Nonprofit community health centers in the mid-Atlantic region provide healthcare services and resources to a vulnerable patient population with many chronic conditions and limited to no health insurance. The community clinics have seen a variation in patient care and nursing practice by the clinical nurse managers. This variation in practice is secondary to the lack of a formal orientation program. This quality improvement initiative aims to implement an orientation program that actively engages the experienced nurse to enhance the application and retention of critical onboarding information. A nurse manager orientation that lacks clear objectives can lead to feelings of incompetence, disempowerment, and job dissatisfaction for the nurse managers and their staff members. The American Organization for Nursing Leadership (AONL) nurse manager competencies ensure that nurse managers acquire knowledge and enable them to be effective leaders. Nurse managers efficiently manage the unit’s operations, patient outcomes, and staff. The American Organization for Nursing Leadership’s (AONL) nurse manager competencies have been implemented as the clinical nurse manager orientation. The nurse manager competencies are based on the nurse manager learning domain framework and capture the skills, knowledge, and abilities that guide nurse leaders' practice. The American Organization of Nurse Leadership (AONL) competency orientation program was implemented over 12 weeks. A 12-week lesson plan was implemented with one new clinical nurse manager. The lesson plan includes weekly objectives and resources to ensure the clinical nurse manager is competent to lead and oversee the daily operations of the community clinic. A pre-assessment of the CNM’s knowledge and understanding of the AONL nurse manager competencies was completed before the implementation of the CNM orientation program. The AONL nurse manager competencies are measured weekly after weekly curriculum, content outline, and resource materials have been reviewed and applied to clinical practice. Weekly evaluations are completed to ensure the clinical nurse manager has met the objectives. The project lead provides education and support to the preceptor throughout the orientation. A weekly meeting between the orientee, preceptor, and project lead occurs to provide feedback on the progress of the orientee in meeting the weekly objectives, orientation expectations, goals, and competencies. Preliminary results show the clinical nurse manager orientee has progressed from novice to competent or proficient in many of the required competencies in the role of a clinical nurse manager. The CNM has rated 18% of the competencies as advanced beginner, 50% of the competencies as competent, 27% of the competencies as proficient, and 4.5% as expert. Preliminary conclusions suggest that the clinical nurse manager orientation effectively prepares new clinical nurse managers in a community clinic setting to enhance the application and retention of critical onboarding information.

Purpose: Implement innovative leadership initiatives to promote a platform for nursing staff collaboration and supportive education environment to increase certification preparation and achievement.

Description: High certification rates can represent skilled registered nurses' commitment to nursing professionalism. Research has shown that certified nurses are associated with better patient outcomes and a higher sense of nursing empowerment. “Limitations to obtaining certification include costs, weak interest, poor access to resources, and stressors.” Our institutional data showed that from 2019 to 2021, » 108 certified ambulatory care nurses with » 255 ambulatory care nurses not certified. Addressing the certified nurse gap can lead to improved patient outcomes, job satisfaction, retention, and increased nurse empowerment. The desired state is to increase the knowledge base of ambulatory care nurses for preparation and achievement of certification. Anticipating 10% or more increase after implementation of strategies to improve certification rate.
Planning included writing a $5,000 grant approved to purchase study resources to make accessible for nurses to check-out (3-6 months) before taking certification exam. A 2-day certification review course on October 14-15, 2021 (11 contact hours offered). Due to the restrictions during the COVID-19 pandemic in 2021- 2022, strategies were modified to comply with social distancing guidelines. e.g., the certification review course in-person event required limited in-person attendees. (37 attendees participated virtually via WebEx). The leadership team recognize certified nurses via congratulatory email blast, $1000 reimbursement, CNO letter of recognition, special gift boxes prepared that included CNO letter of recognition, tea, condiments, cup, napkin, spoon, and certified nurse badge that were specially delivered by ambulatory care clinical resource nurses during National Certified Nurses Month (March 2021-2023).

Evaluation/outcome: Despite the challenges, nurses remained motivated to continue to study, become certified, and celebrate the accomplishments of their peers. Due to the implementation of informational, celebratory, and supportive strategies, by December 2021, the certified nurse rate (42%) increased by 10%. Currently, 52% of ambulatory care nurses have achieved certification. During August 2022, a SurveyMonkey was sent to nurses: 82% of nurses reported interest in obtaining certification and 78% reported interest in attending on-campus certification review course. Per data collection feedback, the leadership team offered the 2nd annual certification review course on September 7- 8, 2023. 46 nurses were in attendance; 4 nurses achieved certification and 10 nurses have committed to take the certification exam by December 2023. As of November 1, 2023, data is still ongoing.

The ambulatory care clinical leadership of a large academic medical center with an expansive ambulatory care network established a clinical ladder for ambulatory care registered nurses in 2018. A committee consisting of managers and clinical directors gathered stakeholder buy-in to create and execute the first offering of the ambulatory care advancement program. At cycle completion, it was noted that the accessibility and ownership of the program remained in leadership’s hands. Believing “if you can see it, you can be it,” the committee engaged the newly minted ambulatory nurse IIIs to serve as program committee members, thereby bringing the voice of the ambulatory care nurse to the program decision-making table.

In reflection of the second cycle, it was identified that one of the eligibility criteria – national board certification – was a financial barrier for many nurses interested in the program. In response, the organization partnered with ANCC to institute the Success Pays® program. In removing the financial barrier, the number of certified nurses and therefore advancement eligible nurses increased. While certification is a standardized way for nurses to demonstrate a commitment to learning, quality care and competency in practice, the cost associated with taking a certification exam is exclusionary. By requiring certification and not supporting the cost of certification, only those that had the financial means could attain eligibility for advancement. While the intent was to hold a standard, the unintended effect was inequitable exclusion.

In continuing to strive for an equitable program, the third cycle taught us that mentorship, while a critical tool, could not be left up to chance. Without a standard mentor structure, those with existing connections, working in well-staffed clinics, or with previously existing relationships received beneficial counseling. Those without did not. To provide equitable access to the committee’s guidance, all applicants in the third cycle were assigned a committee member mentor and required to meet with that mentor. Through this update, the committee was able to support all applicants equitably.

Most recently, a learning needs assessment identified that nurses desired access to certification review instruction. While established programs already provided reimbursement for certification test review materials, few nurses were taking advantage of the benefit. In response, we contracted to host a live, free, instructor-led ambulatory care certification review course recognizing that some nurses are not able to shoulder the costs for review materials up front and many learners desire live, instructor-led learning. When we create programs to support, recognize, and promote nurses, we must make sure they are accessible and inclusive. We must tirelessly examine blind spots and continuously reimagine what is possible.

Ensuring optimal staffing levels in the ambulatory care settings within a hospital housing over 150 outpatient clinics presents a myriad of intricate challenges. These challenges stem from the sheer diversity of clinics, the specialized skill sets required for staff, and the ever-fluctuating staffing needs due to a multitude of factors, including regular shift management, absences due to illness or family medical leave (FMLA), and shifts in clinic structures. To tackle these complexities and fortify support for clinics grappling with staff shortages, this quality improvement project endeavored to introduce an innovative staffing care model that can effectively address outpatient staffing deficiencies, and revitalize the existing float team ambulatory care nurse cohort, known as the ambulatory clinical resource team (A-CRT). This project will allow the learner to delve into the intricacies of using an expert nursing team to support the diverse challenges in ambulatory care staffing.

Our investigation involved posing six critical questions, touching upon aspects like shift management, clinic complexity, and the expertise of the A-CRT staff. This inquiry led to a transformative overhaul of our care model and gave rise to four pivotal initiatives aimed at bolstering the provision of care in outpatient ambulatory care clinics. These initiatives encompass an enhanced orientation process, specialized training geared towards supporting a select number of clinics with daily staffing needs (DAYS program), the implementation of a proactive system to predict and prepare for future staffing needs (MONTHS program), and the establishment of standardized terminology to define the concept of "critical staffing needs" through a shared tool.

The novel care model, notably the DAYS and MONTHS programs, has produced a remarkable upswing in the support provided to outpatient clinics. Furthermore, it has helped identify and create an “RN in-basket support” role for clinics who use the electric medical record (EMR) system to communicate with families using MyChart. The Capacity tool has fundamentally reshaped our approach to redistributing staff to areas with acute staffing needs, ensuring a more efficient and responsive allocation of resources.

Future endeavors will entail optimizing the size of the A-CRT RN cohorts to align with outpatient clinic DAYS and MONTHS staffing needs, completing the integration of clinic schedules into a centralized software program, and conducting regular reviews of best staffing practices with clinic managers to assess support needs. This transformative approach to clinic staffing is poised to significantly enhance the support provided to ambulatory care settings and further the success of the new care model.

Purpose: Cancer services at a large academic medical center began offering regional non-hospital license services in 2019. Rapid growth, including the addition of three multi-specialty oncology/hematology clinics, two infusion centers, an onsite pharmacy, expansion of service lines, and plans for additional facilities highlighted the demand for community access to high-quality cancer care.

Learning objective: To understand a comprehensive method to address the unique regulatory, quality, and safety needs at off-license ambulatory care clinical sites. To evaluate and verify consistent, quality care across sites, the satellite oncology annual review team, or SOAR team, was created. The SOAR team provides annual and ongoing standardized support to ambulatory care cancer teams, ensuring they meet the same exacting quality standards and safety measures and goals as the on-license sites.

Evaluation: To ensure quality of care is maintained in unique off-license ambulatory care settings, the SOAR team conducts onsite assessments of the following, according to the organization’s standards: Joint Commission ambulatory care survey and tracers, laboratory environment and practices, pharmacy environment and practices, workplace violence prevention, environment health and safety, and hand hygiene audits.

Coordination with organizational regulatory services, nursing education, facilities, and onsite leadership to ensure organizational consistency. SOAR team experts, including pharmacy, quality, nursing, and operations conduct an annual inspection and evaluation of each site, and provide findings within one week of evaluation. Clinical leadership at each site is provided a compliance report and 90-days to resolve non-compliant tracers. 605 assessment points were reviewed. 78 previously unidentified addressable findings were found. Over 30 have been resolved, including creation of unique contacts for emergencies in the different geographic locations and implementation of updates to onsite emergency signage and resources with the local information – a SOAR team dashboard created with all survey results, providing updates for site leaders and senior leadership to review, access, and make decision; and coordination of management services agreements for sites’ unique needs.

Outcome: Through systematic evaluation by internal experts, quality of care at these sites can be analyzed and adjusted, maintaining reputational, cultural, and clinical consistency across the enterprise. The team is also prepared to evaluate acquisitions, co-brand sites and joint ventures, and open new locations with baseline evaluations and scheduled reviews. The SOAR team dashboard provides documented compliance and resolution for informed decision-making and continuous quality improvement, creating higher confidence in the quality and safety of these regional sites.

Purpose: Examine the relationships among nurse manager leadership, ambulatory and emergency care nurse workforce characteristics, and patient quality of care.

Background/significance: Nurse managers are responsible for leading nurses and the nursing care provided in their assigned departments. There is growing evidence reporting the influence of nurse manager workload and competence to direct care nurses’ job satisfaction, intent to stay, and the acute care work environment. Few studies have examined the relationship among the nurse manager, direct care nurse outcomes, and quality of care in the ambulatory care settings. Given the importance of nurse retention and quality of patient care, we sought to examine these variables in ambulatory and emergency care settings.

Methods: Data from the 2022 National Database of Nursing Quality Indicators (NDNQI) nurse surveys and clinical indicators were used to examine the relationships among the variables. Nurse manager leadership was measured using the Nurse Manager Ability, Leadership and Support (NMALS) subscale of the practice environment scale of the Nurse Work Index (PES). The 5 items quantify the presence of each item in the nurses’ work environment using a 5-point Likert scale. NDNQI survey items included intent to stay in the same position for the next year, missed nursing care, and nurse-assessed quality of care. NDNQI clinical indicators included assaults on nursing personnel, RN education, RN certification and patient falls.

Nursing departments were ranked according to nurse manager performance using their NMALS score. Outcomes for the top performers were compared to the lowest performers. Sample sizes for clinical settings included 178 ambulatory care clinics and 100 emergency care departments. T-tests identified significant differences in direct care nurse characteristics, nurse survey items, and patient clinical outcomes based on top and bottom performing nurse managers.

Results: Top-performing nurse managers in ambulatory and emergency care settings achieved significantly higher RN intent to stay, RN-assessed quality of care, and lower missed nursing care compared to bottom performing nurse managers. Top performing nurse managers in ambulatory care settings achieved significantly fewer patient falls. No significant differences were found in nurse education and certification based on nurse manager performance.

Conclusions/implications: Consistent with prevailing literature found in acute care settings, findings suggest top performing nurse managers in ambulatory and emergency care settings are associated with better nursing and patient outcomes. Evidence for acute care nurse managers suggests that effective nurse managers need reasonable workloads and organizational support. Research is needed to determine drivers of effective nurse managers in ambulatory and emergency care settings.

Team-based organizations rely on leaders throughout the organization to champion and execute new ways of working to reflect best standard practice. Professional development and cultivation of effective collaboration with leadership in health care can be challenging. Our education team noticed a challenge in this area and invested time and investigated ways we could offer support. After a gap analysis was completed, lack of educational and professional development support for informal leaders across all departments was identified. The specific needs identified were cultivation of peer accountability, workplace conflict resolution, and increased competence and adherence to best practice standards. The ambulatory care lead program was designed to close gaps through a comprehensive program hosted by the education department.

Clinical and non-clinical (i.e., front desk) lead roles exist within the organization. A platform to provide leadership education and a dedicated, ongoing forum for network lead collaboration and discussion of current clinic topics was created. The development of the program was initiated by creating curriculum for an evidenced-based leadership course. This 2-hour virtual course is made available to all current and new staff members who hold the lead title. A validation process has also been implemented to evaluate skill competency and measurement of meeting course objectives. Finally, a virtual 1-hour forum hosted on a monthly cadence is offered for all lead roles to provide ongoing professional development education and an opportunity to discuss new workflows and challenges.

The methodology for this evidence-based project includes both qualitative and quantitative components stemming from a PICO framework. The identified gaps in leadership educational support were chosen through qualitative reports from clinic leadership throughout the departments as well as the quantitative data reported through an internal education request tracking system and an annual learning needs assessment. Both provide numerical data categorized by system and network specific requests through the ambulatory care departments within the organization. Inconsistent workflows were identified as the major focus of the problem as reflected in the analysis of data within the tracker. Development of a program that would support lead roles to guide and exemplify best practice standards became the focus of implementation. The methods of evaluation are in process as this program is still in the initial implementation phase.

Comparison of pre- and post-implementation data is currently being processed to assess effectiveness. Our team has been utilizing the education tracker to provide quantitative data in other projects and has proven to be reliable. Our methods for evaluation will include a survey obtained at the end of each course and at each lead forum to gather data on our goals and objectives as well as leadership testimonials.

In cultivating an environment of professional development and leadership support for the lead roles in all departments, we have preliminary data that shows positive impact for staff and ultimately for patient care. We anticipate that data will continue to show goal outcomes of consistent workflows that align with best standards of practice, increased peer-to-peer accountability and decreased unresolved workplace conflict.

Ambulatory care practice is of critical interest to healthcare executives, nurse leaders, and patients. Total medical expense can be managed through the full deployment of ambulatory care staff with a focus on ensuring patients are receiving the right medical care at the right time in their health and wellness trajectory. This is essential as the cost of health care remains top of mind for executives, providers, and nurses alike. This interprofessional approach to practice in the ambulatory setting of care ensures all members of the care team are aligned reducing unnecessary care, diagnostics, and hospitalizations. All members of the care team must be optimized to provide consistent high-quality care in the right settings at the right time. This discussion will leave the participant with concrete thought leadership and tools as to how to leverage and excite the nursing workforce in their care delivery models in ambulatory care medicine.

The discussion will begin with a focus on organizational governance and optimized clinical structural coordination within a system matrix . It will then examine what an assessment of ambulatory care staffing mix and nursing engagement entails. This will lead to a discussion of the development of innovative roles to facilitate patient throughput, care coordination, and drive excellence in clinical quality outcomes and population health.

Some of the tactical opportunities in the evolution of ambulatory care practice include clinical staff alignment with a reporting structure that supports and is accountable for clinical competence and team-based care. In this model, population health management and at-risk payment models are also aligned with clinical knowledge and outcomes management. This panel discussion will describe best practice in the approach to these goals.

This program will provide a rapid facilitated discussion on assessment and evaluation of organizational governance and its alignment with operational goals, introduce a well-thought-out assessment process to better understand the critical strengths and weaknesses in their operational efficiency and patient experience, show how innovative and emerging leadership roles can optimize skill sets and facilitate operational evolution deep into an organization, give participants examples and tools for utilization in their own organization and show how alignment of clinical care team members in an ambulatory care setting with thoughtful change management tactics can help an organization excite and optimize their clinical care team. Additionally, the presentation will focus on how to drive population health management from clinical quality outcomes perspective, leveraging organized efforts specific to disease areas exhibiting an integration between primary care and specialties.

The use of an actual case studies will provide thought provoking content, including practical tactics for immediate use.

Learning objectives: 1) Understand why the current healthcare landscape affects ambulatory care structure, need for innovative roles, and alignment with clinical leadership, 2) understand the best practices for alignment of clinical care team members in an ambulatory care setting with thoughtful change management tactics, and 3) draw implications of how to interweave population health practices through the care team to achieve excellence in clinical quality outcomes.

Learning outcome: The audience will be able to discuss the benefits of a centralized model compared to a decentralized model for prescription renewal management, understand the components required for a prescription renewal program, evaluate best practices with prescription renewal management, and leave with tips on how to begin within their practice environment.

In the post-pandemic resource-scarce environment, nursing leaders and healthcare executives must find innovative and scalable approaches to provide patients with safe and quality care. In many ambulatory care practice environments, a proportion of the work of ambulatory care nurses involves prescription renewal management per protocol. In addition to being a key driver for patients' timely access to care, managing prescription renewal requests in a timely manner also has other benefits such as decreasing physician and provider workload and decreasing repeat calls.

In 2020, the primary care department within a large multi-site ambulatory care medical practice group recognized the need to develop a new model to manage the large volume of incoming prescription renewal requests. Three years later, what started as a pilot involving 4 primary care practices has evolved into a successful and rapidly growing centralized nursing prescription renewal team that now supports 56% of the eligible primary care practices within the group.

Significant changes were necessary to successfully develop and operationalize the prescription renewal team including the development of new standard work, pool (in-basket) management process development, the development of a pool (in-basket) report that allows for data collection and analysis, the development of a staffing model, the development of new effective communication channels, and the implementation of a quality assurance process.

Since 2020, 14 of the 25 eligible primary care practices have merged into the centralized prescription renewal team and the primary care department has benefited from a greater than 25% reduction in prescription message handle time and a decrease in the turnaround time as the centralized team addresses 85% of renewal messages within 24 hours.

Overall findings from this work indicate that a centralized model for prescription renewal management is more efficient than a decentralized model. Additional benefits of centralizing include strong nurse engagement and retention, a standardized hybrid staffing model, and decreased workload for physicians and providers.

Nursing leaders should advocate for centralized, standardized care delivery models when appropriate. Due to the success of this model, the organization chose to fund a pilot to embed prescription renewal technology into the electronic medical record. The pilot begins in the fall of 2023. At the conclusion of the EMR embedded renewal pilot, we expect to see a further decrease in prescription message handle time which in theory should allow the remaining eligible practices within the department to join the centralized prescription renewal team without adding additional nursing staff.

Jennifer Wall discloses that she is employed by FTI Consulting, Inc. as a nurse.

Purpose: The purpose of this evidence-based practice project is to share lessons learned and outcomes from a pilot ambulatory care nurse residency program (NRP). Estimates show a gap of 450,000 registered nurses (RNs) by 2025. Increased retention will build more robust pipelines for new RNs, especially in the ambulatory care setting where the workforce is traditionally older. Learning outcome for attendees include ambulatory care NRPs can be successful with ambulatory care-specific curriculum in collaboration with a systemwide NRP structure.

Description: In the current times of high RN turnover, many organizations use NRPs to support transition to practice of newly licensed RNs. In the United States, RN first-year employment retention is currently 67%. NRPs are proven to reduce turnover and sustain the RN workforce. Many organizations have not yet implemented NRPs in ambulatory care settings due to financial and operational challenges. Fiscally, each percent change in turnover costs healthcare organizations $380,600 annually. Organizations must focus on retaining early career RNs who are often the most likely to leave.

In 2021, a large health system in the northeast implemented a pilot NRP for 7 newly licensed RNs. As a healthcare system, the organization has had proven success implementing an in-patient NRP for over 20 years. However, until 2021, never implemented an ambulatory care NRP. This abstract depicts the top 5 lessons learned from the pilot ambulatory care NRP: 1) Established systemwide NRP curriculum is applicable to ambulatory care clinics. 2) Supplementary curriculum, including role of the ambulatory care nurse, population health, care coordination, preventative care, scope of practice, social determinants of health, and telehealth nursing is critical. 3) Autonomous role of an ambulatory care RN necessitates greater need for cohorted ambulatory care NRP model; all newly licensed RNs need to start together and have many opportunities for interaction considering geographical spread and limited number of RNs per practice. 4) Pre-scheduling NRP curriculum is necessary to facilitate attendance due to the autonomous nature and staffing challenges in ambulatory care clinics. 5) Established academic practice partnerships and increased clinical rotations in ambulatory care settings will feed a new to practice ambulatory care pipeline.

Evaluation/outcomes: 7 newly licensed RNs completed the ambulatory care NRP with a 100% retention rate. Nursing leadership is currently evaluating next steps of the pilot. In conclusion, implementing a program that takes nurses away from clinics may seem counterproductive while facing the workforce challenges. However, by proactive planning, ambulatory care clinics can offer this vital resource to first-year RNs.