EP 28: Support Staff Expectations & Delegation

Clear expectations lead to better patient outcomes. In this episode, we dive into the intricacies of support staff management, and how NPs can support non-clinical workers in busy, fast-paced medical environments. You will hear real cases of support staff overstepping bounds, and actionable examples of how to navigate these instances. Listen to this conversation and become a more competent, efficient supervisor. 

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Transcript

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Voiceover 0:02

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico -De nino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Vanessa Pomarico 0:35

Hi everyone, and welcome to this episode of NP Launchpad. Tonight we are going to be talking about support staff expectations and delegation. And I'm once again joined by my co-host, Dr. Christopher Gleason and Dr. Jason Gleason. How are you doing, guys? Doing great. Thank you. Awesome. So good to see you. To see you. So I just want to remind all of our listeners that if you have any questions for us, um, any comments, you can reach us at nplaunchpad @fhea.com. That's nplaunchpad @fhea.com. And please remember that this is these podcasts really serve for education only. Um please verify any of this information with your particular state, your employer, or any payer rules that would be applicable to your particular area. So let's kick off the hot topic discussion. All right. Bring it on. And I, you know, I know that I always say this, and I say it with much love in my heart that you two are the princes of the VA system. Oh, you're sweet. Um, you are the queen of healthcare everywhere.

Jason Gleason 1:37

Yes, you are.

Vanessa Pomarico 1:38

I don't know about that, but you know, I go back to my office and I say, I don't know, my friends have an actual RN and an LPM working with them. Like, why can't we get one in this office? So, what should support staff expect from the nurse practitioner, Jason? What would you let's start off with that? What should our support staff expect from the nurse practitioner?

Jason Gleason 1:56

You know, one of the biggest challenges I think new NPs, just new grads getting out of school, your first job are gonna have is moving to that position where you're it. You're the leader of the team, right? And to recognize that because they're looking to you to be the leader. And many of these LPNs, RNs, medical technicians, whoever you're working with, your entire team, they've worked with other providers that have been the leader. So you got to kind of bucket up, walk into these clinics like you own the place because you do, but balance that with not having a crappy attitude. Like if you go in there with a big ego, you're gonna get sunk right away. So recognizing that you're a leader, you're gonna do great. You have all these skills and wonderful knowledge to share with anyone else. But I'll tell you what, it's not about just sharing your knowledge, it's about learning. I worked in an emergency department as an NP, and I learned the most, not from a physician, not from an NP colleague, but from an LPN that I worked with. Yeah, a lot of orthopedics. He taught me a ton of stuff that I didn't know. So you can always learn from anybody on your team, regardless of who they are, what their skills are. Take an opportunity, be curious, be curious about different roles, and then you will be loved and admired, and most of all, you'll be accepted as part of the team.

Christopher Gleason 3:04

Absolutely. Absolutely.

Vanessa Pomarico 3:06

Great points. Yeah, thank you. So, Christopher, on the flip of that, what should the nurse practitioner expect from the team?

Christopher Gleason 3:13

I think first off, when you're especially when you're going into a new team, you need to you need to establish clear del a clear delegation and clear responsibilities. Make sure that they know what what they need to do or what they or what you expect them to do. And the what the NP should expect from the team is that they're gonna they're going to be able to do their role and you know and serve in that capacity. So if I'm delegating responsibilities to an LPN or an RN, then you know, I'm trusting that they know what they're doing and that they're gonna get this get the job done. And if you're finding that, you know, you're delegating these responsibilities and later on you're finding out that they're not done or they're done, you know, haphazardly, then that's really when you have to have that conversation with, you know, whoever and say, you know, I I really I see that you're not quite getting the concept. So because maybe it's maybe it's education, maybe you just need to educate them, you know.

unknown 4:03

Right.

Jason Gleason 4:04

You know what well, you know what I love that you just said though, is you gotta talk with them about things when they're not meeting expectations. So much of the time it's human nature, like if somebody is not doing what they should be doing and you want them to do something differently, so much of the time we go to their boss, right? And we have a discussion with their boss, and then their boss gets involved and it's a bigger deal. And if it is a big deal like a safety issue, obviously you want to do that. But from day-to-day stuff, I'd say the petty stuff, don't get involved in that, but just go to the person and talk to them and say, hey, this is driving me bananas. Can you please do it this way? Or if you thought of this, right? And then tell them this say, you know what, if I ever do anything that drives you absolutely nuts and crazy, tell me, tell me, because we're human beings. But communication, I think that's a lost art in in so many of our experiences. And we're just likely to go to the top and you know, report people and complain and whine. The other thing I would say too is if you're gonna bring up an issue with somebody that you're working with, suggest some solutions to it too. Just don't tell them how negative it is. So yeah, you could have a positive outcome from all that. Absolutely. That's why the education. Oh, yeah.

Vanessa Pomarico 5:08

So I think it's really important, you know, especially when you're when you're starting to work with new support staff or if you're the new person on the job, that you look for job descriptions to see what is within their job description because you guys work with nurses, we work with medical assistants. So their job descriptions are going to be very different, and therefore they're the my expectations have to shift because I don't I'm not working with somebody that can, you know, write orders and and that kind of thing. So, you know, looking at job descriptions, looking at workflows that have already been approved, looking at um any of your escalation pathways, and those are the things that as a new nurse practitioner, you need to know those things going into the job. But also, too, how do you guys address the well, we've always done it this way?

Jason Gleason 5:55

Oh boy, that's a tough one.

unknown 5:58

I don't know.

Christopher Gleason 5:59

Jason, I think I think that kind of uh goes along the line with your what you're talking about with communication. You know, you can always have that conversation with them. I understand that you've you've always done it this way, but you know, looking at a new approach or you know, trying to take this approach and melding it with your approach is not necessarily a bad idea. Yeah. You're always you should always be willing to learn and you should always be willing to shift because things are gonna change.

Jason Gleason 6:22

Well, I think when you're faced with that too, you know, when you go into a new place, you're so excited to share your knowledge and your experience and your new ideas because you're gonna go in that place and turn it upside down and improve it, you know, do 100,000 percent better, right? That that that's our goal. And it's not that you're a bad person or you're just self-centered or ego-driven. You just want to help and you have all this great knowledge and enthusiasm to share. But if you walk into a situation where they say, no, we've already we've always done it this way, so we'll stick with this. How I would manage that is, you know what? I'm new to the team. I am in charge of the team as the provider, right? And it's your license that's on the line, so you should be because the buck stops with you. And you know what I would tell those folks that the pushback and say, oh, we've already done we've always done it this way. You can say, I am so interested in learning how you've always done it. Will you tell me about this and show me what you do? And then here's the deal. For the next month, I would like to watch how this plays out. And then would you be open to us meeting again? And I can offer some suggestions on things that I find, you know, that might be helpful to the process. I love your process. I think it's great. But, you know, I might have some ideas as well that I could share. And I'm new, you know, so sometimes fresh ideas are good, but I'm gonna take a month. I'm not gonna jump into this and change everything up right away. I'm gonna take a month and see how things go. And I want to learn from you just as much as you're gonna learn from me. Would that be okay? How can anybody on the planet Earth argue with that? Right. That's that shuts that we've always done it this way, kind of business down. I think it's been helpful in my past. Yeah. What do you think, Vanessa?

Vanessa Pomarico 7:48

Uh yeah, I agree. Um, you know, when I had joined my practice, and I use this as an example many times, um the manager, when I had assumed that one of the docs had left and I had to absorb a lot of her patients. Um, and she had done a tremendous amount of narcotics and controlled substances without having patients coming in. And so patients would say, Well, Dr. So-and-so never did it that way. And my man, and I finally said to my manager, Listen, I will give them 30 days of a refill, but they either need to come in or they're going to psych. But I'm not gonna continue to refill these medications, it's my license. No. And I would hear her on the phone and she would say, you know, I know that that's how Dr. So-and-so did it, but you know, we now have a new provider, and the patient would give them whatever lip they would say, and I would hear her say, Listen, there's a new sheriff in town. So we love it. I love it. We're gonna be we're gonna be changing things. And I'm just gonna tell you, she's not gonna be the same way the other doc did. So you have two decisions here. You can either stay with her and work with her, or you can find another provider and she'll give you refills for 30 days. Wow. And and that was pretty much what we had to do because the, you know, we've always done it this way adage doesn't always apply. And sometimes I find that when I've been told that at other practices, well, we've always done it this way, it's out of sheer laziness that they don't want to change their ways. And, you know, you come in as a new grad, you know, you're idealistic, you've got some great ideas, but you also don't want to start off on the wrong foot by coming in, like you said, Jason, you don't want to come in and trying to change things overnight. So just kind of taking that backseat, watching how they do things, and then start to slowly integrate some of the changes in a way that doesn't feel threatening to your staff. Absolutely.

Christopher Gleason 9:33

Definitely.

Vanessa Pomarico 9:34

Right. So the other thing you have to also consider too, and we've talked about the dreaded inbox, but you know, who owns the messages, who's in charge of the refills, who's in charge of the folder of all the forms that we have to fill out. I don't know if you if you all have the know your numbers. Do you have the know your numbers for employees?

Jason Gleason 9:53

No, I don't. Tell us, what is that?

Vanessa Pomarico 9:56

Yeah. So we have something that's called know your numbers, and it's part of um it's part of the healthcare uh that the hospital offers. So the employees that have that work for our health system that see me, they have something that's called know your numbers, and they have to know what their what their um BMI is, their waist circumference, their lipid panel, their blood sugar, their A1C if it's applicable, when their last eye exam was, when their last pelvic exam was, or PAP test was, or mammogram. And it really is a way to help patients um become and employees start to really own their own health care and be much more engaged in their health care. So what they do is they actually get money back when they do the know your numbers. Right. But as a result, we have a you know, a file that you have to fill all this paperwork out. Um, most of the patients do a pretty great job because when the numbers come back, what they do is they fill their part out. They'll actually put all the numbers in there. So I just have to verify it online. It takes me less time. Um, but the forms, you know, we all know the the back to school forms, you know, any of the, I don't know if if any of you, you know, the the daycare forms when they have to, you know, every year they have to have a physical and have a PPD done and you know, that kind of thing. And so then there's always a myriad of forms that we have to fill out. So who owns those? And that's always part of of what the uh delineation and what the the uh job descriptions will tell you who is going to be in charge of all of that. But also, too, you have to think about your deadlines because many times as we're getting ready to go back to school, I'll get a lot of of teachers and students that come in and they need to have their form done that day. And we always have to say to them, listen, it takes seven days. I have a stack of of other forms on my desk that came in before you. So no, I can't fill this out today because they want you to do it right then and they're like, well, I have to hand this in tomorrow. Guess what? It's not gonna get done until you know a week from now because again, there's probably 20 people ahead of you waiting for their forms. Right. I mean, I do try to honor that and and fill the forms out, but it's really nice if you have a nurse that is able to fill those things out and you just have to review it and sign it.

Jason Gleason 12:03

Yeah. Well, what I have found on that issue too is you know, sometimes you can look at things with fresh eyes and actually make the people's lives that you work with better and easier and more workflow, you know, more streamlined. At the VA, when I first started at the VA, and I've been there for over 10 years, so these providers are no longer there, they've retired. But when I came into the VA, I came in after working at the emergency department, and I was used to entering my own orders in the EHR. If I wanted labs or something, I would enter the order myself and sign it, right? So it's done right away. And so I was used to that. So I come to the VA and I'm like, okay, I'll enter my own orders in for labs and return to clinic visit and you know, any special consults or anything like that that I would have to order that I wanted to order for the patient. And this provider told me, oh no, no, we don't do that. You just tell your nurse, your nurse, right? The nerd, the nurse that we have the honor to work with is how that should be said always. And so if you catch yourself, I catch myself saying your nurse sometimes too, all of us do, but the wonderful nurse that we work with, that's their job. You just come out of the room and you tell them, I want this and I want this and I want this, and they're writing it down, right? And then they'll go enter it in. In my mind, I'm like, well, that's just crazy work because you're duplicating work. Why don't you just enter it in yourself? It takes the same amount of time and the burden off your staff. Right. So sometimes a fresh approach, they will love you for it. So bring those ideas. Yeah, I like that. And knowing each other's roles and responsibilities.

Vanessa Pomarico 13:28

So, Christopher, how do you feel about the unlicensed personnel, those people who are uh answering the phones, triaging, and giving medical advice before it even reaches your inbox?

Christopher Gleason 13:41

That's very frustrating, actually, especially because, you know, as we talked about before, it's always your license online, the buck stops with you. So if you have these unlicensed personnel that are giving medical advice, then you're they're putting your patients at risk. Bottom line, they're putting your patients at risk. So I remember when I was uh when I was a nurse, the um I had there was another nurse that I was working with, and she was talking with one of the patient's family members, and she was talking about um uh specific medication, I believe it was PERCASA, but the information that she had given them was completely wrong. And this was actually a licensed personnel. So I, you know, kind of going back to the unlicensed personnel, if you have licensed people that are giving them wrong information, then the unlicensed personnel are giving them or have the potential to be giving them even more wrong information. So the they really should, you know, if it's if they have medical questions, they shouldn't they shouldn't be fielding them. They should be saying, hey, I know you really need to talk to your provider about that. You need to talk to the RN about that, you need to talk to the medical assistant, LPN, what have you.

Jason Gleason 14:38

And how easy is that scripting right there, right? Yeah, I don't have the answer, but let's get it for you. I'll have you talk to them.

Vanessa Pomarico 14:44

Yeah.

Jason Gleason 14:44

Yeah.

Vanessa Pomarico 14:45

But you know, also we've talked about this in past episodes. You know, Jason, the daily huddle. Don't you find that the daily huddle is so vital to start the day off on the right foot and look at the patients that are on the schedule to say, this one needs an EKG, this one's gonna need blood work, this one's probably gonna be late, this one's not gonna know their medications, but at least it prepares our team for what's going to lie ahead for the day. Right. I mean, I love the daily huddle and I think that it's it's really important because it really does help to, you know, shift the priorities and you know, look at to see what's gonna be happening for the day and help it to streamline a little bit. Yeah.

Jason Gleason 15:23

I I agree. And without that, don't you find the days that you don't do that, the days are tend to be the days tend to be a disaster. Oh, yeah. Yeah. Out of control. The other thing I have found this too let's say you chase your dog down the street, you drop your $10 cup of coffee as you're going into the clinic that day and life sucks for you, and you go in there with a shitty attitude, right? All of us have done that. We're human beings. But you need to reset at the huddle, right? Before you do the huddle, because if you go in there with a crappy attitude, the whole day is shot and everybody's pissed off at each other and nothing's working right. And that's that's so hard to do sometimes because we're human beings and crap happens to us, right? But I would say check your attitude because you choose, you choose a lot of times to have a bad attitude or not. So I I would recommend that too.

Christopher Gleason 16:05

What I recommend is. I feel like you just described. Oh, sorry, what I recommend is going into the patient room, screaming really loudly, closing the doors first, screaming really loudly, then going to your huddle. Oh, there you go. That would work. That would work.

Jason Gleason 16:18

Yes, yes. Vanessa, what were you going to say?

Vanessa Pomarico 16:22

If your walls are paper thin, that won't work or stuff.

Jason Gleason 16:26

Somebody called me.

Vanessa Pomarico 16:27

But Jason, you were just you were just describing exactly what happened to me last week. I was getting ready for work and I was pouring my iced coffee into my container in the glass jar. I hit it against the um my um concrete. It's not concrete. Take two. I hit it on the um for Micah?

Jason Gleason 16:49

This is great for a blue burill.

Vanessa Pomarico 16:50

Granite. Well of us. Okay, let's try that again. You just you described exactly what happened to me last week. I was getting ready for work and I was pouring my iced coffee, and I hit the glass container onto uh the the top, my cabinet top. And the entire and it was full and the entire glass shattered everywhere. I got coffee all over me. And now I'm I'm running late. Now I have to go upstairs. I've got to change my scrubs, I've got to wash the coffee off because it went right through my scrubs. I smelled like coffee all day, even though I think it was probably just in my nose. I'm trying to race to work, and of course, don't you know there's an accident on the highway. Now I'm gonna be late. Of course. And by the time I rolled in the door, I was not in a good place, but I had to check myself. And oh, did I mention it happened to be the day that my brand new medical assistant was starting? Oh, not perfect. It's perfect timing. What did she walk into? It's perfect timing. So I had to, I didn't want to start it off on a I didn't want to scare her and just say, why did I take this? So I just said to her, just give me five minutes. I and I told her what had happened, and she said, not to worry, I'll come back in five minutes and we'll huddle. I'm gonna go get the first patient ready. And she was great about it. That's perfect. But you're right, you have to check yourself and you need to, you know, really take a look at at yourself and then have that huddle so you can reset your whole day.

Speaker 4 18:06

You do.

Vanessa Pomarico 18:06

So so let's take a look at how do you delegate without turning your teamwork into what we call a task dumping. Jason.

Jason Gleason 18:15

Wow, you know, number one, I would say that when you're delegating, never ever use the language, I don't have time for this. So you need to do this when you're checking a patient or whatever, right? Because you're the people you work with, the amazing nurse, LPN, medical technician, whoever it is, right, is working with you, they don't have the time either. And they will take that as a big insult, like, well, screw you, because I don't have the time either. I'm a I'm busting my butt here. And so I always say, you know, would you mind doing this for me when you're checking the patient in, do the visual acuity exam on the Snell and I chart, or, you know, make sure you calculate out their BMI for me or whatever you need, do it very kindly and say, because while you're doing that, I'm going to work on blank, blank, blank. So they know you're just not sitting around and having them do all the work. I I find that how we talk to each other is so important. So important.

Christopher Gleason 19:04

I think one of the important things though is too is when you're asking people to do those jobs, um, one thing is to mention is, you know, don't say it's not my job or that's not my job. Right. I think if you're delegating a responsibility to another team member, then you should be well aware that you you yourself can do that job or should be able to do that job. Yeah. So I think that's really important too.

Jason Gleason 19:27

Although I have to say, as an RN, I worked in a hospital once that uh I went to empty the garbage can on night shift, and uh, an RN came up to me and said, Oh, we don't do that. Only the LPNs do that. It's like, are you kidding me? Are you kidding me? You are not nurse of the year, right? Yeah. It's like, well, I'm gonna do it anyway, and I'm gonna empty all the garbages, right? Yeah. But their fear was that we would have to empty the garbage every night. It's like, come on, be a nice human being, help each other out, right? What do you guys think about the hierarchy? Like RNs and LPNs and medical technicians. I I hate when there's this hierarchy that there's a lot of conflict, like, oh, you're an RN, so you're so good, and the LPNs kind of get sidelined or the med techs. The way I look at the team members is everybody is equal in their importance and they're vital to the team and success and good outcomes with our patients. We just have different roles, you know? And we're we're nurses as NPs, we're nurses, right? Sometimes we forget that. Um, but what do you all think about that? Do you see that out there? I have seen that and I just I don't feel good about it.

Vanessa Pomarico 20:26

I I do see that. And it's interesting because I had the reverse happen to me. My medical assistant was uh busy doing something else, and I went in and one of my exam rooms hadn't been cleaned. So all I did was I just took the paper, you know, the gown into the hamper and I started cleaning. And she came in, she said, What are you doing? And I said, I'm cleaning the room. She said, That's not your job, that's my job. And I said, No, we work together as a team here and when you're tied up, I'm gonna clean the room like this is not a big deal. So we we really have to look that delegation is really not like a blanket permission. Delegation really is very specific to different things so that they don't say, Well, she gave me permission the last time to do this, so I'm just gonna do it now. They need to know that when I'm delegating something, it's going to be for this particular thing, but it doesn't mean that it's gonna happen all the time. Do you find that as well?

Jason Gleason 21:19

I I do.

Christopher Gleason 21:19

I do, I absolutely do. Chris, you the yeah, I think it's I think it's really important because like you said, uh Vanessa, when you're delegating that responsibility in that instance, it's just for that instance. And if you give them the carte blanche to do it all the time, you may be, you know, putting yourself at risk as the as a licensed professional. Especially as the NP.

Jason Gleason 21:39

And you know, the other thing I've run into too is, and this is fairly recent, I don't know, in the last year and a half, um, I have had the wonderful honor of working with a new LPN that I get to work with, not have to work with, but get to work with. And she is absolutely amazing. I would I would argue she's the best LPN in our entire clinic, but Christopher might have disagree with that. I disagree. Yeah. Thankfully, we're a hallway. Way away. But uh, but you know, in that case, let me share this with you. She would go into the room and room the patient and do vital signs and get history and all that stuff. But it was taking a little longer than I was used to, you know, with working with other staff. And so she would come out and she'd give me this big long diatribe of information on the patient stuff I was gonna ask the patient anyway about their health and history and why they're there and doing a deep dive on all their health issues. And I asked her once, you know, I I really don't need all this information because I'm gonna ask them this anyway. You know, you you work so hard and you know, we get behind in things. You're already working so hard. I can do some of this, and it's my job to do some of this. Well, perspective is everything. She told me, you know what? That is such a relief. Thank you so much. Because I worked with a cardiologist that expected me, that expected me to get the entire history, what the patients are for, every single detail about every health issue, and report to him. And if I didn't, he would get very angry and then he'd go in the room for like five seconds, right? So perspective's everything. Who you're working with maybe worked for a complete bozo before, right? And so they're terrified or they don't know what to do. So just open communication from day one. Yeah. And don't assume anything. Because I just assumed in that case, well, maybe this is just the way they do things here, the way she does things. When in fact it was all based on that horrible, horrible experience. Christopher, are you seeing that?

Christopher Gleason 23:18

I haven't, but yeah, I'm blessed to work with an LPN that has been there. She's been in the clinic for I want to say six or seven years now. So she's really, she's really have has a solid foundation there. She knows the process. So it when we work together, the the process is rather seamless. So I don't have to I don't have to really worry worry about that so much. Yeah.

Jason Gleason 23:39

Have you have either of you this is a question? Have either of you worked as an RN in an outpatient clinic? I did. I filled in once and I could not get out of there soon enough. Oh my gosh. They are amazing. They're incredible at what they do because it takes a specialist person with lots and lots of different skills that I didn't have at the time. So yeah, yeah. I really appreciate the work they do.

Vanessa Pomarico 24:02

So, you know, just the bottom line is that those of us who have to delegate, we have to be accountable for the decision. And ultimately it is our license. And those that we delegate to, they are accountable for whatever it is that we're telling them that they need to do. So we have to make sure that they understand the nature of being delegated to and that they're not it's not that we're bossing them around, but we're giving them things that are really, let's face it, they're hired to make our jobs go smoother and easier during the day. So again, it's all in your verbiage and all how you approach it with people. Um, but you know, when you state your expectations about, I need you to do this or I'm going to ask you to take care of this particular thing. Let's say it's a prior authorization. So I need you to, this is your priority to do this prior authorization to get this patient's MRI. The patient needs to have this MRI within the next 24 hours. Here's all the documentation that you need for the insurance company. Um, and this is what I need you to look at. And so I'm giving them to tell them, I'm giving them the deadline. I want them to know it's got to be done. The patient's gonna be having it in 24 hours. Here's the information you need. It's all in my note here. You just need to tell the uh insurance company exactly what's in my note here. Um, and then if there's a problem, then you can get me out of the room. But at least this way they know that here's your task, this is what you need to do. And then if you are not able to get it done, then I will have to get on the phone. But again, we have to hold them as accountable for whatever task, as just like we're being held accountable.

Jason Gleason 25:36

You know, on that topic at the at the VA, what I do, especially for important things that just cannot be missed that I'm delegating to them. I'll finish my progress note. And let's say I need to refer a patient to a specialist or I receive test results that I want the specialist to see, or the patient has to get an appointment with a specialist like urgently or within a few days. And I want the LPN that I work with to handle that and get all that arranged or fax those labs or those study results to the specialist so they can see it. I'll I'll document all that in my progress note, I'll sign my progress note, and then what I do, because our system allows this, I don't know if every EHR allows this, but at the VA it does. We can do an addendum to our note that shows right at the top of the EHR, like the most recent note. And I'll do a little addendum and I'll type in their PACT LPN or PACT RN so they know right there that it's for them. And I'll put in there, please fax these labs to this office and call their office to alert them of the incoming facts, speak with the nurse, not the receptionist, because the receptionist has a whole other role and responsibility. You know, they don't have the clinical knowledge to know what's important. And then at the end of that, I'll put please document that this was done. And then she'll actually enter a note in there and I sign it and then I also assign her so it shows up in her inbox. And that's that system has worked great for us because otherwise, you know, I've had them say to me occasionally, gosh, did you enter that addendum? Because I'm gonna miss that if I don't see it, because that's part of our system. So just having a system down, but I would say on those important things and document well because when things bad happen, it's gonna turn into, well, I didn't know, or they didn't say that, or you know, yeah.

Vanessa Pomarico 27:13

And and most of the electronic health systems, and I'm not sure which one all of you work on, but most of them will actually have um the ability or a tab to close that loop like you just talked about. But let's say that, you know, I need a pay I have a patient that needs to go back and have, you know, a mammogram in three months as a follow-up. I can actually put that in so then it comes up as a reminder two weeks before if the patient hasn't made their appointment. So those are the things that you can do because again, it's a liability for us. It's all falls on us as the uh licensed people. So having that closed loop loop communication is going to be so important again to make sure everything has been documented. Do you all use the SBAR, the situation background assessment and recommendation?

Jason Gleason 27:58

No, tell us more about that. Yeah.

Vanessa Pomarico 28:01

So we, our hospital system adopted SBAR many, many years ago, and it's across the board. It's not just for medical, but they actually use SBAR for um if there's something going on with our electronic health records and there's a problem and something's been reported, they'll send an SBAR communication to our emails just explaining that, you know, um electronic health system was out or like duo. Duo is our two-step system that we use for prescribing um scheduled medications. You have to actually get it on your phone before and it that you have to do the two-step approval. Well, there was an issue with it a couple of weeks ago, and we reported it. I said, I can't get into my my duo here, it's not accepting it. And I kept restarting my phone. I'd restart my computer. And what I did was I reported it. I apparently wasn't the only one. They sent out an S-bar. So it's really good for when you have like an urgent update and you want to close the loop on a particular problem. But the S-bar is something that a lot of people tend to use. I love that. How about like the delegation when you're delegating, you know, helping our support staff to understand red flags, like things with that we need like an immediate interruption, come get me in the room, that kind of thing. How do do you all deal with the red flags or like a critical result with a patient?

Christopher Gleason 29:18

I think the the huddle in the in the morning is so important because if you as a pr uh provider know that you're awaiting labs that have the potential to be critical labs, you know, discussing that with your with whoever, you know, in our case, RNs and LPNs, in your case, uh Venice and discussing it with your you know, you know, your medical assistant saying, hey, I keep an eye out for these labs. You know, if there's if there's critical values, I need to know immediately. I need you need to interrupt me, what have you. Just so I can uh have those labs at hand and then you know develop your plan of care, whatever that may be.

Jason Gleason 29:51

I agree. And that's what I do too. And from day one, I I'd recommend that new NPs out there going into a practice, even during your job interview, ask ask administration how do you handle inter-office emergencies and whose role is to do what during those emergencies? Because often we're we're the lead medically, right? Yeah, from that standpoint when we're seeing a patient, but to know the different roles. Because if if you have an emergency, that is not the time to decide whose role is to do what. You know, but absolutely you want to have that up front.

Vanessa Pomarico 30:18

Oh, yeah. Yeah.

Jason Gleason 30:18

Yeah.

Vanessa Pomarico 30:19

So on that note about delegation, how as a new nurse practitioner would you encourage new nurse practitioners how they can coach their support staff without coming off as being a micromanager? Christopher.

Christopher Gleason 30:34

I figured you'd ask that. Are you a big one?

Vanessa Pomarico 30:38

I can redo that and ask Jason if you want, no, that's fine.

Christopher Gleason 30:43

Not to beat a dead horse here, but again, it goes back to that communication, that clear communication, that clear expectations. Um but you know, have have that conversation with them. If you're if you need something done, just say, you know, have that conversation, say this this is really important, it needs to be done. And the um and try not to hover over them.

Jason Gleason 31:03

Yeah.

Christopher Gleason 31:03

You know, you you can check in with them, check in with them later on in the day or what have you, but try not to hover over them and and you know, check in with them every every two minutes, two or three minutes, or what have you. I mean, if it's important, it should be done at that at that moment. It shouldn't they shouldn't have to wait for it. But if it's if it's something that can wait, then you know, check in with them later in the day. Yeah. They have they have jobs too, they have roles too, that and things that they need and tasks that they need to get done at that moment. Yeah.

Jason Gleason 31:27

And I would say for me, what I'd recommend our listeners and friends out there should do is, and it comes back to kind of summarize some of the points already made during this episode earlier, but on day one, when you go into work, go in there with a good attitude, like we talked about earlier, and tell your staff from day one, you know what, I'm just gonna hang out here for a month. That's another key thing we talked about. I'm gonna hang out here and just kind of observe and learn from all of you for about a month before I share any ideas on what I think would work well with this or that we can add. And go in there with a good attitude, go in there as the leader, lots of confidence. Because if you don't have confidence when you walk in there, they pick up on that. Yep. And that could be a disaster for you. So make sure you walk in as a leader, but not a dictator. You also want to be nice. So find a balance there. I worked with one NP that just had a God complex from day one when she started, and people didn't like her very much. And if people don't like you, they're not gonna come to you, they're gonna be afraid of you, right? Yeah. So go in there with a good attitude. Tell folks, you know, I'm not gonna change anything. I'm gonna seek to understand before I seek to be understood. I love that quote. Seek to be understood. Seek to understand before seeking to be understood. And and so go in there with a great attitude and just work well with your team from day one, though, because they'll pick up on it and that'll set the pace for the rest of your career in that, in that setting.

Christopher Gleason 32:42

I think too since we're getting to go ahead and getting to know our our teams, that micromanaging aspects tend to fade away. If you're if you're you know new on the team and you're just starting with a team and you don't know necessarily you don't have that trust built with the team yet. I think once you develop that trust with the team and you know that they're the um they know the role, they know the responsibilities, and they're able to get the job done for you. I think that micromanaging aspect tends to go away on its own.

Jason Gleason 33:09

Well, and and there will be days. There will be days as human beings that we are that we're gonna screw up, that we're gonna say something wrong that that irritates the crap out of somebody else, or is frankly rude to a teammate and a coworker. That's gonna happen throughout our career, right? Because we're human beings, we make mistakes. But I would say apologize early. Don't let things fester, right? Don't let things fester. I did that. I can admit my faults, right? I mean, we talked about that our first episode. We're gonna give you how it is, right? Tell the truth on this stuff. But I did have a disagreement with one of our staff members. I was completely inappropriate, completely wrong. And the and I didn't let it wait, though. The very next day, she loves plants. And the very next day, I turned her desk into Jurassic Freaking Park, right? With a big note, an apology letter, and I think some chocolates too. But that's not enough. That's not enough. You got to eat your pride, go in there and say, you know what, I really screwed up and I'm sorry. That's how you make a connection. Because these people you're gonna work with, you're gonna spend more time with them than you spend with your family, right? They become your second family. You know, so yeah, be quick to apologize and mean it and be sincere about it. Christopher, do you think that's a good thing?

Vanessa Pomarico 34:14

And when you when you train Oh, I'm sorry.

Jason Gleason 34:16

I was gonna ask Christopher if he ever messes up like that.

Christopher Gleason 34:19

Yes, I have.

Jason Gleason 34:20

And what have you done to rectify it?

Christopher Gleason 34:22

Um funny, it's similar to what you're doing. Did this happen today? Did this happen today? No. This was a while ago now. But um, the next day, the person had a card on their desk and they happened to like um love pink starbursts, so they had a bag. Oh, nice pink starbursts. And uh and a conversation. You know, like you said, that open communication and just saying, you know, I realize I messed up, I apologize. You know, and then you can you can continue to build the relationship moving forward.

Jason Gleason 34:50

Go from there. And if you don't, it fasters. Vanessa, how about you?

Vanessa Pomarico 34:53

How do you make up to somebody that you're really uh I I I probably don't do Jurassic Park, but I've done exactly what Christopher has done. And and I just, you know, I just appeal to them and say, you know, we have to work together. I'm not your boss. We we work as a team. Um, and you know, I'm sorry. And you know, we all have our bad stay, bad days at different times, and uh, you know, I hope that we can move forward from this. And I've never had a medical assistant that didn't I mean fortunately those are few and far between, but I've never had any of my assistants that didn't say, Yeah, I get it, because Lord knows they have bad days as well.

Jason Gleason 35:28

So and you will know, don't you find too, when the longer you work with somebody, and this is really important for our new NPs out there walking into these situations, eventually, and if you're not doing this and being very curious about your your teammates you're working with, because they truly become your second family and you spend a lot of time with them, but spend some time reckoning, pick up on the small things like the nuances. Like the wonderful register nurse that I get to work with, I I love this person. I truly do. She's amazing at what she does. She's been doing it for years. She's so talented and skillful and just a good human being. But she also tells me, you know what? If I have a grumpy face before 10 a.m., don't talk to me a lot. But after 10 a.m., it's fine, right? But understanding those nuances that, you know, because all of us are humans and we don't we want to find out what buttons set people off so we don't push them. Take some time and be curious, or even ask people directly, you know, what what buttons do you have that I I don't want to push, definitely don't want to push. Have you done that, Christopher, with your team?

Christopher Gleason 36:26

I don't. Well, I think that comes I think that kind of comes comes naturally with when you're building that relationship with the team. As a human being. And as uh because as you're building that relationship with the team, you're gonna start to notice those, like those nuances that you're suggesting and the things that, you know, the triggers that can you can potentially trip with certain people and you know, avoid avoid um tripping those triggers and avoid the the things that you know are gonna you know potentially make a another um team member mad.

Jason Gleason 36:52

Yeah, yeah. Otherwise you're buying Starburst and turning people's desks into Jurassic Park all the time, right? Right. And then letting your buttons let them know about your buttons too. Like and it doesn't have to be some heavy conversation. It could be, you know what, this absolutely drives me bananas when people do this. They'll get a hint. And then if things continue, it obviously becomes more serious. But right.

Vanessa Pomarico 37:13

So how about competency validation? If you're teaching your staff a new particular type of skill that you're going to be delegating to them, do you do competency validation at all?

Jason Gleason 37:25

Not for the staff that we work with. You know, for each other we do. For each other, but no. Yeah, because it it's pretty stovepiped at the VA. They go to their leadership and you know, for all that.

Christopher Gleason 37:35

But I know that they have a competency checklist that they have to that that they have to follow. So when there's a new there's a new procedure that comes out for the nursing staff, they have to the um the clinic manager has to check in with them and they have to check off my um a list basically saying, yes, I'm competent in this, and and somebody has to sign off on it. Trevor Burrus, Jr.

Jason Gleason 37:54

And we can be part of that process depending on your organization. I would say new NPs out there, find out what your organization does. Because that might be a big part of your job. Is it a part of your job, Vanessa?

Vanessa Pomarico 38:04

Uh so it's more part of our lead MA or our our um uh office supervisor. Um, but it is part, I mean, I do have to sign off on a couple of different things, but we do a lot of teachbacks. So we we do, we're we're very close in in that we make sure that they they feel comfortable before they have to start doing something on their own. So it's not just a do one, see one, teach one. Yeah or see one, do one, teach one. Um, but it's more uh, you know, how comfortable are you? So, for example, in Connecticut, they passed a law a few years ago that medical assistants can start to give um injections now. So they can give vaccinations and that kind of thing. And uh, you know, I will be the first one to tell you that I was not in favor of medical assistants being able to do that because I don't think that their education prepares them the way a nurse does. So um, but what they did do was they implemented, they took all of our concerns because many of us have our faculty at different universities, so we're coming from a very RN-centric background. And what we ended up doing was they came up with um a couple of lead people who are stellar medical assistants, and they have a whole program that they have to go through. They do need to become certified, so they have to go through the process, and then they have to uh go through this whole checklist in order to get validated. But again, you know, I had somebody, so the other day I was running a little behind, and one of my patients wanted a, I don't know, a pneumoncine or a TDAP or something. And so I said to one of our senior MAs who is uh uh on the clinical ladder, you have to be an MA too in order to be able to give injections. And I said, you know, I know that you've been thinking about doing these again, I've got an injection, and she said, I need to see some. And I said, well, then come in the room and we're gonna get you comfortable with this. But I I know you want to go through the training again, but you can't avoid doing this. This is part of your job. And, you know, we need to just jump in. So what can I do to support you? And and having that training and that validation and that teach map was really helpful for her.

Jason Gleason 40:04

It sounds like it. It sounds like and using every opportunity, right? How about how about the time when you have somebody come up to you and say, you know, I got this list of um skills I need to sign off on? Would you mind going through this? And you're busy, you don't have time, you just wing it and sign away, initial away, check boxes. Never, ever, ever, ever do that. Because you know what? If something happens, those lawyers are gonna have a heyday. Yeah an absolute heyday with that. So yeah. Yeah. I love our discussion. This is so good.

Vanessa Pomarico 40:31

Yeah. Yeah. So uh, you know, we have some resources to share uh with you, and these are gonna be in your show notes as well. And the first one is the National Council of State Boards of Nursing. Uh, there's a web address for that, the Agency on Healthcare Research and Quality Team Steps, and also the American Association of Medical Assistants. They have state scope laws. So make sure that you familiarize yourself with what the laws are in your particular state when you start to practice if you're going to be working with a medical assistant. So now we get into our favorite part of the program, which is our fact or fiction. Still waiting for the confetti and the prices to come down.

Christopher Gleason 41:10

And the music, yes. Where is it?

Vanessa Pomarico 41:12

All right. So, Christopher, a job description alone provides a task is safe to delegate or proves a task is safe to delegate. Is that fact or fiction?

Christopher Gleason 41:21

Absolutely no. That is that is pure fiction. Because you can you can have um a job description and uh somebody you're trying to delegate to that can't even accomplish that job description.

Vanessa Pomarico 41:33

Right. Exactly. All right, Jason. The five rights include the right task, circumstance, person, directions, and communication, supervision and evaluation, fact or fiction.

Jason Gleason 41:44

I would say fact.

Vanessa Pomarico 41:46

Yes, absolutely. Absolutely. Just like just like when we used to do the five rights of, you know, before we gave a medication to your patient, it's the same thing. So good.

Jason Gleason 41:55

And that'll be in our show notes for folks out there who didn't know that. So yeah, take a look at it.

Vanessa Pomarico 41:59

Exactly. All right, Christopher, closed loop communication confirms that a message was received and correctly understood. Fact or fiction? Absolute fact. Absolutely. Yeah. And we need that because again, our licenses are on the line and closing that loop, and everything is documented and documented clearly.

Jason Gleason 42:17

You know, here's a question. Here's a question on that.

Vanessa Pomarico 42:20

Go ahead.

Jason Gleason 42:20

How do we do closed loop communication which is effective with our kids? You need to clean your bedroom. Close the loop. You know, did you clean your bedroom yet? I feel like a broken record. Any ideas on that? Or is that a different podcast? That's a different podcast.

Vanessa Pomarico 42:33

I think that's a different podcast. Parenting is not part of this.

Jason Gleason 42:38

Next time.

Vanessa Pomarico 42:39

All right. Well, this one's for you, Jason. After delegating, the NP no longer needs to supervise or evaluate the outcome. Fact or fiction.

Jason Gleason 42:46

Yeah, go with it and lose your license soon, right? Yeah, yeah. Absolute fiction. Yeah.

Vanessa Pomarico 42:52

Absolutely. All right. So, everyone, we appreciate you so much for tuning in and listening to our podcast, and we want to share some special savings with you. If you visit FHEA.com and use the code launchpad20, you'll get an additional 20% off our continuing ed library and our memberships. And we have a huge library of a variety of topics. I dare say there's probably not a topic on there that you can't find in our library, but launchpad 20 for 20% off in our way of thanking you for supporting our show. Now I'm going to move into our mailbag. Uh, we're gonna you can email your questions. You never know. We might use it on a future uh podcast at nplaunchpad at fhea.com. That's nplaunchpad at fhea.com. So we have a couple questions here. Uh Christopher, which recurring task creates the most confusion about ownership? Any ideas?

Jason Gleason 43:46

Wow, that's kind of a tough one.

Christopher Gleason 43:48

That's a hard one. Yeah, because there's so much. Which recurring could you repeat the question?

Vanessa Pomarico 43:56

Which recurring task creates the most confusion about ownership? So in other words, what does our support staff do where there might be a gray area as to who is responsible for the results or the outcome of that task?

Christopher Gleason 44:13

I'm going to feel this adjacent actually.

Jason Gleason 44:15

Oh, that is no fair. No fair. My goodness. You know what I mean when I think of tasks, um, I would say, gosh, you know, when things get busy, it it's great to have these plans in place, right? You should do this and this and this, but when things get busy, those plans tend to go to the side and things get missed, right? So to have to reinforce that no, this needs to be done every single time. Every single time. Like, you know, with annual visits, make sure the the uh visual acuity test is done for me, those kind of things. And that does require some massaging and reminders, and you might uh find yourself getting frustrated. But again, choose your attitude and work through that with your team and lots of reminders. And I would say the biggest thing, the biggest benefit when you're faced with those things where things are not getting done, but you really need them done is clear, open, honest communication and to be kind.

Vanessa Pomarico 45:07

How's that? Always be kind. How's that? Was that a good answer? That was a great answer.

Jason Gleason 45:10

All right, I guess my friend point for me.

Vanessa Pomarico 45:14

All right. Which one of you wants to take the next one? What red flags should your staff know means interrupt me now?

Christopher Gleason 45:22

Actually, that's a really good question. You touched on it earlier. The um when you have those critical lab values that are coming back, or you have uh an imaging study that's coming back, something that you need to know, you know, right then, right then and there, have that conversation in morning huddle and say, you know, these these imaging studies, these labs, these results should be coming back today. And even if I'm with a patient, you need to interrupt me and you know, we need to close that loop.

Jason Gleason 45:46

Yeah, you know, and something not as emergent as that, but so important. Let me share this with our audience that let's say you're ordering an MRI and a patient, or let's say this. Let's say the register nurse you're working with comes up and says, Yeah, you know, the specialist recommended we put in this test. Let's say it's an MRI. Always do this. You always have to close the loop on these big tests. Oh, yeah, would you mind go ahead and ordering that? And then they order to sign and we sign the order, but you have a million orders to sign. So you're looking through them, but you might miss something. So they put the order in, but there's no follow-up, no return of call to a patient to review the results, any of that. So, what I I've told the R and I work with whenever you enter an order like that in for me to sign, please always pair it up with a return to clinic phone visit. So I never ever miss that. That's my system, but you have to have a system in place. So adding those little nuanced things like, yes, you can enter this order in, but this is so important, so important that I also need a return to clinic order through a phone visit. So that's an example of something not emergent or a red flag, but so important that it's not missed. So you have to have a system in place and open communication.

Christopher Gleason 46:50

Absolutely. Um the RN I work with actually takes the when they get the results from the imaging studies back. I have a folder on my desk that is for provider review. And I'll I go in there, I review the um review the imaging studies, review the results, what have you, and then you know, respond to the patient with the uh information. It's good. Yeah.

Vanessa Pomarico 47:09

Nice. Good. All right. So here's your wrap-up landing checklist, everyone. For our new nurse practitioners, you want to create a one-page role and task matrix. This will really help you guide you into what the expectations would be for a particular delegation, uh, and depending on who you're delegating to. And write your escalation triggers for any routine, urgent, and emergency concerns, having them written down again in a place where other people can access it will make sure that everybody's not literally on the same page. And then audit one workflow using the five rights and closed loop completion. That's right. So that's your landing checklist. And your homework for next week is again to audit that one workflow, but define the owner, the deadline, your escalation rules, and the proof of completion. And this will just help you to prepare you on what it means to have closing those loops and what you do in terms of workflow and who is responsible for what. So that's your homework for the next week. All right. So I want to thank everybody again for joining us. Uh, if you wouldn't mind, we would love it if you would drop us five stars. Hit follow, uh, tap subscribe, and most importantly, please share this with anyone else you know, with your friends, your colleagues, somebody that may be thinking about becoming a nurse practitioner. Um, and we just appreciate you showing up for us and being part of this amazing podcast. So um, I want to say thank you to everyone. Guys, do you have anything you want to wrap up with?

Christopher Gleason 48:40

No, take care, everyone. Yeah, great episode. Y'all have a good week. Take care. Great. And we'll see you next time, everyone.

Vanessa Pomarico 48:46

See ya.

Christopher Gleason 48:46

Good week, y'all. Take care.

Vanessa Pomarico 48:48

Bye now.

Christopher Gleason 48:50

You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.