1. Matlock, Ann Marie DNP, RN, NE-BC
  2. Start, Rachel MSN, RN, NE-BC
  3. Aronow, Harriet PhD
  4. Brown, Diane Storer PhD, RN, FAAN, FNAHQ

Article Content

In the spring of 2013, the American Academy of Ambulatory Care Nursing's (AAACN) board of directors commissioned a task force to identify and define nurse-sensitive indicators specific to the ambulatory care setting. Members included indicator development experts from the Collaborative Alliance for Nursing Outcomes (calnoc) and the National Database of Nursing Quality Indicators(R) (NDNQI(R)), as well as a past president of AAACN who was part of the original work done by the American Nurses Association (ANA) in the late 1990s to identify indicators sensitive to nonacute settings. Members of the task force represented all geographic areas in the United States and a broad range of practice settings.

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Shifting focus

Over the past 2 decades, healthcare delivery has shifted from the inpatient setting to the ambulatory care setting. According to the American Hospital Association, inpatient admissions per 1,000 persons decreased 12%, from 119 in 1993 to 106 in 2013. In the same time frame, the average inpatient length of stay dropped from 7.0 to 5.4 days, inpatient surgeries decreased from 10.2 to 9.1 million, outpatient surgeries increased from 12.6 to 17.4 million, and the total outpatient visits in community hospitals increased from 1,422 per 1,000 persons to 2,145 (a 50% increase).1 Although this shift has occurred, the RN workforce in the outpatient setting, and particularly in primary care, has declined. The move from inpatient to ambulatory care settings has created challenges with access to care and coordination of services, and increased care complexity.2


The National Association of Community Health Centers estimates that 56 million people have inadequate access to a primary care medical provider and health centers need to increase the number of patients served from 16 million to 30 million, which requires another 16,000 to 20,000 RNs.3 According to, 17.6 million uninsured people have obtained healthcare coverage under the Affordable Care Act (ACA).4 With a dramatic reduction in the number of people who are without insurance, there's an expectation that more RNs are needed. A recent Commonwealth Fund report estimated the impact of the first 5 years of the ACA: primary care visits are increased by 3.8% per week and visits to hospital outpatient departments by 2.6% per week nationally.5 The report's authors suggested that the current supply of hospitals and physicians can absorb the increase through adapted delivery models, including nurse-managed centers, and increased use of advanced practice nurses.5


The percent of RNs employed in ambulatory care-clinics, physicians' offices, and health centers-remained unchanged between 2004 and 2008 at 12%.3 Market forces suggest that percentage distribution will need to change to accommodate the shift of care from inpatient to ambulatory settings. It's also evident to the professional nurses in ambulatory care settings that identifying, defining, and measuring the elements of their practice related to patients' care and outcomes are critical. To date, the value of the ambulatory care RN's role in patient outcomes hasn't been measured.


The need for meaningful measurement

Members of the AAACN Nurse-Sensitive Indicators Task Force reviewed published information about ambulatory care nursing and quality. This review included a definition of ambulatory care nursing, defining characteristics of the professional RN, a short overview of the history of nursing quality, and the work of the task force in the development of a nursing metrics set. The results have been compiled in an industry report made available by the AAACN.6


Task force members began this journey using an evidence-based practice approach to identify and develop measures that can be applied to the ambulatory nursing care environment. This was accomplished using a variety of methods, including:


* reviewing historical efforts to measure nursing care quality and outcomes


* conducting a literature review of quality metrics


* eliciting expert opinion


* reviewing current standards, scope, definitions, and dimensions of ambulatory care RNs


* reviewing all currently endorsed measures in the ambulatory and acute healthcare settings


* collaborating to identify ambulatory care nursing measures at the January 2015 ANA Summit


* specifying the process for developing appropriate indicators


* outlining the pilot testing process.



The literature review revealed that although efforts were undertaken in the past to identify the work and role of the RN in the ambulatory care setting, outcome measures were underdeveloped and untested.7 Current measures were identified, including those proposed by the ANA and developed by Press Ganey/NDNQI, and the nurse-sensitive measures endorsed by the Ambulatory Surgery Center Quality Collaboration (ASCQC).8,9 (See Table 1.) The CALNOC pilot tested a series of ambulatory surgery and procedure unit measures in 2015 for release in 2016.10 (See Table 2.) In its review of all currently endorsed healthcare indicators (nonspecific to nursing), the task force proposed several new indicators to be adapted for the ambulatory nurse. (See Table 3.)

Table 1: Existing me... - Click to enlarge in new windowTable 1: Existing measures
Table 2: Available m... - Click to enlarge in new windowTable 2: Available measures for ambulatory surgery and procedure centers benchmarking
Table 3: Proposed in... - Click to enlarge in new windowTable 3: Proposed indicators for adaptation from existent, endorsed healthcare measures

Finally, the task force developed and proposed four indicators for complex development. These indicators weren't taken from already endorsed healthcare indicators; rather, they were the product of feedback from AAACN membership and knowledge of emerging significant healthcare trends. (See Table 4.) Some components of the proposed indicators/measures are new and untested, whereas others are documented in the literature in a subset of nursing environments. Proposed measures may act as catalysts to assist in assigning value to key ambulatory nursing role dimensions that have the potential for positive patient outcomes, yet have been inadequate and/or inconsistently measured. The task force and the AAACN are fully aware that nursing quality metrics will be an ongoing process as future changes occur in ambulatory care settings. Therefore, the AAACN and CALNOC established a collaborative partnership in 2015 to measure the development of the proposed measures.

Table 4: Proposed ne... - Click to enlarge in new windowTable 4: Proposed new indicators for development and endorsement*

Work in progress

As the volume and complexity of patients in the ambulatory care setting continue to rise, developing nurse-sensitive indicators becomes increasingly important. For the first time, there are several indicators available for use in the ambulatory care setting. As this body of work continues to develop, the indicators and metrics for use in a variety of ambulatory care settings will increase. Ambulatory nurse leaders need data to hold resource and patient outcome discussions with senior leaders and boards, and nursing practice will be a vehicle to achieve the triple aim of affordable, accessible, quality care.




1. American Hospital Association. Trendwatch chartbook 2015: supplementary data tables, utilization, and volume. [Context Link]


2. Mastal M, Matlock AM, Start R. Capturing the role of nursing in ambulatory care: the case for meaningful nurse-sensitive measurement. Nurs Econ. In press. [Context Link]


3. Institute of Medicine. Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. [Context Link]


4. U.S. Department of Health and Human Services. The Affordable Care Act is working. [Context Link]


5. Glied S, Ma S. How will the Affordable Care Act affect the use of health care services? [Context Link]


6. Start R, Matlock AM, Mastal P. Ambulatory Care Nurse-Sensitive Indicator Industry Report: Meaningful Measurement of Nursing in the Ambulatory Patient Care Environment. Pitman, NJ: American Academy of Ambulatory Care Nursing; in press. [Context Link]


7. Martinez K, Battaglia R, Start R, Mastal MF, Matlock AM. Nursing-sensitive indicators in ambulatory care. Nurs Econ. 2015;33(1):59-63, 66. [Context Link]


8. National Database of Nursing Quality Indicators. Guidelines for data collection and submission on care coordination in ambulatory settings. Press Ganey Associates, Inc.; 2014. [Context Link]


9. Ambulatory Surgery Center Quality Collaboration. ASC quality measures: implementation guide. [Context Link]


10. Brown DS, Aronow H. Reaching for the tipping point in measuring nursing-sensitive quality in the ambulatory surgical and procedure environments. Nurs Econ. In press. [Context Link]