DURING the past 5 years, implementation of the Affordable Care Act has seen millions of Americans gain health insurance coverage, many for the first time. This transformation is occurring rapidly: Between the first part of 2013 and the first part of 2014, 30.2% of nonelderly adults who were previously uninsured gained coverage. This represents a higher rate of acquiring coverage than for similar time periods in 2012 and 2013 (24.6%),1 according to recent data from the Agency for Healthcare Research and Quality's (AHRQ) Medical Expenditure Panel Survey, which collects extensive data about the health services Americans use and how much they pay for it.
This expanding universe of newly insured patients will include many who are seeking care for the first time in primary care or other ambulatory settings. Their care needs put renewed attention on current resources and emerging evidence that nurses engaged in clinical practice, policy, academics, and research can use to promote quality and safety in ambulatory care.
OPPORTUNITIES TO IMPROVE 'PATIENTS' EXPERIENCE
Improving care while meeting the demands of this expanding patient pool will not be easy. Results of AHRQ surveys of patients' experience of their care in ambulatory settings suggest there is ample room for improvement to enhance access.
Data voluntarily submitted to AHRQ's CAHPS (Consumer Assessment of Healthcare Providers and Systems) Clinician & Group Surveys in 2013 showed that only 62% of respondents said they got timely appointments, care, and information from primary care providers.2 The CAHPS Clinician & Group Surveys, which are currently being revised and updated, are the national standard for assessing patient experience in ambulatory care practices. Slightly fewer patients (57.9%) reported in AHRQ's 2012 Medical Expenditure Panel Survey that they always got an appointment as soon as they wanted. These data are drawn from interviews with persons 18 years and older who reported making an appointment for illness and injury in the past 12 months.3
THE CURRENT PRIMARY CARE NURSING LANDSCAPE
Addressing these challenges will require a team effort, with concerted attention to implementing research-based approaches that make care safer and higher quality. In Patient-Centered Medical Homes, where the health care team works together to meet the patient's needs, both the nurse practitioner and the registered nurse (RN) provide a critical role in achieving the quadruple aim of health care.4 However, the role of the RN in today's changing care delivery environment is undergoing a significant transformation. In the ambulatory environment, RNs have a clinical and risk management role. RNs are the first members of the core clinical team to evaluate the ambulatory patient and are well positioned to intervene quickly to address any potential safety risks. RNs in the ambulatory setting play a critical role in triage and coordination of care, thereby contributing greatly to the quality of care of patients with multiple chronic conditions, whose care is often complex and dynamic.
Technology: A help or hindrance to quality?
Nurses are at the forefront, establishing the initial relationship with the patient, collecting medical information, and coordinating different aspects with the rest of the team, including transitions and coordination to other clinical or community-based settings. In primary care, technology serves as a lever that can maintain-or even enhance-the relationship between health care providers and patients, often through enhanced communication.
This is one of the reasons that the nursing profession has supported the use of electronic health records (EHRs). Since the EHR Incentive Program established by the Centers for Medicare & Medicaid Services took effect in 2011, more than 400 000 clinicians and hospitals have adopted and are "meaningfully using" EHRs.5 Yet, with all major transformations that require changes in human behavior, complex systems, and evolving technology, the shift to adopting and meaningfully using EHRs has not been without its challenges. Technology alone cannot reduce harm, but enhanced interprofessional team communications coupled with technology can help deliver informed and coordinated care and improve patient safety.
Research and tools to enhance primary care safety and quality
Primary care has been described as a complex system with practices required to provide services to a larger and more clinically diverse group of patients than inpatient hospital teams do.6 The complexity of day-to-day operations of delivering patient-centered primary care may lead to potential communication breakdowns and increased risks to patients. While the underlying conceptual risks and harms in ambulatory settings might be similar to those that occur in inpatient care settings, the methods for estimating and understanding them are different and must be tailored to ambulatory clinical practice.
In the face of growing changes in the primary care environment, RNs and advanced practice RNs are well positioned to lead practice improvement efforts in ambulatory settings. AHRQ has many evidence-based products and resources to help nurses improve the care they provide to patients on a daily basis.
For several years, AHRQ has developed research-based tools to promote quality and patient safety practices in the hospital setting. More recently, tools have been created and adopted for use in ambulatory settings. While quality and patient safety research are hallmarks of AHRQ's work, what makes its approach unique is the focus on developing tools and resources that make the knowledge gained practical and applicable to real-world settings. This approach helps the health care team understand not just what the problem is but also how to address it.
For example, an AHRQ-funded research study published in 2013 found that a significant portion of diagnostic errors occur in primary care settings, errors that had the potential for moderate to severe harm. What is more, most errors were due to process breakdowns in the patient-practitioner clinical encounter, such as history-taking, examination, or ordering diagnostic tests for further workup. The study, one of the largest of its kind involving diagnostic errors in the outpatient setting, concluded that a greater emphasis is needed to avoid process and communication breakdowns when completing basic clinical tasks such as gathering data for medical history, ordering examinations, and summarizing the patient-provider visit.7
Recognizing that diagnostic errors related to office testing processes is a key problem area, AHRQ funded a grant that led to the development of Improving Your Office Testing Process: A Toolkit for Rapid-Cycle Patient Safety and Quality Improvement.8 The tool helps nurses and other clinicians apply quality improvement techniques to improve processes and reduce one kind of diagnostic error in primary care practices. The toolkit offers step-by-step instructions to help practices evaluate their testing procedures and identify and address areas that require improvement.
Similar tools include:
* Health Assessments in Primary Care: A How-To Guide for Clinicians and Staff9 provides tools to enhance preventive care and patient wellness. The guide's checklist helps practices evaluate readiness for implementing health assessments and a questionnaire determines what type of health assessment to choose on the basis of the type of patients served. It also provides recommendations to help practices integrate assessments in their workflow and use the information collected and suggestions for engaging patients. As part of the Affordable Care Act, clinicians conducting health assessments can also receive incentive payments from the Centers for Medicare & Medicaid Services for conducting Annual Wellness Visit services for Medicare-eligible patients.10
* TeamSTEPPS, another evidence-based tool, was developed initially for use in hospitals by AHRQ in partnership with the Department of Defense Patient Safety Program. A new primary care module11 for use in office-based settings is currently in development and is being tested in primary care practices. Building on the core TeamSTEPPS concepts, the primary care module focuses on team skills and leadership strategies (briefs, huddles, debriefs), situation monitoring (cross-monitoring to avoid errors), conflict resolution, mutual support, and communication techniques, all tailored for primary care practices.
AN OPPORTUNITY FOR NURSE RESEARCHERS
In 2015, AHRQ is launching a multimillion dollar effort to enhance the current knowledge of patient safety in the ambulatory setting. Building on what is known to already work in the hospital setting, this research will be tailor-made for the ambulatory setting. To formalize its intention to expand this type of research, AHRQ in February published a Special Emphasis Notice12 that outlines research areas that the agency is interested in funding. Researchers can use this information to propose projects and ideas that (1) identify the appropriate methods of conducting studies of the epidemiology of patient safety events in ambulatory settings; (2) test and evaluate those methods; and (3) apply proven approaches that describe the nature and extent of these events and how they can be prevented.
In addition, AHRQ has announced funding for several high-impact research projects that will not only discover new ways to make care safer but also build on what we already know in the ambulatory and long-term care settings. This multiyear initiative is expected to expand the scientific evidence, strategies, and tools that are available for improving patient safety in all health care settings so that people can expect safe care whenever and wherever they receive it. Nurse researchers are at the cornerstone of this effort. As the primary point of contact for patients and the key driver of day-to-day operations in primary care and ambulatory practices, nurse input in AHRQ's efforts to expand the knowledge base in these research areas is critical.
Nurses play a key role in exercising a culture of patient safety and can generate a new level of thinking that leads to faster and sustained practice transformation. Improving ambulatory patient safety will require a culture shift in which RNs take a leadership role in clinical decision making and assessing risk management, both at the individual patient level and at the population level. Optimizing the skills of the RN on the ambulatory care team and strengthening teamwork and communication techniques in everyday practice can help improve patient safety culture and eradicate harm.
SUMMARY
As AHRQ looks to expand its ambulatory safety research efforts, the agency seeks the involvement of a variety of nurses to provide expert opinion and consultation and to conduct research. In addition, this is an opportunity for both PhD and Doctor of Nursing Practice prepared nurses to lead interprofessional teams to conduct research that can translate into meaningful improvements in ambulatory quality and safety as well as to include implementation and evaluation of best practices in ambulatory care. As the largest and highly trusted member of the health care workforce, nursing is well positioned to lead as we continue our progress toward reducing-and ultimately eradicating-lapses in safety that occur all too often in the ambulatory setting and improving care for patients regardless of where they seek it.
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