Open Forum

Good morning,

Happy new year, all! A couple of curiosities came up in recent discussions with colleagues, and I'm hopeful maybe others can offer some insight into your own practices. Some background: our organization has quite a few hospital-based specialty clinics which are included in our periodic Joint Commission hospital surveys. At times, we're challenged to create and apply clinical practice policies that relate to both acute care and our hospital-based specialty environments, providing consistency in the care we provide while also meeting Joint Commission expectations and standards for both areas. I've added some specific questions related to this below:

1. If your ambulatory care areas are hospital-based like ours, how does your organization manage policies related to ambulatory care (i.e. patient weights and measures, vital signs frequency, etc.)? Are they embedded in hospital policies, separate but generalized for all ambulatory areas, or department-based for each clinic?
2. If your ambulatory care areas use Epic EMR, what is your workflow within the EMR for patient orders? Specifically, how does your ambulatory team manage orders for refills, DME, etc. when providers are not always available to sign in a timely manner? What Epic ordering mode does your team use in these instances (pend and sign, per protocol, etc.)? Does your team utilize written protocols for these needs?

I know these are a bit specific, but we appreciate any information you may be able to share!

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Alaina Strain MSN, RN, CPN
Cook Children's Health Care System
Mansfield TX
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Alaina,

1. We developed comprehensive ambulatory policies that apply to all hospital-based clinics. If specific service line departments require unique guidelines, these are detailed within the policy. For significant deviations, the department creates its own policies. For instance, the cancer center has specific policies for medical and radiation oncology due to unique needs not covered by general hospital ambulatory policies. But things like oxygen tank storage, etc are the same across all ambulatory sites.
2. We have a policy that mandates a 72-hour turnaround time for signing routed orders. We ensure that providers have coverage during their absences. The Joint Commission requires hospital-approved "standing" orders for staff to sign per protocol at our system. Typically, orders are pended and routed to the provider for signature. Our MD/APP teams operate with the expectation that if one member is out, the other is available. Additionally, we assign a provider of the day who can sign orders if both primary providers are unavailable, and they feel comfortable doing so.

I hope this gave you some insight.  If you would like to discuss in more detail, just let me know.  

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Kimberly Hurley MHA BSN RN OCN
Director, Nursing
UNC Health Rex
Raleigh NC
9197842501
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Thank you so much, Kimberly! I will be in touch if my colleagues and I have any further clarifying questions.

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Alaina Strain MSN, RN, CPN
Ambulatory Quality Improvement Coordinator
Cook Children's Health Care System
Fort Worth TX
alaina.strain@cookchildrens.org
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Original Message:
Sent: 01-09-2025 15:08
From: Kimberly Hurley
Subject: Hospital-based clinic considerations

Alaina,

1. We developed comprehensive ambulatory policies that apply to all hospital-based clinics. If specific service line departments require unique guidelines, these are detailed within the policy. For significant deviations, the department creates its own policies. For instance, the cancer center has specific policies for medical and radiation oncology due to unique needs not covered by general hospital ambulatory policies. But things like oxygen tank storage, etc are the same across all ambulatory sites.
2. We have a policy that mandates a 72-hour turnaround time for signing routed orders. We ensure that providers have coverage during their absences. The Joint Commission requires hospital-approved "standing" orders for staff to sign per protocol at our system. Typically, orders are pended and routed to the provider for signature. Our MD/APP teams operate with the expectation that if one member is out, the other is available. Additionally, we assign a provider of the day who can sign orders if both primary providers are unavailable, and they feel comfortable doing so.

I hope this gave you some insight.  If you would like to discuss in more detail, just let me know.  

------------------------------
Kimberly Hurley MHA BSN RN OCN
Director, Nursing
UNC Health Rex
Raleigh NC
9197842501
------------------------------

Original Message:
Sent: 1/10/2025 9:30:00 AM
From: Alaina Strain
Subject: RE: Hospital-based clinic considerations

Thank you so much, Kimberly! I will be in touch if my colleagues and I have any further clarifying questions.

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Alaina Strain MSN, RN, CPN
Ambulatory Quality Improvement Coordinator
Cook Children's Health Care System
Fort Worth TX
alaina.strain@cookchildrens.org
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