Digital Repository Doctoral Projects Spring 2022 Implementation of a Standardized Training Program for New Hire Medical Assistants Apolonia Silva Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Silva, A. (2022) Implementation of a Standardized Training Program for New Hire Medical Assistants Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Implementation of a Standardized Training Program for New Hire Medical Assistants by Apolonia Silva A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE or MASTER’S OF SCIENCE IN NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 18, 2022 _________________________ _April 18, 2022_________________ Student Signature (Apolonia Silva, FNP-BC) Date ________ _April 18,2022_________________ Faculty Lead Signature (Erica Avidano WHNP, MPH) Date _______________________________ __________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 1 Implementation of a Standardized Training Program for New Hire Medical Assistants Apolonia G. Silva Weber State University Annie Taylor Dee School of Nursing Doctorate of Nursing Practice Project Faculty Project Lead: Melissa Neville Norton DNP, APRN, CPNP- PC, CNE Project Consultant: Erica Avidano, WHNP, MSN Date of Submission: April 18, 2022 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 2 Abstract Orientation training for medical assistants (MA) provides new employees with the necessary knowledge to meet the essential work requirements. The Utah Planned Parenthood affiliate hires medical assistants with varying patient care experience and training. Medical assistants receive exceptional training from many senior medical assistants, leading to considerable knowledge and skill differences. Variances in MA training can negatively impact confidence, competency, and skills leading to higher error rates. Consequently, MAs have a fluctuating understanding of the skills and knowledge needed for clinical support. Project goals included development of an evidence-based MA training program for newly hired medical assistants. The MA Confidence Survey and MA Knowledge Questionnaire were used to collect data from participants regarding their perceptions related to knowledge and skills attainment. The pre-and-post MA confidence and knowledge surveys were conducted at the commencement and conclusion of the project with an n = 4. However, during the 90-day follow-up, the number of the participants had decreased to an n = 2. The project average results showed at least a 25% improvement in MA confidence and knowledge post-intervention comparatively. Implementing a standardized training program increased the knowledge and confidence of newly hired medical assistants working in the Salt Lake City, UT area reproductive clinics. New hires reported feeling more competent in understanding patient care needs while simultaneously demonstrating the proper techniques for intramuscular injections and venous punctures, in line with care standards. Completing critical patient care tasks with standardized protocols diminishes the probability of errors. Eradicating process variation improves performance and reliability. Keywords: medical assistant, new hire training program, evidence-based, knowledge, confidence, clinical skills, assessment IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 3 Table of Contents Implementation of a Standardized Training Program for New Hire Medical Assistants ............... 6 Background and Problem Statement ........................................................................................... 7 Diversity of Medical Assistant Population and Project Site ....................................................... 9 Significance for Practice Reflective of Role-Specific Leadership ........................................... 10 Literature Review and Framework ............................................................................................... 11 Framework ................................................................................................................................ 11 Search Methods ......................................................................................................................... 12 Synthesis of Literature .............................................................................................................. 13 Team-Based Primary Care .................................................................................................... 16 Barriers to Incorporating Medical Assistants into Team-Based Care .................................. 17 Evolving Roles of Medical Assistant .................................................................................... 18 Communicating the Value of Medical Assistants Roles to Stakeholders ............................. 21 General Medical Assistant Education ................................................................................... 22 Standardized Orientation ...................................................................................................... 23 Mentoring and Role of Peer Training ................................................................................... 24 A Gap in Practice Knowledge............................................................................................... 25 Discussion ................................................................................................................................. 26 Implications for Practice ........................................................................................................... 27 Project Plan ................................................................................................................................... 28 Project Design and Outcomes ................................................................................................... 28 Cost Analysis and Sustainability of Project .............................................................................. 31 Consent Procedures and Ethical Considerations....................................................................... 32 Instruments to Measure the Effectiveness of Intervention ....................................................... 32 Project Implementation ................................................................................................................. 33 Project Intervention ................................................................................................................... 33 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 4 Project Timeline ........................................................................................................................ 37 Project Evaluation ......................................................................................................................... 38 Data Maintenance/Security ....................................................................................................... 39 Data Collection ......................................................................................................................... 40 Data Analysis/ Findings ............................................................................................................ 41 Limitations of a Small n ........................................................................................................ 49 Qualitative Analysis .............................................................................................................. 49 Strengths ............................................................................................................................... 50 Project Limitations ................................................................................................................ 50 Quality Improvement Discussion ................................................................................................. 51 Translation of Evidence into Practice ....................................................................................... 52 Implications for Practice and Future Scholarship ..................................................................... 53 Sustainability......................................................................................................................... 54 Dissemination ....................................................................................................................... 54 Conclusion ................................................................................................................................ 55 References ..................................................................................................................................... 57 Appendix A ................................................................................................................................... 70 Appendix B ................................................................................................................................... 77 Appendix C ................................................................................................................................... 80 Appendix D ................................................................................................................................... 88 Appendix E ................................................................................................................................... 89 Appendix F.................................................................................................................................... 90 Appendix G ................................................................................................................................... 92 Appendix H ................................................................................................................................... 94 Appendix I .................................................................................................................................... 97 Appendix J .................................................................................................................................. 115 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 5 Appendix K ................................................................................................................................. 116 Appendix L ................................................................................................................................. 119 Appendix M ................................................................................................................................ 121 Appendix N ................................................................................................................................. 123 Appendix O ................................................................................................................................. 124 Appendix P.................................................................................................................................. 126 Appendix Q ................................................................................................................................. 130 Appendix R ................................................................................................................................. 133 Appendix S.................................................................................................................................. 134 Appendix T ................................................................................................................................. 136 Appendix U ................................................................................................................................. 137 Appendix W ................................................................................................................................ 140 Appendix X ................................................................................................................................. 142 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 6 Implementation of a Standardized Training Program for New Hire Medical Assistants Creating and implementing robust employee onboarding programs is essential for leaders to orient and retain new employees (Araújo et al., 2020; Berridge et al., 2016). Onboarding is the process of helping new employee hires orient to organizational philosophies and adjust to social and performance job expectations (Araújo et al., 2020). Healthcare orientation training introduces the organizations' mission, expectations, and responsibilities while enhancing skills proficiency and promoting goal attainment (Berridge et al., 2016). Unfortunately, onboarding processes and training of new employees can vary within organizations and can be additionally challenging in outpatient clinic settings (Miller et al., 2019). Specifically, every clinic at Planned Parenthood in Utah has its version of medical assistant (MA) new hire onboarding through which new hires learn attitudes, knowledge, skills, and behaviors required to function effectively. The training objectives are not always practical or effective without standardization. Subsequently, employees begin their new roles with different training, resulting in decreased compensation, field experience, and on-the-job learning supported by line management (Araújo et al., 2020). Developing standardized training for new hire MAs ensures evidence-based practice while decreasing the wide variance among the training program. Implementing standardized new hire training programs will encourage partnerships to develop a highly-skilled workforce directed at outpatient care (Ferrante et al., 2018). As healthcare becomes increasingly complex, medical assistant roles evolve to include more prominent roles in outpatient care. In order to develop a highly-skilled employee, an effective onboarding program must be sustainability developed using best practices. Historically, clinics adopted on-the-job training that did not involve structured orientation, leaving individual managers to devise their educational objectives (Araújo et al., 2020). On-the-job training IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 7 involved job shadowing by placing the new medical assistant with an experienced medical assistant. The purpose of this combination was to ensure that the new employee could observe and learn clinic flow and skills needed for patient care. Orientation training for medical assistants increases job fulfillment and retention, but a standardized program offers a systematic curriculum that prevents variation in both practice and basic medical understanding (Karacsony et al., 2019; Lo et al., 2018). Research supported the correlation between MA retention and increased job satisfaction when organizations invest in new hires’ comprehensive standardized training and mentorship programs (Karacsony et al., 2019). Staff development, primarily for medical assistants, can vary in clinical settings due to disparate individual experiences, including dissimilar educational foundations. Although onboarding new employees incorporate training programs, the objectives and outlines are not always practical or effective without standardization. Background and Problem Statement Planned Parenthood is a non-profit organization that provides reproductive services to adolescents and adults across the United States. Planned Parenthood is divided into different affiliates that share the mission of providing medically accurate education and complete reproductive health care. The Planned Parenthood Association of Utah (PPAU) affiliate is embedded in the Planned Parenthood Federation of America (PPFA) organization, leading to a shared mission, purpose, and need as articulated by PPFA. In Utah, services are provided by family nurse practitioners, women's health nurse practitioners, physician assistants, and medical assistants. Healthcare providers find it challenging to provide exemplary patient care without the support of medical assistants. Nevertheless, MAs, inadequately prepared for clinical support, do not understand the value of high-quality patient care or the need for accurate data collection, IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 8 leading to mistrust and resentment in healthcare providers. Presently, patient care teams in the clinical setting are healthcare providers and medical assistants who regularly collaborate on patient needs. With this in mind, medical assistants are clinic team members who assist healthcare providers with various patient undertakings. Traditional MA activities include communicating with and educating patients and performing clerical and maintenance duties (Planned Parenthood, 2019). This quality improvement project incorporated research and other evidence sources to develop a standardized training program for new hire MAs at a Planned Parenthood clinic in the Salt Lake City, Utah area. The project focused on the clinical microsystem, where a small group of people who work together relies on all team members' cooperation to provide care for teenagers and adults seeking health care at Planned Parenthood (Planned Parenthood, 2021). The healthcare team members are critical participants of the PPAU microsystem. The standardized training program had immediate and circuitous effects on the organization, medical assistants, and patients. Due to the project, PPAU directly noted increased medical assistant knowledge and confidence, leading to superior patient care (Ferrante et al., 2018). Additionally improved healthcare delivery indirectly affected patients, while medical assistants were immediately affected by developing an increased understanding of their job role, including healthcare provider expectations. The project demonstrated improved MA clinical skills and understanding of basic patient care, leading to an enhanced healthcare provider and patient trust (Chapman & Blash, 2016; Miller et al., 2019). The project yielded results that supported improvement at the local clinic level and on a systems level for the entire Planned Parenthood Association of Utah affiliate. Medical assistants at PPAU receive exceptional training from many senior medical assistants, leading to considerable knowledge and skill differences. Variances can negatively IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 9 impact self-confidence, competency, skills, and patient outcomes, leading to unintended patient harm (DeAngelis et al., 2017; Spiva et al., 2020). Although the preceptors consist of skilled and knowledgeable medical assistants, due to the preceptor subjectivity, the current method is unreliable for testing knowledge and skills gained in the orientation training period without a standardized approach. Consequently, MAs who work with healthcare providers have a fluctuating understanding of the skills and knowledge needed for clinical care. Healthcare providers at PPAU have expressed the need to ensure that all medical assistants conclude their training with similar skills, confidence, and knowledge foundations. Standardizing training offers a solution to circumvent the complexity of subjectivity associated with teaching (Caggianese et al., 2019; Johnsen et al., 2016; Tan et al., 2017). Medical assistants work with healthcare providers to deliver optimal healthcare, which requires a logical understanding of primary basic patient care. Standardizing new hire MA training programs increases skills and decreases knowledge discrepancies. This DNP project was designed to understand if implementing a standardized training program for newly hired medical assistants increased skills, knowledge, and confidence in the PPAU organization. Diversity of Medical Assistant Population and Project Site Through identifying the need for improved education, this project impacted internal and external stakeholders, including medical assistants, healthcare providers, and the patient population. Upon arrival, medical assistants greet patients, guide the patient to the exam room, obtain vital signs, collect needed specimens and provide valuable health education. Health care is delivered equally and equitably to all seeking services at Planned Parenthood. Additionally, most medical assistants are bilingual and assist patients who do not speak English during the entire appointment. Medical assistants providing interpreting services for patient care also play an IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 10 essential role in building a sustainable bridge to close the gap in healthcare accessibility in a culturally sensitive manner. The diversity in population benefits from the project through their created connection with medical assistants. Planned Parenthood also increases access to affordable health care and sex education to diverse patient populations. Patients who seek services at Planned Parenthood are from various backgrounds, but they all share healthcare needs. Reproductive health care clinics are ideal for medical assistants to learn the importance of their role in a diverse setting, as MAs interact with various healthcare issues to provide care and education. Significance for Practice Reflective of Role-Specific Leadership The Association of American Colleges (AACN), in 2006, published eight essential points which serve as the cornerstone of the doctor of nursing practice curricula (AACN, 2006). This project supports Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking to demonstrate applicability. Identifying a practice need and developing a standardized training program were developed to deliver evidence-based healthcare. In particular, as a future leader and graduate of the Doctorate of Nursing Practice (DNP) program, this project provided the opportunity to design, implement, and evaluate a quality improvement practice change at the systems level. The objective was to implement a sustainable standardized pilot training program for all newly hired medical assistants in the Utah Planned Parenthood affiliate. After successfully applying and completing the project at the pilot site, the project discussion, results, and entire program were disseminated and shared with the leaders and managers of the South Jordan, Salt Lake, Utah Valley, Ogden, Logan, and St. George, Utah Planned Parenthood clinics which are all in the PPAU organization. As developed, this project could be transitioned into the PPFA policy to be instituted affiliate-wide across the United States. IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 11 Literature Review and Framework The literature review gathered and analyzed supporting evidence on the effectiveness of a standardized educational program for newly hired medical assistants. In addition, the IOWA Model for Evidence-Based Practice was used to guide the analysis and application of the quality improvement project (Damschroder, 2020). The purpose of including the original search terms and database names allowed reproducing searches to depict the identification of themes. The literature review was an essential component of building a solid evidence-based foundation that served as the basis of the project, while the framework provided a clear map to appraise the development, implementation, and assessment of interventions. A review of outcomes and sustainability ensured that the implemented changes produced the desired results using the step-by-step conceptual framework. Framework The IOWA Model for Evidence-Based Practice was chosen for its direct application to micro-system levels and used for macro-system change innovation (Duff et al., 2020; Hanrahan et al., 2019; Schaffer et al., 2012). Nurses have used the IOWA Model many times in various healthcare organizations to implement practice changes successfully. Damschroder (2020) describes how expert nurses, and the supporting team, take systematic approaches to support high-quality decision-making by using current peer-reviewed literature before implementing system organizational change. The IOWA Model provided an approach to guiding the project's development by providing a clear framework to implement new practice paradigms in the health care setting (Buckwalter et al., 2017; Hanrahan et al., 2019). The framework used to guide the decision-making and implementation of the project was the IOWA Model for Evidence-Based Practice. As a healthcare provider for Planned Parenthood, IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 12 this model provided the foundation for asking questions and seeking a systematic, evidence-based approach to developing a standardized training program. In this project, the IOWA Model was used for its straightforward, intelligible approach to discover various propositions to rectify the identified knowledge deficits in medical assistants at PPAU. Interviews took place with existing staff members at all levels, who were interviewed for ideas and suggestions to improve existing training practices, and question whether there was a need to improve the current program. After determining that all healthcare providers and staff were in agreement, the project was started. Using the step-wise approach of the IOWA Model, supporting evidence was gathered and reviewed to reinforce the need for sustainable solutions to facilitate the knowledge base of medical assistants. The IOWA Model helped direct clinical practice changes to reduce the identified deficits in care practices. Search Methods Three database search engines, Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete, OVID Medline, and PUB MED, were used to collect supporting literature to answer the clinical question. The incorporation of Boolean operators and MesH terms widened the retrieved results. Keywords included medical assistant(s), primary care, team-based, standardization [MesH], role, satisfaction, and education. Narrowing of the 209,407 initially found articles with the inclusion criteria of 2017-2021 publication dates, English, peer-reviewed, ages 19 and older, human investigations, and free full text yielded 12 articles. The removal of 2 articles occurred due to duplication, leaving ten studies. After the abstracts were reviewed and believed appropriate, a critical appraisal was performed to determine the reliability and robustness of the studies using the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool (Hanrahan et al., 2019). IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 13 Articles used for the literature review consisted of four cluster randomized controlled trials, one cross-sectional study, one retrospective case-control study, and four qualitative studies. Inclusion criteria for all conducted searches were articles published in scholarly journals, English language and published between 2017 and 2021. Exclusion criteria included articles unrelated to the project topic, non-peer-reviewed articles, and articles of inconsistent quality. A single report from 2015 was included in the literature review, as the study was a randomized control study that discussed the medical assistant's role. Synthesis of Literature A comprehensive review of the literature was performed to discover relationships in the literature regarding medical assistant training. After synthesizing the articles, three main concepts were identified: • team-based care models provide higher levels of comprehensive care • the role of the medical assistant is evolving to keep up with the complexities of patient health • medical assisting is the only healthcare profession that does not have an official credentialing body or set of educational requirements leading to varying levels of care Medical assisting is a dynamic role emerging as a transformed role in healthcare (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Willard-Grace et al., 2015). Evidence shows that as patient health becomes increasingly complex, the MA role is evolving to include management and coaching in patients with chronic illness under the purview of protocol-based standing orders to improve patient outcomes (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Willard-Grace et al., 2015). Willard-Grace et al. (2015) conducted a IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 14 quantitative cluster randomized control trial (n=441) and demonstrated statistical significance in improving hemoglobin a1c and cholesterol levels among patients with chronic disease by working alongside a medical assistant health coach. In another cluster, randomized control trial, Fortmann et al. (2021) found that patients (n=600) with diagnosed Type 2 Diabetes Mellitus (T2DM), elevated cholesterol, and blood pressure readings showed health improvements in all three categories when working directly with a medical assistant. In contrast, Rodriguez et al. (2018), in another cluster randomized control trial, compared the changes in health outcomes and reported experiences in patients with T2DM when applying team-based care, which consisted of working with a community health worker (n=3) or a medical assistant (n=3) in primary care clinics (n=10). Subsequently, the only statistically significant improvement occurred in the care experiences category in the MA group (p < 0.05). Furthermore, the researchers had key informants who reported that managers often pulled MAs when providing diabetes care management to cover staffing shortages. As a result, there were no measurable differences in improving the control versus the intervention groups with T2DM values. Despite the last trial showing minimal improvement in patient control values, these studies support how the expanded medical assistant role improves patient health outcomes when provided with sufficient time to work directly with patients. As can be seen, the MA's role is evolving to remain current with the healthcare demands of today's patients (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Scharf et al., 2019; Sheridan et al., 2018). Working under established healthcare provider-approved protocols, medical assistants offer minimal yet vital patient triage, namely in the primary care team model (Scharf et al., 2019; Sheridan et al., 2018). Team-based models and primary care homes have demonstrated higher positive patient outcomes (Willard-Grace et al., 2015). Following the IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 15 introduction of the Affordable Care Act and the creation of the healthcare marketplace, many individuals who previously did not have health insurance qualified for coverage and needed a primary care home (Courtemanche et al., 2018). Consequently, healthcare clinics have found it challenging to find additional time to add a patient to an already busy healthcare provider schedule (Friedman & Neutze, 2020; Sheridan et al., 2018). For this reason, many clinics are expanding the role of medical assistants and utilizing their skill set to the fullest extent, which helps decrease healthcare providers' burnout while increasing satisfaction (Seay-Morrison et al., 2021; Sheridan et al., 2018). Research supports the notion of extending the role of medical assistants to increase the opportunity to deliver high-quality patient care. In an inductive qualitative research study, Sheridan et al. (2018) interviewed 30 medical assistants from nine primary care clinics to discuss responsibilities, teamwork, learning, and job satisfaction perceptions. Of those interviewed, 73% of the MAs reported happily accepting additional tasks with appropriate training, and 86% reported improved job satisfaction when working in team-based care. Given these points, Sheridan et al. found four themes emerged from interviewing the MAs about their perceptions of team-based care: increased connections with colleagues, increased contacts with patients, a more extensive sense of production, and leadership. Notably, by providing MAs with meaningful roles and support through education, MAs develop increased satisfaction despite increased responsibility (Fortmann et al., 2021; Rodriguez et al., 2018). Scharf et al. (2019) surveyed 887 outpatient care MAs with a 20-item questionnaire in a cross-sectional study to discern what medical assistants needed to thrive in their position. Out of 887 MAs surveyed, 97.3% expressed at least one type of need: 87.0% wanted a higher wage, 75.4% wanted increased recognition, and 76.0% wanted reduced documentation responsibility. 76% of MAs felt they needed increased teaching in the electronic IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 16 charting system to navigate patient records quickly. In brief, acknowledging MA perceptions by providing greater responsibility through support and role expansion leads to increased retention and job satisfaction (Friedman & Neutze, 2020; Scharf et al., 2019; Seay-Morrison et al., 2021; Sheridan et al., 2018). In conclusion, healthcare providers progressively rely on collaboration with team members to provide patients with complete health care. Thus, as time with the healthcare provider decreases and shorter appointments are given to patients, a high-trained team is necessary to provide patients with safe health care to improve patient outcomes. Team-Based Primary Care With team-based care, a medical assistant collaborates with a single or group of assigned healthcare providers to deliver high-quality patient care (Willard-Grace et al., 2015). In addition to improving healthcare outcomes, studies also demonstrate that team-based care reduces healthcare costs by increasing the use of electronic health record software to track and manage patient data more effectively (Fortmann et al., 2021; Rodriguez et al., 2018; Scharf et al., 2019). The National Academy of Medicine defines team-based care as healthcare services provided by a group of healthcare providers working in combination with the patient population to achieve the highest level of healthcare (Mitchell et al., 2012). Studies indicate that patients with chronic illnesses benefit from team-based services as medical assistants can liaise between patients and healthcare providers, increasing accessibility to care and reducing unnecessary barriers (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Rodriguez et al., 2018; Willard-Grace et al., 2015). In. a retrospective cohort study, Reddy et al., 2018, found well-functioning healthcare teams had patients who had fewer emergency room visits and hospitalizations, thereby reducing healthcare costs associated with receipt of unnecessary services. Patients often prefer the team-based system, which decreases the difficulty of accessing health care team members (Fraher et IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 17 al., 2020; Friedman & Neutze, 2020; Willard-Grace et al., 2015). Medical assistants play a vital role in increasing accessibility and reducing healthcare costs (Fortmann et al., 2021; Fraher et al., 2020; Sheridan et al., 2018). Team-based models lead to lower clinical and emergency room services, as patients can connect with the healthcare team quicker (Fraher et al., 2020; Friedman & Neutze, 2020; Willard-Grace et al., 2015). The goal is to use every healthcare member to their fullest potential to meet the diverse healthcare needs of the patient (Friedman & Neutze, 2020; Willard-Grace et al., 2015). Several monumental reports published in the late 90s and early 2000s, in addition to the Affordable Care Act, served as the impetus for healthcare systems and organizations to face the challenge of transforming the current paradigm to one that consistently provides high-quality, high-value, safe, and equitable healthcare to all Americans (Courtemanche et al., 2018; Langley et al., 2009). Solutions include reforming payment models, expanding telehealth services, and supporting the development and integration of team-based healthcare (Hardy et al., 2021). Strengthening the quality of care given to patients in primary care is a priority in ensuring the health of patients and their community (Fraher et al., 2020; Friedman & Neutze, 2020; Willard-Grace et al., 2015). Increased investment in creating team-based services will benefit patient outcomes and improve team members' job fulfillment (Courtemanche et al., 2018). Obstacles found in the formation and implementation of team-based care must be addressed to successfully build a team that meets the challenge of providing high-quality, high-value, and safe healthcare (Fraher et al., 2020; Friedman and Neutze, 2020). Barriers to Incorporating Medical Assistants into Team-Based Care Hindrances, including the attitudes and comfort level of the healthcare provider in delegating to medical assistants, are challenging to overcome when minimal trust is given (Seay-IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 18 Morrison et al., 2021). In a descriptive qualitative study, Fraher et al. (2020) determined that physicians are either resistant or reluctant to delegate larger tasks to medical assistants due to discomfort related to the unfamiliarity of knowledge held. This same study noted that the unyielding physicians were male (p < .01) with the age of 59 years and older (p < .01) (Fraher et al., 2020). Friedman and Neutze (2020) revealed that as patient volume and complexity increase, healthcare providers find it difficult to effectively deliver excellent patient care without the support of medical assistants. Due to the increase in data collection, planning, and coordination, healthcare providers cannot provide efficient care alone (Djuric et al., 2017; Mitchell et al., 2012). Team-based care is most effective with clear communication, mutual trust, and motivation (Fraher et al., 2021; Friedman & Neutze, 2020; Willard-Grace et al., 2015). Several studies report conflict as a barrier to fully forming solid team-based care (Djuric et al., 2017; Fraher et al., 2020). Teams work best in organizations with conflict resolution policies in place to provide guidance and solutions when disagreements arise (Djuric et al., 2017; Fraher et al., 2020; Seay-Morrison et al., 2021). When all participating team members agree on roles and responsibilities, the health of individuals and communities improve overall (Seay-Morrison et al., 2021). Evolving Roles of Medical Assistant Medical assistants are vital members of the outpatient healthcare team and contribute to patient care (Freund et al., 2016; Sheridan et al., 2018). The typical clinical role of the medical assistant includes: transferring patients to their exam room, measuring vital signs, collecting laboratory samples, and educating patients (Fraher et al., 2020; Willard-Grace et al., 2015). Equally important is the administrative role, which includes clinic management positions in many clinic settings (Fraher et al., 2020; Sheridan et al., 2018). As such, MAs are taking on a IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 19 more significant roles by participating in patient outreach for care management purposes to improve outcomes (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Sahoo & Mishra, 2019; Willard-Grace et al., 2015). MAs also complete pre-visit planning by reviewing records to identify gaps in care for patients overdue for preventive care or screenings. After verifying the patient's healthcare need, medical assistants alert the healthcare provider to ensure the patient receives appropriate wellness testing, leading to opportunities for MAs to impact patient health positively (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020). Depending on the clinical setting, MAs are called upon to perform various essential patient care or administrative tasks. However, the role of the MA is advancing to include much more than simple care tasks. The role of the MA is evolving to include greater responsibility for patient management (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Rodriguez et al., 2018; Willard-Grace et al., 2015). Developing vital standardized orientation programs is imperative to improve clinical practices (Fraher et al., 2020; Ferrante et al., 2018; Sahoo & Mishra, 2019). As Fraher et al. (2020) concluded, the expansion of the MA role can help close healthcare-related gaps as the healthcare system trends towards a value and team-based care system (Rokicki-Parashar et al., 2021). MAs assist healthcare providers with patient care as the increase in patient volume often leaves healthcare providers unable to spend enough time with patients. Medical assistants with comprehensive training under healthcare provider direction or standing orders can spend valuable time with patients to answer questions and provide teaching or coaching (Friedman & Neutze, 2020; Song et al., 2020). With the implementation of value-based patient care initiatives, the role of the medical assistant has evolved to include patient outreach, advocacy, and education (Djuric et al., 2017; Ferrante et al., 2018; Rodriguez et al., 2018; Scharf et al., 2019; Willard-IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 20 Grace et al., 2015). The impetus for expanding the medical assistant role is increased patient volume in clinical settings, as healthcare providers can no longer devote considerable time to patients due to increased demand for health services (Djuric et al., 2017; Ferrante et al., 2018; Fortmann et al., 2021). Conversely, medical assistants have a long-established cooperative role in assisting healthcare providers in conducting patient care directly, resulting in the healthcare provider informing the MA of duties needing completion (Djuric et al., 2017; Ferrante et al., 2018; Rodriguez et al., 2018). Currently, the medical assistant role is evolving from the traditional position to the independent medical assistant, who understands the expanded role regarding patient care. Djuric et al. (2017) showed that patients (n=82) with access to a medical assistant with an extended position (n=2) had healthier habits related to lifestyle support, leading to increased wellness and health. Harper et al. (2018) and Duff et al. (2020) agreed that medical assistants are lower cost underutilized resources. Duff et al. (2020) surveyed medical assistants (n=118) who reported a desire to expand their job roles. As a result, medical assistants offer a more comprehensive array of support to patients and healthcare providers, typically only when appropriately trained (Ferrante et al., 2018; Fortmann et al., 2021; Rodriguez et al., 2018 The traditional MA role is progressing, and evidence supports a standardized orientation program for improving patient outcomes and lowering healthcare costs (Rodriguez et al., 2018; Willard-Grace et al., 2015). MAs provide essential support to patient care teams when confidence and knowledge solidify during the training period (Fortmann et al., 2021; Rodriguez et al., 2018). By allowing increased time for direct patient care, healthcare providers benefit from the expanded role of medical assistants (Fraher et al., 2020; Fortmann et al., 2021; Sheridan et al., 2018). Studies IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 21 support that knowledgeable MAs positively impact patient health outcomes, which benefit organizations (Fortmann et al., 2021; Rodriguez et al., 2018; Willard-Grace et al., 2015). Communicating the Value of Medical Assistants Roles to Stakeholders Korneta (2020) reports that healthcare organizations, patients, healthcare providers, and the community are interested in positive patient experiences, delivering high-quality healthcare, and decreasing costs. Increased investments in MA training decrease turnover costs while patient care experiences and satisfaction levels increase (Korneta, 2020; Sheridan et al., 2018). However, the evidence shows that these improvements only occur with thoroughly trained medical assistants, which often is not happening. As such, medical assistants are given more tasks without proper training, leading to increased turnover rates related to burnout. Seay-Morrison et al. (2021) noted that burnout in medical assistants decreased with receptive organizational culture and support. In a retrospective case-controlled study, Friedman and Neutze (2020) estimated the cost of medical assistant turnover to be $14,200 per individual or $213,000 total approximate cost per medical assistant to the organization. Friedman and Neutze also reported that the estimated cost of low retention increased initially due to comprehensive training of medical assistants who hold expanded roles. By initially investing in medical assistant training to expand the role, healthcare organizations, patients, healthcare providers, and communities will receive high-quality, high-value care, leading to lowered costs. Many cross-case comparison studies acknowledged that leaders must be cognizant of obstacles and barriers, including patient load, and allocate time for multitasking when increasing expectations of medical assistants in primary care (Ferrante et al., 2018; Scharf et al., 2019). Medical assistants expected to function in more than one role in a day need dedicated training time to achieve set goals (Ferrante et al., 2018). A medical assistant's motivation to assume an IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 22 expanded role increases by providing empowerment and direction through mentoring and effective standardized training. Hence, improvements in MA, healthcare provider, and organization satisfaction result from improved training (Fortmann et al., 2021; Fraher et al., 2020; Sheridan et al., 2018). General Medical Assistant Education Ferrante et al. (2018) report that medical assistants receive various levels education, from formal programs to on-the-job training. As mentioned, no certifying state boards exist for MA licensing. However, two credentialing organizations exist in the United States. The American Association of Medical Assistants and Registered Medical Assistant grant credentials through the American Medical Technologists Agency. In accredited medical assistant programs, students graduate with an understanding of direct and indirect care with cross-training in organizational goals (Fraher et al., 2020). Curricula include courses in primary health, biology, and medical terminology. Formal programs offer the opportunity to develop skills used in daily care. Ferrante et al. (2018) observed that medical assistants increased their understanding of collaboration and patient advocacy with practical support. Providing MAs with supportive educational measures builds confidence and skill set, which benefits key stakeholders. Due to incongruent educational requirements, medical assistants provide varying levels of quality health care (Fraher et al., 2020). As healthcare becomes complex, and with the lack of a governing credentialing organization for medical assistants, standardizing training needs is necessary for high-quality health care delivery (Sheridan et al., 2018). Similarly, many studies show that patients receiving health care coaching from fully present and well-educated medical assistants are cost-effective by reducing the cost incurred by the healthcare system (Fraher et al., IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 23 2020; Fortmann et al., 2021; Sheridan et al., 2018). Standardized training aims to ensure that medical assistants understand their role and increase confidence, skill, and job satisfaction. Standardized Orientation A standardized training approach ensures that all medical assistants develop the same basic medical knowledge regardless of educational or work background (Harper et al., 2018). Transitioning the MA role from reactive to proactive, medical assistants have a measurable impact on patient health goals. Researchers observe improvements in blood pressure and hemoglobin a1c in a patient with T2DM through coaching and education (Djuric et al., 2017; Fortmann et al., 2021; Rodriguez et al., 2018). Structured teaching improves skills, knowledge, confidence, and satisfaction (Harper et al., 2018; Djuric et al., 2017; Duff et al., 2020). The research findings support a standardized orientation program with an evidence-based practice foundation and offer a straightforward pedagogical approach to patient care for all newly hired medical assistants, regardless of experience (Ferrante et al., 2018). Additionally, healthcare provider overload and stress reduction are seen in primary care practices with structured self-directed medical assistants (Rodriguez et al., 2018; Sheridan et al., 2018). Ferrante et al. (2018) described how healthcare provider satisfaction increases with knowledgeable and reliable medical assistants. Well-trained MAs enhance patient and health care provider wellness (Ferrante et al., 2018; Fortmann et al., 2021; Rodriguez et al., 2018). Standardized orientation programs benefit the MA, patient, organization, stakeholders, and community by ensuring high-quality training education. Medical assistants need universal training to help the team develop high-quality healthcare (Djuric et al., 2017). Fortmann et al. (2021) and Freund et al. (2016) identified that when medical assistants lack appropriate training, patient health improvements are less IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 24 significant than MAs receiving comprehensive medical training. Patient outcomes are mainly afflicted when medical assistants lack understanding and knowledge regarding the best patient practices (Djuric et al., 2017; Willard-Grace et al., 2015). Educational training yields increased knowledge, skills, and confidence in MAs (Djuric et al., 2017). A standardized training program returns the best results when combined with mentoring and peer training (Fortmann et al., 2021; Fraher et al., 2020; Sheridan et al., 2018). Mentoring and Role of Peer Training Mentoring includes imparting knowledge regarding skills, procedures, patient care, and clinic policies (Moehring et al., 2018). Coupled with peer training, an experienced medical assistant guides the new medical assistants through discussion, observation, and recommendations to increase success in the workplace (Seay-Morrison et al., 2021). Additionally, mentors encourage role development combined with reflection and introspection (Wermelinger et al., 2020). Also, increased accessibility to a mentor contributes to developing the confidence and knowledge of the medical assistant by improving the probability of success (Ferrante et al., 2018). Mentoring is an integral part of employee development through guidance. Seay-Morrison (2021) showed that new employees who choose a mentor to work with also view the mentor as a role model. Of note, training is mainly focused on task reproduction, while mentoring and peer training involves guiding the new medical assistant as an individual (Tsai et al., 2018). Research supports the addition of mentors willing to dedicate time to enriching a new medical assistant's education and having job satisfaction growth (Djuric et al., 2017; Ferrante et al., 2018). Palsson et al. (2017) showed that students' learning improves when working alongside peers. Pairing medical assistants with seasoned staff increases skill and knowledge, improving IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 25 clinic flow and patient safety (Friedman & Neutze, 2020; Willard-Grace et al., 2015). Pålsson et al. (2017) reported improved self-productivity and direction with supportive education than traditional on-the-job training. Moehring et al. (2018) illustrated how students’ comprehension and learning increased with a hands-on skills lab approach. Seay-Morrison et al. (2021) encouraged an effective training program to ensure patient safety and reliable patient outcomes. With adequate communication, confidence, and peer learning, medical assistants positively contribute to patient care. A Gap in Practice Knowledge Medical assistants with various medical knowledge and skills have various job satisfaction and fulfillment (Fraher et al., 2020). Many have no formal medical education, experience, or understanding of medical office culture, flow, or expectation (Ferrante et al., 2018). Solutions to developing a reliable medical assistant include several essential points, including communication training, improving critical thinking skills, building trust, and peer training. In states that do not have a governing credentialing board, the employing organization dictates the requirements for education in medical assistants (Fraher et al., 2020). No license or certification exists in Utah, leaving the education level required to hire healthcare organizations (Utah Medical Practice Act, 2013). Medical assistants trained by their employers are not always adequately prepared to provide care while balancing patient needs with office needs daily (Djuric et al., 2017; Rodriguez et al., 2018; Sheridan et al., 2018). Interacting with patients and colleagues is an essential aspect of medical assistant training. Teaching medical assistants to understand the significance of patient care leads to healthier and safer outcomes (Sheridan et al., 2018). Sheridan et al. (2018) showed that the satisfaction of medical assistants grew with IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 26 increased responsibility for patient care, leading to increased satisfaction in clinics with team-based care models. Discussion The search of the current evidence did not return systematic reviews. The recently published randomized controlled trials discussed using medical assistants as health coaches for patients with chronic diseases to improve outcomes. Articles focused on how a medical assistant can increase productivity within primary care practices but lack solutions to achieve such a goal. Several articles published in the 1960s identified the training needs of medical assistants and discussed solutions to implement practical training. Due to the aged publication dates, the reports were unable to be used. In the last 15 years, there have been no articles explicitly found that addressed training MAs with solutions. Many current articles examined newly graduated nurses' training plans or continuing education to ensure a correct understanding of the role. Considering much focus has been placed on implementing residencies and comprehensive training for newly graduated nurses, why has the same concept not been applied to medical assistants, as they serve an immense purpose for patient care? The gap in literature allows future research to investigate approaches to developing medical assistant flourishment in primary care by using concepts formed in this given project. The literature review was to identify evidence-based research to support the necessity of developing and implementing a standardized training program to advance the skills and knowledge of medical assistants. Ensuring consistency among medical assistant skills, knowledge, and confidence increases stakeholder and healthcare provider satisfaction. The evidence demonstrated the need for MA role expansion and advanced training to reduce patient error. Many studies have shown patients' success in working with medical assistants with IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 27 comprehensive training. Preparing medical assistants for diversified roles enhances the care details concerning patient care (Song et al., 2020). Expertly trained DNP-prepared nurses have the skills to identify organizational gaps in practice and review the evidence-based literature to formulate solutions to innovate outdated clinical practices and policies. Implications for Practice The West Valley Planned Parenthood clinic has a high MA turnover rate, translating into increased organization expenses. With the high turnover, seasoned staff frequently train new medical assistants, leading to burnout. Similarly, health care providers also fatigue from instructing new medical assistants, only to repeat the process a few months later. Ultimately, patients are affected by the various degrees of care medical assistants deliver. Developing a standardized training program for medical assistant training at the West Valley Planned Parenthood is critical to reducing high turnover. After implementing the project, job satisfaction for medical assistants and health care providers increased, which led to improved patient outcomes. The evidence reviewed reinforces the need for widening and strengthening the MA role today, as team-based care becomes the healthcare delivery model of tomorrow (Ferrante et al., 2018; Fortmann et al., 2021; Rodriguez et al., 2018). The West Valley Planned Parenthood Clinic is the busiest in the Utah Planned Parenthood clinics, with a high turnover rate of medical assistants, and chosen to pilot the project. Evidence supports the obligation to ensure high-quality patient care, which begins with the commitment to support and adequately educate MAs using evidence-based recommendations. Medical assistants are an essential part of team-based care who support patients and healthcare providers (Ferrante et al., 2018; Fortmann et al., 2021; Rodriguez et al., 2018). IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 28 Project Plan Engaging in quality improvement in primary care is essential to achieve the triple aim of improving health outcomes, the population's overall health, and improving the provider experience (Institute for Healthcare Improvement [IHI], 2012). Additionally, quality improvement involves recognizing, analyzing, and optimizing existing systems (Duff et al., 2020). Healthcare organizations that highly regard quality improvement continually seek to build upon their patients' outcomes by identifying and investigating new methods to optimize organization performance (Teisberg et al., 2020). As a result, this quality improvement project achieved the aims and objectives of the Triple Aim by improving outcomes through an evidence-based standardized educational intervention. The project recognized the opportunity to enhance current systems after analyzing organizational needs. Additionally, the pilot project introduced a standardized training program for MAs at the Utah Planned Parenthood to improve current practices with a systemic focus on QI and patient safety. Understanding process improvement involves recognizing the importance of standardizing training programs (Damschroder, 2020). Lastly, the pilot aimed to promote primary care practices among MAs with a strong QI orientation to improve their performance and communicate changes that may benefit future training. Specific areas identified as training priorities included venipuncture, intramuscular injections, and blood pressure collection techniques. Continuous quality improvement involves a systematic approach that strives to improve health care quality measures (DeAngelis et al., 2017). Project Design and Outcomes Project designs organize ideas, structures, and processes to achieve set goals (Berridge et al., 2016). The development of the quality improvement project required understanding the needs IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 29 of the organization by conducting a gap analysis, using the data to create an evidence-based project, and monitoring MA performance from the pilot project over a set period to help target areas for future improvement of training (Duff et al., 2020). This project aimed to determine whether the developed standardized training program increased MA knowledge, skills, and confidence. The project design consisted of two four-hour classroom and practice sessions with a 32-hour preceptorship. Participants learned about blood pressure, accurate charting, correct room setup, and contraception on day one. On day two, topics included pregnancy test types, intramuscular injection administration, and venipuncture. See Appendix A for the complete classroom schedule. The SMART Goals framework guided the project goals. Short-term goals included strengthening new knowledge by the end of day two by standardizing the training and testing used. Intermediate outcomes included assessing the skills and knowledge required for the participants to conduct intramuscular injections and venipunctures without supervision by the end of October 2021. Likewise, the long-term outcome was for participants to continue to retain learned knowledge and confidence by March 2022. This goal was achieved using the MA Knowledge Test and MA Confidence Survey to directly measure changes in knowledge and confidence resulting from the standardized educational training. In brief, the project design and evaluation instruments were derived from the organization's needs and supported by evidence. Needs assessments enable organizations to identify obstacles in practice or policies that prohibit the achievement of the desired goals (Brouwer et al., 2018). In order to ensure the program's effectiveness, plans were developed, the target population determined, and resources were identified (DeAngelis et al., 2017; Woo et al., 2017). In the spring of 2021, a gap analysis revealed the opportunity to improve patient outcomes by strengthening the training given to newly hired MAs using best practices. Newer MAs interviewed reported varying levels of patient IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 30 care confidence. Specific areas identified as training priorities included venipuncture, intramuscular injection administration, and blood pressure collection techniques. Participants consisted of four new hires whose role was to apply new knowledge to improve patient care. Participants were initially recruited as the four latest hires from the pilot site. Shortly before the project started, as a testament to the value noted in the project, leadership's consensus changed to include the organization's four newest hires. As a result, the hire dates ranged from one day to three months, and the participants came from three different clinics. All were in their early to mid-20s. Due to the limited number of participants, demographic data was not collected for confidentiality purposes. Two held nursing assistant certificates, one was a certified phlebotomist, and one did not have any previous medical training. Although education varied, literacy rates were adequate, as all were high school graduates. In addition, social determinants of health (SDoH) considered included age, language, literacy, previous training, and education (Hardy et al., 2021). Understanding how the project directly affected participants related to SDoH, the aim was to increase health literacy to affect outcomes positively. As participants, part of the MA’s role as stakeholders was to bring different experiences and feedback to the project. The role of the stakeholder was to help the project team achieve the goals by providing feedback and observations on the training program (Brouwer et al., 2018). In addition, stakeholders provided the materials and resources required to complete the project. Stakeholders included administrators, experienced and newly hired MAs, healthcare providers, and the DNP student. The management provided the resources necessary for the project and made critical decisions. Experienced MAs and healthcare providers were also crucial to influencing the staff's acceptance of changes made to the training program, while feedback from participants was vital to improving the program. Finally, the DNP student raised organizational awareness about the IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 31 need to update newly hired MA training to incorporate evidence-based practices. Hence, engaging all stakeholders is fundamental to program success. Cost Analysis and Sustainability of Project Introducing a standardized training program for MAs can offer effective onboarding and practical new hire training methods (Duff et al., 2020). Although change involves cost, highly trained MAs are more motivated and deliver confident care (Berridge et al., 2016). The total estimated project costs, including labor and materials, equaled $6,330.11. Expenses consisted of binders, paper copies, medical supplies, computer equipment, and office space. See Appendix B for table consisting of projected costs. Understanding costs associated with quality improvement involves analyzing budgets and developing a sustainability program to support implemented changes (Damschroder, 2020). Cost control is crucial in managing project costs to avoid excessive spending (Brouwer et al., 2018). Properly developed budgets lead to essential decisions that directly impact the sustainability of a project (Damschroder, 2020). Sustainability involves introducing new innovative methods to ensure high-quality health care by integrating long-term changes in organizational culture (Duff et al., 2020). Organizations invested in sustainability reduce waste, lower training costs, and improve patient outcomes (Damschroder, 2020). Organizations must invest in sustainability and quality improvement to make evidence-based changes to enhance healthcare and reduce patient harm. Knowledge of waste reduction is crucial to minimize the impact on human health to improve outcomes (Kleber & Cohen, 2020). Reducing high turnover rates allows organizations to eliminate harm to patients by providing a stable workforce. Planned Parenthood can build upon the pilot findings and continue the training using developed tools like the pre-recorded introductory PowerPoint, supplemental handouts, and pre-made binders. In addition, future program instructors trained to IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 32 run the program would also demonstrate proficiency through the Instructor Skills Pass-Off list to increase inter-rater reliability. See Appendix C for the Instructor Skills Pass-Off list. Sustainability plans increase employee engagement and ensure the change becomes standard practice (Duff et al., 2020). Consent Procedures and Ethical Considerations All medical organizations are responsible for providing consistent and reliable training education to each new employee. In addition, beneficence, justice, and respect for human dignity were essential project considerations (Duff et al., 2020). Participants were informed and allowed to continue or withdraw at any time without any consequences. The data was collected anonymously and stored in a locked device to which only the DNP student had access. Ethical considerations for MAs who needed additional assistance were initiated in a remediation program and monitored during patient care. See Appendices D, E, and F for the remediation flow diagram, guide, and agreement form. Furthermore, the project was submitted to the Weber State University Institutional Review Board (IRB) to ensure that the methods used were ethically responsible and protected the rights of participants. The organization did not require IRB approval. Instruments to Measure the Effectiveness of Intervention Data collection is imperative to understanding how effective developed interventions are for a target population. During this project, pre-and post-tests assessed the impact of the training on MA knowledge and confidence. Pre-tests were given at the beginning of the program, and post-tests were performed at the program culmination. Surveys were again distributed at three and six months to measure the project's long-term impact on confidence and knowledge. The MA Knowledge Test, located in Appendix G, consisted of ten multiple-choice questions, and the IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 33 MA Confidence Survey, found in Appendix H, consisted of a five-point Likert scale survey. The DNP student collected and uploaded the data points to Microsoft Excel for analysis. Skills were evaluated using a skills checklist, located in Appendix I to investigate MA knowledge development. See Appendix J for the Practicum Hours Log that was designed to keep track of skills practice hours while paired with a mentor. However, time constraints did not allow for the preceptorship to be fully implemented during the pilot. Initially, the PPAU Assistant Medical Director was the content expert, who retired during the project term and passed the project to the Lead Clinician. The training program tools proved to be effective in collecting the requisite data. Project Implementation The purpose of the implementation phase of the DNP project is to execute the project plan through implementation in the practice arena (Aarons, et al., 2017; Brandrud et al., 2017). Project implementation plans are necessary to depict tasks required for project completion, and this section will discuss the project interventions and timelines. Project Intervention An intervention is a process that impacts outcomes and is designed to create change and transform a system or population (Belcher & Palenberg, 2018). Therefore, the project aspired to increase new hires' MA Skills, knowledge, and confidence through an educational intervention and training program. The four participants came from different locations and had different training experiences that led to a wide range of medical understanding. Of the four participants, two held nursing assistant certificates (CNA), one did not have any medical background, and the last participant was a phlebotomist. Although two were CNAs, they did not draw blood or administer intramuscular injections in their previous workplaces. As a result of the project, both CNA participants acquired these valuable skills, which are needed and applied to daily practice. IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 34 The third participant did not have any previous medical experience and demonstrated little knowledge or skill of required MA proficiencies. The final participant was a former employee of the organization and a certified phlebotomist. Although there was a history of working with PPAU, there had been a three-year hiatus, so the participant said the training program was a critical review of the skills needed to work at PPAU. Improvements in organizations and patient outcomes occur by creating evidence-based changes within a system (Zipfel et al., 2020). In order to improve the quality of care, support healthcare providers, and improve patient outcomes, evidence-based training programs must be developed (Albarqouni et al., 2018). In health professions, evidence-based practices are integrated into school curricula to bridge the gap between assimilating new knowledge into practice earlier (Brownson et al., 2018). New hire training programs should also strive to remain on the same level as school programs to understand best practices, leading to excellent patient outcomes. The project deliverables were created from various evidence-based resources and customized expressly for MAs, including injection diagrams (Appendix K), blood pressure technique handouts (Appendix L), PowerPoints, and a skills lab. The project deliverables were reviewed by a team of experts who provided guidance, ideas, and feedback for success. The DNP student served as project manager and led the project team by coordinating the resources needed to ensure the timely completion of the project objectives for newly hired MAs. On September 2, 2021, a small-scale quality improvement project was implemented. The project was designed with interventions to broaden and increase new MA skills, knowledge, and confidence by developing a standardized competency-based orientation program piloted at a reproductive healthcare clinic in the Salt Lake City area. Evidence supports competency-based, standardized training programs to improve patient care outcomes (CDC, 2021; Lucey et al., IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 35 2018). The competency-based standardized training program was provided to MAs the organization had employed in the last three months from the project start date. The Director of Scheduling selected the number of program participants. The four newest hires to the organization were selected by scheduling to participate in the training for two four-hour face-to-face classroom didactic sessions, including a hands-on practice lab and a 32-hour preceptorship. Four participants were scheduled to receive: • two four-hour face-to-face classroom didactic sessions • including a hands-on practice lab In actuality, four participants received: • One 6 hour didactic and hands-on practice session • One 8 hour didactic and hands-on practice session The longer class time was related to the higher-than-expected level of participant engagement. Additional material was planned for, but the topics were not discussed due to time constraints. Participants were given binders to keep containing educational handouts designed explicitly for the project. Also, the PPFA skills training videos which are created for the Planned Parenthood affiliates were shown during the training to reinforce the education provided. Evidence-based training led to project achievement of goals (Belcher & Palenberg, 2018). In addition, due to the staff scheduling changes related to the global COVID-19 pandemic, the 32-hour preceptorship could not be instituted. The project objectives served as a guide to successfully and succinctly convey the project's goals. Project objectives included adding evidence-based practices to the training program to increase teaching consistency through standardization, training effectiveness, and refining MA learning experiences. Transferring knowledge to MAs through a standardized IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 36 education program means imparting the proper knowledge to MAs at the right time (Shahmoradi et al., 2017). As healthcare consists of knowledge-driven processes, establishing goals is imperative to managing knowledge. The short-term goals were to increase MAs' knowledge base and demonstrate blood pressure skills, intramuscular injections, and venipuncture techniques. The goal measured knowledge improvement by developing training-specific multiple-choice testing given before and after the intervention. Intermediate outcomes included signing off the participants to independently perform intramuscular injections and venipunctures without supervision by October 2021. This objective was achieved with a skills checklist developed for this training. Likewise, the long-term outcome was for participants to continue to retain learned knowledge and confidence by March 2022. The MA Knowledge Test, MA Confidence Survey, and MA Skills Checklist tools compared baseline results with post-intervention findings to assess the program's effectiveness. Ensuring knowledge growth was retained by comparing the MA Knowledge Test and MA Confidence Survey results after three- and six months to the baseline data. This comparison was to ensure that practice change improvement continued for MAs individually due to the training. These results have an impact on the organization at the systems level. The pilot showed that the program was successful at the microsystem level. The next goal was to disseminate and implement the project at the systems level for the Utah Planned Parenthood affiliate. This DNP project focused on a micro-systems level, focusing on the medical assistant population. Implementing an educational intervention in the MA training arena leads to organizational improvement through improved patient outcomes. Equally important, this project was designed to evaluate the processes and outcomes to guide both practice and policy. Seeking participant feedback (Appendix M) after every training course through a program survey allows IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 37 the program to continue evolving, striving for improvement. Outcomes were evaluated through standardized checklists and testing. Implementing the project on a micro and meso systems level improves interprofessional collaboration and improves patient and population health outcomes. As part of the project's sustainability plan, an organizational practice change involving implementing the systems-level training program was developed. Organizational change is imperative to the success and growth of healthcare systems. Pilot programs identify any challenges or changes that need to be addressed to minimize the impact before implementing change on a large scale (Brandrud et al., 2017). Empowering medical assistants to communicate effectively promotes increased collaboration with patients, healthcare providers, and the community, which results in a cohesive healthcare team striving to achieve the same goals and outcomes, thus improving patient health. Project Timeline The project timeline is a visual display that communicates an overview of the deliverables and due dates (Hande & Phillippi, 2018). In the Spring of 2021, the project began after assessing the population's needs and developing a proposal for the educational intervention. After receiving project approval from the organization, the project team created instruments to evaluate the program's effectiveness. Following this, IRB approval was obtained in August 2021 (Appendix N), and the project was implemented in the Fall of 2021. At that point, data was collected pre-and post-intervention and again at the three- and six-month marks. Data interpretation occurred from Fall 2021 through Spring 2022. Lastly, the DNP project was presented to the project committee in the Spring of 2022. The dissemination of the project findings began in April 2022 with plans for professional publication. See Appendix O for the detailed project timeline. IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 38 Project Evaluation Quality improvement (QI) in healthcare seeks to standardize organizational processes and structures to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations (Centers for Medicare and Medicaid Services [CMS], 2021; Mortimer et al., 2018). When followed at the systems level, QI processes ensure the dissemination of evidence-based practices through standardizing operating procedures aligning changes in practices and behaviors across the organization (Jackson et al., 2020). Furthermore, managing human capital through training new employees promotes staff members to contribute effectively to the organization. In comparison, structures involve understanding technology, culture, and leadership. Therefore, QI is a continuous evaluative activity where opportunities to address barriers, issues, and challenges occur as changes are implemented (Jackson et al., 2020; Mortimer et al., 2018). In a microsystem, interacting elements are interdependent yet unpredictable in operation (Jackson et al., 2020). The Plan, Do, Study, Act (PDSA) cycle offers a QI framework through systematic steps for gaining valuable learning and knowledge to shift strategies as needed for the continual incremental improvement of a process (McNicholas et al., 2019). In this project, formative assessments monitored participants' learning and provided feedback to stakeholders, while summative assessments evaluated participants' knowledge at project completion and compared the results to benchmarks (Li et al., 2021). This DNP project created a pilot program to determine if standardizing the West Valley Planned Parenthood training program increased knowledge, skills, and perceived confidence in newly hired MAs. Therefore, the project included the development of an evidence-based MA training program for newly hired medical assistants. The tools used in this project were adapted from two previously validated survey instruments. IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 39 • the MA Knowledge Test consisted of ten multiple-choice questions • the MA Confidence Survey consisted of a five-point Likert scale survey Instruments were used to assess the impact of the training on initial knowledge and confidence compared to the long-term impact on confidence and knowledge. Tools such as The MA Confidence Survey and the MA Knowledge surveys were developed for this project. The confidence survey measured confidence baseline and changes post-intervention. The knowledge questionnaire applied a multiple-choice test to measure knowledge expansion. The purpose of the skills observation and surveys was to access MA knowledge, skills, and perceived confidence. The confidence survey quantified confidence before the intervention, immediately after the intervention, then again at 90 days and 180 days after the intervention. The knowledge questionnaire quantified knowledge before the intervention, immediately after the intervention, then again at 90 days and 180 days after the intervention. The evidence supports increased MA confidence and knowledge with sustained retention when training with standardized protocols. Data Maintenance/Security Data security protects the confidentiality of participants' responses from accidental disclosure (Mannebäck & Padyab, 2021). Project data was collected utilizing a pre-post design in which observations are made before and after the educational training programs over a specified period (Bagot et al., 2019). The survey did not include any possible direct identifiers, such as individual names, addresses, and clinic locations, linking respondents to the survey. Due to the low number of participants, n = 4, demographics were not collected to ensure that personal characteristics could not be attributed to individual participants. Surveys were collected in aggregate form and placed in a secure and locked location to prevent the possible identification IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 40 of individuals, thereby protecting participants' confidentiality. Only the DNP student had access to the secured and locked location of the data. Data Collection Organizations cannot improve processes if data is not reliably measured (Akbarzadeh et al., 2020). Due to the limited number of participants, demographic variables were not collected for confidentiality. Follow-up surveys were initially distributed to participants via Qualtrics survey, but only one response was returned. The follow-up tools were then converted and distributed via pencil and paper, which yielded a higher response rate. Surveys were collected in aggregate form and placed in a secure and locked location to prevent the possible identification of individuals. The MA Confidence Survey measured how comfortable assistants were in providing clinical care (Gandhi et al., 2021; Thomas & Mackey, 2012). A five-point Likert scale questionnaire was used to measure the participant's confidence levels and how comfortable MAs were in measuring blood pressures, giving intramuscular injections, and performing a venous puncture before and after the educational training (Gandhi et al., 2021). The scale ranged from (1) not confident to (5) highly confident. The MA Knowledge Test evaluated the clinical knowledge of medical assistants by measuring MA knowledge levels before and after the educational intervention. The test consisted of multiple-choice questions to measure the knowledge base and growth before and after the training (Gandhi et al., 2021; Thomas & Mackey, 2012). Comparisons were performed with the results obtained pre/post-intervention and at 90- and 180-days post-intervention. Participants were provided with a program evaluation on day two. During the project's launch, the goal was also to measure the satisfaction of healthcare providers regarding participant skillset (Gandhi et al., 2021). The health care providers assigned IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 41 to the participant's home clinic were going to be surveyed initially. However, anonymity was a challenge because of the small number of health care providers. After consulting the project team, the survey was changed to measure the manager's satisfaction with the perceived ability of the participating medical assistants to accurately perform common medical assisting skills based on managerial observation at Planned Parenthood. On account of the survey change, the manager's satisfaction survey was administered at 30- and 90-day post-intervention. The survey was based on the MA Knowledge Test and asked managers to circle their level of satisfaction regarding the ability of medical assistants to answer the questions accurately. The correct answers to the questions were bolded, and a five-point Likert scale where one was highly dissatisfied and five was highly satisfied was attached to each question. See Appendix P for complete survey. The qualitative analysis was incorporated into the project with open-ended questions to identify common themes by participants (Weller et al., 2018). The same surveys measure participants' knowledge and confidence results throughout the pilot. Furthermore, the small sample size and lack of leadership interest due to extraneous circumstances, including the COVID-19 pandemic, affected project results. Data Analysis/ Findings The purpose of gathering MA confidence and knowledge results was to transform the collected data into meaningful and valuable information for the practice setting (Reavy, 2016). Data measuring MA confidence and knowledge at specified intervals were gathered and then inputted into Microsoft Excel 2021 to efficiently analyze and interpret the data. Therefore, the Excel program converted data into a table to show the mean visually and standard deviation of the pre-and post-MA Confidence Survey and a follow-up MA Confidence Survey 90- and 180-days post-intervention. The mean and standard deviations for the pre-post MA Confidence IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 42 Survey are depicted in Tables 1 and 2. Participants pre to immediately post had about a 25% improvement in confidence and knowledge. Table 1 Means and Standard Deviation of Scores on Pre-Post Measures for MA Confidence MA confidence questions Pre-assessment n = 4 Post-assessment n = 4 M SD M SD How confident are you in: 1. Choosing the correct sized cuff? 5.00 .00 5.00 .00 2. Placing the stethoscope on the correct location on the arm? 4.50 .58 5.00 .00 3. Listening for the correct heart sounds? 4.50 .58 5.00 .00 4. What to do with a reading of > 140/90 3.50 1.29 5.00 .00 5. Identifying landmarks for the ventrogluteal and deltoid sites? 3.25 1.50 4.75 .50 6. Inserting the needle at a 90-degree angle using a dart-like action? 3.50 1.29 4.75 .50 7. Collecting a venous blood sample? 2.00 2.00 4.50 .58 8. Inserting the needle in the correct location and needle angle? 2.00 2.00 4.50 .58 9. Knowing when a sufficient amount of blood has been collected in the tube? 2.25 1.26 4.50 .58 10. Providing patients with clear education on sexually transmitted disease prevention, treatment, and management? 3.00 1.16 3.50 1.00 11. Providing contraceptive education and options counseling? 3.00 1.16 3.75 1.50 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 43 12. Preparing the exam room for the healthcare provider? 3.25 0.96 4.50 1.00 13. Using the electronic medical health record? 2.75 0.96 4.50 1.00 Note. Key question responses are presented from the Nurses' Clinical Confidence Scale. Table 2 Means and Standard Deviation of MA Confidence Scores at Ninety and 180-days MA confidence questions Ninety-day assessment n = 2 180-day assessment n = 2 M SD M SD How confident are you in: 1. Choosing the correct sized cuff? 5.00 .00 5.00 .00 2. Placing the stethoscope on the correct location on the arm? 5.00 .00 5.00 .00 3. Listening for the correct heart sounds? 5.00 .00 5.00 .00 4. What to do with a reading of > 140/90 4.50 .71 5.00 .00 5. Identifying landmarks for the ventrogluteal and deltoid sites? 5.00 .00 5.00 .00 6. Inserting the needle at a 90-degree angle using a dart-like action? 5.00 .00 5.00 .00 7. Collecting a venous blood sample? 4.5 .71 5.00 .00 8. Inserting the needle in the correct location and needle angle? 4.00 1.41 5.00 .00 9. Knowing when a sufficient amount of blood has been collected in the tube? 5.00 .00 5.00 .00 10. Providing patients with clear education on sexually transmitted disease prevention, treatment, and management? 4.5 .71 5.00 .00 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 44 11. Providing contraceptive education and options counseling? 4.5 .71 5.00 .00 12. Preparing the exam room for the healthcare provider? 4.5 .71 5.00 .00 13. Using the electronic medical health record? 4.5 .71 5.00 .00 Note. Key question responses are presented from the Nurses' Clinical Confidence Scale. In order to analyze and interpret the data collected from the pre-post measures on the MA Knowledge Test, collected results were transferred to Microsoft Excel. The DNP student then transformed the data into a table using Microsoft Excel to visualize the mean and standard deviation of the measures. The mean and standard deviations for the pre-post MA Knowledge Test are depicted in Table 3. Participants at 180 days post-intervention had scored 100% on the knowledge test and rated their confidence levels for every question as highly confident. Table 3 Means and Standard Deviation of Scores on Pre-Post Measures for MA Knowledge MA knowledge questions Pre-assessment n = 4 Post-assessment n = 4 M SD M SD 1. Which blood pressure is within the expected range? .75 .50 1.00 .00 2. How often is Depo-Provera given? 1.00 .00 1.00 .00 3. Which vital sign must be documented in the chart when a patient presents with painful urination? 1.00 .00 1.00 .00 4. While asking a patient questions about her social sexual history, she tells you her last menstrual period was over 30 days ago. Which of the following is the correct initial step? .75 .50 1.00 .00 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 45 5. What vital signs will you collect and document in the patient chart when escorting patients to their exam room? Select all that apply. .25 .50 .25 .50 6. T or F After performing a venous blood draw, immediately put the needle down on the exam table to apply gentle pressure with a cotton ball at the insertion site. .25 .50 .75 .50 7. T or F A male patient tells you his sexual partner tested positive for chlamydia three days ago, which you have verified. He cannot be treated because the healthcare provider needs his chlamydia and gonorrhea results before any medication may be given. 1.00 .00 .75 .50 8. A concerned patient calls the clinic and tells you he has bumps on his genitalia. What are two questions you should ask? 1.00 .00 4.50 .58 9. You are completing a venous blood draw on a patient before the needle punctures the skin. Which way does the bevel on the needle face? .25 .50 1.00 .00 10. Which statement identifies the vital role of the medical assistant working alongside the healthcare provider? .50 .58 0.75 .50 Note. Key question responses are presented from the Nurse Clinical Competence Scale. In order to analyze and interpret the data collected from the ninety and 180-day measures on the MA Knowledge Test and MA Confidence Survey, collected results were transferred to Microsoft Excel. The DNP student then transformed the data into a table using Microsoft Excel IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 46 to visualize the mean and standard deviation of the measures. The mean and standard deviations for the 90- and 180-day MA Knowledge Test are displayed in Table 4. Table 4 Means and Standard Deviation of MA Knowledge Scores at Ninety and 180-days MA Knowledge Questions Ninety Day Assessment n = 2 180-day Assessment n = 2 M SD M SD 1. Which blood pressure is within the expected range? 1.00 .00 1.00 .00 2. How often is Depo-Provera given? 1.00 .00 1.00 .00 3. Which vital sign must be documented in the chart when a patient presents with painful urination? 1.00 .00 1.00 .00 4. While asking a patient questions about her social sexual history, she tells you her last menstrual period was over 30 days ago. Which of the following is the correct initial step? 1.00 .00 1.00 .00 5. What vital signs will you collect and document in the patient chart when escorting patients to their exam room? Select all that apply. 1.00 .00 1.00 .00 6. T or F After performing a venous blood draw, immediately put the needle down on the exam table to apply gentle pressure with a cotton ball at the insertion site. 1.00 .00 1.00 .00 7. T or F A male patient tells you his sexual partner tested positive for chlamydia three days ago, which you have verified. He cannot be treated because the healthcare provider .50 .71 1.00 .00 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 47 needs his chlamydia and gonorrhea results before any medication may be given. 8. A concerned patient calls the clinic and tells you he has bumps on his genitalia. What are two questions you should ask? 1.00 .00 1.00 .00 9. You are completing a venous blood draw on a patient before the needle punctures the skin. Which way does the bevel on the needle face? 1.00 .00 1.00 .00 10. Which statement identifies the vital role of the medical assistant working alongside the healthcare provider? 1.00 .00 1.00 .00 Note. Key question responses are presented from the Nurse Clinical Competence Scale. In order to analyze and interpret the data collected from the 30-and 90-day Clinic Manager Satisfaction Survey, results were uploaded to Microsoft Excel. The DNP student transformed the data into a table to visualize the mean and standard deviation of the measures by compiling the manager's satisfaction with their perceived ability of the participating MA to answer the MA Knowledge Test questions correctly. The mean and standard deviations are depicted in Table 5. Table 5 Means and Standard Deviation of Clinic Manager Scores at 30- and 90-days Satisfaction Questions Thirty Day Assessment n = 2 90-day Assessment n = 2 M SD M SD 1. Which blood pressure is within the expected range? 5.00 .00 5.00 .00 2. How often is Depo-Provera given? 5.00 .00 5.00 .00 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 48 3. Which vital sign must be documented in the chart when a patient presents with painful urination? 4.50 .71 5.00 .00 4. While asking a patient questions about her social sexual history, she tells you her last menstrual period was over 30 days ago. Which of the following is the correct initial step? 4.50 .71 5.00 .00 5. What vital signs will you collect and document in the patient chart when escorting patients to their exam room? Select all that apply. 5.00 .00 5.00 .00 6. T or F After performing a venous blood draw, immediately put the needle down on the exam table to apply gentle pressure with a cotton ball at the insertion site. 5.00 .00 5.00 .00 7. T or F A male patient tells you his sexual partner tested positive for chlamydia three days ago, which you have verified. He cannot be treated because the healthcare provider needs his chlamydia and gonorrhea results before any medication may be given. 4.50 .71 5.00 .71 8. A concerned patient calls the clinic and tells you he has bumps on his genitalia. What are two questions you should ask? 5.00 .00 5.00 .00 9. You are completing a venous blood draw on a patient before the needle punctures the skin. Which way does the bevel on the needle face? 4.50 .71 5.00 .00 10. Which statement identifies the vital role of 5.00 .00 5.00 .00 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 49 the medical assistant working alongside the healthcare provider? Note. Key question responses are presented from the Nurse Clinical Competence Scale. Limitations of a Small n Small sample sizes can weaken the reliability of the findings by increasing variability. For this reason, it is crucial to note that this project began with an n = 4, which decreased to an n = 2. Data collection occurred pre-and post-intervention on four newly hired medical assistants who agreed to participate in the pilot project. However, during the 90-day follow-up, the number of the participants had decreased to an n = 2. One participant was lost to follow-up after resigning from the organization, and another lost interest in further participation at the 90-day follow-up point. Therefore, there is difficulty determining if outcomes are genuinely representative of new hire medical assistants when working with a small sample size. Contributing factors that led to a small sample size were accessibility to new MA hires, little interest in the project after the assistant medical director retired, difficulty eliciting seasoned staff assistance, frequent scheduling changes, and above all, the impact of the COVID-19 pandemic on employee coverage. Qualitative Analysis Qualitative methods were derived from open-ended questionnaires (Weller et al., 2018). Participants were encouraged to give feedback on program improvements and record their confidence levels related to the training. Topics, such as participant feedback, were: "It helped me so much!! I am more confident with my skills. This has been such a positive and helpful training." The qualitative aspect focused on the participant's experience and meaning of the training. The feedback given on the program evaluation was feeling more competent and IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 50 knowledgeable in understanding patient care. All of the initially participating assistants requested that the program continue with the material that had been planned for, but had not been taught. Participants also demonstrated the proper techniques for intramuscular injections and venous punctures, in line with care standards. Strengths This project demonstrated the benefits of a standardized training program for newly hired medical assistants. Participants continued to show high levels of confidence and knowledge at 180 days post-intervention. An essential aspect of this project was to develop, pilot, and promote a standardized educational training program for newly hired MAs that could be incorporated at Planned Parenthood's multicentered clinic. The project demonstrated the benefits of a standardized training program for newly hired medical assistants. Additionally, the feedback given by participants supports the desire for new hires to continue the standardized training program demonstrating an organizational gap that this project successfully fills. The importance of developing a personal leadership style that promotes interprofessional collaboration, communication, and flexibility throughout was reinforced during the project. Collaborating and seeking feedback from stakeholders was crucial to bringing about the necessary improvements to the project. Maintaining open communication and regular discussions with key stakeholders reduced initial reservations about changing the current training program, and flexibility allowed for rapid updates as needed. Project Limitations During the project, the COVID-19 global pandemic brought unexpected challenges. Leadership continually needed to alter schedules to cover open shifts for ill employees or employees who had resigned, diminishing the interest held in the project. IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 51 Consequently, recruiting MAs took precedence over the retention of MAs during the project duration. Recruiting was imperative to continue to provide care versus updating the training protocol during the particular arduous time for the organization. Thus, minimal interest in the project could potentially impact sustainability, as the leadership may not fully understand the importance due to organizational distractions. Of equal importance, lead medical assistants were initially scheduled to precept participants, monitor skills, and complete a skills checklist, but this was unfeasible due to frequent scheduling conflicts and time limitations. Furthermore, complete planned lessons could not be fully realized due to time constraints which may have led to artificially deflated MA confidence and knowledge test scores. Additional material was developed for the project, but due lack of time, material items could not be used. See Appendices Q, R, S, T, U, V, W, and X for developed, but unused handouts. Quality Improvement Discussion New hire training is vital to ensure positive patient outcomes because inconsistent training leads to varying care and potential error (Mortimer et al., 2018). After completing a needs gap analysis and forming a project team, a rigorous review of the evidence led to developing a quality improvement project to standardize new hire medical assistant (MA) training. Development of the training program occurred for micro-systems setting adaptable to a macro-system level. This Doctor of Nursing Practice (DNP) project was created to improve patient and community health outcomes by influencing newly hired medical assistants' quality, efficiency, and safety. Implementation of the project took place at the West Valley Planned Parenthood clinic. The program standardized the education and training program to improve knowledge, skills, and perceived confidence in newly hired MA employees. Outcomes were measured using two adapted, previously validated survey instruments to measure MA confidence IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 52 and knowledge (Gandhi et al., 2021; Thomas & Mackey, 2012). The confidence survey consisted of a five-point Likert scale questionnaire to establish baselines to compare the differences. The knowledge questionnaire used a multiple-choice test to measure the initial understanding of primary care skills and then compare the results after the intervention. Furthermore, the satisfaction levels of clinical managers were measured using the Clinical Manager Survey based on the MA Knowledge Test. Managers rated their satisfaction level with the ability of medical assistants to perform essential skills correctly (Gandhi et al., 2021). Quality improvement aims to improve uncovered operational deficits, as the consequences can affect efficiency, safety, and results (Dixon-Woods & Martin, 2016). Therefore, this QI project sought to improve patient care by standardizing the MA training process to reduce practice discrepancies, increase safety, and promote high-quality outcomes. Translation of Evidence into Practice The translation of evidence into clinical practice delivers the best results and value while reducing risks to the community and patient population (Fencl & Matthews, 2017). Evidence-based recommendations support standardizing training programs to provide effective, safe, and patient-centered care to increase knowledge, confidence, and skills (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Freund et al., 2016; Willard-Grace et al., 2015). However, system changes are often challenging to implement, even with evidence-based recommendations (Bagot et al., 2019). Implementing updated protocols, policies, and guidelines often lags behind the research due to a lack of leadership and health care providers expertly trained to identify system improvement opportunities (Akbarzadeh et al., 2020; Bagot et al., 2019; Ketron, 2019). The DNP project used evidence-based practice recommendations and frameworks to guide decision-making and program development. A gap analysis performed at IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 53 the project's inception identified the need to update and standardize organizational training protocols for MAs. The inconsistency in MA training indirectly contributes to decreased confidence, knowledge, and skills, affecting care delivery while placing the organization, staff, and patient population at risk. Additional lessons mastered by developing the project included: • learning the importance of creating a collaborative culture within the organization • developing metrics to evaluate outcomes • communicating with key stakeholders to promote the adoption of new clinical practice standards Furthermore, the DNP student developed an end-of-course evaluation to collect feedback regarding participant perceptions and experiences with the training program. The returned end-of-course evaluation surveys showed overwhelmingly positive results. Implications for Practice and Future Scholarship Practice scholarship aims to use evidence-based recommendations to solve healthcare complications, preventing the development of a safer, higher-quality, higher-value healthcare system (Trautman et al., 2018). This DNP project uses evidence-based recommendations to develop a standardized training program to increase patient safety and quality. Additionally, the feedback given by participants supports the desire for new hires to continue the standardized training program demonstrating an organizational gap that this project successfully fills. A substantial amount of time and resources were invested in developing the implementation and sustainability phases of the DNP project. As a result, other health leaders, health care providers, management, and future DNP students can use the results of this DNP project to address identified barriers further, find other limitations, and develop strategies to improve training for new staff in outpatient care. In addition, the reappraisal of the standardized training process IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 54 could lead to new models that use different frameworks or structures for continuous ongoing quality improvement (Ketron, 2019). Sustainability The sustainability of evidence-based interventions is based on the continuation of newly implemented changes over time (Lennox et al., 2020). The goal of sustainability is to improve performance, health outcomes, efficiency, and delivery of care. The sustainability plan includes using the Instructor Skills Checklist to train the registered nurse to continue to deliver the standardized training. In addition, within six months of resuming the program, she will use the Instructor Skills Checklist to train the lead MAs from each clinic. The sustainability concepts in this project support the continuation of the newly implemented program developed to improve MA orientation training (Ketron, 2019; Mortimer et al., 2018). Sustainability aims to improve performance, health outcomes, patient care, and systems efficiency. Practice changes continue over time and allow for a comprehensive and rigorous evaluation (Ketron, 2019). Ensuring project sustainability required developing various educational tools, including videoed PowerPoint presentations, developing educational handouts, creating lesson plans, generating instructor skills checklists, designing remediation plans, and constructing questionnaires and surveys uploaded into the organization's intranet medical drive for the future use. Collaborative efforts with other health professionals and continuous intervention assessment through improvement models are recommended, and the impact of these strategies should be investigated in the future. Dissemination Disseminating the project findings helps others benefit from the information, results, and lessons learned. By contributing to a culture of improvement, patients and systems benefit from IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 55 improving health care for all patients. QI dissemination aims to share knowledge and exchange information with healthcare leaders and healthcare providers. The dissemination of the project intends to distribute information, results, and evidence-based interventions to the clinical practice and leadership audience (Ketron, 2019). Disseminating information is facilitated by creating educational posters, speaking at conferences, publishing the findings, and presenting new knowledge and information worldwide, national, or local platforms. The goal of dispersing new knowledge to the clinical community improves clinical practice and patient outcomes. The results of the DNP project can be generalized to help organizations understand the importance of standardizing training programs. The DNP student will present project findings at the Sigma Theta Tau 2022 Leadership Conference. Conclusion Quality improvement (QI) seeks to systematically address operational issues related to healthcare delivery by standardizing processes to reduce variation and improve patient outcomes (Mortimer et al., 2018). Medical staff trained to provide exceptional care through standardized training provide a higher quality of care that correlates with better health outcomes (Ferrante et al., 2018; Fortmann et al., 2021; Fraher et al., 2020; Freund et al., 2016). Implementing a standardized training program increased the knowledge and confidence of newly hired medical assistants working in Planned Parenthood clinics in the Salt Lake area. New hires reported being more competent in understanding patient care needs while demonstrating the proper techniques for intramuscular injections and venous punctures in line with care standards. Furthermore, standardizing the orientation training program undeniably positively impacts the medical assistant new hire experience. Adapting the Iowa Model for Evidence-Based Practice and facilitating effective communication with key stakeholders can positively impact introducing a IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 56 standardized training program for newly hired MAs. This quality improvement project offers the opportunity to improve health outcomes at the individual and community level by reducing practice discrepancies, increasing safety, and promoting high-quality outcomes. IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 57 References Aarons, G. A., Sklar, M., & Sevdalis, N. (2017). Implementation science: Translating research into practice for sustained impact. Surgical Patient Care, 277–293. https://doi.org/10.1007/978-3-319-44010-1_18 Akbarzadeh, M., Abootalebi, M., & Dehghani, M. (2020). Implementing of mental health training programs for promotion of health affected teenage girls to premenstrual syndrome: A community-based study. Journal of Education and Health Promotion, 9(1), 155. https://doi.org/10.4103/jehp.jehp_118_20 Albarqouni, L., Hoffmann, T., Straus, S., Olsen, N. R., Young, T., Ilic, D., Shaneyfelt, T., Haynes, R. B., Guyatt, G., & Glasziou, P. (2018). Core competencies in Evidence-Based practice for health professionals. JAMA Network Open, 1(2), e180281. https://doi.org/10.1001/jamanetworkopen.2018.0281 American Association of Colleges of Nursing (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf *American Diagnostic Corporation. (n.d.). How to Take Blood Pressure [Image]. https://www.adctoday.com/learning-center/about-sphygmomanometers/how-take-blood-pressure Araújo, M. S. D., Medeiros, S. M. D., Costa, E. D. O., Oliveira, J. S. A. D., Costa, R. R. D. O., & Sousa, Y. G. D. (2020). Analysis of the guiding rules of the nurse technician’s practice in Brazil. Revista Brasileira de Enfermagem, 73(3). https://doi.org/10.1590/0034-7167-2018-0322 Bagot, K., Moloczij, N., Arthurson, L., Hair, C., Hancock, S., Bladin, C. F., & Cadilhac, D. A. (2019). Nurses' role in implementing and sustaining acute telemedicine: A Mixed‐IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 58 Methods, Pre‐Post design using an extended technology acceptance model. Journal of Nursing Scholarship, 52(1), 34–46. https://doi.org/10.1111/jnu.12509 Belcher, B., & Palenberg, M. (2018). Outcomes and impacts of development interventions. American Journal of Evaluation, 39(4), 478–495. https://doi.org/10.1177/1098214018765698 Berridge, C., Tyler, D. A., & Miller, S. C. (2016). Staff Empowerment Practices and CNA Retention: Findings From a Nationally Representative Nursing Home Culture Change Survey. Journal of Applied Gerontology, 37(4), 419–434. https://doi.org/10.1177/0733464816665204 Brandrud, A. S., Nyen, B., Hjortdahl, P., Sandvik, L., Helljesen Haldorsen, G. S., Bergli, M., Nelson, E. C., & Bretthauer, M. (2017). Domains associated with successful quality improvement in healthcare – a nationwide case study. BMC Health Services Research, 17(1). https://doi.org/10.1186/s12913-017-2454-2 Brouwer, W., van Baal, P., van Exel, J., & Versteegh, M. (2018). When is it too expensive? Cost-effectiveness thresholds and health care decision-making. The European Journal of Health Economics, 20(2), 175–180. https://doi.org/10.1007/s10198-018-1000-4 Brownson, R. C., Fielding, J. E., & Green, L. W. (2018). Building capacity for Evidence-Based public health: Reconciling the pulls of practice and the push of research. Annual Review of Public Health, 39(1), 27–53. https://doi.org/10.1146/annurev-publhealth-040617-014746 Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B., Steelman, V., Tripp-Reimer, T., & Tucker, S. (2017). Iowa model of Evidence-Based practice: IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 59 Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175–182. https://doi.org/10.1111/wvn.12223 Caggianese, G., Cuomo, S., Esposito, M., Franceschini, M., Gallo, L., Infarinato, F., Minutolo, A., Piccialli, F., & Romano, P. (2019). Serious games and In-Cloud data analytics for the virtualization and personalization of rehabilitation treatments. IEEE Transactions on Industrial Informatics, 15(1), 517–526. https://doi.org/10.1109/tii.2018.2856097 *Cardellichio, P. (2021, March 27). Preparing Ampicillin and Gentamicin for Injection [Image]. https://health-orb.org/resource/view/preparing-ampicillin-and-gentamicin-for-injection Centers for Disease Control and Prevention. (2021). CDC Newsroom. CDC. https://www.cdc.gov/media/releases/2021/p0125-sexualy-transmitted-infection.html Centers for Medicare and Medicaid Services. (2021). Quality measurement and quality improvement. CMS. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Measure-and-Quality-Improvement- Chapman, S. A., & Blash, L. K. (2016). New Roles for Medical Assistants in Innovative Primary Care Practices. Health Services Research, 52, 383–406. https://doi.org/10.1111/1475-6773.12602 Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., Zapata, D., & Fazlul, I. (2018). The three-year impact of the affordable care act on disparities in insurance coverage. Health Services Research, 54, 307–316. https://doi.org/10.1111/1475-6773.13077 Damschroder, L. J. (2020). Clarity out of chaos: Use of theory in implementation research. Psychiatry Research, 283, 112461. https://doi.org/10.1016/j.psychres.2019.06.036 DeAngelis, K. R., Doré, K. F., Dean, D., & Osterman, P. (2017). Strengthening the healthy start workforce: A Mixed-Methods study to understand the roles of community health workers IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 60 in healthy start and inform the development of a standardized training program. Maternal and Child Health Journal, 21(S1), 65–74. https://doi.org/10.1007/s10995-017-2377-x Dixon-Woods, M., & Martin, G. P. (2016). Does quality improvement improve quality? Future Hospital Journal, 3(3), 191–194. https://doi.org/10.7861/futurehosp.3-3-191 Djuric, Z., Segar, M., Orizondo, C., Mann, J., Faison, M., Peddireddy, N., Paletta, M., & Locke, A. (2017). Delivery of health coaching by medical assistants in primary care. The Journal of the American Board of Family Medicine, 30(3), 362–370. https://doi.org/10.3122/jabfm.2017.03.160321 Duff, J., Cullen, L., Hanrahan, K., & Steelman, V. (2020). Determinants of an evidence-based practice environment: An interpretive description. Implementation Science Communications, 1(1). https://doi.org/10.1186/s43058-020-00070-0 Fencl, J. L., & Matthews, C. (2017). Translating evidence into practice: How advanced practice RNs can guide nurses in challenging established practice to arrive at best practice. AORN Journal, 106(5), 378–392. https://doi.org/10.1016/j.aorn.2017.09.002 Ferrante, J. M., Shaw, E. K., Bayly, J. E., Howard, J., Quest, M. N., Clark, E. C., & Pascal, C. (2018). Barriers and facilitators to expanding roles of medical assistants in Patient-Centered medical homes (PCMHs). The Journal of the American Board of Family Medicine, 31(2), 226–235. https://doi.org/10.3122/jabfm.2018.02.170341 Fortmann, A. L., Philis-Tsimikas, A., Euyoque, J. A., Clark, T. L., Vital, D. G., Sandoval, H., Bravin, J. I., Savin, K. L., Jones, J. A., Roesch, S., Gilmer, T., Bodenheimer, T., Schultz, J., & Gallo, L. C. (2021). Medical assistant health coaching (“MAC”) for type 2 diabetes in diverse primary care settings: A pragmatic, cluster-randomized controlled trial IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 61 protocol. Contemporary Clinical Trials, 100, 106164. https://doi.org/10.1016/j.cct.2020.106164 Fraher, E. P., Cummings, A., & Neutze, D. (2020). The evolving role of medical assistants in primary care practice: Divergent and concordant perspectives from MAs and family physicians. Medical Care Research and Review, 78(1_suppl), 7S-17S. https://doi.org/10.1177/1077558720966148 Friedman, J. L., & Neutze, D. (2020). The financial cost of medical assistant turnover in an academic family medicine center. The Journal of the American Board of Family Medicine, 33(3), 426–430. https://doi.org/10.3122/jabfm.2020.03.190119 Freund, T., Peters-Klimm, F., Boyd, C. M., Mahler, C., Gensichen, J., Erler, A., Beyer, M., Gondan, M., Rochon, J., Gerlach, F. M., & Szecsenyi, J. (2016). Medical Assistant–Based care management for High-Risk patients in small primary care practices. Annals of Internal Medicine, 164(5), 323. https://doi.org/10.7326/m14-2403 Gandhi, S., Glaman, R., Yeager, J., & Smith, M. (2021). Evaluation of anxiety and Self-Confidence among baccalaureate nursing students post pandemic simulation exercise. Clinical Simulation in Nursing, 56, 91–98. https://doi.org/10.1016/j.ecns.2021.04.007 *Greenway, K. (2004, March 3). Using the ventrogluteal site for intramuscular injection [Image]. Location of the Ventrogluteal Site for Intramuscular Injection. https://link.gale.com/apps/doc/A114367991/PPNU?u=ogde72764&sid=summon&xid=0c07e880 Hande, K., & Phillippi, J. C. (2018). DNP project timeline template. Nurse Educator, 43(3), 115–116. https://doi.org/10.1097/nne.0000000000000472 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 62 Hanrahan, K., Fowler, C., & McCarthy, A. M. (2019). Iowa model revised: Research and evidence-based practice application. Journal of Pediatric Nursing, 48, 121–122. https://doi.org/10.1016/j.pedn.2019.04.023 Hardy, R., Boch, S., Keedy, H., & Chisolm, D. (2021). Social determinants of health needs and pediatric health care use. The Journal of Pediatrics, 238, 275–281.e1. https://doi.org/10.1016/j.jpeds.2021.07.056 Harper, P. G., van Riper, K., Ramer, T., Slattengren, A., Adam, P., Smithson, A., Wicks, C., Martin, C., Wootten, M., Carlson, S., Miller, E., & Fallert, C. (2018). Team-based care: An expanded medical assistant role – enhanced rooming and visit assistance. Journal of Interprofessional Care, 1–7. https://doi.org/10.1080/13561820.2018.1538107 Institute for Healthcare Improvement. (2012). Guide to measuring the triple aim: Population health, experience of care, and per capita cost. Cambridge, Massachusetts: Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx Jackson, G. L., Cutrona, S. L., Kilbourne, A., White, B. S., Everett, C., & Damschroder, L. J. (2020). Implementation science. Journal of the American Academy of Physician Assistants, 33(1), 51–53. https://doi.org/10.1097/01.jaa.0000615508.92677.66 Johnsen, H. M., Fossum, M., Vivekananda-Schmidt, P., Fruhling, A., & Slettebø, S. (2016). Teaching clinical reasoning and decision-making skills to nursing students: Design, development, and usability evaluation of a serious game. International Journal of Medical Informatics, 94, 39–48. https://doi.org/10.1016/j.ijmedinf.2016.06.014 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 63 *Johnson, L. (2020). Teens and sexually transmitted disease impact of education on knowledge on std prevention. Creighton University. http://dspace.creighton.edu:8080/xmlui/handle/10504/122555 Jones, A., Marlatt, S., Geske, J., & Khandalavala, B. (2021). Utilizing a community dance to hold STD testing for chlamydia and gonorrhea in High-Risk adolescents. PRiMER, 5. https://doi.org/10.22454/primer.2021.785793 Karacsony, S., Good, A., Chang, E., Johnson, A., & Edenborough, M. (2019). An instrument to assess the education needs of nursing assistants within a palliative approach in residential aged care facilities. BMC Palliative Care, 18(1). https://doi.org/10.1186/s12904-019-0447-0 Ketron, C. J. (2019). What is it all about? Examining the sustainability of the DNP project. Journal of Doctoral Nursing Practice, 12(1), 93–95. https://doi.org/10.1891/2380-9418.12.1.93 Kleber, J., & Cohen, B. (2020). Reducing waste and increasing sustainability in health care settings. AJN, American Journal of Nursing, 120(4), 45–48. https://doi.org/10.1097/01.naj.0000660032.02514.ec Korneta, P. (2020). Stakeholders and performance management systems of small and Medium-Sized outpatient clinics. Foundations of Management, 12(1), 211–222. https://doi.org/10.2478/fman-2020-0016 Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd ed.). Jossey-Bass. IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 64 Lennox, L., Linwood-Amor, A., Maher, L., & Reed, J. (2020). Making change last? Exploring the value of sustainability approaches in healthcare: A scoping review. Health Research Policy and Systems, 18(1). https://doi.org/10.1186/s12961-020-00601-0 Li, T., Yeung, M., Li, E., & Leung, B. (2021). How formative are assessments for learning activities towards summative assessment? International Journal of Teaching and Education, 9(2), 42–57. https://doi.org/10.52950/te.2021.9.2.004 Lo, T. K. T., Hoben, M., Norton, P. G., Teare, G. F., & Estabrooks, C. A. (2018). Importance of clinical educators to research use and suggestions for better efficiency and effectiveness: Results of a cross-sectional survey of care aides in canadian long-term care facilities. BMJ Open, 8(7), e020074. https://doi.org/10.1136/bmjopen-2017-020074 Lucey, C. R., Thibault, G. E., & Ten-Cate, O. (2018). Competency-Based, Time-Variable education in the health professions. Academic Medicine, 93(3S), S1–S5. https://doi.org/10.1097/acm.0000000000002080 Mannebäck, E., & Padyab, A. (2021). Challenges of managing information security during the pandemic. Challenges, 12(2), 30. https://doi.org/10.3390/challe12020030 McNicholas, C., Lennox, L., Woodcock, T., Bell, D., & Reed, J. E. (2019). Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: A retrospective mixed-methods study. BMJ Quality & Safety, 28(5), 356–365. https://doi.org/10.1136/bmjqs-2017-007605 Miller, E. K., Beavers, L. G., Mori, B., Colquhoun, H., Colella, T. J., & Brooks, D. (2019). Assessing the clinical competence of health care professionals who perform airway suctioning in adults. Respiratory Care, 64(7), 844–854. https://doi.org/10.4187/respcare.06772 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 65 Mitchell, P. H., Wynia, M. K., Golden, R., McNellis, B., Okun, S., Webb, C. E., Rohrbach, V., & Von Kohorn, I. (2012). Core principles & values of effective team-based health care. NAM Perspectives, 2(10). https://doi.org/10.31478/201210c Moehring, A., Schroeders, U., & Wilhelm, O. (2018). Knowledge is power for medical assistants: Crystallized and fluid intelligence as predictors of vocational knowledge. Frontiers in Psychology, 9. https://doi.org/10.3389/fpsyg.2018.00028 Mortimer, F., Isherwood, J., Wilkinson, A., & Vaux, E. (2018). Sustainability in quality improvement: Redefining value. Future Healthcare Journal, 5(2), 88–93. https://doi.org/10.7861/futurehosp.5-2-88 Pålsson, Y., Mårtensson, G., Swenne, C. L., ÄDel, E., & Engström, M. (2017). A peer learning intervention for nursing students in clinical practice education: A quasi-experimental study. Nurse Education Today, 51, 81–87. https://doi.org/10.1016/j.nedt.2017.01.011 Planned Parenthood. (2019). National statistics. https://www.plannedparenthood.org/uploads/filer_public/2e/da/2eda3f50-82aa-4ddb-acce-c2854c4ea80b/2018-2019_annual_report.pdf Planned Parenthood. (2021). Our services | affordable healthcare & sex education. https://www.plannedparenthood.org/get-care/our-services Reavy, K. (2016). Inquiry and leadership: A resource for the DNP project (First ed.). F.A. Davis Company. Reddy, A., Wong, E., Canamucio, A., Nelson, K., Fihn, S. D., Yoon, J., & Werner, R. M. (2018). Association between continuity and Team-Based care and health care utilization: An observational study of Medicare-Eligible veterans in VA patient aligned care team. Health Services Research, 53, 5201–5218. https://doi.org/10.1111/1475-6773.13042 IMPLEMENTATION OF A STANDARDIZED TRAINING PROGRAM 66 Rodriguez, H. P., Friedberg, M. W., Vargas-Bustamante, A., Chen, X., Martinez, A. E., & Roby, D. H. (2018). The impact of integrating medical assistants and community health workers on diabetes care management in community health centers. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3710-9 Rokicki-Parashar, J., Phadke, A., Brown-Johnson, C., Jee, O., Sattler, A., Torres, E., & Srinivasan, M. (2021). Transforming interprofessional roles during virtual health care: The evolving role of the medical assistant, in relationship to national health profession competency standards. Journal of Primary Care & Community Health, 12, 215013272110042. https://doi.org/10.1177/21501327211004285 Sahoo, M., & Mishra, S. (2019). Effects of trainee characteristics, training attitudes and training need analysis on motivation to transfer training. Management Research Review, 42(2), 215–238. https://doi.org/10.1108/mrr-02-2018-0089 Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2012). Evidence-based practice models for organizational change: Overview and practical applications. Journal of Advanced Nursing, 69(5), 1197–1209. https://doi.org/10.1111/j.1365-2648.2012.06122.x Scharf, J., Vu-Eickmann, P., Li, J., Müller, A., Wilm, S., Angerer, P., & Loerbroks, A. (2019). Desired improvements of working conditions among medical assistants in Germany: A cross-sectional study. Journal of Occupational Medicine and Toxicology, 14(1). https://doi