Standardization of Provider Support Care in a Specialty Medical Clinic

In the United States, the societal title of "nurse" has a broad definition that includes varying educational levels, ranging from medical assistant certification to a doctorate degree, and a wide spectrum of provider support roles for both clinicians and the general public. The differences between certifications and licensures for these support roles are often unclear to everyday public. Medicine has evolved to incorporate specialties for better patient care. Medical specialists may have a diverse provider support staff to meet the needs of the patient population. The support staff may include medical assistants (MAs), licensed practical nurses (LPNs), and registered nurses (RNs). This diverse staff with varying educational levels creates challenges in providing consistent quality nursing care. Discrepancies, such as patient teaching, education, critical thinking skills, and communication skills, can occur. Trust among colleagues and patients becomes an issue when inaccurate or inconsistent information is given to patients from staff members, who have good intentions but may lack the education to give sound information. The purpose of this project was to establish protocols to standardize provider support staff tasks, reduce variability in care, and decrease frequency of poor communication or clerical errors. To achieve this task, the first need was to determine current staff practice for triage calls and teaching. A literature review analyzed the similarities and differences of provider support staff in order to maintain diversity within a clinical setting and to determine if national standards have been established. The nurse practice act in each state clearly states the scope of practice for LPNs and RNs. Most states do not have a scope of practice for MAs. The practice of MAs depends on what the licensed practitioner teaches or allows the MAs to do. Medical offices, compared to hospital settings, do not define the scope of practice and roles. Several steps where taken to address variability in care. First, identifying gaps and shortfalls of provider support care and patient teaching starts with determining current staff care with triage calls was needed. A survey helped identify gaps and in the development of a protocol/tool. A protocol was then developed and proposed. A trial implementation was initiated to aid in reducing the variability of patient care. Staff implemented the protocol in an attempt to bridge the gaps that exist with varying staff educational levels. Provider support staff members are instrumental in the care of the patient in a medical specialty clinic. They are usually the first line in clinical patient care. Despite the varying educational levels of the provider support staff, each staff member adds value and contributes to patient care. Establishing a standard protocol for triage calls will diminish the variability of care, improve the quality of that care, and improve outcomes.

Running head: STANDARDIZATION OF PROVIDER SUPPORT CARE Standardization of Provider Support Care in a Specialty Medical Clinic Jinil Harvey-Wells MSN, APRN, FNP-BC University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 STANDARDIZATION OF PROVIDER SUPPORT CARE 2 Standardization of Provider Support Care in a Specialty Medical Clinic Executive Summary In the United States, the societal title of "nurse" has a broad definition that includes varying educational levels, ranging from medical assistant certification to a doctorate degree, and a wide spectrum of provider support roles for both clinicians and the general public. The differences between certifications and licensures for these support roles are often unclear to everyday public. Medicine has evolved to incorporate specialties for better patient care. Medical specialists may have a diverse provider support staff to meet the needs of the patient population. The support staff may include medical assistants (MAs), licensed practical nurses (LPNs), and registered nurses (RNs). This diverse staff with varying educational levels creates challenges in providing consistent quality nursing care. Discrepancies, such as patient teaching, education, critical thinking skills, and communication skills, can occur. Trust among colleagues and patients becomes an issue when inaccurate or inconsistent information is given to patients from staff members, who have good intentions but may lack the education to give sound information. The purpose of this project was to establish protocols to standardize provider support staff tasks, reduce variability in care, and decrease frequency of poor communication or clerical errors. To achieve this task, the first need was to determine current staff practice for triage calls and teaching. A literature review analyzed the similarities and differences of provider support staff in order to maintain diversity within a clinical setting and to determine if national standards have been established. The nurse practice act in each state clearly states the scope of practice for LPNs and RNs. Most states do not have a scope of practice for MAs. The practice of MAs depends on what the licensed practitioner teaches or allows the MAs to do. Medical offices, compared to hospital settings, do not define the scope of practice and roles. Several steps where taken to address variability in care. First, identifying gaps and shortfalls of provider support care and patient teaching starts with determining current staff care with triage calls was needed. A survey helped identify gaps and in the development of a protocol/tool. A protocol was then developed and proposed. A trial implementation was initiated to aid in reducing the variability of patient care. Staff implemented the protocol in an attempt to bridge the gaps that exist with varying staff educational levels. Provider support staff members are instrumental in the care of the patient in a medical specialty clinic. They are usually the first line in clinical patient care. Despite the varying educational levels of the provider support staff, each staff member adds value and contributes to patient care. Establishing a standard protocol for triage calls will diminish the variability of care, improve the quality of that care, and improve outcomes. This scholarly project committee consists of Clinton Child, DNP, MBA, RN (Project Chair); Gillian Tufts, DNP, FNP (Track Director); Pam Hardin, PhD, RN (Executive Director MS & DNP Programs); and content expert Sharla Morgan, MSN, APRN, FNP-C. STANDARDIZATION OF PROVIDER SUPPORT CARE 3 Table of Contents EXECUTIVE SUMMARY ...........................................................................................................2 ACKNOWLEDGEMENTS ..........................................................................................................4 1. PROBLEM STATEMENT ...............................................................................................5 2. CLINICAL SIGNIFICANCE AND POLICY IMPLICATIONS .................................6 3. PURPOSE ...........................................................................................................................7 4. OBJECTIVES ....................................................................................................................7 5. LITERATURE REVIEW A. B. C. D. E. F. Defining Nursing ....................................................................................................7 Scope of Practice ....................................................................................................7 Nursing Workforce .................................................................................................8 Reasons for Diverse Nursing Staff in Medical Offices ..........................................9 Protocols and Standardization of Nursing Care ...................................................10 Adult Learning Theories ......................................................................................11 6. THEORECTICAL FRAMEWORK ..............................................................................11 7. IMPLEMENTATION AND EVALUATION ...............................................................13 8. RESULTS .........................................................................................................................16 9. FUTURE RECOMMENDATIONS ...............................................................................17 10. THE DNP ESSENTIALS ................................................................................................18 11. CONCLUSIONS ..............................................................................................................19 12. REFERENCES .................................................................................................................20 13. APPENDICES A. B. C. D. E. F. G. H. Proposal Defense PowerPoint ..............................................................................22 IRB Determination Justification ...........................................................................28 Current Post Surgical Template ...........................................................................30 Pre-/Post-survey ...................................................................................................32 New Tool/Protocol Template ...............................................................................37 Pre-/Post Survey Responses .................................................................................42 Abstract Submission to Professional Conference ................................................51 Poster ....................................................................................................................53 STANDARDIZATION OF PROVIDER SUPPORT CARE Acknowledgements There are several individuals that I would like to thank during this academic journey these past five semesters. First, I would like to thank my husband for his support, encouragement, and love. Second, my stepchildren, for their understanding of the late nights of studying. Next, my colleagues at work, for their support and understanding of a modified work schedule to accommodate the school schedule. I would also like to express my thanks to my parents, for their understanding and foresight knowing that a nursing degree would provide so many options and fulfillment as a career, not only professionally but personally. There are also numerous extended family members and friends that have been instrumental during this journey and accomplishment. 4 STANDARDIZATION OF PROVIDER SUPPORT CARE 5 Problem Statement In the United States, the societal title of "nurse" has a broad identification that includes various educational levels, from a medical assistant (MA) certification to a doctorate degree. It is often the perceived understanding from patients that anyone in scrubs is a nurse. There is a wide spectrum in formal provider support roles and minimal public awareness of the differences between these levels. The public may not be aware of these variations; in fact, the clinicians themselves often find these lines blurred. In medicine, we have evolved to incorporate specialties for better patient care. It is because of the focus and detailed training within specialty practices that we can treat with greater efficacy, recognize complex symptomatology, and diagnose accurately. A lack of public understanding permeates into provider support staff and lends credibility to this misunderstanding of patients' perceptions, and thus the patient may receive variations from staff members' care. These misunderstandings can be easily addressed by medical protocol, with the more difficult perceptions about specialties being amended over time. To be successful with these protocols office staff, clinicians and other medical personnel within the practice, must follow the protocol. The absence of a protocol makes providing consistent quality nursing care challenging. Due to this variability, there is the risk of error in providing important information to the patient, which may cause undesirable outcomes. This project sought to standardize nursing care with post-surgical telephone triage calls. Reigel et al. (2002) showed that standardization of nursing case management of patients with heart failure reduced hospital costs and other resources. Standardization may also prove to be beneficial for patient care in a specialty medical office to STANDARDIZATION OF PROVIDER SUPPORT CARE 6 improve patient teaching, decrease error, and provide consistency among the variety of provider support staff. Clinical Significance and Policy Implications The nursing workforce in the United States (US) consists of MA, licensed practical nurses (LPN), and registered nurses (RN) (associate or bachelor degree). Most assistants and nurses work in hospitals, physicians' offices, skilled nursing facilities, and other health care services. Medical assistants work closely with nursing staff and physicians and/or advanced practice clinicians direct their supervision. In a medical office setting, discrepancies occur between the different levels of nursing staff specifically due to the different tiers of education such as teaching patients, giving and explaining lab results, and general patient care. These discrepancies affect all medical personnel, nursing staff, and patients. Trust becomes an issue when inaccurate or missed information is provided to the patient from a person who has good intentions but lacks education to give sound information. Provider support staff members are often perceived to be nurses by the patients they take care of; however, their credentials may vary. The inconsistencies and lack of standardization of nursing care result in patients being put at risk for poor outcomes, over utilization of after-hour resources such as urgent care or emergency departments, and patient confusion. By implementing standardized provider support care in a medical office, the potential exists to increase the quality of patient care, assure that instructions given to the patient will have better consistency, decrease the errors caused by inconsistences in protocol, and minimize the overuse of resources, thus optimizing wellness, health care and patient outcomes. STANDARDIZATION OF PROVIDER SUPPORT CARE 7 Nursing preparation, training, and education vary greatly among MAs, LPNs, and RNs, and thus the level of nursing care varies. The need to standardize nursing care in specialty medical office is instrumental in providing consistent nursing care. Purpose The aim of this scholarly project is to establish protocols to standardize provider support care in a specialty medical office for nursing staff (MAs, LPNs, and RNs), to reduce the variability of clinical care, decrease the frequency of communication or clerical errors, and improve the quality and consistency in provider support care. Objectives 1. Determine current support staff practice for calls and teaching 2. Compare findings of current staff practice with national standards. 3. Develop a proposed tool/protocol guided by the findings from objective 2. 4. Disseminate the project findings and recommendations to the stakeholders and present the findings in a professional poster session. Literature Review Defining Nursing Scope of Practice. Nursing roles in the US have become unclear to society because of the evolution of multiple titles that get placed under the umbrella term of "nurse". The nursing profession has been enriched by the variety of nursing roles such as MAs, LPNs, and RNs. The broad definition of RN needs to be retooled because the education levels of the practitioners who obtain the title vary, ranging from a 2-year associate degree to a 4-year bachelor's degree. The nursing roles are better defined within hospitals and skilled nursing facilities, but are not as clear within medical offices. Patients seen in the clinic setting have exposure to various nursing STANDARDIZATION OF PROVIDER SUPPORT CARE 8 personnel. The nursing care and information provided can vary because of the educational differences of the nursing staff, which may cause variability and inconsistencies in patient care. The databases for literature search included PubMed, CINAHL, and ERIC. The search terms included nursing care, standardization of nursing care, medical assistant, provider support staff, clinical protocol, decision tree, triage, nurse role, nurse education, outpatient, medical office, quality of care, adult learning, motivation, profession, adult learning principles, adult education, adult learning theory, and adult learning theory in nursing education. Nursing Workforce. National and state statistics outlining the workforce in the US have been tracked since the beginning of the last century (D'Antonio & Whelan, 2008). Population studies done by the U.S. Department of Health and Human Services in 2010 and 2013 show a slight increase in the number of RNs working, from 2,596,399 to 2,824,621, respectively (U.S. Department of Health and Human Services, 2010; U.S. Department of Health and Human Services, 2013). Most RNs are employed in hospitals (62.2%) and ambulatory care facilities (10.5%) (U.S. Department of Health and Human Services, 2010). In the state of Utah, RN employment is slightly higher than the national average, with 79% working in hospitals and 27% working in medical offices (Utah Medical Educational Council, 2012). In 2014, the number of jobs held by MAs was 591,300 with 356,000 working in physician offices (United States Department of Labor: Bureau of Labor Statistics, 2016). MAs are usually educated via postsecondary education programs, or they enter the occupation after high school and then receive on-the-job training (United States Department of Labor: Bureau of Labor Statistics, 2016). There are 690,000 LPNs and 2.8 million RNs (including advanced practice RNs) in the United States (U.S. Department of Health and Human Services, 2013). LPNs usually receive STANDARDIZATION OF PROVIDER SUPPORT CARE 9 one year of training in a vocational or community college program. RNs, have multiple levels of education: diploma, associate degree, and baccalaureate degree (U.S. Department of Health and Human Services, 2013). In Utah, there are 6,880 MAs (Utah.gov Department of Work Force Services, 2016), 18,771 RNs (U.S. Department of Health and Human Services, 2013), and 2,728 LPNs (U.S. Department of Health and Human Services, 2013). The number of RNs working in physician offices is 6.9%, and LPNs 11.2% (U.S. Department of Health and Human Services, 2013). Reasons for Diverse Nursing Staff in Medical Offices. The challenge is to provide adequate and quality nursing care in all aspects of health care. In some settings, this goal is achieved by hiring nurses who have a higher educational level, such as a bachelor's in nursing (BSN). In other settings, nursing staff members do not have the same education. This does not imply that education determines the quality of care a nurse gives, but systems should be established to deliver quality nursing care across the various levels of backgrounds and education. Factors that influence hiring a MA versus a LPN/RN include costs, the nursing shortage, and preference. Medical assistants can be licensed (certified medical assistants [CMAs]) or unlicensed (American Association of Medical Assistants, 2016). Duties of an MA are usually split between administrative and clinical in medical offices (Flavin, 2015). Most of the training is done on site because no formal education is required. As a result, more employers are hiring CMAs as credentialed staff and employers are less likely to have a negative litigious result. Certain state and federal laws, however, have established statutes and regulations for MA licensure. The private sector prefers, although does not mandate, that certified MAs prove their level of competency (Balasa, n.d.). LPNs/RNs are subject to more strict credentialing requirements. STANDARDIZATION OF PROVIDER SUPPORT CARE 10 They attend credentialed nursing programs and must pass the National Council Licensure Examination (NCLEX) (Flavin, 2015). Researchers have examined staffing needs in various settings. Studies have been done outside the US that demonstrate differences in staffing. Namaganda, Oketcho, Maniple, and Viadro (2015) and Dgedge et al. (2014) looked at nursing staff within their own countries of Uganda and Mozambique respectively. Both articles discuss the discrepancies that can occur that influence staffing needs and the ability to provide consistent care. Dgedge et al. (2014) found that the level of tasks delivered by nursing and nursing assistants was consistent with the education they had received, but that some nurses were underperforming according to the scope of the practice. The literature search did not find any reports of studies conducted within the United States. Protocols and Standardization of Nursing Care. As the majority of nurses work in a hospital setting, fewer studies focused on the medical office setting for nursing care. Riegel et al. (2002) focused on standardizing nursing care with the implementation of telephone triage for heart patients who were discharged from the hospital. They found that through this nursing intervention, patient costs were reduced and outcomes improved. The Riegal et al.(2002) article helps establish the theory that standardization of nursing care does improve patient outcomes; however, further research is needed. There is knowledge about differences between nursing roles (MA, LPN, RNs), but no research has been done when all three roles are present in the same setting. Adult Learning Theories. How one learns, retains, and is able to retrieve information is variable and complex. The levels of education as well as the quality of the education provided can enhance or diminish the learning process. Appelgren, Penny, and Bengtsson STANDARDIZATION OF PROVIDER SUPPORT CARE 11 (2014) studied the mechanism of internal and external feedback through understanding three performance phases. An adult's ability to learn is also influenced by how much interference occurs during the learning process (Darby & Sloutsky, 2015). Research has supported the association between learning and memory and how previous knowledge builds upon learning new concepts (Darby & Sloutsky, 2015). The ability to acquire, synthesize, and implement new information is necessary for members of a nursing staff. Multitasking is often required and distractions often occur, which is when errors can happen. Overall, the literature shows that the variations in education, practice setting, and standards lead to issues with patient care. Establishing and implementing protocols can mitigate these variations. Bridging varying educational backgrounds requires an understanding of adult learning theories. Theoretical Framework Communities of Practice Theory (CoP), originated by Jean Lave and Etienne Wenger, focuses on situated learning (Learning Theories, 2016). There are two definitions for CoP: one is feature-based or "community that shares practices," and the other process-based which is a "process of knowledge, generation, application, and reproduction, is that communities of practice are groups in which a constant process of legitimate peripheral participation takes place" (Hoadley, n.d., pp. 288, 290). The provider support staff is a community that shares the same vision and mission in providing good patient care. To achieve this goal, staff members needs to be proactive members of the community. The CoP includes three domains: domain, community, and practice (Learning Theories, 2016). According to the CoP, there is a shared domain of interest and committed membership (Learning Theories, 2016). The members of the domain interact, help one another, and share STANDARDIZATION OF PROVIDER SUPPORT CARE 12 information, in other words members learn from one another (Learning Theories, 2016). Interest alone is not enough; the members are practitioners through developing resources that can include "stories, helpful tools, experiences, and ways of handling typical problems" (Learning Theories, 2016). Learning can be individual participation or social participation or both. In trying to implement standardization of provider support care, the process of learning is vital to make changes in practice. By attempting to bridge the various learning styles and educational backgrounds of the staff, the CoP model aids and supports the building and structuring of optimal learning experiences. Technical or task learning is part of knowledge acquisition; however, motivation and identity within a community support the provider staff [members] learning, understanding, and retention of information. Provider support staff members form a community of shared practice. Implementation and Evaluation Table STANDARDIZATION OF PROVIDER SUPPORT CARE Objective 1. Determine current support staff practice for calls, teaching, and triage calls Implementation • • • 2. Compare local survey findings of current staff practice 3. Develop and trial proposed tool/protocol guided by findings from objective 2 • • • • 4. Disseminate project findings to stakeholders and in poster presentation 13 • • Target specialty clinic Organize focus group with pre-survey Get IRB approval Identify what other clinics do from literature review Develop tool/protocol Trial protocol with clinic staff Post survey completed by focus group Meet with content expert to present findings and recommendations Submit application for poster presentation Evaluation • • • • • • • • • Survey tool created Collected and analyzed surveys, using survey tool IRB approval obtained Write summary of the survey results Protocol developed Protocol trial implemented Evaluated and compared pre-/postsurveys Attended meeting with stakeholders Abstract submitted to a professional conference Implementation and Evaluation Prior to initiating the implementation portion of this project, a project defense was presented and passed (see Appendix A). The University of Utah Institutional Review Board (IRB) reviewed the project application and determined it was not generalizable and thus did not meet the criteria for IRB oversight (see Appendix B). Because the staff members voluntarily participated, project ethical considerations include respect for and the confidentiality of the participants. Objective #1: Determine current support staff practice for calls and teaching. The content expert and office administrator approved the location of the target specialty clinic, which has 12 provider support staff members, with an additional eight staff in the associated subspecialty clinics. The staff includes MAs, LPNs, and RNs (ADN and BSN). The selected participants directly work with surgeons who perform sinonasal and adenotonsillectomy STANDARDIZATION OF PROVIDER SUPPORT CARE 14 surgery. The staff members who met this criterion voluntarily agreed to participate in this project and gave their verbal consent to participate, with the understanding (based on verbal and written notification) they could decline to participate at any time. A review of the post-surgical call template employed by the staff determined the current practice (see Appendix C). This office uses a generic post-surgical note in which the staff members briefly chart and identify what type of surgery was performed, if the patient is taking medications as directed, and if the patient has been reminded about the scheduled post-operative appointment. This template does not go over expected recovery symptoms nor symptoms of when to call the office or go to the emergency department. The tool (survey) was created to assess the provider support staffs' understanding and knowledge of current practice (see Appendix D). The content expert reviewed and approved the survey. The staff and providers completed the hand-delivered 10-question surveys, which were subsequently collected and prepared for evaluation. Objective #2: Compare findings of current staff practice with national standards. The literature search was undertaken to determine if national guidelines exist regarding how other medical offices approach and solve problems the provider support staff encounter Most of the literature focused on standardizing protocols, which will reduce utilization of resources and costs and improve quality of care. No articles in the literature searched concerned the variety of provider support staff and how it is a factor in trying to bridge the differences, nor how to unify the staff. Objective #3: Develop proposed tool/protocol guided by findings from objective 2. The specialty clinic uses an electronic medical record (EMR) in which charting templates can be created and individualized. The staff currently uses a generic post surgical template for STANDARDIZATION OF PROVIDER SUPPORT CARE 15 all post surgical calls, but the template does not take into consideration the potential risks or the normal recovery, nor does it aid in guiding the staff by providing additional education and teaching for the patient, who has heightened anxiety and concerns during the post recovery period. A new template for post surgical sinonasal and adenotonsillectomy telephone calls (see Appendix E) created for this protocol for post-surgical calls was designed to provide a guideline for the staff to think methodically through the recovery process, and to not miss any important information or opportunities to educate the patient. The content expert suggested revisions to the template. The template was then explained and demonstrated to the staff to utilize for those patients who had either sinonasal or adenotonsillectomy surgery. A review of the EMR charts of those patients who had had surgery indicated whether the staff used the template according to its design and purpose. The staff then completed a post-survey, which was compared to the presurvey (see Appendix F). Objective #4: Disseminate the project findings and recommendations to the stakeholders and present the findings in a professional poster session. To disseminate the findings of the project, an application/abstract was submitted for a professional poster presentation. An abstract was submitted to the Snowbird Conference in 2017 on April 6, 2017 (see Appendix G). Documentation of the approved application was provided, with anticipated acceptance of the application by a professional conference. A project poster defense was presented and passed (see Appendix H). The findings were verbally disseminated during a provider support staff meeting held on April 12, 2017, and additional information was gathered and feedback from the staff members obtained. STANDARDIZATION OF PROVIDER SUPPORT CARE 16 The pre-/post surveys were succinct and did not take much time to complete. The participants returned the surveys for data collection and analysis. The initial plan was to focus on only two surgeons' schedules but this number was expanded to five to capture an adequate number of surgeries. The staff used the new template and found that it was easy to access within the EMR. In the post-survey, the staff strongly agreed that the template was useful and that they had learned something new that they had not incorporated in their post phone calls prior to using this new template. Some staff, however, felt the template was cumbersome, particularly going through the list of items to discuss with the patient. Results The primary determinant of projects success is dependent on the utilization of the new protocol for post-surgical calls, followed by staff satisfaction, understanding, and confidence in providing information and care over the telephone. The participants (N=13) completed the pre- and post-surveys. The participants included provider support staff (N=8) and surgeons (N=5). The data were collected by reviewing prior staff charting for post-surgical calls and talking to the staff. The method of analysis included accessing EMR, performing a search of patients who were on the surgical schedule, and observing if a post-surgical call was made. Following data collection, the majority of the staff reported that they had read through the educational surgical handouts that are given to the patients pre-operatively. The challenge of this project is putting this information into practice, to have consistency and standardization of care provided by all staff members with post-surgical calls. The time frame to utilize the template was two weeks. Because of this short time frame, one MA and one LPN did not have time to use the template due to their work schedules, but they STANDARDIZATION OF PROVIDER SUPPORT CARE 17 did review the additional information given in the post call note and indicated their approval. Also, the surgeons perform various other surgeries, and the time frame did not capture the surgery schedule of patients who desired sinonasal or adenotonsillectomy procedures. The staff, through the post-survey and comments, indicated the new template was helpful and aided in their understanding of post-surgical recovery for these two specific surgeries. It provided a methodological and systematic checklist for them to address. Most of the staff felt that prior to this new template, they had a good understanding and would ask the general question of the patients "do you have any questions"; however, they reported this questions did not reveal the knowledge gaps that may exist for the patient or for the providers. The participants commended that the bullet or list format of the template made them feel they were reading off a list, making it hard to keep the patient on the phone call long enough to go through the template. Overall, the new tool/template guided the staff to address aspects of the recovery period that perhaps neither the patient nor the staff would think of without the prompts, understanding and education. Future Recommendations Usage of the new protocol had positive feedback from staff members. The future recommendations would be to utilize the template for a longer period of time, over 1 to 2 months, allow a better capture of surgeries as well as assuring all staff members to utilize the template. Several participants verbally requested other templates to be created for other surgical procedures (such as bilateral myringotomy with tube placement, thyroidectomy, parathyroidectomy, etc.). Different templates could also be tailored for staff use in subspecialty clinics. Further evaluation of the effectiveness of the protocol by comparing pre- and postprotocol with patient care, such as the nature and frequency of after-hour patient calls and/or STANDARDIZATION OF PROVIDER SUPPORT CARE 18 emergency department visits, is also recommended, as are providing patients with sound information, and helping them understand normal expectations of the recovery process versus the red flags and potential complications from surgery. Another recommendation is to involve nurse practitioners, who see the majority of post-surgical visits. To enhance the rigor of this study, the templates should be implemented in multiple sites. This project did not have clinic-to-clinic variability. These sites would need to be organizationally similar, and then randomly selected for protocol use. Evaluation of the study should include measurement of health outcomes, patient satisfaction, and staff satisfaction, and determination of meaningful objectives. DNP Essentials The DNP essential that correlates the strongest with this project is "Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking" (American Association of Colleges of Nursing, 2006). This DNP essential focuses on improving patient care and outcomes. Implementing a new policy or procedure takes sophisticated and clear communication to achieve quality improvement. Part of the evaluation of the variety of nursing personnel (MA, LPN, RN [ADN/BSN]) is to determine why there is variation and consider whom to hire. The variation is strongly driven by personnel costs and whether these costs equate to quality of nursing care and improved outcomes. Careful analysis and thorough understanding of variables will help establish sound protocols that will reduce the variability of nursing care and in turn will improve the quality of health care to the targeted population. Another applicable DNP essential is "Essential V: Health Care Policy for Advocacy in Health Care" (American Association of Colleges of Nursing, 2006). The building, use, and STANDARDIZATION OF PROVIDER SUPPORT CARE 19 application of policies and procedures are instrumental to guide health care. The main focus of this project was developing a better template, available to all staff to use, which will aid in providing continuity of care. Conclusions There are indistinguishable differences that patients are exposed to because of the universal use of the singular term "nurse" to identify health care providers who are not medical doctors. Because of these various significant differences, it is expedient upon the health care staff to identify and clarify the differences with office protocol and educational backgrounds. There are clear differences in the educational backgrounds, communication skills, and experiences in the varying staff, such as those within this particular specialty office. Despite these differences, the participants in this project strongly agreed on having a good working relationship with each other. The surgeons' attitudes towards and confidence in the staff skills and educational levels indicate the staff meet their expectations. The staff expressed confidence in their educational level to perform job duties, partly from the initial orientation and training at their hire date. Only the MAs had not read the educational surgical handouts; however, after the initiation of the template, all the staff had read the handouts. The comments by the staff members that the template was more of a bullet point suggested they are task oriented and perhaps not able to easily adjust to or tailor the phone call teaching. This factor will need to be addressed to give the staff confidence in their ability to look at the template and discuss the items without finding it cumbersome. STANDARDIZATION OF PROVIDER SUPPORT CARE 20 References American Association of Colleges of Nursing. (2006). http://www.aacn.nche.edu/dnp/Essentials.pdf American Association of Medical Assistants. (2016). http://www.aama-ntl.org/medicalassisting/what-is-a-cma#.V6AU0Vd2ZSU Appelgren, A., Penny, W., & Bengtsson, S. L. (2014). Impact of feedback on three phases of performance. Experimental Psychology, 61, 224-233. http://dx.doi.org/doi: 10.1027/1618-3169/a000242 Balasa, D. A. (n.d.). Why more employers are hiring CMAs (AAMA). Retrieved from http://www.aama-ntl.org/docs/default-source/employers/more-emps-hirecma.pdf?sfvrsn=4 D'Antonio, P., & Whelan, J. C. (2008). Counting nurses: The power of historical census data. Journal of Clinical Nursing, 18(19), 2717-2724. http://dx.doi.org/doi:10.1111/j.13652702.2009.02892.x Darby, K. P., & Sloutsky, V. M. (2015). The cost of learning: Interference effects in memory development. Journal of Experimental Psychology, 144, 410-431. http://dx.doi.org/doi:10.1037/xge0000051 Dgedge, M., Mendoza, A., Necochea, E., Bossemeyer, D., Rajabo, M., & Fullerton, J. (2014). Assessment of the nursing skill mix in Mozambique using a task analysis methodology. Human Resources Health, 12. http://dx.doi.org/doi: 10.1186/1478-4491-12-5 Flavin, B. (2015). Medical assistants vs. licensed practical nurses: Diagnosing the differences. Retrieved from http://www.rasmussen.edu/degrees/health-sciences/blog/medicalassistant-vs-licensed-practical-nurses-telling-the-two-ap/ STANDARDIZATION OF PROVIDER SUPPORT CARE 21 Hoadley, C. (n.d.). What is a community of practice and how can we support it? (pp. 289-300). Retrieved from https://steinhardt.nyu.edu/scmsAdmin/uploads/006/677/CHAP12HOADLEY.pdf Learning Theories. (2016). Communities of practice (Lave and Wenger). Retrieved from https://www.learning-theories.com/communities-of-practice-lave-and-wenger.html Namaganda, G., Oketcho, V., Maniple, E., & Viadro, C. (2015). Making the transition to workload-based staffing: Using the workload indicators of staffing need method in Uganda. Human Resources for Health, 13. http://dx.doi.org/DOI: 10.1186/s12960-0150066-7 Riegel, B., Carlson, B., Kopp, Z., LePetri, B., Glaser, D., & Unger, A. (2002). Effect of a standardized nurse care-management telephone intervention on resource use in patients with chronic heart failure. JAMA Internal Medicine, 162(6). http://dx.doi.org/doi:10.1001/archinte.162.6.705 U.S. Department of Health and Human Services. (2010). https://www.hhs.gov/ U.S. Department of Health and Human Services. (2013). The U.S. nursing workforce: Trends in supply and education. Retrieved from http://bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce/nursingworkforcefullrepo rt.pdf United States Department of Labor: Bureau of Labor Statistics. (2016). http://www.bls.gov/oes/current/oes319092.htm Utah.gov Department of Work Force Services. (2016). https://jobs.utah.gov/jsp/wi/utalmis/reempfullrept.do?soccode=319092&oititle=Medical %20Assistants STANDARDIZATION OF PROVIDER SUPPORT CARE Utah Medical Educational Council. (2012). https://www.utahmec.org/ 22 STANDARDIZATION OF PROVIDER SUPPORT CARE Appendix A Proposal Defense Power Point 23 STANDARDIZATION OF PROVIDER SUPPORT CARE 24 STANDARDIZATION OF PROVIDER SUPPORT CARE 25 STANDARDIZATION OF PROVIDER SUPPORT CARE 26 STANDARDIZATION OF PROVIDER SUPPORT CARE 27 STANDARDIZATION OF PROVIDER SUPPORT CARE 28 STANDARDIZATION OF PROVIDER SUPPORT CARE Appendix B IRB Determination Justification 29 STANDARDIZATION OF PROVIDER SUPPORT CARE 30 ERICA IRB New Study Approval [e-mail] To: JINIL HARVEY Cc: CLINTON L CHILD Wednesday, January 25, 2017 8:35 PM To help protect your privacy, some content in this message has been blocked. If you're sure this message is from a trusted sender and you want to re-enable the blocked features, click here. IRB: IRB_00095661 PI: Jinil Harvey Title: Standardization of Provider Support Care In A Specialty Medical Office Date: 1/25/2017 Thank you for submitting your request for approval of this project. The IRB has administratively reviewed your application and has determined on 1/25/2017 that your project does NOT meet the definitions of Human Subjects Research according to Federal regulations. Therefore, IRB oversight is not required or necessary for your project. DETERMINATION JUSTIFICATION: This project appears to be a quality improvement project at a specific medical office and does not meet the definition of a systematic investigation that contributes to generalizable knowledge. This determination of non-human subjects research only applies to the project as submitted to the IRB. Since this determination is not an approval, it does not expire or need renewal. Remember that all research involving human subjects must be approved or exempted by the IRB before the research is conducted. If you have questions about this, please contact our office at 581-3655 and we will be happy to assist you. Thank you again for submitting your proposal. Click IRB_00095661 to view the application. Please take a moment to complete our customer service survey. We appreciate your opinions and feedback. STANDARDIZATION OF PROVIDER SUPPORT CARE Appendix C Current Post Surgical Template 31 STANDARDIZATION OF PROVIDER SUPPORT CARE 32 NURSE/MA POST OP CALL NOTE PROVIDER: ~x~ ~x~ ~x~ ~x~ ~x~ ~x~ DATE: ~Todays Date~ PATIENT NAME: ~Last Name~, ~First Name~ ~Middle Name~ DATE OF BIRTH: ~Date of Birth~ AGE: ~Age~ PHONE NUMBER: ~Home Phone~ SURGERY PERFORMED ~x~ Sinus surgery (F/E/M/S) ~x~ Septoplasty ~x~ SMR of turbinates/turbinate reduction ~x~ DNVS repair ~x~ Nasal mass excision ~x~ Septal perforation repair ~x~ Cosmetic Rhinoplasty ~x~ Closed reduction of nasal fx ~x~ Adenoidectomy ~x~ Tonsillectomy ~x~ Neck mass excision ~x~ BMT/t-tubes ~x~ Paper patch myringoplasty ~x~ Tympanoplasty ~x~ ~x~ ~x~ ~x~ ~x~ ~x~ ~x~ Oscillar chain reconstruction ~x~ Stapedectomy ~x~ Cochlear/Osteoprosethic implant Parotidectomy Neck dissection Thyroidectomy, total or hemi Parathyroidectomy UPPP BOT ablation ~x~ Other: Patient had recent surgery on []. I called and spoke with [patient/mom/dad] who reports is doing well. They will take post surgical medications as directed and f/u on [] as scheduled. No other concerns voiced at this time. Encourage pt to call the office prn. [MA/NURSE initials] STANDARDIZATION OF PROVIDER SUPPORT CARE Appendix D Pre-/Post-Survey 33 STANDARDIZATION OF PROVIDER SUPPORT CARE SCHOLARLY PROJECT PRE-SURVEY 1. What is your job role? Medical Assistant; Licensed Practical Nurse; Registered Nurse, Associate Degree Registered Nurse, Bachelor Degree; Nurse Practitioner; Medical Doctor 2. My co-workers and I have a good working relationship Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 3. I am satisfied with my opportunities for professional growth Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 4. I am satisfied with the job-related training my organization offers Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 5. I feel confident in my educational level to perform all duties within my job Strongly Disagree Disagree 34 STANDARDIZATION OF PROVIDER SUPPORT CARE Neutral/Neither Agree nor Disagree Agree Strongly Agree 6. I have read through the educational surgical handouts given pre-operatively to patients Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 7. I am comfortable in performing and teaching patients during post-surgical telephone calls Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 8. I feel comfortable asking for help if needed Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 9. *PROVIDER: I am confident in the skill and educational level of all the providers support staff Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 35 STANDARDIZATION OF PROVIDER SUPPORT CARE 10. *PROVIDER: I feel the provider support staff educational levels meet the expectation/standards within the scope of their practice Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree SCHOLARLY PROJECT POST-SURVEY 1. I have read through the educational surgical handouts given pre-operatively to patients Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 2. I utilized the new template for post-surgical calls Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 3. The new template for post-surgical calls was helpful and useful Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 36 STANDARDIZATION OF PROVIDER SUPPORT CARE 37 4. The new template for post-surgical calls enhanced my understanding and knowledge of postsurgery recovery and potential complications Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 5. I learned something new from using the template that I did not incorporate into my postsurgical calls prior to the trial of new template Strongly Disagree Disagree Neutral/Neither Agree nor Disagree Agree Strongly Agree 6. Additional comments: STANDARDIZATION OF PROVIDER SUPPORT CARE Appendix E New Tool/Protocol Template 38 STANDARDIZATION OF PROVIDER SUPPORT CARE *ADENOTONSILLECTOMY POST OP CALL NOTE PROVIDER: DATE: «~Todays» PATIENT NAME: «~Last», «~First» «~Middle» DATE OF BIRTH: «~Date» AGE: «~Age~» PHONE NUMBER: «~Home» DATE OF SURGERY: PERSON SPOKE WITH: SURGERY PERFORMED «~x Adenoidectomy ~» «~x Tonsillectomy ~» Risks and complications included, but not limited to: bleeding, infection, reflux of fluids or food into the nose, voice changes, the need for a second surgery Discussed with the patient or parent the following: «~x Taking medications as directed ~» «~x Cold liquids help with pain ~» water, juice, frozen juice bars AVOID: citrus juice or bars, which can be irritating «~x Diet: Cold foods and soft foods ~» options include: icecream, gelatin, yogurt AVOID: very hot, spicey, or scratchy foods (like chips) «~x Stay hydrated! ~» «~x White patches may form in the throat which is normal and should come off ~» in about a week «~x Ear pain is common ~» «~x Avoid strenous exercise, lifting, straining or bending over ~» «~x Chewing gum recommended to keep mouth moist ~» «~x Avoid spitting or drooling which can lead to dehydration ~» «~x DO NOT take aspirin or aspirin containing products ~» «~x It is normal for breath to smell bad after surgery ~» «~x Voice may sound funny after surgery and should resolve in 7-10 days ~» «~x If patient was having problems while sleeping prior to surgery, please note ~» how the patient is sleeping following surgery «~x Bowel movement: [yes / no] ~» «~x Follow up appointment date: ~» «~x When to call the office: ~» fever of 100.4F (38C) or higher 39 STANDARDIZATION OF PROVIDER SUPPORT CARE 40 severe pain not relieved by medication bright heavy red bleeding from the mouth or nose vomiting that doesn't stop or bloody vomit inability to drink fluids signs of dehydration (such as urinating less often or dark urine) «~x ~» [INSERT NURSE/MA INITIALS] *SINONASAL POST OP CALL NOTE PROVIDER: DATE: «~Todays» PATIENT NAME: «~Last», «~First» «~Middle» DATE OF BIRTH: «~Date» AGE: «~Age~» PHONE NUMBER: «~Home» DATE OF SURGERY: PERSON SPOKE WITH: SURGERY PERFORMED «~x Sinus surgery (F/E/M/S) ~» «~x Septoplasty ~» «~x SMR of turbinates/turbinate reduction ~» «~x DNVS repair ~» «~x Nasal mass excision ~» «~x Septal perforation repair ~» «~x Cosmetic Rhinoplasty ~» «~x Closed reduction of nasal fx ~» Risks and complications included, but not limited to: [nasal] bleeding, infection, bruising, swelling, change in sense of smell, damage to nearby nerves, muscles, or blood vessels, scarring, failure to achieve desired result, risk of anesthesia [sinus] infection, bruising, excessive bleeding, altered sense of smell or taste, damage to a tear duct, spinal fluid leakage (very rare), vision loss (very rare), risk of anesthesia Discussed with the patient or parent the following: «~x Taking medications as directed ~» STANDARDIZATION OF PROVIDER SUPPORT CARE «~x ~» «~x ~» «~x ~» «~x ~» «~x ~» «~x ~» «~x ~» «~x ~» «~x ~» «~x ~» Do saline rinses WITH distilled water 3-4 times per day Stay hydrated Change mustache gauze as needed Keep nasal splint clean,dry,intact Avoid blowing nose If need to sneeze, do so with mouth open Avoid strenuous exercise, lifting, straining or bending over Bowel movement: [yes / no] Follow up appointment date: When to call the office: sudden increase in pain, swelling or bruising fever of 100.4F (38C) or higher heavy bleeding drainage that is yellowish or greenish drainage of a large amount of clear fluid unrelieved headache or constant headache decreased vision, double vision or changes in vision swelling around the eye extreme tiredness or a stiff neck any questions about the recovery [INSERT NURSE/MA INITIALS] 41 STANDARDIZATION OF PROVIDER SUPPORT CARE Appendix F Pre-/Post Survey Responses 42 STANDARDIZATION OF PROVIDER SUPPORT CARE 43 Pre-Survey Responses What is your job role? • • Answered: 13 Skipped: 0 Medical Assistant Licensed Practical Nurse Registered Nurse,... Registered Nurse, Bache... Medical Doctor 012345678910 2 2 1 3 5 Answer Choices- Responses- 15.38% 2 - Medical Assistant (1) 15.38% 2 - Licensed Practical Nurse (2) 7.69% 1 - Registered Nurse, Associate Degree (3) 23.08% 3 - Registered Nurse, Bachelor Degree (4) 38.46% 5 - Medical Doctor (6) Total 13 Basic Statistics Minimum 1.00 ? Maximum 6.00 Median 4.00 Mean 3.92 Standard Deviation 1.90 Q2 Export Customize My co-workers and I have a good working relationship • • Answered: 13 Skipped: 0 Strongly Agree 02468101214161820 13 Answer Choices- Responses- 100.00% 13 - Strongly Agree (5) Total Basic Statistics 13 ? STANDARDIZATION OF PROVIDER SUPPORT CARE Answer Choices- Minimum 5.00 44 Responses- Maximum 5.00 Median 5.00 Mean 5.00 Standard Deviation 0.00 Q3 Export Customize I am satisfied with my opportunities for professional growth • • Answered: 13 Skipped: 0 Neutral/Neither Agree nor... AgreeStrongly Agree 012345678910 2 4 7 Answer Choices- Responses- 15.38% 2 - Neutral/Neither Agree nor Disagree (3) 30.77% 4 - Agree (4) 53.85% 7 - Strongly Agree (5) Total 13 Basic Statistics Minimum 3.00 ? Maximum 5.00 Median 5.00 Mean 4.38 Standard Deviation 0.74 Q4 Export Customize I am satisfied with the job-related training my organization offers • • Answered: 13 Skipped: 0 Neutral/Neither Agree nor... AgreeStrongly Agree 012345678910 2 6 5 Answer Choices- - Neutral/Neither Agree nor Disagree (3) - Agree (4) - Strongly Agree (5) Total Responses- 15.38% 2 46.15% 6 38.46% 5 13 STANDARDIZATION OF PROVIDER SUPPORT CARE Basic Statistics Minimum 3.00 45 ? Maximum 5.00 Median 4.00 Mean 4.23 Standard Deviation 0.70 Q5 Export Customize I feel confident in my educational level to perform all duties within my job • • Answered: 13 Skipped: 0 AgreeStrongly Agree 012345678910 5 8 Answer Choices- Responses- 38.46% 5 - Agree (4) 61.54% 8 - Strongly Agree (5) Total 13 Basic Statistics Minimum 4.00 ? Maximum 5.00 Median 5.00 Mean 4.62 Standard Deviation 0.49 Q6 Export Customize I have read through the educational surgical handouts given preoperatively to patients • • Answered: 13 Skipped: 0 Disagree Neutral/Neither Agree nor... AgreeStrongly Agree 012345678910 1 2 5 5 Answer Choices- - Disagree (2) - Neutral/Neither Agree nor Disagree (3) Responses- 7.69% 1 15.38% 2 Agree (4) 38.46% 5 - 38.46% - STANDARDIZATION OF PROVIDER SUPPORT CARE Answer Choices- 46 Responses- 5 Strongly Agree (5) Total 13 Basic Statistics Minimum 2.00 ? Maximum 5.00 Median 4.00 Mean 4.08 Standard Deviation 0.92 Q7 Export Customize I am comfortable in performing and teaching patients during postsurgical telephone calls • • Answered: 13 Skipped: 0 Neutral/Neither Agree nor... AgreeStrongly Agree 012345678910 1 6 6 Answer Choices- Responses- 7.69% 1 - Neutral/Neither Agree nor Disagree (3) 46.15% 6 - Agree (4) 46.15% 6 - Strongly Agree (5) Total 13 Basic Statistics Minimum 3.00 ? Maximum 5.00 Median 4.00 Mean 4.38 Standard Deviation 0.62 Q8 Export Customize I feel comfortable asking for help if needed • • Answered: 13 Skipped: 0 AgreeStrongly Agree 012345678910 4 9 Answer Choices- - Agree (4) - Strongly Agree (5) Responses- 30.77% 4 69.23% 9 STANDARDIZATION OF PROVIDER SUPPORT CARE Answer Choices- 47 Responses- Total 13 Basic Statistics Minimum 4.00 ? Maximum 5.00 Median 5.00 Mean 4.69 Standard Deviation 0.46 Q9 Export Customize *PROVIDER: I am confident in the skill and educational level of all the providers support staff • • Answered: 5 Skipped: 8 AgreeStrongly Agree 012345678910 3 2 Answer Choices- Responses- 60.00% 3 - Agree (4) 40.00% 2 - Strongly Agree (5) Total 5 Basic Statistics Minimum 4.00 ? Maximum 5.00 Median 4.00 Mean 4.40 Standard Deviation 0.49 Q10 Export Customize *PROVIDER: I feel the provider support staff educational levels meets the expectation/standards within the scope of their practice • • Answered: 5 Skipped: 8 AgreeStrongly Agree 012345678910 3 2 Answer Choices- Responses- 60.00% 3 - Agree (4) 40.00% 2 - Strongly Agree (5) Total 5 Basic Statistics Minimum 4.00 ? Maximum 5.00 Median 4.00 Mean 4.40 Standard Deviation 0.49 STANDARDIZATION OF PROVIDER SUPPORT CARE 48 Post Survey Responses I have read through the educational surgical handouts given preoperatively to patients • • Answered: 7 Skipped: 0 Agree 42.86% (3) Strongly Agree 57.14% (4) Answer Choices- Responses- 42.86% 3 - Agree (4) 57.14% 4 - Strongly Agree (5) Total 7 Basic Statistics ? Minimum 4.00 Maximum 5.00 Median 5.00 Mean 4.57 Standard Deviation 0.49 Q2 Export Customize I utilized the new template for post-surgical calls • • Answered: 7 Skipped: 0 Strongly Agree 100.00% (7) Answer Choices- Responses- 100.00% 7 - Strongly Agree (5) Total 7 Basic Statistics Minimum 5.00 ? Maximum 5.00 Median 5.00 Mean 5.00 Standard Deviation 0.00 Q3 Export Customize The new template for post-surgical calls was helpful and useful • Agree 28.57% (2) • Answered: 7 Skipped: 0 STANDARDIZATION OF PROVIDER SUPPORT CARE 49 Strongly Agree 71.43% (5) Answer Choices- Responses- 28.57% 2 - Agree (4) 71.43% 5 - Strongly Agree (5) Total 7 Basic Statistics Minimum 4.00 ? Maximum 5.00 Median 5.00 Mean 4.71 Standard Deviation 0.45 Q4 Export Customize The new template for post-surgical calls enhanced my understanding and knowledge of post-surgery recovery and potential complications • • Answered: 7 Skipped: 0 Agree 42.86% (3) Strongly Agree 57.14% (4) Answer Choices- Responses- 42.86% 3 - Agree (4) 57.14% 4 - Strongly Agree (5) Total 7 Basic Statistics Minimum 4.00 ? Maximum 5.00 Median 5.00 Mean 4.57 Standard Deviation 0.49 Q5 Export Customize I learned something new from using the template that I did not incorporate into my post-surgical calls prior to the trial of new template • • Answered: 7 Skipped: 0 Agree 14.29% (1) Strongly Agree 85.71% (6) Answer Choices- Responses- STANDARDIZATION OF PROVIDER SUPPORT CARE Answer Choices- 50 Responses- 14.29% 1 - Agree (4) 85.71% 6 - Strongly Agree (5) Total 7 Basic Statistics Minimum 4.00 ? Maximum 5.00 Median 5.00 Mean 4.86 Standard Deviation 0.35 Q6 Export Additional comments: • • Answered: 1 Skipped: 6 w Responses (1) C Text Analysis z My Categories D PRO FEATURE Use text analysis to search and categorize responses; see frequently-used words and phrases. To use Text Analysis, upgrade to a GOLD or PLATINUM plan. Upgrade Learn more » ? s Categorize as... Filter by Category Showing 1 response I really liked the information on the template. the only thing i didn't like was the "list fashion". I almost felt like I was listing off info to the pt. i don't know if there's a better way to categorize the info or make it flow more 3/9/2017 9:13 AM View respondent's answers STANDARDIZATION OF PROVIDER SUPPORT CARE 51 Appendix G Abstract Submission to Professional Conference Jinil Harvey <[e-mail]> STANDARDIZATION OF PROVIDER SUPPORT CARE 52 Abstract 3 messages Jinil Harvey <[e-mail]> To: [e-mail] Thu, Apr 6, 2017 at 9:48 PM Abstract Snowbird.docx 34K Michael Huntsman <[e-mail]> To: Jinil Harvey <[e-mail]> Fri, Apr 7, 2017 at 8:13 AM Dear Jinil, Thank you for submitting your abstract. I has been made available to a panel of reviewers who will make a decision about having it presented at the SnowbirdCME (NP/PA) conference on Wednesday, August 9th from 6-6:45 PM at the Cliff Lodge at Snowbird Ski & Summer Resort. Mike On Thu, Apr 6, 2017 at 9:48 PM, Jinil Harvey <[e-mail]> wrote: -- Michael Huntsman Snowbird CME Conference 188 W. 2000 S. Bountiful, Utah 84010-5553 Phone: [phone] Email: [e-mail] Web site: www.snowbirdcme.org STANDARDIZATION OF PROVIDER SUPPORT CARE Appendix H Poster 53 STANDARDIZATION OF PROVIDER SUPPORT CARE 54