NR 588AI Week 6 Override Policy Draft Example

Override Policy Draft: Nurses May Add Any Patient to the Transitional Care List at Any Hour, Removals Need a Reason, and Who Reads the Reasons

Student Name

College of Nursing, Chamberlain University

NR 588AI: Advanced Nursing Leadership in Artificial Intelligence-Integrated Complex Systems

Instructor Name

Month Day, Year

Override Policy Draft: Nurses May Add Any Patient to the Transitional Care List at Any Hour, Removals Need a Reason, and Who Reads the Reasons

1. Scope

This policy applies to the transitional care list produced daily by the readmission risk model at all four system hospitals, and to every registered nurse, nurse practitioner and physician involved in discharge.

2. Definitions

2.1 List: the patients selected each day by the readmission risk model and the equity floor for a transitional care call within 48 hours of discharge.

2.2 Addition: placing on the list a patient the model did not select, by completing the "Add to transitional care" field in the discharge navigator.

2.3 Removal: taking off the list a patient the model selected, by completing the "Remove from transitional care" field.

2.4 Override: an addition or a removal. A patient on the list who simply is not called is not an override; it is a missed call, handled under section 7.

3. Permission to Add

3.1 Any registered nurse, nurse practitioner or physician may add a patient to the list at any time, including nights and weekends, without approval from anyone.

3.2 The addition takes effect immediately. The transitional care team calls added patients on the same schedule as selected ones.

3.3 A reason is requested but not required. The reason field offers choices, including "no primary care provider," "language or communication concern," "lives alone," "concern about medications" and "clinical judgment," and a free-text box.

4. Removing a Patient

4.1 A registered nurse, nurse practitioner or physician may remove a selected patient only with a recorded reason, chosen from: "patient declined," "discharged to hospice," "discharged to a facility with its own follow-up," "already enrolled in another transitional program" or "other," with free text.

4.2 Removal does not need approval, but "other" removals are reviewed by the transitional care manager within one working day.

5. What Each Override Costs

5.1 Each addition uses a list place. If additions push the list beyond the transitional care team's daily capacity, the team calls patients in order of score, with added patients placed at the same priority as patients in the top 10%.

5.2 The manager reports to the vice president of care management any day when the list exceeds capacity, so staffing can be adjusted.

This clause exists because an unlimited right to add patients costs nurse time. Stating that cost openly is more honest than pretending additions are free.

6. Who Reads the Recorded Reasons, and for What

6.1 The clinical quality analytics team reads addition and removal reasons each month, in aggregate, to see whether the model is missing patients in a pattern, and reports to the patient safety officer.

6.2 The transitional care manager reads "other" removals within one working day, to check that no patient was removed wrongly.

6.3 Recorded reasons are not used to evaluate the performance of individual nurses, and are not shared with managers for that purpose.

Gaube et al. (2021) found that clinicians often follow algorithmic recommendations even when they are wrong. A nurse who fears that additions will be counted against them will add fewer, and the analytics team will lose its best evidence of what the model misses.

7. The Mirror Case: Following the List When Judgment Disagrees

7.1 A nurse who believes a patient not on the list needs follow-up is expected to add that patient. Not adding a patient because the model did not select them is not a defense if the nurse had a concern.

7.2 A nurse who adds a patient who turns out not to need follow-up has acted correctly under this policy.

7.3 A patient on the list who is not called within 48 hours is reported by the transitional care team as a missed call, through the event reporting system.

Goddard et al. (2012) describe the tendency to defer to automated advice as automation bias. Section 7.1 states that the nurse's judgment, not the list, decides when the two disagree.

Why Additions Need No Approval

Requiring approval for additions would make the right unusable on the shifts when it matters most. Many discharges happen in the evening, when no manager is available. A nurse who has to find someone to approve an addition will often not bother. The equity review found that the model under-selects patients with no primary care provider and Spanish-preferring patients; nurses who know these patients are the best correction, and the policy must let them act at once. An algorithm that steered extra care toward high-cost patients missed many sick Black patients (Obermeyer et al., 2019), and the people closest to patients are often first to notice such patterns.

Why Removals Need a Reason

Removing a patient takes away care the model recommended. A reason creates a record that the analytics team can review for patterns, such as patients removed because they declined calls, which might show a problem in how the call is offered.

What Happens When the Model Is Suspended

If the patient safety officer suspends the model, the list reverts to the previous diagnosis and age criteria. This policy continues to apply to that list: nurses may still add any patient without approval, and removals still need a reason.

How the Policy Was Drafted

The draft was shared with discharge nurses at two of the four hospitals before review. Night nurses asked that additions not require a phone call; section 3.1 reflects that. Transitional care nurses asked that removals carry a reason, so they could see why a patient was taken off; section 4 reflects that.

8. Education

Training states plainly that the list misses most patients who will be readmitted, so nurses do not treat it as complete.

New nurses learn this policy in discharge navigator training. Every nurse involved in discharge receives a one-page summary at go-live.

9. Owner and Review

Owner: Vice President of Care Management.

Effective: 1 March 2027, the planned go-live date.

Review: by 1 March 2028, or earlier if the patient safety officer requests it, using the year's override data.

Notes on the Draft

The draft is short so that it will be read. It contains no language about valuing clinical judgment; section 7 states the obligation instead. It requires no phone call or approval for additions, so a night discharge nurse at 02:00 can act without waking anyone.

References

Gaube, S., Suresh, H., Raue, M., Merritt, A., Berkowitz, S. J., Lermer, E., Coughlin, J. F., Guttag, J. V., Colak, E., & Ghassemi, M. (2021). Do as AI say: Susceptibility in deployment of clinical decision-aids. npj Digital Medicine, 4, 31. https://doi.org/10.1038/s41746-021-00385-9

Goddard, K., Roudsari, A., & Wyatt, J. C. (2012). Automation bias: A systematic review of frequency, effect mediators, and mitigators. Journal of the American Medical Informatics Association, 19(1), 121-127. https://doi.org/10.1136/amiajnl-2011-000089

Obermeyer, Z., Powers, B., Vogeli, C., & Mullainathan, S. (2019). Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), 447-453. https://doi.org/10.1126/science.aax2342