AMGA CNO CouncilInaugural Meeting Notes

March 9, 2016

Attendees:Chair: Mary Jane Lowrance, Community Physician Network, Indianapolis, INCarole Cassidy, Christus Physician Group, Irving, TXChristine Stromp-Hanba, Oakwood Physicians now Beaumont Health, Dearborn, MIDebbie Golub, PIH Health Physicians, Whittier/Los Angeles, CA Deena Gilland, Emory, Atlanta, GADoris Mulder, Beloit Health System, Beloit, WIJean Tealey, University of Utah Community Clinics Jill Powelson, RN, Director, Clinical Translation, AMGA AnalyticsJoe DeLisle, Membership and Council Relations Manager, AMGALaura Weber, USMD, Dallas/Fort Worth, TXMary Morin, Sentara Medical Group, VirginiaMaxine Ullery, Loma Linda Univ. Health Care, CA Sarah Baca, Centura Health Physician Group, Colorado Sue Klenner, Olmsted, Rochester, MN Susan Southard, Univ. of PennsylvaniaTiffany Luckett, Baptist Medical Group, Memphis, TN Valerie Williams, University Medical, Tampa FL

(follow-up items are highlighted)

Mary Jane Lowrance, Chair of the CNO Council, opened the inaugural meeting of the council with a welcome, and everyone introduced themselves.

An AMGA survey about patient reported outcomes was administered. Results will be distributed after the conference.

Topic: Scope of practice of clinic staff

Mary Jane: We are considering a potential dyad at Community where the practice manager and the clinical manager work together. The nurse leaders are at the supervisor level, and their authority seems less than ideal. We’ve hired 16 or 17 RN’s to do care management in the last several months. Medical assistants have been getting certified for meaningful use purposes. Lots of staff time is required to coordinate re-certification and pay adjustments for MA certifications. We have been considering how to get medical assistants to work at the top of their ability. We want to get them to do more than room patients and get vital signs. Can they tee up vaccines and handle health maintenance alerts? We have a number of protocols in place.

Mary: Are MAs regulated in your state? RNs can’t delegate medication administration in Virginia. MAs are not regulated per se, and there is no education requirement. We are requiring formal education for MAs.

Debbie: In California there is a defined scope of practice for MAs.

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Valerie: We have changed the MA job description to be a certified patient care specialist. You have to be certified. We are working on a competency program and orientation to the specialist practices. We have a technical center to help with simulations. If they can’t pass the simulation/orientation, they can’t work for us. But we elevate their salaries accordingly.

Deena: We have been getting our MAs certified. We had a lot of folks who learned their job through on-the-job training. We had to get them competency tested for Rx administration. There is a certification exam. It’s a 5 semester program. We now only hire CMAs who went to an accredited school.

Mary Jane: We compete heavily for MA staff. It’s not always easy to hire people from an accredited school. We are making some special arrangements for on-the-job training.

Deena: We find qualified candidates through rotations from the schools. It is great marketing for us. We did develop a grid with required skills for each type of staff on the care team. It’s been a great tool for us. (Deena provided Emory’s grid to AMGA, and it will be posted on the CNO council portal.)

Mary: We do this too at Sentara. We review that list annually.

Mary Jane: Our competency test is written. We ask them to do things like draw where 0.5 cc falls on this syringe. Also we test them on abbreviations.

Christine: We have a simple medication test as well as skills validation including taking a blood pressure correctly. We validated the skills assessment with the local community college.

Tiffany: Do you use this pre-employment?

Some do, some don’t.

Jean: We don’t even do typing tests pre-employment.

Debbie: I can’t give them an actual test in my organization/state. But I can ask interview questions to try to get at it.

Mary Jane: There are some differences between states. Some tests aren’t “validated”, but we have to start somewhere. If you have an education department, get them engaged to help you. With practice acquisition, this issue comes up a lot.

Carole: In Texas, there is strictness about peer review by nurses for a quality issue.

Mary: MAs seem to have taken over many RN duties. But following protocols requires clinical judgment. Physicians push back on that. If there is a patient assessment or evaluation, then judgment is required and a RN should do that. We try to design protocols that have yes/no answers so they do not require judgment by a RN. This is an issue with refill decisions.

Mary Jane: The movement of services from RNs to MAs was an economic decision by physician practices.

Carole: It’s tricky at times if the nurse is supposed to supervise an MA. It may be out of scope for the RN.

Susan: We are concerned about getting the RNs out of the office where they may just do paperwork. We want to get the nurses out in the clinic to supervise patient touches.

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Tiffany: How many of your clinics are tied to your hospitals’ licensure or accreditation? Our clinics are not JCAH certified.

Mary: I have both certified and non-certified clinics, but we use DNV (Det Norske Veritas) not JCAH.

Sarah: I wrote a scope of practice collaboratively but had physician pushback at my organization, even with change management and legal review. We decided to go with national certification. We developed a way to test for knowledge which was adopted by our system. All MA’s have practice standards now. You have to have a culture that it’s ok for the MA to say “I’m not willing to do that.” They may feel afraid of losing their job.

Mary Jane: It helps to have a RN in the clinic to support the MAs to speak up.

Sarah: We do not have RNs in all of the clinics at this time. It would help to have a CNO in the c-suite. I report to the CMO. All of the practice teams report to a COO.

Deena: You can try to meet with the right folks to try to change the structure, and show the return on investment (ROI).

Sarah: We are getting closer. I wrote a value impact statement about this.

Carole: We have had Magnet on the hospital side, but not on the clinic side.

Mary Jane: When value based care really kicks in, the hospital census will drop and the number of needed hospital nurses will decrease. Can we use them in the ambulatory setting? We need to look ahead to that time. This council can help with the ROI calculation. There is also an American Academy of Ambulatory Care Nursing position paper on this subject (we will post this on the CNO portal).

Mary: I am on a committee on the Academy of Nurse Executives (AAACN) Not every practice needs a RN. The nurses don’t always enjoy the high volume work of a clinic and less challenging duties. We had some turnover when we put nurses into clinic situations like this. Now every clinical position has to be approved by me, to avoid putting RNs in the wrong places. I look for RN leaders. It’s important to keep a healthy balance of RNs and other staff. We do have care managers/population health nurses. I have a RN practice manager/coordinator position, but there are only 2 of these in the medical group. Most practice managers are not nurses.

Mary Jane: Also consider California Health Care Foundation August 2015: “The RN role re-imagined”. It explains how to revise/re-engineer your RN role.

Carole: Can we get a reservoir of job descriptions? (Mary Jane provided several to post.) What are the roles of nurses in ambulatory? AAACN has a lot of what we are looking for.

Topic: Pay for Nurses

Mary Jane: Pay is an issue between the hospital and clinic settings. Acute care is paying more for less responsibility in some cases.

Mary: We have a 9% difference in base salary between hospitals and clinics. I took the job description for a care manager and just changed the word ‘hospital’ to ‘clinic’. So the job descriptions are identical. Where I still have issues is a front line staff nurse. Some clinic nurses have more autonomy than hospital nurses. We are consolidating job descriptions across the system. They have to have the same salary if

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the job description is the same. The CEO and COO of the system believe the ambulatory environment is easier.

Mary Jane: I am told that the ambulatory nurse salaries are market driven. But there does not seem to be any real data on the market.

Tiffany: Another issue is there are no clinic experiences in our nursing schools, so nurses graduate and go into hospital work. They don’t know if they would like working in a clinic.

Mary Jane: I give nurses clinic experience and other types of experiences. I ask the nursing students what they are interested in. I’ve hired a lot of the best graduates from universities because they get experiences in our clinics. Be sure to let nursing students know that jobs in hospitals may decrease in number eventually.

Mary: I may have one RN in a practice, so finding a nurse to precept a brand new graduate is very challenging. It sounds like Mary Jane has built infrastructure to support precepting. We require hospital experience to build assessment skills before we hire a nurse to work in a clinic.

Mary Jane: There are jobs for nurses in our health system and elsewhere that don’t require assessment skills like those of a hospital nurse. We don’t require hospital experience per se.

Jean: We put into place ambulatory capstone experiences for BSN students. We presented to students and had an overwhelming number of students interested. We started with primary care and OB/GYN. We are adding some specialty now. We worked with AAACN to start a program of precepting.

Carole: Can we explain what a nurse does in ambulatory? Nursing leaders on the acute side don’t understand. Some people think that clinic nursing is a step toward retirement.

Mary Jane: If you have schools of nursing in your area, I encourage you to meet with the Deans of those schools and talk about how to place their students with you. It may be under the Community Health Curriculum. Our local schools get good reviews from having their students placed in ambulatory settings. The students can follow a doctor for a day and see how they like it.

Sue K.: We compete with Mayo Clinic for nursing students, and they have done a good job of connecting with the nursing schools. We now offer a paid internship for nurses in the summers, and that seems to be working well.

Doris: We do the same thing with students at inpatient and outpatient. They have to be a senior in their nursing program. Back to pay, if it’s M-F during the day there is about $1 less pay per hour. If you have to work weekends and holidays, then you get more. But urgent care that requires after hours work does get paid more. Ambulatory surgery which is only open M-F gets the same as clinic nurses.

Mary Jane: Doesn’t the pay differential make up for that? 7a-7p gets no differential. Saturday clinic hours don’t get differential – I am fighting for this. The base rates need to be the same.

Doris: If 50% of your shift is after hours, you get the differential. The base salary is higher for inpatient because we don’t pay weekend differential.

Mary: I am not a proponent of shift differentials – I want to build it into the base.

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Deena: We did do a market survey with 3 zones. I would be glad to share it. It truly did include all work settings. It was also disease based. We had a consultant help us with the survey. Zone 3 represented the highest acuity disease including oncology and critical care. Zone 1 was general med-surg. A RN in primary care gets the same pay as a RN in med-surg because they are in the same Zone.

Debbie: We also did a market analysis. All RNs are on the same base pay. They get shift differential.

Carole: Do the areas that are specialized require certification and pay more for the certification?

Doris: We want our ambulatory and med-surg nurses to be certified too.

Deena and Mary: We don’t care what the certification is in. We just see better outcomes with any certification.

Deena: We have a ladder too, but we call it a “lattice”. They get $1000/year bonus for a certification, plus we pay for the exams. Sometimes they let the certification lapse, so we didn’t put it in their base. They can use the bonus to pay for CEUs or conference attendance. This is as long as it is not required for your job. If the certification is required for your job, there is no bonus. The certification bonus also applies for non-nursing roles.

Mary Jane: Do others have a clinical ladder program?

(Many of the attendees do not have a clinical ladder. There was also group discussion of the need to recognize MAs in non-monetary ways. We have “nurses week” but how do we recognize MAs? There was discussion about encouraging MAs to go back to school to become nurses.)

After lunch session

Valerie: We use a central triage for all of the clinics. Barton Schmitt and Thompson is the resource for protocols.

Joe: We will have a portal where you can store documents that only the CNO council has access to. You will have to log in. I will send out a link in the next couple of weeks.

Topic: Protocols

Mary Jane: Submit protocols to Jill, and we’ll post them on-line.

Mary Jane: We don’t have a CMO anymore. We have a primary care medical director and a specialty care medical director. Indiana has a favorable environment for standing orders.

Mary: In Virginia, you can only have one protocol, and it’s for vaccines. The flexibility to use protocols varies state by state. Nurses cannot sign prescriptions in Virginia. There is a difference between doctor preference and doctor protocol. Staff should not authorize per physician preference.

Valerie: In our state (Florida), a MA can create an order and pend it for sign-off.

Tiffany: In Epic, we have a medication management protocol that goes to the provider to sign.

Mary: Our providers have to sign the Rx before it is released.

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Carole: We found that all of our medication errors were because of verbal orders or vaccines administered without an order. The written order is better to prevent errors before administration.

Sarah: What is your process to get protocols approved? More than the protocols themselves, I would be interested in the infrastructure around how you are managing protocols?

(There was discussion about what EHRs people have: Epic, NextGen, Cerner, Athena.)

Doris: We have inpatient order sets.

Mary: We have lots of inpatient order sets. Our inpatient anti-coagulation nurses use warfarin protocols, but they are ordered by the provider in advance. This discussion we are having is different – it’s about activities permed by a nurse, without a prior physician order.

Carole: There is a difference between individual patient orders and broad across-the-board protocol orders.

Mary Jane: As you look at efficiencies in the ambulatory setting, do you have protocols for nurse driven care?

Mary: Not in Virginia – nurses can’t initiate medications. We have 250 APNs, but we are still working on getting protocols which the APNs can implement. We have a rapid strep protocol that a MA can follow with yes/no questions. There are some protocols that only RNs can follow. Anti-coagulation RNs have to use judgment to decide whether the protocol even applies in each situation. That is definitely a RN role.

Carole: You have to know your state’s scope of practice limits when you start working on protocols. If you are in an organization in multiple states, you can say, “per standing order, if your state allows”. If it’s a patient specific protocol requiring a diagnosis, then that is the role of a provider or APN.

Topic: Population health

Mary Jane: What are you doing around population health today and some of the roles you are creating? Are you putting focus there yet, are you using analytics, and what are they?

Sue K.: We’ve done little. We do have a ‘healthcare home’ with 3 coordinators. Regarding analytics, we are in the early stages.

Susan S.: We have patient centered medical homes (PCMH) in all of our primary care practices. We use analytics to find patients with gaps in care or who haven’t been to the practice in the last year. We are working to expand to the next level, using Epic.

Valerie: We are using call centers for gap closure. They can’t order per protocol. We are trying to capture the patients who haven’t been into the clinic. The call center is reaching out to them to make an appointment. We just switched to Epic from Allscripts. The call center gets physician orders when needed.

Christine: I have 2 registry coordinators with a MA background, and we generate patient letters using the registry. Last year we sent out over 100,000 reminders. Anything that is not done within the office (i.e. mammogram, colonoscopy) can be in these letters.

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Tiffany: For our patients with hypertension, we are beta testing a reminder letter. Our target is patients with an out of range blood pressure not seen within a certain number of days. We send messages via MyChart and send letters. We ask them to come in for a nurse visit for a BP check. Letters via MyChart were originally signed by me or our quality director, and that caused a stir. So our OneCare team is creating a generic sender: “The quality care team of BMG”. Things like whose name is on the letter matter.

Mary Jane: We are trying to embed the team into the practice. We have a primary care navigator or quality data assistant in the practice. It makes a big difference in patient acceptance. Patients are afraid of identity theft. They are concerned about people getting their information.

Mary: We have something called ‘member abrasion’ with over-calling from Sentara. There is a department of population health management. We have someone else working with payers. We have 20 RNs supporting 150 patients each – the sickest of the sick. We have another group of transitional care RNs. Population health management is not one thing - it has a lot of different components. You have to decide what your strategy includes – what you are tackling? We didn’t embed the care managers because our pilot showed that they were being pulled into daily duties. We changed their reporting to be centralized. The payers are giving us incentives. We are analytics poor. We don’t have it.

Carole: We are working on annual wellness visits. Athena is our electronic health record. We can see which patients need a re-call. We have chosen a narrow focus for population health. We are trying to find things that don’t require a RN’s judgment.

Mary: We are piloting 2 RN’s doing annual wellness visits. The care managers can do them too. The providers didn’t like it because of loss of RVUs. Using RNs, we can get 13 annual wellness visits (AWV) visits done per day.

Carole: We talked to The Advisory Board about helping us to do this, but it was expensive. We set it up by ourselves less expensively. CMS designates RNC (RN Certified) as an eligible provider.

Mary Jane: We use pharmacists (we have 13 of them) for AWV. They are all doctors of pharmacy. They do at least 4 AWV a day and the rest of their time is for high risk patients and seeing referrals from our providers. They do all the med reconciliation. They make all the changes with Rx as needed. It’s been wonderful. Patients love the pharmacists. They see them as an advanced practice provider. I can pay for some of the pharmacist cost with their billing. From a referral perspective, the pharmacists can see some of the difficult physician patients who are not doing well for some reason. If you have a school of pharmacy, I recommend that you pay for half of the pharmacist salary in exchange for their placement in your clinics. The pharmacy school pays for the other half. They are technically faculty with the school. I also do this with NPs and PAs, by the way. We were overwhelmed with precepting requests, so now we require you to be an employee of the organization in order for us to precept you.

Mary: Pharmacists are expensive, and we can’t afford very many of them. I have 7 of them, soon to be 8.

Deena: We don’t incentivize individual RVU production anymore. One of the things we incentivize is does the provider take on students.

Tiffany: I have questions about what you all are doing for transitional care management (TCM) billing and incident-to billing.

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Mary Jane: TCM billing is very specific as to who has to do what.

Sarah: Our transitional care management is by RNs, not APNs. The RN doesn’t bill. They do the work and route it to doctor, the doctor does his/her part, and then the bill is dropped. A physician is seeing the patient. The nurse does med reconciliation and documentation, and the doctor has a face-to-face visit. We use licensed nurses for this. We are using nurses for CCM, TCM, and “welcome to Medicare” visits. We have some practices which aren’t fully staffed even by medical assistants, so staffing all of this is a challenge.

Carole: We have been approached by some vendors to help provide TCM with contracted face-to-face resources.

Mary Jane: The regulations state that you can use ‘qualified clinicians’ for TCM. But it is not clear what the definition of ‘qualified clinician’ is.

Tiffany: Regarding general vs. direct supervision related to care management, does the provider have to be in the same location as the person on the phone?

Mary: The provider has to sign off on a care plan for CCM. For TCM, a provider has to document a comprehensive visit. Are you billing the TCM code on home visits?

Debbie: For TCM, we do the phone call. We schedule a RN visit (1st half hour) with the provider. The RN component makes for a more comprehensive visit and helps us to bill TCM.

Mary: Nurse sensitive indicators sitting with Press Ganey (NDNQI) include falls in the ambulatory environment (mostly in surgery centers or home), readmission rates, skill mix, and some care management (pediatric asthma).

Mary Jane: Who does anything with NDNQI – what are you doing with them? What do you do with the results on the inpatient side?

Mary: We do lots with it on the inpatient side. There is nothing on the ambulatory side for this.

Carole: You could do a lot on the outpatient side if you had a grant for this. This is especially true with falls.

Mary: Falls are not always elderly people. Sometimes they are our age. At our trauma center, falls are the #1 trauma cause in the elderly. We have a fall screening which we’re trying to get into Epic. Assessment leads to scoring which leads to intervention. It’s all community based. Physicians don’t see their role in falls clearly. There is a body of work about teaching people how to fall well. One physician is teaching elderly patients how to fall through situational awareness. What a great opportunity for nursing!

Mary Jane: How many of you have an ambulatory harm score? There is no CAUTI or CLABSI in ambulatory, so what do you track? Hospitals have never events and 0 harm events. It has to be measurable.

Mary: There isn’t literature out there. The issues are delay in diagnosis and delay in treatment. One area is around adverse drug events. How do you determine whether it’s due to your management, or lack thereof?

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Tiffany: We can evaluate time to release lab to physicians with abnormal results and then time to notify the patients.

Mary: Do you allow staff to communicate critical labs?

Tiffany: We allow staff to communicate normal results. Doctors are supposed to call or notify the patient if the lab is abnormal.

(The group discussed that Epic allows you to set a release time for labs.)

Mary Jane: I suggest that the best practice is releasing the entire record to the patient via MyChart. I do not believe that holding lab results for provider review is a best practice. I suggest getting rid of blue script pads if you have e-prescribing. They can be stolen and sold. We’ve been advised that their street value is $100 per sheet and $5,000 per pad. Our clinic safety audits include checking for accessible blue pads. You can also check for med errors.

Mary: We push labs out without waiting for provider review, to the medical record accessible via the portal. You can check for verbal orders during your safety check. Can we distinguish between an adverse event vs. a safety event? The “authority gradient” can make people afraid to speak up about errors.

Valerie: For non-portal users (30-40% of our patients are portal users), we have the staff call.

Tiffany: I can share what SVMIC (our liability provider) considers harm after they give us their report. They are doing a safety assessment now. What about informed consent and getting it into the chart?

Carole: Informed consent is state dependent.

Jean: We use informed consent for invasive procedures. Local anesthetic may require a separate consent.

Deena: University HealthSystem Consortium (UHC) is working hard on ambulatory sensitive metrics – there is a list of about 10 of them. They could be used for risk scores. Admissions for dehydration are one.

Tiffany: Access is another metric.

Topic: Nurse Practitioners

Mary Jane: We’ve combined NP and PA into a “APN section”. We re-did our credentialing. We are not going to take ambulatory-only providers through medical staff credentialing anymore. This speeds up our credentialing time. We can put our credentialing manual on the CNO council portal. We have a 90-day termination for cause clause on both sides (provider and organization). We chose not to have a non-compete clause. We don’t have NPs with their own panel of patients. We pay a $2,500 stipend for CME and provide 5 days for CME. We did not require them all to sign the contract, but if they didn’t sign, they lost $CME and other perks, so they all signed. We did CRNA, NP, PA, urgent care, behavioral health, inpatient and outpatient. In short, anyone employed by the group. There are 300 of them. Regarding PharmD’s, there are only 12 on the ambulatory side. We are starting conversations with them now about employment contracts. We had NPs giving 2 weeks’ notice, which was far too short. We invite APPs to our “all provider” meetings. We have a governance council where NPs and PAs peer review the candidates’ files, and I am the executive sponsor.

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Tiffany: It takes 90-120 days to get our NPs credentialed.

Doris: Our NPs are all paid salary vs. doctors paid on RVUs. We do have a NP contract, but it doesn’t have a notice period if they leave. The contract is simple. NPs do have a non-compete clause. They do get a stipend for CEU/CME. Our NPs have their own panel of patients. We offer $2,500 for CME.

Christine: We have a base salary plus incentives through a contract.

Mary: Magnet status requires a nurse executive to sign off on credentialing of all advance practice nurses. It’s a lot of work.

Carole: We have a monthly quality, credentialing, risk, and safety meeting. Physicians have voting authority. I am not a voter though. My approval is captured in the minutes but I don’t have an official vote.

Deena: We hired a director of APPs. APPs need to have their own governance structure. We have 700 of them. The director provides the overview/peer review/practice review on the credentialing team. She reports to me.

Sarah: I would love to see that job description.

Mary Jane: We have a charter for our nurse governance council. The director of APPs has monthly meetings with the chief physicians of both primary and specialty care. She has 1-on-1 meetings with the chief physicians to update them about what is happening with APP’s and in the community. We have our own separate peer review for APPs. Nurses aren’t used to peer reviewing their own people so there have been some wrinkles to iron out. Some HR issues have been brought to peer review that should have been handled by HR. The PAs and NPs have been working well together on their shared governance council. Their scope of practice is different from physicians. The mid-levels can govern their own best. Continuing education is a topic. Their incentives are aligned. Any APP who is never going to step foot in a hospital does not need to go through medical staff credentialing; JCAH doesn’t require it. Once a APP accepts job, they can be ready to work in 60 days. We use Cactus as our credentialing database. The 60 days is for internal credentialing. Payer credentialing follows that. A NP/PA cannot admit at the hospitals anyway.

Debbie: We have had physicians take patients away from NPs. [Some discussion followed with advice about how to handle that.]

Mary: If you have provider based billing/hospital based department, you have to take the APPs through the entire credentialing process.

Hot Topics: MAs as scribes?

Tiffany: Epic runs an efficiency report for us for some of our physicians. We think that scribes will help them become more efficient.

Mary Jane: A problem we face is that scribes cannot enter orders at our organization. They don’t have access, because they are non-clinical. We use Scribe America for $21/hour. This is more expensive per hour than MAs, but there is a return on investment particularly in specialty care. They pay for themselves. Providers can see 2-3 more patients per day and all charting is done and charges are dropped quickly. If you have staff splitting their time between roles, they have to have dual sign-ons in

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Epic. When scribing they have one log in. When working as a MA, they have a different log in. Some doctors use their PA/NP as a scribe; this is not ideal. Scribe America gives me monthly reports. They bring in a master scribe to oversee and train. They recruit college students thinking of going to medical school, nursing students, etc. They watch and supervise the staff. The scribes have to take a test and learn anatomy and abbreviations, then they can start observing, then they can start scribing under supervision. Community pays for it but can recoup the cost by getting charts done. Some doctors just want a scribe, and they pay for directly for Scribe America. Your own employees take vacation/sick leave, then you have to figure out how to cross cover. That is a consideration in your ROI analysis vs. outsourcing. To staff it yourselves, you need to have back-up staffing like a pool. I didn’t want to be in the business of keeping a resource team of scribes.

Mary: We do have dual log ins, but they are designated for a full day to be one or the other. They are internal, not contracted. CHESS model is the one we looked at. We pay a MA salary level for this scribe role. We require all of our MAs to be certified.

Sarah: We have two MAs to a provider plus scribe for a 3:1 total ratio. Our providers see 24 patients in 8 hours for primary care.

Laura: We are considering using physicians in India to do the scribing for us.

Deena: We would be interested in seeing data on scribes and productivity.

Doris: We use scribes in ophthalmology. We have ophthalmology techs. We went to that team and said you need to all be able to do all of those jobs. We require physicians to sign off on scribes in real time.

Jill: I’m a coder, and coders are very concerned about the increase in scribing leading to fraudulent documentation practices. For example, a scribe could document more than the doctor really says to increase the encounter level. This is more likely to happen in a situation where the scribe has worked with the doctor for a long time (i.e., I know what Dr. X meant when he said that) and probably less likely when you use a contract firm like Mary Jane described. So be cautious when you use scribing and think about how you can monitor/observe and audit it.

Tiffany: About 25% of our MAs are certified.

Mary Jane: Regarding our CMAs and RMAs, we helped them to become certified, and in return we made them sign a one-year commitment to stay. We gave them a scholarship and gave them 12-13 weeks to get certified. We handled 575 MAs in the course of 12 months. It basically takes a full time project manager to manage this process of tracking the MA certifications/re-certifications. We gave the MAs a 5% increase to their base salary for passing the test and maintaining certification. If they didn’t pass, they may be able to function in a non-certified role. We have 3 levels of MA. Level 1 rooms patients and cannot do order entry. Then Level 2. Level 3 is certified with a 5% increase. If you let your certification lapse, the project manager gives you 30 days’ notice, then you lose your 5% and lose your order entry ability. If you left in less than 1 year, we made you re-pay a $250 fee. The 5% was intended for them to cover the cost of CEUs annually.

Valerie: We paid for the first test attempt. We only had one MA that we had to let go.

Mary: We handled 500 MAs over a 6 month period. We used the NHA study guide. You can get CCMA which is not as restrictive as RMA, where a physician may have to attest that you were in that role for 1

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year. There are study guides and lots of aids. We had study groups for people who needed help. We don’t hire anyone now who isn’t certified. We worked with the schools to build it into their curriculum. We pay for CE Direct. But even then, some of them require a $75 annual fee.

Sarah: We developed an internal CMA review course for them to become certified, and on a monthly basis to maintain certification. We budget for one certification annually. We also offer scholarships. To get reimbursed, it takes as much as 3 months. If they fail, they are on their own dime.

Jean: Our HR department is actually tracking the CEU deadlines, so that took it off Nursing’s plate. Our physicians pooled money and gave them a $200 surprise recognition. We did not have any turnover after that!

Other MA topics

Tiffany: Do you require uniforms? Our local uniform shop agreed to handle the purchases by payroll deduction. And they are going to come to our work sites.

Mary Jane: We had uniforms all picked out. The doctors did not want it though. Primarily because we didn’t offer a stipend for the staff. Hospital nurses do have uniforms.

Debbie: We offer $100 per year for uniforms for every clinical staff member.

Jean: We offer a $60 one-time uniform stipend.

Deena: The patient advisory committee raised this issue, and that made it easier to get through. There was a one-time help from us, and after that, it was on the staff’s own dime.

Tiffany: Do you call MAs “nurses”?

Mary Jane: Indianapolis has a health coalition which agreed that all RNs should wear a RN badge in bright red which hangs below their name tag. Physicians have a magenta tag. Everyone in the city wears the same color tag. Also, they agreed that the right shoulder is the location for your nametag. You can’t wear it on the waist or around your neck.

Doris: Our policy is the same.

Carole: Only the providers wear white jackets. We changed the prompts on automated phone scripts to take off references to nurses who weren’t really nurses.

Mary: We also label people’s role clearly on their nametags.

Hot topic: Magnet status in ambulatory

Mary: We are looking at submitting for Magnet status in 2017. I am working with ANCC to do a crosswalk on source of evidence (SOE) which is currently hospital centric. I would like to see them be more ambulatory in nature. AAACN people including myself are going to meet with the Magnet program office in April. There are two measures about nurse sensitive indicators, and those are fine. The others are very challenging. We want a crosswalk that says in the ambulatory environment this is how you would answer this. For patient satisfaction, you need RN specific questions with 8 quarters of data, and that also costs money. There are no Magnet designated medical groups today (some are through the hospital side).

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Carole: Do you have to have a certain percentage RN presence?

Mary: No. But you only have Magnet at the sites with RN. We use NRC Picker for patient satisfaction. For physician satisfaction, we use the Jackson Group. We can break out APPs from other providers. They won’t give you data unless you have at least 3-5 responses per site. You have to have one completed research project, which is very challenging in the ambulatory environment. It has to be IRB approved and completed. A RN or APRN has to be PI or co-PI. You cannot just do process improvement work and have it count toward this research requirement.

Deena: It doesn’t have to be a randomized control trial. We did a study about peppermint oil as aromatherapy to reduce nausea for chemotherapy patients. This met the requirement. The front line nurses thought of it.

Mary Jane: We have a vice president of innovation. Once a year they come up with a question, and RNs and others compete for an innovative idea on that topic. Some of the ideas can be commercialized.

Deena: We are excluding ophthalmology because we only have 1 LPN there. It’s not about Magnet, it’s about excellence. We’ll have the same standards at ophthalmology but not include them in application. You can group the applications into departments. At Emory two of our five hospitals are Magnet. Each hospital is licensed individually. All are on the journey to Magnet.

Mary: Sentara has 12 hospitals. 6 are Magnet, 1 site visit is going on this week, and 2 more are in the queue. 3 are not ready yet. Ambulatory is on the list. 99.9% of Magnet appraisers are hospital based. Each site with 1 RN must participate in the Magnet application, but it’s difficult to meet the annual RN peer review requirement in those sites with only 1 RN. How can we think through that creatively?

Carole: We can do peer review telephonically. It is an events related review, not regular annual peer review.

Hot topics: Technology & telehealth trends

Mary: We are using remote monitoring of patients.

Sarah: We are using Exploris as our disease registry. It has integrated claims and electronic health record and a concurrent risk stratification tool. It also functions as our warehouse to populate dashboards and balanced scorecards. The data needs to be dynamic. We can see ADT data within Centura. We are using ADT feeds to mesh and see when there are patients at other facilities, especially those patients at high risk. I built a staffing model using this data. We don’t use LACE. The risk model is in Exploris. We were previously getting that info by payer: who costs the most. It shows me the percentage of patients at critical risk vs. what it should be. It may take years to move that percent as much as we want. We’re trialing some bundled agreements and working on Medicare Advantage. If we rely on our traditional approach, we’re going to struggle. I spent some time working on a staff model that would make sense. I’m deploying RN care managers to those patients at high risk or critical risk. I’m deploying RN clinic staff to other patients. We’re going to sunset Exploris after we go live on Epic/Healthy Planet.

Mary Jane: We use Optum and Health Catalyst to do the same thing. You cannot do population health without analytics. Go look at analytics tools in the exhibit hall. Pay attention to the election and how it will impact payment models and healthcare systems, as nursing leaders. The degree of impact depends on what part of the country you are in. Risk will force you to change compensation models and

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everything. If you have Epic, you can use Healthy Planet to get risk stratification and registries. You can see on the same day who’s been to the ED or hospital. If you have Epic, go to their User Group meetings to understand how the technology is working and what they are beginning to develop. Without that, we will be behind the eight ball.

Jean: We’re sending home BP cuffs, oximetry, glucometer, scale etc. on some of our patients. Care managers scrub the information provided by those remote devices. It’s just a pilot. About care navigation, we’re doing a pilot on video conferencing with patients. We’ve done this with Skype too, including triage of patients.

Carole: Protected health information (PHI) and security are issues.

Tiffany: Patients can enter weights and glucose directly into MyChart. It will show the trend line for you.

Mary Jane: Telehealth is the coming wave. It’s like the speaker this morning about riding a bike differently. It’s different way of doing things, and it’s hard to think through.

Susan S.: We just did a pilot to keep patients with high blood pressure normotensive. An application called Twine is used for the employee to report their own BP to a nurse. It’s a version of telemedicine, similar to Withings. Patients loved it.

Carole: For dictation automation, we use Dragon. Sometimes it’s gibberish though.

Mary Jane: We hold the doctors accountable for that.

Deena: The doctors have to re-do their documentation when that happens.

General discussion/Hot topics

Mary Jane: How do we sustain this group of people?

Joe: We can do whatever you want to do. Each council does things a little differently. Some councils meet 1 or 2 times a year and hold webinars. The list serve is our major method of communication. IQL is in San Francisco this year. If the council is doing something innovative, we can set up a webinar or a call for AMGA at large.

Tiffany: Regarding hot topics, I want to know about training and competencies.

Carole: AAANC has a group focused specifically on that.

Maxine: I would like to see staffing models, including a recommended ratio for primary care and specialty care. The patient portal and e-visits is falling to clinic staff, which is impacting our staffing. The staff start the e-visit and pass it along to the providers.

Carole: This group could make recommendations for responsibilities for different team members.

Jean: We have been working on an ambulatory nurse residency program. We focused on it recently and it’s being reviewed right now. Is anyone interested in a program like that for new grads? I would be willing to do a webinar about it after it’s reviewed and edited.

Carole: I would like to discuss keeping up with the nurse sensitive indicators (Magnet).

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Mary: That gets to the efficacy and value of the RN.

Susan S.: When we look at Press Ganey indicators, which ones can the nurses impact?

Mary Jane: NRC just switched to a 10 question “Connect” survey (down from 60 questions) which meets CG-CAHPS, but it’s all provider focused with no nurse questions. The response rate is much higher than our old surveys with more questions. You can customize the questions if there are things that you are interested in. I’ve been told that it would cost $15,000 to add a nurse specific question! You can internally benchmark if you use custom questions, but you cannot externally benchmark them.

Sarah: Are there any medical assistant sensitive questions that you can look at?

Mary Jane: Yes, we can look at that.

Tiffany: How can this group influence the bottom line by mitigating cost or bringing in new revenue?

Carole: What is the role of a nursing leader in an ambulatory setting?

Mary Jane: What is the value of PCMH and renewing it?

Mary: Your payers may require PCMH. Magnet status is half a million dollars per site to put into place. Just to get to the point where you are ready.

Mary Jane: On some of these questions, we will not be able to reach a unified decision because it’s organization specific.

Carole: Often acute care people don’t understand ambulatory.

Mary Jane: We have a system CEO who has an executive leadership team, and an ambulatory nurse sits on that to represent nursing. People are curious about what a CNO does in an ambulatory setting. Can we have a joint meeting with CMOs? or CEOs. Please submit your role summary for the group’s benefit.

Joe: You can suggest a joint meeting of the councils. You can invite the CEOs/CMOs to your meeting and present to them, or you can go to present to their council. We can also move the webinars around on different days of the week to help fit different council members’ schedules.

Tiffany: I would like to talk about our role and our vision for the medical practices.

Laura: I would like to see more about the vision too.

Joe: IQL will be held November 15-17. The councils meet on the 15th. 16-17 is the main IQL conference.

Mary: Every other month would be better for me than every month.

Mary Jane: Lunchtime 12:00 – 1:00 webinars are good for many people, but we are on different time zones. Let’s do something fun together in San Francisco. Let’s do an evaluation of this meeting with “fist of 5” voting.

Joe: You can also go onto your app to submit comments.

Christine: This sharing was great! We are in the same boat.

Valerie: I wish we had more time. It’s a great start.

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Susan S.: Can we have a more formal approach for people to present what they have already done?

Joe: We can reach out to AMGA members who are experts on the subject for guest speakers.

Sarah: We have a really strong list of topics going forward.

Mary Jane: We’ll send out minutes and follow-up topics going forward. Not one person in this group can take on everything, but we can focus and divide it up. Read about MACRA. (Jill will obtain policy summary of MACRA/MIPS)

Mary: I’d like to see more about analytics. We can do some presentations on analytics.

Jill: We can ask Dr. John Cuddeback at AMGA Analytics to talk to you with an analytics orientation. He is most knowledgeable about Optum One’s population health analytics, but he can orient you in a product neutral fashion.

Joe: If you want more information about MACRA, we could have a policy update presentation. Chet Speed with AMGA gave a presentation to the COO and CMO council. We can do that here in the future.

Mary Jane: I receive AMGA’s daily news with legislative updates. You need to get that from AMGA.

Joe: You can let me know if you are not getting it.

The meeting was adjourned.

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