KEY ACTIVITY #6:
Develop and Implement Standing Orders
This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.
Overview
A standing order is a pre-approved clinician order to perform a specific intervention for any patient who meets the criteria for the order and is used when the step in the workflow specifically requires the order of a qualified clinician. Standing orders describe the action to be taken and identify who on the care team is authorized to complete the order. Standing orders are designed to enable care team members other than the primary care provider (PCP) to initiate specific clinical actions to provide timely screening and care, provided that specific criteria are met. Common standing orders include preventive measures, such as immunization, to be prepared for, or potentially conducted ahead of the clinician’s time with the patient.
To limit the potential for errors and ensure patient safety, standing orders should be carefully designed, regularly reviewed and revised as necessary. They should be based on evidence-based recommendations and best practices, and they should have broad support from the medical director, practice manager, physicians and other staff. Assessment of current attitudes and strategies to respond to them should inform the testing and adoption process. For more discussion of these matters, see the AAP publication Use of Standing Orders for Vaccination Among Pediatrics. In addition, standing orders should outline the criteria for initiating, modifying or discontinuing a particular course of action or treatment for a patient.[1]
Standing orders, in concert with other key activities, allow care team members to work to the full scope of their license and provide scaffolding to support care team members as they work to greater autonomy. They promote practice workflow efficiency and effectiveness by standardizing who gets what care while freeing up time for the prescribing clinician.
Standing orders help promote equity by ensuring that every patient who meets the criteria for an intervention under the standing order is provided with appropriate services, limiting variation that could occur in interpersonal encounters.
Most EHRs have the ability to enable creation of order sets that can be utilized to create standing orders. Depending upon the health center’s workflows, these can be placed on the chart by providers or can be drawn down by responsible designated staff according to protocols.
Relevant HIT capabilities to support this activity include electronic access to care guidelines, registries, care gap reports and clinical decision support.
Effectiveness of standing orders can be tracked through registries and care quality reports.
Action steps and roles
Outlined below are the actions and steps required to create standing orders and are adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care.[2]
1. Review and understand the latest clinical guidelines for the required standing order and your practice’s already established protocols.
Suggested team member(s) responsible: Quality improvement lead and panel manager, data analyst, or medical director (or equivalent).
Standing orders for recommended immunizations are based on the CDC Child and Adolescent Immunization Schedule by Age.
For some vaccines, clinics need to pay careful attention to how the standing orders are generated. For example, vaccines for diseases such as rotavirus follow a specific timeline; if kids don't receive their first vaccine by a certain age, they are no longer eligible for the vaccine. For other diseases, such as hepatitis A, the vaccine doses must be given six months apart. Additionally, patients who are following a modified or catch-up schedule will receive immunizations on a different timeline than those who are receiving them on the standard recommended timeline.
Consider creating standing orders for additional well-care visit activities (e.g., the periodicity schedule). Some screenings, such as postpartum depression screening, do not require a physician order and are often integrated into clinic workflows and pre-visit planning without utilizing standing orders. However, the distinction between a standing order and a protocol can have different meanings and implications for different teams, so there are instances where practices find it useful to create standing orders for these screenings as a way to support the care team to provide evidence-based care.
2. Translate the appropriate clinical guidelines into a standing order.
Suggested team member(s) responsible: Panel manager or data analyst.
The standing order will follow the relevant clinical guidelines and be updated whenever clinical guidelines are updated. It will generally allow the following:
- Registered nurses (RNs) and/or medical assistants (MAs) with proper training may initiate the agreed upon standing order process when patients meet the agreed upon criteria for initiating screening, and do not have any clinical history that may require a PCP to address the concern.
- Tip: Verify if carrying out standing orders falls within the legal scope of practice for the supportive clinical staff intended to carry them out.
- This may include initiating an order, initiating a referral or notifying the PCP of the need for screening and testing.
Immunize.org has an array of resources for developing and implementing standing orders for use in pediatrics. Many materials on the site can be adapted for other types of standing orders.
In addition to the written standing order, the practice should develop a process map or update other documentation outlining how and when the standing order is to be implemented in the practice’s current workflows.
3. Obtain approval for standing orders from clinical leadership.
Suggested team member(s) responsible: Panel manager or data analyst and medical director (or equivalent).
For the standing order to be valid and in effect, it must be approved by clinical leadership at the practice, signed by a designated valid signatory (e.g., medical director or other physician) and dated, and it must include the effective date for the standing order. Practices should consider including an expiration date and flagging this date in their system to help ensure that the standing order is reviewed and updated regularly. As the clinical guidelines change or other components are updated, the standing order should be signed and dated again by the appropriate party with an effective date for the revision.
4. Train practice staff on how to use standing orders and include this training in clinical onboarding of new staff.
Suggested team member(s) responsible: Medical director or equivalent.
It is critical that practice staff, both those directly named in the standing order and other members of the care team, receive training on the use of this standing order. Such training should include a thorough review of the written standing order and ensure that practice staff understand all of its aspects, including the associated workflow and any additional materials related to the workflow, such as patient education or instructional materials, that include nuances that the care team will need to understand.
Training should be provided on each standing order at least annually, retraining should be provided before the effective date on any revisions, and the training should be part of the orientation for all new members of the practice care team.
Based on feedback from the staff, the standing order can be refined to make the instructions clearer (e.g., during training several staff members were confused by a specific instruction, indicating that the instruction needed to be revised).
5. Institute mechanisms to ensure the proper use of the standing order and its effectiveness.
Suggested team member(s) responsible: Clinical director or equivalent or their designee.
It is likely that one or more aspects of the standing order will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing to one or more staff members, or the standing order’s protocol may not be regularly followed exactly (e.g., staff are using workarounds). The practice should routinely check for these and other common challenges and revise and update the standing order as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.
Complete an annual review of the immunization schedule, WCV activity, and key screenings recommendations to ensure standing orders align with the most up-to-date recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention.
Implementation tips
Avoid common pitfalls of standing orders:
- Standing orders are not updated when screening guidelines are revised and reflect an outdated practice. The remedy is to assign the task of updating the protocols to a member of the team who is responsible for at least annual review and modification.
- New staff are not instructed on the clinical protocols. The remedy is to include review of standing orders as a core element of orientation for all roles named in the standing order.
- Standing orders include the signature of a clinician who is no longer with the practice. The remedy is to review standing orders at least annually and any time a clinician responsible for setting the order has changed roles.