection of a disease they received treatment and/or lowered the risk of serious complications.
Self pay patients may not have funds to pay for screening, look for programs that pay for the screenings.
Educate patients that being preventive not only helps decrease the risk of serious illness but may help them financial by hopefully avoiding high medical expenses and loss income because they were unable to work due to illness.

6. Staff Easier process Saves time
For staff it is an easier process. How many times has a nurse or ma received a request from a patient or a co-worker with a health check program for a provider’s order for example for a mammogram? If the physician is seeing patients, the nurse or ma need to wait to speak to him in between patients or at the end of the day, but with a SO for mammograms the nurse or ma can order the procedure without have to wait for the provider order and sign off the request. Thus save both time for the staff and the provider and a faster response time to the patient.
Regarding a easier process, if a patient is in for nurse visit and the nurse notices that it is time for the patient to have a screening or the flu shot, the nurse can move forward with either or both; requesting the screening and administering the flu shot. Again this is return save both provider and nursing staff time and helps keep cost down to the patient because they did not need to see a physician to accomplish this.

7. Creating the SO Content/Scope Who is your target population
Documentation
Content/Scope – what are the particular circumstances in which the standing order will apply
You also want to describe the SO patient population – as an example for colorectal cancer screening – the SO applies to patients over 50, no FOBT in last 12 months or no colonoscopy in last 10 years
What is the process – order colonoscopy which is your golden standard of care for this screening – patient can’t afford or declines order an FOB; don’t forget to include specific for patients under surveillance for previous abnormal results.
Documentation EHR or the patient’s medical record. This also provides the ability to review stats for improvement.

8. What are your desired outcomes
Increase delivery of services.
Identify care gaps.
To meet and exceed screening protocols.
SO can help increase the delivery of services and is an effective tool for preventative health screening. Essentially there is no wrong door for the patient, whether a clinical staff notices that it is time for a screening they can order it. If a patient is meeting with a CHA or a non-clinical person and mention the need the non clinical person can get the order through the nurse or ma and the patient can leave with the order in hand.
By documenting in patient’s medical charts/EHR you now have the possibility of running reports or baselines and identify the patients by different categories, male/female, insured and no uninsured, as well as checking for improvement on your screening protocols.

9. Getting your SO approved
Organizations will have different processes.
Medical Director
Nursing Director
Committees
Most Organizations have their own process on how they approve P & P. It can be the decision of the Medical Director, Nursing Director or even a committee.
As example for El Rio all P&Ps that impact nursing must go through the Clinical Advisory Council. When you submit your P&P you must describe why the P&P is needed, is it a best practice, have you discussed/spoken with the medical disciplines the P&P will affect and did they demonstrate support of the P&P. The committee reviews the P&P and approves the P&P or will request changes/edits. This is a good practice; only best practice, relevant and needed P&P are implemented instead of overwhelming staff with P&Ps that have no relevance to their duties.

10. Implementation of SO Introduction of new SO. Training of staff.
Resources available for both staff and patients.
Start with introduction of the new SO and it’s process. Staff training should include nonclinical staff as well as clinical staff – such advocates Community Health Advisors, Health Care Coordinators – many times this staff is aware of health check programs available for patients who are self pay and do not have the means to pay for screenings. As example patient could be referred to a CHA for assistance to enroll the patient on a free screening program. Or a CHA may be assisting a patient with other needs when the patient states you know it is also time for me to have my mammogram done but I don’t have the funds; the CHA can enroll the patient on a Well Check program, The CHA can request assistance from the clinical staff to please enter the SO for a screening lab or procedure such as the mammogram without the patient having to see their provider.
Have resources and educational information available to both patients and staff. This can be brochures or web sites.

11. Outcomes How do you measure Baseline at implementation.
Review at 3 months, 6 months, 12 months.
Review SO for effectiveness.
Important note “Have staff buy in!”
In order review if your SO is working you should run a baseline before you implement the SO.
Then you will want to run your baseline again whether it is at 3, 6 months - you decide when or how often.
One important note is have staff buy into the SO – they will be the ones who make your SO successful. You should also touch base with staff often in beginning to remind them of the new SO -- keep it upfront and current in their minds.
When measuring your outcomes you should see increases – higher percentages in your screenings!!
But of course we need to also touch on - What if you are not seeing the results you would like, follow up with staff, do additional training and review your process; make changes as needed.

12. Questions?