Diane Storer Brown Harriet Udin AronowPerspectives in Ambulatory Care.Ambulatory Care Nurse-Sensitive Indicators Series: Reaching for the Tipping Point in Measuring Nurse-Sensitive Quality in the Ambulatory Surgical and Procedure Environments

Executive Summary ? The value of the am bulatory care nurse remains

undocumented from a quality and patient safety m easurem ent perspective and the practice is at risk of being highly variable and of unknown quality.

The Am erican Academ y of Ambulatory Care Nursing and the Collaborative Alliance for Nursing Outcomes propose nurse leaders create a tipping point to meas­ ure the value of nursing across the continuum of nursing care, moving from inpatient to ambulatory care.

As care continues to shift into the ambulatory care environment, the quality imperative must also shift to assure highly reliable, safe, and effective health care.

A tipping point is reached when a large number of group members change be­havior rapidly by widely adopting a previously rare prac­ tice. Malcolm Gladwell’s The Tipping Point (2000) is a best­ selling book that helps us under­ stand our nursing leadership role to introduce the concept of meas-

Diane S torer Brown uring nurse-sensitive quality indicators m ambulatory care to large numbers of people and to connect our quality and informa­ tion specialists with stakeholders to share the possibilities. After achieving a tipping point of inter­ est, as the persuaders we must translate the tipping point into a starting point for action, to help encourage adoption of this prac­ tice. Two organizations, Ameri­ can Academy of Ambulatory

Harriet Udin Aronow Care Nursing (AAACN) and the Collaborative Alliance for Nur­

sing Outcomes (CALNOC), are collaboratively leading

an endeavor to reach a tipping point for ambulatory care nursing quality measurement.

As identified in the initial article in this series (Mastal, Matlock, & Start, 2016), and in the AAACN Industry Report (AAACN, 2016), nurse-sensitive quality measurement in ambulatory care systems is less developed than in acute care settings. There are no standardized measure sets that allow organiza­ tions to benchmark performance across settings or to understand the impact of nurse staffing on processes of care and patient outcomes. Nor are there well- understood and standardized definitions for the myr­ iad ambulatory settings for care. As a result, the value of the ambulatory care nurse remains undocumented from a quality and patient safety measurement per­ spective and the practice is at risk of being highly variable and of unknown quality.

The Quality Imperative Fundamental to high reliability in health care is

that every patient receives the right care, every single time – ensuring patient care safety, quality, effective­ ness, and efficiency (Agency for Healthcare Research & Quality, 2008). Lack of reliability in patient care processes contributes not only to medical errors, but also to inconsistent quality, suboptimal outcomes, and system inefficiencies. While a wide range of improvement methods are currently embraced in health care, all require comparative data to under­ stand performance and comparative data require stan­ dardized measurement and the ability to benchmark performance with internal and external comparisons (Brown, Donaldson, Burnes Bolton, & Aydin, 2010).

High reliability has been a health care topic for many years, but the predominant focus has been aimed

DIANE STORER BROWN, PhD, RN, FNAHQ, FAAN, is Executive Director, Medicare Strategy and Operations, Kaiser Permanente – Northern California Region, Oakland, CA; and Founding Member and Senior Scientist, Collaborative Alliance for Nursing Outcomes.