Nursing Quality Indicators for Military Ambulatory Care: A Pilot Study
Name: Leilani A. Siaki
Organization: The Geneva Foundation
Performance Site: Madigan Army Medical Center (MAMC)
Year Published: 2017
Purpose: This project seeks to pilot test nurse-sensitive indicators (NSIs) in Army, Navy, and Air Force ambulatory care settings. The team for this project is comprised of ambulatory care nurse researchers from the three services, as well as experts in NSI development and testing. Nurse-sensitive indicators are defined as structures, processes, and outcomes of care specific to or influenced by nursing. The American Academy of Ambulatory Care Nursing (AAACN) recently published the first ambulatory care-specific NSIs and recommended pilot testing to further refine and develop these 13 indicators. From these 13 NSIs, a panel of clinical ambulatory care nursing and/or NSI experts from the three services narrowed the selection to 2 structural and 4 process NSIs to test in this pilot.Rationale: This pilot study will be the first to actually test the AAACN NSIs in military ambulatory care clinics. This pilot study is critical to understanding the performance of the selected NSIs and for further developing NSIs as indicators of quality care in the ambulatory care settings.Specific aims: 1a) In representative Air Force, Army, and Navy ambulatory care clinics, evaluate scientific acceptability (reliability and validity), feasibility, and utility of collecting, monitoring, and reporting NSIs listed in the AAACN 2016 Industry Report related to blood pressure, depression, vaccines, and pain and two nursing structure indicators: nursing care hours and registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel (UAP) ratio to enrolled patients; and 1b) Describe perceptions of how useful and meaningful these six NSI and respective reports are to nursing staff and leadership (clinic nurse managers and facility nursing executives). 2) Develop and deliver recommendations for future NSI testing and use in military ambulatory care settings based on aim 1 results.Design and methods: This sequential, mixed methods design will evaluate ambulatory care NSI data reliability, validity, feasibility, and end user meaningfulness over a 6-month period using de-identified clinic data specific to each NSI as defined in the AAACN report. Quantitative data regarding the prevalence of patients with the condition (high blood pressure, due for a pneumococcal or influenza vaccine, screened positive for depression, or have pain at the time of the appointment) that have a documented follow up plan addressing the condition, will be collected according to a Codebook detailing definitions and data collection procedures to ensure fidelity of data collection across sites (Aim 1a). Individual indicators will be assessed regarding nursing sensitivity, ease and sustainability of implementation and data collection, and scientific acceptability and feasibility. Nursing staff and clinic leaders’ perceptions of the usefulness and meaningfulness of these NSIs as quality indicators (Aim 1b) will be explored using an indicator rating form and qualitative interviews with a structured interview guide. Quantitative analysis will entail using descriptive statistics and inter-rater agreement (percent agreement, kappa coefficient, and Kendall’s W) at the clinic and facility levels. Interview data will be analyzed using descriptive qualitative analysis and integrated with quantitative data to develop final recommendations (Aim 2). In addition to answering the study aims, recommendations regarding testing these NSI in a larger sample of clinics across services and testing the remaining AAACN developed NSI will be included. A summary of the final recommendations will be submitted to the respective Ambulatory Nursing Consultants to the Surgeon Generals and Nurse Corps Chiefs for consideration of inclusion in the current quality improvement dashboards.Relevance: This proposed study is relevant to nursing clinical practice, addresses access, quality, and safety concerns identified in the recent MHS (2014) review, and meets two TSNRP priorities: 1) Force health protection by evaluating metrics that will standardize and improve care; 2) Nursing competencies and practice by focusing on data-driven performance improvement tools nurses can use to advance the quality and safety of ambulatory care.