Preventive Care - Key Activity 5

KEY ACTIVITY #5:

Develop and Implement Standing Orders

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.

 

A standing order – a preapproved provider order to perform a specific intervention for any patient who meets the criteria for the order – is used when the step in the workflow specifically requires the order of a qualified provider. 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. 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 immunizations, cancer screenings, and other screenings to be conducted ahead of the clinician’s time with the patient. While California does not require a provider order to obtain a screening mammography, the FDA requires that Nevertheless, health centers may provide their patients with a referral that specifies the name and address of the primary care clinician requesting the test.

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, 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 together to support patient care. They promote practice workflow efficiency and effectiveness by standardizing routine care, thus freeing up time for the ordering 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. Standing orders are particularly useful for preventive care and screening for chronic diseases and conditions such as diabetes, hypertension, cardiovascular disease and cancer, which disproportionately affect certain groups.

Most EHRs have the ability to enable the 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-making support.

Effectiveness of standing orders can be tracked through registries and care quality reports.

See Appendix E: Guidance on Technological Interventions.

Action steps and roles

The steps below outline the actions required to create standing orders. They are adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care (CEPC).[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; panel manager, data analyst, medical director or equivalent.

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.

See the clinical practice guidelines section earlier in this guide.

  • Note: 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.
  • Note: Because California does not require provider orders for screening mammography but does suggest provider referral, the care team should consider whether and how they wish to initiate screening mammography orders. Assisting patients to schedule a mammography supports their ability to carry out the screening plan.

2. Translate the appropriate clinical guidelines into a standing order.

Suggested team member(s) responsible: Panel manager.

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 clinician to address the concern.
  • This may include initiating an order, initiating a referral, or notifying the PCP of the need for screening and/or testing.

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 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 important that practice team members understand the purpose, scope and limits of standing orders and be ready to implement them appropriately and within legal constraints of professional practice and of the state of California. In some cases, portions of the standing order will be carried out by professionals outside the practice (e.g., mammography center for breast cancer screening or surgical center for colonoscopy). In the case of these standing orders, it may be helpful for the practice to share the orders with the entity carrying out the order so that results are appropriately communicated to the practice in a timely fashion.

It is possible 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.

Implementation tips

  • The same basic workflow for other standing orders that your practice already has in place can be used as a jumping-off 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 draw from as you develop this one.
  • Verify if carrying out standing orders falls within the legal scope of practice for the supportive clinical staff intended to carry them out.
  • The first two to four weeks of implementing a specific standing order should be used to test and refine it. We recommend that the practice start with smaller scale tests (e.g., test for one day), study the successes and challenges (including errors) of the test, refine the standing order and/or training on it, as needed, and then test again, increasing the scale of the test as they result in fewer challenges or errors. While this approach may slightly slow down the full implementation of the standing order, by working out the inevitable kinks in the process before taking it to full scale, the practice will make the process safer for patients and less frustrating to the care team. Testing and refining can also eliminate the workarounds that occur when a policy doesn’t fit well into the system or workflow it is being placed into.
  • Note that California does not require a practitioner’s order to obtain a screening mammogram, but it does require that the mammography provider inform the patient and the patient’s healthcare provider. Therefore, the standing order should note the procedure for contacting patients. Additionally, practices may wish to share these orders with local imaging centers to facilitate timely and accurate communication of results.
  • 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.
  • See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

Evidence base for this activity

Alberti LR, Garcia DP, Coelho DL, De Lima DC, Petroianu A. How to improve colon cancer screening rates. World J Gastrointest Oncol. 2015 Dec 15;7(12):484-91.

Ishida K, Weiss E, Kee SA, Yingling CT. Increasing colorectal cancer screening orders using unlicensed assistive personnel. BMJ Open Qual. 2019 Jun 29;8(2):e000545.

Percefull J, Butler J. Improving mammography through effective screening, brief intervention, and referral to treatment at a rural health center. J Am Assoc Nurse Pract. 2020 Jan 16;33(4):324-330. doi: 10.1097/JXX.0000000000000356. PMID: 31972786.

Endnotes

  1. Leubner J, Wild S. Developing Standing Orders to Help Your Team Work to the Highest Level. Fam Pract Manag. 2018 May/Jun;25(3):13-16. PMID: 29989776. 
  2. https://cepc.ucsf.edu/standing-orders