KEY ACTIVITY #9:
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 preapproved order to perform a specific intervention for any patient who meets the criteria for the order. Standing orders describe the action to be taken and identify who on the care team is authorized to execute the order. They are designed to enable care team members other than the primary care clinician to initiate specific clinical actions to provide timely screening and care, provided that specific criteria are met. Common standing orders include measures such as lab work, immunizations or cancer screenings, which are initiated ahead of the clinician’s time with the patient. An important characteristic of a standing order is that all the patients who meet the criteria for the order receive the same treatment, thereby embedding equity into the clinical approach.
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. In addition, they should outline the criteria for initiating, modifying or discontinuing a particular course of action or treatment for a patient.[1]
Standing orders allow care team members to work to the full scope of their license and provide infrastructure to support care team members as they work toward greater autonomy. They promote practice workflow efficiency and effectiveness by standardizing 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, thereby limiting variation that could occur in interpersonal encounters. Standing orders are particularly useful for preventive care and screening for chronic diseases and conditions – such as diabetes, hypertension, cardiovascular disease and cancer – that historically have disproportionately affected certain groups.
Most EHRs have the ability to enable creation of order sets that can be utilized to create standing orders. Order sets are particularly effective for managing a group of standard adult screening orders for a population. (See Appendix E: Guidance on Technological Interventions for more details on implementing order sets in a commercial EHR.) Depending upon the health center’s workflows, these order sets 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
The steps below outline the actions and steps required to create standing orders. These steps are adapted from the University of California, San Francisco’s 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 or data analyst or medical director (or equivalent).
For guidelines from the United States Preventive Services Task Force (USPSTF), the USPSTF site should be reviewed at least annually and/or upon notification of changes to ensure that the latest recommendations are being used by the practice.
The University of California, San Francisco’s Center for Excellence in Primary Care provides guidance on developing standing orders along with examples of standing orders for several clinical conditions.
Regardless of the specific guidelines being used by the practice, the care team should monitor the website containing these guidelines at least annually and/or upon notification of changes to ensure that the latest recommendations are being used by the practice.
Resources
- USPSTF’s Prediabetes and Type 2 Diabetes Screening Guidelines.
- ADA’s Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2023.
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).
They should allow registered nurses (RNs), Licensed Vocational Nurses (LVNs), and/or Medical Assistants (MAs) with proper training to initiate the agreed upon standing order process if the patient does not have any clinical history that may require a clinician to address the concern themselves. Actions that may be initiated during a standing order include an order, a referral or a clinician notification of the need for a screening/test.
Some examples of standing orders to review are from the Great Plains Quality Innovation Network, University of California, San Francisco, San Francisco Health Plan and Idaho Health West. Chapa-De Indian Health also developed a diabetes protocol for medication refills, which provides examples of what could be checked prior to refilling a medication as part of a standing order.
Redwood Community Health Coalition (now Aliados Health) provided this policy and procedure template for their patient health centers. It includes standing orders for treatment intensification by registered nurses. The American Academy of Family Physicians developed a plan to assist practices in utilizing standing orders to help teams work to their highest level.
In addition to the written standing order, the practice should develop a standard workflow (or similar tool) outlining how the standing order is to be implemented and how it fits into the practice’s existing workflow (with or without changes to the practice’s existing workflow).
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.
- Be signed and dated by a designated valid signatory (i.e., medical director or other physician).
- Include the effective date for the standing order.
Practices should consider including an expiration date to help ensure that the standing order is reviewed and updated regularly. If possible, a notification should be put in place to ensure that the order is reviewed regularly. As the clinical guidelines change or other components of the standing order 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.
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 the standing order. Training should include a thorough review of the written standing order, the associated workflow and any additional materials related to the workflow, such as patient education or instructional materials. Documents, such as a checklist, may be utilized to provide resources for clinic staff. This standing orders checklist for diabetic patient visits guides a team-based care approach and ensures that patients get the care they need at each visit.
Training should be provided on each standing order at least annually. Updated training should be provided before the effective date on any revisions. Training should also 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., several staff members who are confused by a specific instruction during training indicates that the instruction needs to be revised).
5. Regularly review the standing order to ensure it is effective.
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 or the standing order’s protocol may not be followed correctly (i.e., staff are using workarounds). The practice should routinely check for these and other common challenges and revise/update the standing order as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.
Implementation tips
- A basic workflow for other standing orders that your practice already has in place can be used as a starting point when developing a new standing order. Before beginning work on a new standing order, determine whether your practice has existing standing orders that you can learn from as you develop this one.
- Verify if carrying out standing orders is within the legal scope of practice for the staff member intended to carry them out.
- The first two to four weeks after implementing a standing order should be used to test and refine it. We recommend that practices start with smaller-scale tests (e.g., test for one day or one area), study the successes and challenges (including errors), and refine the standing order and/or respective training as needed. Then the practice can test again, increasing the scale of the test as fewer challenges or errors arise.
- Common pitfalls of standing orders:
- Standing orders that are not updated when screening guidelines are revised and that reflect an outdated practice: Practices should assign the task of updating the protocols to a member of the team who is responsible for maintaining the order.
- New staff do not know clinical protocols: If new staff are not instructed on the clinical protocols, a review of standing orders as a core element of orientation for all roles named in the standing order should be implemented.
- Standing orders include the signature of a clinician who is no longer with the practice: Standing orders should be reviewed at least annually and any time a clinician responsible for setting the order changes roles.
- To further integrate behavioral health into primary care, consider what protocols may be appropriate for behavioral health activities, such as screening for depression, anxiety or unhealthy substance use. Screening for depression, substance use, anxiety and health-related social needs does not require a physician order and is often integrated into clinic workflows and pre-visit planning without utilizing standing orders. However, in practice, the distinction between a standing order and a protocol can mean different things to different teams, so there are instances where practices find it useful to create standing orders for behavioral health screenings as a way to support the care team to provide evidence-based practice. See the PHMI People with Behavioral Health Conditions Guide for more information.
Evidence base for This activity
- Alberti LR, Garcia DPC, Coelho DL, Lima DCAD, Petroianu A. How to improve colon cancer screening rates. World Journal of Gastrointestinal Oncology [Internet]. 2015 [cited 2019 Dec 10];7(12):484. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678395/Ishida K, Weiss E, Kee SA, Yingling CT. Increasing colorectal cancer screening orders using unlicensed assistive personnel. BMJ Open Quality. 2019 Jun;8(2):e000545.
- Percefull J, Butler J. Improving mammography through effective screening, brief intervention, and referral to treatment at a rural health center. Journal of the American Association of Nurse Practitioners. 2020 Jan 16; Publish Ahead of Print.