The shift of medical care from the inpatient to outpatient setting coupled with the emphasis on transformative designed patient-centered medical home models provides measurement challenges and opportunities. The challenges are how to effectively measure quality in this setting given the range of services that are provided—from routine preventive care to complex surgical and invasive procedures. The concurrent opportunity is to measure and promote the role of nurses in providing and leading the care and coordination services that are at the core of ensuring improved patient experiences and outcomes in the outpatient setting.

Table 1: Percentage Share of Inpatient vs. Outpatient Surgeries (1988-2008)^[1]

Table 2: Trends in Inpatient and Outpatient Utilization (1987-2007) ^[2]

Professional nursing associations have taken notice of these trends and are accelerating the effort to improve the measurement of both quality and nursing impact in the ambulatory setting. In January of this year the American Nurse Association (ANA), American Nurses Credentialing Center (ANCC), and American Nurses Foundation (ANF) hosted the Ambulatory Measurement Summit. This meeting, and the work leading up to the summit, involved 40 nursing leaders representing stakeholders in national/specialty nursing organizations, payors with delivery systems, measure developers (including Milliman), delivery systems, and payors.

The charge to this group was to come to consensus on five existing measures that warranted further investigation and potential adaptation as an ambulatory nursing measure. Participating in this exercise with this impressive set of nursing leaders representing a wide range of interests, I was struck by several observations:

- There is a clear need to develop outpatient measures that go beyond preventive and chronic care and address other quality concerns. Ambulatory care (especially procedure-based care) involves complex services with risks and consequences that are not well addressed by today's measures of processes such as immunization and screening rates.
- There is a continued opportunity to pilot new measures of coordination. There is clear recognition that the new value to consumers (and opportunity for nursing) will be the ability of the healthcare system to help them successfully move from one service to another and it will take innovative minds to design these measures.
- It is hard to measure the impact of nursing independent of other factors. As you examine specific measures it is difficult to claim nursing as the driver of performance in that measure but perhaps this serves to emphasize even more that healthcare involves teams and ultimately identify that nursing remains a key part of that team.

At the close of the summit the attendees reached consensus on five nationally endorsed measures, as having high relevance to nursing impact:

1. Medication reconciliation (NQF #0097)
2. Controlling high blood pressure (HEDIS measure)
3. Depression assessment conducted (NQF #0518)
4. Pain assessment and follow-up (NQF #0420)
5. All-cause readmissions (NQF #1768)

The next step will be for the ANA and the National Database of Nursing Quality Indicators to undertake further review of the five consensus measures for possible refinement and testing for use within the ambulatory setting. We will watch this initiative closely as we refine Milliman's measurement tools to fully reflect the changes underway in the healthcare system, as well as the role of stakeholders such as the nursing profession, and to improve the ability to measure the impact of these changes.

[1] Frakt, Austin (October 2010). Inpatient vs. outpatient surgeries. The Incidental Economist. http://theincidentaleconomist.com/wordpress/inpatient-vs-outpatient-surgeries
[2] Johnson, Tracy K. (May 2010). Ambulatory care stands out under reform. Healthcare Financial Management. http://www.hss-inc.com/healthcare-report/ambulatory-care-stands-out-under-reform.pdf

This article first appeared at Milliman MedInsight.