Background: Patient care provided in ambulatory care practices has become increasingly complex over the past decade. This complexity represents both patient characteristics, such as requiring transitions in care from the hospital to the outpatient setting, and complexity of providing care through increasingly more complex insurance processes. Concomitantly, there has been a significant increase in ambulatory care visits over the past decade.

The provision of safe, high-quality ambulatory care requires an interdisciplinary team. As a result of the COVID-19 pandemic, a reorganization of our large academic ambulatory care practices was implemented. Six clinical “pods” were created with implementation of a new nursing leadership model. Prior to this reorganization, there was no clinical nursing leadership present in any of our practices.

Methods: Nursing leaders sought to identify quality metrics that were measurable and which nursing could directly impact. Five metrics were chosen, which included patient experience data as measured through Press Ganey CGCAHPS survey scores, hand hygiene compliance via direct observation, data from near-miss reports and actual patient event reports, call center data including the number of calls and time to answer, and formal educational achievement of nursing staff. Specific methods were implemented to improve each of these metrics. Nurse leaders created domain-specific patient experience teams within each pod. The infection control nurse trained our nurse leaders and staff in direct observation hand hygiene monitoring. High-reliability education, including training on Just Culture and reporting, was provided to all nursing leaders and staff. Reports regarding our call center data were utilized by nursing leadership in order to monitor and deploy nurses as needed to adequately handle nursing-related patient phone calls. Finally, nursing leaders and clinical staff were encouraged and supported by the chief nursing officer to obtain further formal education as we work to prepare towards ambulatory care Magnet certification. These measures were obtained over the course of the first year of this new reorganization.

Results: Improvement in all metrics were revealed with the exception of hand hygiene data. Press Ganey data reached its highest overall score in five years. Reporting near-miss and actual patient events more than doubled. Data obtained regarding nurse call volumes revealed an overall increase in calls to a peak of nearly 16,000 calls in June with simultaneous decreases in abandonment rates. Hand hygiene data was the one metric which revealed a decrease in overall compliance. However, this may represent an overall increase in observations revealing more failure points. More time is required to ascertain the validity of this assumption. Finally, educational achievements of the nursing team included a total of four RNs who completed their BSN, one RN who completed her MSN, and one RN that obtained her PhD.

Discussion: Significant areas of improvement were achieved in four of the five metrics measured. Patient care was enhanced through the implementation of a new nursing leadership model. Ongoing evaluation to monitor for sustained improvement is necessary. Nursing leadership in ambulatory care is crucial to providing high-quality and safe care to an increasingly complex patient population.

Kathleen Bolmer BSN, RN

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