Rachel Start Perspectives In Ambulatory Care
Perspectives in Ambulatory CareKathleen MartinezRosemarie BattagliaRachel StartMargaret F. MastalAnn Marie MatlockNursing-Sensitive Indicators in Ambulatory CareEXECUTIVE SUMMARYAmbulatory nursing care can be difficult to comprehend in all its complexity.In August 2013, the American Academy ofAmbulatory Care Nursing commissioned a task forceto identify nursing-sensitive indicators specific toambulatory care settings.Given the great variation in settings, staff mix, patientpopulations, role dimensions, skill sets, documentation systems, and resources, determining metrics thatapply across the entire continuum of care is a daunting task.However, it is incumbent upon nurse leaders todefine the metrics that will promote the value of theregistered nurse in ambulatory practice and carecoordination.Once initial measures are identified, piloted, and validated, the infrastructure can be created for ongoingbenchmarking and collaboration.The long-term goal is to leverage professional nursing practice, based in the ambulatory care setting, toimprove quality, safety, and cost in health care.a better time to be a nurse. Especially for those nursesfortunate enough to practice in ambulatory care settings.The Patient Protection and Affordable Care Act of 2010 focuses onprevention and wellness as wellas improving quality and healthsystem performance. One of theprovisions of the law is to develKathleen Martinezop a national quality improvement strategy that will improve the delivery of services, patient outcomes, as well as population health. Itwill also create a process to develop and select qualitymeasures to be used for reporting and payment(Kaiser Family Foundation, 2013). Carter, Zhu, Ziang,and Porell (2014) found that 62% of medically seriousadverse medical events (AMEs) occur in the outpatient setting. They suggest efforts to monitor and prevent AMEs should be undertaken. Developing nurs-THERE HAS NEVER BEENNOTE: This column is written by members of the AmericanAcademy of Ambulatory Care Nursing (AAACN) and edited by KittyM. Shulman, MSN, RN-BC. For more information about the organization, contact: AAACN, East Holly Avenue/Box 56, Pitman, NJ08071-0056; (856) 256-2300; (800) AMB-NURS; FAX (856) 5897463; E-mail: aaacn@ajj.com; Website: http://AAACN.orgNURSING ECONOMIC /January-February 2015/Vol. 33/No. 1ing-sensitive indicators in the ambulatory care environment can highlight the contributions nurses maketo patient outcomes.Current Environment: Ambulatory Care SettingsWhile the numbers of hospital admissions aredecreasing, the numbers of outpatient visits are estimated to increase to over a billion per year (Haas,Swan, & Haynes, 2013). Models of care in the ambulatory setting are evolving rapidly. In the last fewyears, new concepts have been introduced, such ascare coordination, transition management, health literacy, patient-centered care, patient navigator, andpatient medical home. Ambulatory surgery centersand radiology centers are offering more advanced andsophisticated treatments and services. Further, adultsand children with conditions of breathtaking complexity are often cared for in their home, supported intheir schools, and managed by their primary careprovider.Embracing the ChallengesIn the midst of this turbulent change, ambulatorycare nurses are stepping up to the challenge to identifyand quantify the value of the registered nurse (RN) inthe ambulatory setting. There are increasing opportunities to practice at the top of their license (Institute ofKATHLEEN MARTINEZ, BSN, RN, CPN, is Clinical PolicyOversight Manager, Children’s Hospital Colorado, Aurora, CO.ROSEMARIE BATTAGLIA, MSN RN, is Manager, MUSC Children’sHospital, Charleston, SC.RACHEL START, MSN RN, is Director, Magnet Program,Education/Coordination, Rush Oak Park Hospital, Oak Park, IL.MARGARET F. MASTAL, PhD, MSN, RN, is Past President,American Academy of Ambulatory Care Nursing, Pitman, NJ.ANN MARIE MATLOCK, DNP, RN, NE-BC, is Manager, NationalInstitutes of Health Clinical Center, Bethesda, MD.ACKNOWLEDGMENTS: Sharon Eck Birmingham, DNSc, MA,BSN, RN, Chief Nursing Executive and Owner, Eck Birmingham &Associates; Nancy May, MSN, RN-BC, NEA-BC, Baylor Scott andWhite Health; Nena Bonuel, PhD, RN, CCRN, CNS, ACNS-BC,Harris Health; Diane Storer Brown, PhD, RN, CPHQ, FNAHQ,FAAN, Collaborative Alliance for Nursing Outcomes (CALNOC);Stefanie Coffey, DNP, MBA, FNP-BC, RN-BC, VA System, Florida;Eileen Esposito, DNP, RN-BC, CPHQ, Catholic Health Services ofLong Island; Kris Grayem, MSN, CNP, RN, Akron Children’s; AnnJacobson, PhD, CNS, ACNS-BC, Kent State University; Mary Morin,RN, NEA-BC, RN-BC, Sentara Medical Group; Catherine Rhodes,MSN, CRNP, WHNP-BC, RNC-OB, SANE-A; Karen Seifert, MSN,RN, CDE, Mayo Clinic Arizona; Deborah Tinker, MSN, RN, CENP,University of Wisconsin Hospitals and Clinics; LTC Leilani A.Siaki, PhD, FNP-BC; LTC Sonya Shaw, MSN, FNP-BC; NancyDunton, PhD, NDNQI59
Medicine, 2010) and influence health care as neverbefore. One way to do that is to look at those actionsthat are uniquely managed by nursing, and evaluate theimpact on patient outcomes. This is exactly what nursing-sensitive indicators (NSIs) attempt to do. By definition “Nursing-sensitive indicators identify structures ofcare and care processes, both of which in turn influence care outcomes” (Montalvo, 2007, para. 4).In 1998, the National Database for NursingQuality Indicators (NDNQI ) was established foracute care settings. The creation of nursing-sensitiveindicators for RNs in ambulatory care settings is anecessary first step so that performance can be benchmarked, goals for improvement can be identified, andthe RN role can be utilized in the most effective way.However, “Ambulatory care is more logisticallycomplex and challenging than acute care since infrastructures frequently provide less optimal support formanaging care than in hospitals” (Swan, 2008, p.199).In other words, in the acute care setting, the nurse hassignificant control over the patient environment, interventions, medications, and responses to treatment.In the ambulatory setting, the patient visit is oftenlimited to 15 minutes once per quarter or less. Therest of the care occurs at home, where environmentalconditions are uncontrolled variables, and medications and therapeutic interventions are delivered bythe patient or an untrained caregiver. In acute caresettings the nurse can use all five senses to assess thepatient, and that assessment is enhanced by technology such as monitors and telemetry. Much of the careprovided in the ambulatory setting occurs over thephone, where the phone is the stethoscope and thepatient is guided through a self-assessment so he orshe can be the eyes and hands of the remote caregiver.Early EffortsIn the late 1990s and early 2000, there was significant focus on identifying and quantifying the work ofthe RN in the ambulatory care setting. The AmericanNurses Association (ANA) appointed a committee in1997 to expand nursing-sensitive quality indicatorsbeyond acute care (Sawyer et al., 2002). The initial recommendations of the ANA were never operationalized. Although there was a good understanding of therole of the nurse in the ambulatory setting, outcomemeasures were underdeveloped and untested. As theinitial committee members stated in their summary:Indicator development requires extensivetime and money. The Committee membersurge all nurses and nursing organizations,both in the United States and internationally,to join with the ANA to continue expandingthis work. Now, more than ever, it is incumbent upon organized nursing to demonstratethe contributions of professional nursingpractice to improved health outcomes and60cost-effective healthcare (Sawyer et al., 2002,p. 59).Unfortunately, after the early 2000s, work onestablishing ambulatory care NSIs slowed significantly. The necessary time and money were not forthcoming and no progress was made. In 2008, Swan wrote acompelling article challenging nurses to move forward with the work of identifying, testing, and validating ambulatory care NSIs.Nursing-Sensitive Indicators: New InitiativesIn the summer of 2013, the American Academy ofAmbulatory Care Nursing (AAACN) put out a call toits members to create a task force to investigate thepossibility of establishing nursing-sensitive indicators. Members of the task force represented all geographic regions of the United States and a broad rangeof practice settings. One of the members of the taskforce is a member of the original ANA Committee thatlooked at NSI for ambulatory care settings in 1997 andbrought a wealth of experience and knowledge.Another member is the nurse scientist with the Collaborative Alliance for Nursing Outcomes and hasexperience with data collection and tool validation.AAACN Task Force: Initial StepsThe initial meetings were focused on reviewingkey literature related to NSIs and the current ambulatory care environment. In the meeting that followed,task force members brainstormed current trends andpotential indicators based on participants’ background and experience. A list of existing ambulatorymeasures was compiled, including the NationalQuality Forum (NQF), the National Committee onQuality Assurance (NCQA), Centers for Medicare &Medicaid Services, and the Joint Commission. Theneed for a broader literature review was identifiedand a framework was created to evaluate publishedstudies and standards for possible inclusion.ANA EffortsIn December 2013, AAACN learned the ANA, inconjunction with the American Nurses CredentialingCenter (ANCC), had a similar initiative to identifyambulatory care NSIs. The key driver and urgency forthis work was the new Magnet Manual whichrequires ambulatory care NSIs for hospitals applyingfor Magnet designation starting in 2016. The ANAnoted the growing prominence of ambulatory carethat resulted from the advancement of the PatientProtection and Affordable Care Act and recognizedthe time was right to move forward with nationalbenchmarking.ANA Summit. In January 2014, the ANA held a 1day Ambulatory Measurement Summit. Forty-fiveexperts from across the ambulatory care continuumparticipated, including eight from the AAACNNURSING ECONOMIC /January-February 2015/Vol. 33/No. 1
Ambulatory NSI Task Force. Prior to the summit, preliminary work was done to evaluate existing ambulatory quality measures from the NQF and the NCQAthat might serve useful as nursing quality measures.Special emphasis was put on measures in whichnursing care or input is necessary or expected. At thesummit, participants were informed that the workneeded to be completed quickly. As Magnet requiresthe submission of eight quarters of data for all indicators, the timeline was very tight to identify, test, andvalidate the selected measures for hospitals planninga 2016 Magnet application.Summit processes and outcomes. The participants divided into six small focus groups, with thetask of selecting the top five to ten measures that metselection criteria from a pre-populated list. Therequirements for selection on an indicator included: Measure will work across all age groups and populations. Supporting data for the measure can be extractedeasily from the medical record. Nurses had a direct impact on the measure. There was an acknowledged link between themeasure and improved health.Interestingly, there was very high consensusamong all the groups with four measures selected byall groups, and the fifth selected by four of the sixgroups. The five measures selected by the ANA to beused as NSIs for the ANCC Magnet RecognitionProgram are (Lewis, 2014):1. Medication reconciliation.2. Controlling high blood pressure.3. Depression assessment conducted.4. Pain assessment and follow-up.5. Hospital re-admissions.AAACN Task Force Response to Summit OutcomesThe AAACN Task Force left the summit feelingthat, while the above indicators were helpful, someimportant dimensions of ambulatory care nursing hadbeen excluded, such as telehealth (including telephone triage), patient education, and the patientexperience. Still, other challenges unique to ambulatory care settings include variability in the use of electronic health records in the ambulatory setting andthe role of the ambulatory care nurse as a member ofa larger team makes it difficult to tease out independent actions (Haas & Swan, 2011).In the inpatient setting, documentation structuresmake it is easy to identify the care delivered by thenurse, whereas with ambulatory care documentationsystems, tracking specific interactions and interventions can be difficult. There is a need for improvedinformation infrastructure development to supportdata collection and quality improvement activities inoutpatient settings. There was a general sense the workwas not complete, and task force members resolved toNURSING ECONOMIC /January-February 2015/Vol. 33/No. 1continue work to identify indicators that accuratelyreflected the role of the ambulatory care RN.AAACN Task Force Seeks Peer InputIn May 2014, the AAACN Task Force reported theresults of the ANA Ambulatory Summit at theAAACN Annual Conference. Focus groups wereformed and feedback solicited from members andconference attendees. The goal was to identify important measures that may have been missed. Theseinterviews yielded rich data about setting, scope, staffmix and education, roles, and the practice of ambulatory care nursing in the United States. Task forcemembers served as leaders and scribes, facilitatingconversation and taking notes. After the conference, asmall group assessed the data and teased out overriding themes. These constructs were entered into a gridusing Donabedian’s (1966) framework of structure,process, and outcomes. Two additional categorieswere included for barriers and recommendations.(See Table 1 for a complete list of themes.)Next StepsFeedback at the AAACN Annual Conference andrecommendations for next steps were presented at the2014 Fall AAACN Board of Directors meeting. Aftercareful consideration, the AAACN Board of Directorsdetermined the role of the task force will be to inform,educate, and advocate for the creation and implementation of ambulatory care nursing-sensitive indicators. At this time, the scope of the NSI task force doesnot include research and development of nursingsensitive indicators. AAACN recognizes that otherkey partners, including NDNQI, have greater expertise and resources in this area. Collaboration with keypartners will be critical to complete the final product.The advocacy role of the task force will involve working closely with identified key organizations toadvance the establishment of NSI for the ambulatorycare environment.The immediate focus of the AAACN NSI TaskForce includes comparing the structure, process, andoutcome measures identified by the ambulatory carefocus groups with the inventory of existing measures.Task force members will then identify three indicators that are determined to be measurable across allambulatory care settings. Given the diversity of caresettings, this will be a challenge. During the 2014AAACN Annual Conference Town Hall, phone callmanagement and telephone triage were strongly supported by AAACN members as a separate and uniquefunction of nursing. Nurses felt this element of caredelivery crosses all ambulatory care settings andrequires consideration as an NSI. From conversationswith AAACN members during the town hall focusgroups, it is clear efforts are in place across multiplesettings to capture the value of the RN in ambulatorycare. Once the initial three indicators are determined,61
Table 1.Nursing-Sensitive Indicator ThemesStructure:AmbulatoryWork SettingProcessData collection includesmeaningful use andE measures from EPIC,Cerner, ACO requirements, RNNavigator Tool Call CentersOutcomeVarying skill mix– MA, RN, PCT,CNA, LPN – afew were 100%RN and a fewhad no RNs at allHighest percentof staff wereMAs.MultidisciplinarypracticeSetting such asschool, clinic,home, telephone,communitysettingRN more visiblein higher-acuityand specialtyareas Disease-specific indicators– HTN management– A1C levels– Hyperlipidemia– Asthma– Wound care– Infection control– Re-admissions Patient education Self-care measures Care coordination Transition management Patient satisfactionBP levels Screening and review– Immunizations– Depression– Pain– Medication review Patient education Self-care measures Care coordination Transition management Patient satisfactionPainMeaningful useFalls: Humpty Dumpty modelPercentageof patientsat N functions are notbillable.Hospital carecoordinators don’tinteract with ambulatoryclinics.Skill mix is variable anddominated by MAs.Physicians do notunderstand difference ofscope, role, and benefitof RNs.APRNs areunderutilized.Overall ambulatory issuesare recognized, but weneed more tools to gatherdata.Inconsistentmeasurementof outcomes/analyzingdata from charting.Few nationalbenchmarks forambulatory care data.Need standardized tools forcare coordination.Establish RN-managedclinics for chronic disease.Define caseload for carecoordination.Advocacy to educate otherhealth care disciplines aswell as traditional inpatientsetting.Develop a self-efficacyscore.Define caseload for carecoordinationAAACN should approachPress Ganey, discussnurse-sensitive indicatorsand er systems don’ttalk to one another.Interventions for positivedepressionscreen are notstandardized.Few nationalbenchmarks forambulatory care data.Computer systems don’ttalk to one another.Fall data do not reflectambulatory care practice(rather fall risk).continued on next page62NURSING ECONOMIC /January-February 2015/Vol. 33/No. 1
Table 1. (continued)Nursing-Sensitive Indicator ThemesStructure:AmbulatoryWork SettingRN handles alltriage callsQI committeeProcessData collection includesmeaningful use andE measures from EPIC,Cerner, ACO requirements, RNNavigator Tool Call CentersOutcomeBarriersRecommendations Patient education Self-care measures Telehealth– Phone call management(triage and virtual healthvisits)– Discharge phone calls Care coordination Transition management Response time to answercalls Patient satisfaction– Engage, educate,entertain– Re-admissionsRe-admissionin 30 daysInconsistentmeasurement ofoutcomes/analyzing datafrom charting.Few nationalbenchmarks forambulatory care dataConsider telehealth: Callins, call backs, track reasonfor call, track resolution ofpatient problem.Incident reportsManagement of abnormal labsReview of data from tientsatisfactionNeed standardized tools forcare coordination.Define caseload for carecoordination.Computer systems don’ttalk to one another.SharedgovernanceRN leader needs to be apart of planning for andimplementing new/updatedIT systems to identify whatabout RN practice isvaluable and what to countto demonstrate that value.Submitted by: Peg Mastal, PhD, MSN, RN; Rachel Start, MSN, RN; Kathleen Martinez, BSN, RN, CPN; Rosemarie Battaglia,MSN, RN; and Ann Marie Matlock, DNP, RN, NE-BCRecommendations: Follow up with a second survey to collect missing information. Number of RN staff in clinics, RNs insupporting roles, number of providers, number of visits, what does the nurse do in the clinic settinga survey will be distributed to all AAACN membersin an attempt to capture current work in these identified areas as well as ongoing work related to the fivemeasures selected by the ANA, in the hopes of capitalizing on successful strategies already underway.Once initial measures are identified, piloted, and validated, the infrastructure can be created for ongoingbenchmarking and collaboration. The long-term goalis to leverage professional nursing practice, based inthe ambulatory care setting, to improve quality, safety,and cost in health care.Ambulatory nursing care can be difficult to comprehend in all its complexity. This article representsour first goal of informing and e
Perspectives in Ambulatory Care T HERE HAS NEVER BEEN a bet-ter time to be a nurse. Es - pecially for those nurses fortunate enough to prac-tice in ambulatory care settings. The Patient Protection and Affor - dable Care Act of 2010 focuses on prevention and wellness as well as improving quality and health system performance. One of the
LESSON 8: Jacob and Rachel Golden Children’s Bible: pp. 56-63 (Genesis 29-33) FACTS TO KNOW 1. Laban: rebekah’s brother; father of Leah and rachel 2. Rachel: Jacob’s beautiful wife 3. Leah: Jacob’s plain wife 4. Joseph: beloved son of Jacob and rachel 5. Israel: Jacob’s new name, given for contending with God MEMORY VERSE GENESIS 29:20 Jacob served seven years for Rachel and they .
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P 5024 94616 Notre Parole France Paris 1945-1947, 1949, 1957 Rachel P 5050 251134 Notre Volonté France Paris 1948-1988 (avec qqs manques) Rachel P 1634 685 Nouveaux cahiers (Les) France Paris 1965-1997 1965-1997 Rachel P 5136 238566 Nouvelles Juives (Les) Tunisie Tunis 1950 Rachel P 98 164520 Paix et droit France Paris 1921-1940 1923-1940 .
received her prize for the Most Outstanding work during Week 9 of this term. Rachel’s sculpture artworks were inspired by her love of Sharpay from A High School Musical, and Rachel’s favourite colours. We are so very proud of Rachel’s achievement in Visual Arts this year Rachel. She has worked hard all year
Happy 100th Birthday to Rachel Linnell Wynn Rachel L. Wynn, who founded the Linnell Family Association, will cele-brate her hundredth birthday on November 11, 2018. Rachel was born in Wendell, Idaho in the basement of the local Presbyterian Church where her father, E.P.
CLEAR CUT 1 RACHEL CARSON COUNCIL introDuCtion C lear Cut is the fourth comprehensive report from the Rachel Carson Council. These reports, Pork and PollutionFowl Matters, Blast Zone, , and now Clear Cut, constitute a series around a common theme central to the work of the Rachel Carson Council and to the ecological ethic of Rachel Carson —
BAB I PENDAHULUAN A. Latar Belakang Penelitian Sudah menjadi kodrat, bahwa manusia dalam hidupnya tidak dapat terlepas dari sesamanya. Manusia dalam hidupnya membutuhkan orang lain dalam berbagai aktivitasnya, kondisi manusia demikian ini mendorong manusia untuk berinteraksi dengan manusia lain. Aristoteles, seorang filsuf Yunani kuno dalam ajarannya mengatakan, bahwa manusia adalah zoon .
