How Does Your Practice Work? Three Easy Steps to an Effective Practice

Certified nurse practitioner at the Cleveland Clinic in Cleveland, Ohio

In previous “Advanced Practice Perspective” columns, we’ve discussed the duties of advanced practice practitioners (APPs), including all of the various patient, research, and administrative roles that a hematology/oncology APP plays. These perspectives generated multiple calls and emails from friends, colleagues, and others, who were interested in knowing just how we do what we do.

Since the role of the hem/onc APP was not well-defined when I started practicing in the early 2000s, I had to establish myself within my institute. Many years later, I believe my current model of APP practice is an excellent example of how APPs should collaborate with physicians and other members of the health-care team.

While developing this model took years, having gone through the process, I have emerged being able to make three easy recommendations to help APPs and their teams optimize patient (and team member) satisfaction.

Step 1: Know your stuff.

As a young APP, my first goal was to establish trust with patients, colleagues, referring providers, and institutional leaders. I approached achieving this goal in two ways: First, I gained knowledge in my field through a “mini-fellowship” and, second, I worked to prove to my team members that I could function effectively with them to get the job done.

During my six-month “mini-fellowship” (which thankfully I could participate in without the scars of late nights on-call or sleep deprivation), I immersed myself in board review textbooks (mostly hem/onc and internal medicine) to learn all I could about just about anything. Sure, at the time I was board-certified as an adult nurse practitioner, had seven years of nursing experience under my belt, and had eight years of graduate and undergraduate education, but I purposefully wanted to use the medical model to practice nursing and “think” like my physician colleagues.

I studied night after night and also went on regular inpatient hospital rounds with my physician colleagues during the day. I refined my diagnostic skills and knowledge of various disorders by attending smaller “case-based” conferences, grand rounds (hem/onc and internal medicine), and my first ASH meeting. Suffice it to say, I studied a lot. I began to write about various topics and provided lectures to colleagues to further enhance my learning. Through this self-directed training, I gained confidence in my knowledge and abilities – and my team gained confidence in me.

Step 2: Establish trust with your team members.

Trust is not something that just happens; it needs to be built and then established among team members. And to gain trust, one should display trust and employ team-building strategies. Trusting others to do their jobs – and showing that you are willing to go the extra mile to help out a patient or complete essential tasks – is an important aspect of team building.

Although it is an essential part of a collaborative practice, sharing patients can be nerve-wracking for some physicians. One physician even told me that he had not been referring patients to me because he felt like it would be “dumping work” on me. Another said, “I don’t know how to use you. And, if I send you a patient, will I get them back?” In these cases, the referrals problem was easily remedied: We had a conversation to set expectations for how often the APP would see the patient and how often the physician would see the patient. Obviously, this is predicated on the patient’s medical condition at any given time. But once knowledge and trust are established, the physician and APP can work quite well together to manage any acute issues that may arise.

Step 3: Use available technology to your advantage.

Calmly repeat this phrase and use it as your mantra: Technology is my friend, not my enemy.

I know many of you readers can share horror stories of how the electronic medical record (EMR) has failed you in the past, but trust me: You can learn to use available technology to your advantage. Personally, if it wasn’t for the EMR, I don’t think our team would be able to work as efficiently and effectively as we do.

How do I use the EMR technology in my collaborative practice? As my practice is comprised of patients with a variety of hematologic diagnoses (though the majority of these patients have plasma cell dyscrasias), I work with a number of physicians. Like them, I have my own clinic schedule and see patients independently. With physicians and other team members located throughout the clinic, the EMR has become our main communication tool.

At a first visit, the physician will explain the “team” approach of caring for the patient and, in subsequent visits, the patient will alternate between seeing the APP or the physician. (See the FIGURE for an illustration of how the multidisciplinary team works to care for a patient). This team approach to patient care is generally well-received by most patients.

The EMR is invaluable to this team-based approach, especially when communicating a change in patient status, in sharing details of a patient encounter, or when multiple team members need to decide on a plan of care (i.e., radiation oncology or orthopedic surgery). Much of the communication is sent to primary-care providers and team members after traditional working hours when we all have time to check labs and catch up on patient charting. We are able to share lab results through the EMR with notes to each other, such as: “Is the disease stable? Is the patient progressing? What do you think?” and the “Whoo-hoos!” when the patient recovers his or her counts or achieves a complete remission. The key to EMR communication is to sort the “nice-to-know” from the “need-to-know” information.

At Cleveland Clinic, our EMR has the functionality to allow patients to directly message physicians or other staff with refill and appointment requests and other non-urgent questions and concerns. With a simple “click,” I can even share the patient’s chart with them to keep them informed of what I have or have not done – helping to enhance patient care and minimize the work of others.

Finally, a few pieces of advice: As an APP or a physician, be confident in your knowledge or seek to find the answer. Surround yourself with intelligent people and build a team you can trust. If you don’t trust your members, find out why. Work with your team to establish practice standards, and use your EMR for the better good. I am thrilled to be a part of what is, in my opinion, the best team in cancer care. Our institutional leadership inspires innovation and supports my role as an APP (a special thank you to Brian Bolwell, MD, our chairman).

If you heed my advice, you and your team will be efficient, effective, and actually able to take a week-long vacation, resting easy that your patients will be well taken care of.

 


FIGURE. Multidisciplinary Team ­

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