Ambulatory Care Nursing and Magnet® Designation

Perspectives in Ambulatory Care

Advancing the Science of Nursing: Ambulatory Care Nursing and Magnet® Designation

Rachel Start Rebecca Graystone

As health care shifts from an acute, disease, and episodic-based model to one of health, community intervention, and continuum- focused interventions, the ambulatory care nurse is essential in this transformation and its success. Leveraging the ANCC Magnet® Model as a blueprint to improved patient outcomes and care of the nursing workforce can ensure that transformation is achieved.

mbulatory care nursing is a specialty that Shifting Landscape: Ambulatory Nursing is emerging as uniquely capable of and Value-Based Health Care A meeting various challenges across the healthcare continuum (American Academy of Comorbidities, psychosocial needs, frailty, and Ambulatory Care Nursing [AAACN], 2017). As the social determinant factors, among other current healthcare delivery system navigates a complexities of patient care, create challenges for pandemic, the realities of the sobering poor seamless care coordination and health promotion outcomes, lack of access, and equitable care that (ANA, 2013; Freeman, 2006). Additionally, with were present before 2020 persist (Emanuel et al., health care’s focus shifting from a fee-for-service, 2020; Radley et al., 2020). The need for healthcare episodic, acute care approach to that of value, transformation and nursing’s role as leader within health, and efficiency across the patient’s lifespan that mandate is related to the growing volume of and continuum, volumes are also shifting from complex, chronically ill, vulnerable populations, inpatient to outpatient (American Hospital in addition to inefficiencies associated with Association, 2018; Berwick et al., 2008; Schneider coverage, transitions of care, and services offered et al., 2017). throughout the continuum (Haas et al., 2019; Leveraging the role of the ambulatory care Schneider et al., 2017). This current reality, along nurse, who often sees patients for many years, with the pandemic, underscores the need for serving in their communities, may increase the nursing, in every setting and role, to take a value of health care for patients across the leadership stance, growing its scientific continuum (Start et al., 2018; Start et al., 2020). In knowledge base to meet the dynamic needs of this setting, nursing practice has not traditionally the populations it serves (AAACN, 2017; Institute had support for structures or processes that of Medicine [IOM], 2010). Embracing and promote practice commensurate with their advancing the ambulatory care nurse’s role as this education and training (Start et al., 2016). It is transformation occurs may improve the nursing vital nursing embraces this value-based profession’s ability to meet the social contract it perspective, creating interventions and deepening shares with the public to improve and advance discipline-specific science that is responsive to the health (American Nurses Association [ANA], 2010; progressive focus on health rather than disease. Start et al., 2018). RNs must be prepared to articulate their contribution to value-based care for patients and populations alike (Brown et al., 2020; Haas et al., 2019; Start et al., 2020).

90 March/April 2021 | Volume 39 Number 2 Nursing Economic$

Nursing Community Response: Supportive nurse-sensitive measures through the National Strategies at a High Level Database of Nursing Quality Indicators.

As a profession, nursing is given the power to ANCC Magnet Program Description of self-regulate, grow its own body of knowledge, Program and Ambulatory Requirements and govern its practice and practitioners. In response to this authority, the profession is The American Nurses Credentialing Center’s accountable for returning to society the (ANCC) Magnet Recognition Program® has been promotion of health in its many populations strongly linked to improvement of workforce and (ANA, 2010; Donabedian, 1976). Self-regulation patient outcomes through the integration of the and professional governance are realized through Magnet model as a vehicle for nursing excellence nurses who practice to the full extent of their (Barnes et al., 2016; Friese et al., 2015; Lal, 2020; license and education, fully supported and Stimpfel et al. 2016). The Magnet Recognition competent (Clavelle et al., 2016) to conduct Program was started due to a study conducted by “constant surveillance so that departure from an American Academy of Nursing taskforce on standards can be detected early and corrected” Nursing Practice in Hospitals that identified work (Donabedian, 1978, p. 836). The IOM (2010) environments that attracted and retained well- Future of Nursing report noted the nursing qualified nurses while also obtaining excellent profession, due to its “numbers and adaptive outcomes (ANCC, 2021). Forty-one organizations capacity was perfectly poised to bridge the gap that qualified for the original study were able to between coverage and access…to enable the full attract and retain well-qualified nurses amid a economic value of its contributions to be realized” national nursing shortage. Those organizations (p. 1). Further, AAACN, the specialty organization had common themes of structure, process, or for ambulatory care nurses, in their nursing outcome based on the current empirical Magnet position paper on the “Role of the Registered model clustered in five domains: Transformational Nurse in Ambulatory Care” stated, Leadership; Structural Empowerment; Exemplary Creating a future that maximizes the role Professional Practice; New Knowledge, of RNs in an evolving healthcare Innovations, & Improvements; and Empirical environment will require sustained Outcomes. These domains are surrounded by the momentum in nursing practice, education, dynamic and contemporary issues encompassing research, and leadership…to build the nursing and global health care (ANCC, 2017) (see science of ambulatory care nursing, Figure 1). As of December 2020, 548 (including clinical nurse researchers must be 12 international organizations) or about 8.5% of engaged in the development of new registered U.S. hospitals achieved Magnet knowledge and innovation to build the recognition and, as such, are known for evidence base needed to support excellence in outcomes within the five ambulatory care practice. (2017, p. 6) components (ANCC, 2020). From 2013 to 2019, the AAACN nurse- Magnet-designated organizations demonstrate sensitive indicator taskforce identified, developed, strong nursing professional governance, proposed, and pilot tested 15 measures to reflect collaboration, advocacy, research and innovations, the quality of care delivered by ambulatory care and patient and staff outcomes. Combined, these nurses (AAACN, 2017; Haas et al., 2019; Start et factors provide evidence of enculturated Magnet al., 2016; Start et al., 2018). A benchmarking principles across all settings where all levels of structure, where clinical sites could compare RNs practice. In 2019, the ANCC Commission on across specialty, volume size, organizational Magnet enacted a new set of standards, which service line, and system, was also developed more broadly emphasized ambulatory care (Start et al., 2018). These measures and adjoining nursing’s evolution into the recognition process benchmarking database are now a part of the (ANCC, 2017). Ambulatory care nurses must Press Ganey portfolio, which also offers inpatient continue to show evidence of the same structures

March/April 2021 | Volume 39 Number 2 91 Nursing Economic$

Figure 1. Understanding the Magnet Model

as other settings within the applicant organization, crosswalked to the resources available from practice oversight by the chief nursing officer AAACN are listed in Table 1. (CNO), and provide proof of outcomes related to As organizations have sought to meet ANCC nursing care delivery, workforce, and patient care. standards for Magnet recognition, several As ambulatory care nursing practice continues to strategies have emerged as key to integrating the shape and define care delivery, the Magnet Magnet model into nursing practice and the Recognition Program monitors growing evidence organization, in all settings, inclusive of and confers with experts in this specialty setting, ambulatory care. Contacting the Magnet Program including AAACN. Further, the Commission on Office (MPO) is the first strategic step to Magnet includes a member with ambulatory care understand the Magnet application and scope and nursing care expertise. breadth of the appraisal process, including AAACN, the specialty body of nurses who requirements to maintain the credential. Magnet work to advance nursing care in the ambulatory standards (Sources of Evidence), eligibility care setting, has supported the maximization of requirements, and the four phases (application, the role of RNs in the evolving healthcare written documentation, site visit, and decision) are environment via numerous strategies and tactics. foundational for leaders, stakeholders, and the Authoritative position statements, rigorous work organization at large to understand. Ambulatory to develop nurse-sensitive indicators, white care settings frequently have special data papers on telehealth and nurse transition to collection measures, geographic distance, and practice, and toolkits that support the growing matrixed reporting structures, whether in stand- role of the nurse executive in ambulatory care are alone ambulatory care structures or integrated among the supportive tools available. within a larger healthcare organization or system. Additionally, standards and scope for the role of Using the MPO to navigate the fundamental RNs as well as that of the nurse in care elements of Magnet eligibility and appraisal may coordination and transition management, along result in cost savings by avoiding rework or with adjoining specialty certifications, are potential failure to designate due to infrastructure available to support excellent practice in the misalignments or insufficient evidence to support ambulatory care RN. ANCC required elements Magnet requirements.

92 March/April 2021 | Volume 39 Number 2 Nursing Economic$

Table 1. Crosswalk Note: Ambulatory care data and examples are expected in Magnet appraisal documents; certain standards require ambulatory care examples, where noted in the Magnet Application Manual. © Start, 2021. The information in this table is intended for educational use and is not to replace or construe interpretation of the ANCC Magnet Recognition program, guidance, or application manuals.

2019 Magnet Application Available AAACN Ambulatory Manual Topics Items Measured/Discussed/Required Care Resources/Supports Demographic Data Education, certification, turnover, vacancy • Ambulatory Care NSI Industry Report (guidance on Collection and collecting and reporting demographics) Benchmarking • Nurse Executive Toolkit*

Performance Evaluation Require a BSN minimum for nurse managers • Nurse Executive Toolkit* and Peer Feedback conducting performance evaluation and • Scope and Standards of Practice for Ambulatory Care Process overseeing practice Nursing • Scope and Standards of Practice for Care Coordination and Transition Management • Scope and Standards of Practice for Professional Telehealth Nursing • Position Paper on the Role of the RN in Ambulatory Care Nursing

Shared Decision-Making Though not specific, committees, work • Nurse Executive Toolkit* and Organizational items, and inclusion of these nurses is • Annual Conference and educational offerings Initiatives expected in all nursing-driven work. Nurses • Scope and Standards of Practice for Ambulatory Care have a seat at the highest decision-making Nursing bodies in the organization. • Scope and Standards of Practice for Care Coordination and Transition Management • Scope and Standards of Practice for Professional Telehealth Nursing • Position Paper on the Role of the RN in Ambulatory Care Nursing

Organizational Overview All elements must apply wherever a nurse • Nurse Executive Toolkit* practices: policies, CNO oversight and • Scope and Standards of Practice for Ambulatory Care visibility, credentialing/privileging, workplace Nursing safety, process to address interprofessional • Scope and Standards of Practice for Care conflict, nurse involvement in IRB panels Coordination and Transition Management reviewing nursing research studies • Scope and Standards of Practice for Professional Telehealth Nursing

Transformational TL6: One ambulatory care example required • Nurse Executive Toolkit* Leadership for mentoring

TL7: One ambulatory care example required for succession planning

Structural Empowerment SE1EO: One ambulatory care example • Scope and Standards of Practice for Ambulatory Care required for improved patient outcomes Nursing associated with participation of RN in • Scope and Standards of Practice for Care organization-level interprofessional decision- Coordination and Transition Management making committee • Scope and Standards of Practice for Professional Telehealth Nursing SE3, SE4EO, SE5, SE6EO: All nurses • Position Paper on the Role of the RN in Ambulatory required in education and certification count Care Nursing and performance • Ambulatory Care NSI Industry Report (performance improvement strategies for demographic SE8EO: One ambulatory care example improvements) required for improved patient outcomes • Certifications and review courses: Ambulatory care associated with nursing continuing education nursing, CCTM assessment and related implementation plan • Core Curriculum for Ambulatory Care Nursing • Care Coordination and Transition Management Core Curriculum

continued on next page

March/April 2021 | Volume 39 Number 2 93 Nursing Economic$

Table 1. (continued) Crosswalk Note: Ambulatory care data and examples are expected in Magnet appraisal documents; certain standards require ambulatory care examples, where noted in the Magnet Application Manual. © Start, 2021. The information in this table is intended for educational use and is not to replace or construe interpretation of the ANCC Magnet Recognition program, guidance, or application manuals.

2019 Magnet Application Available AAACN Ambulatory Manual Topics Items Measured/Discussed/Required Care Resources/Supports Structural Empowerment SE9: If ambulatory nurses are new or APNs • Ambulatory Care RN Residency Program (continued) are new, evidence of transition to practice • Ambulatory Care RN Residency White Paper program

Exemplary Professional EP1EO: One ambulatory care example • Ambulatory Care NSI Industry Report (performance Practice required for improved outcome associated improvement strategies for engagement, quality, with an evidence-based change made by patient satisfaction) clinical nurses in alignment with PPM • Nurse Executive Toolkit* • AAACN continuing education to supplement practice: EP2EO: Nurse satisfaction, inclusive of all Telehealth, Covid Care, EMR Strategies, etc. nurses and presented by unit types • Scope and Standards of Practice for Ambulatory Care Nursing EP10EO: Turnover rate, inclusive of all • Scope and Standards of Practice for Care nurses Coordination and Transition Management • Scope and Standards of Practice for Professional EP19EO: Requirement for ambulatory care Telehealth Nursing NSIs, as specified in the manual and tracked by a national database or highest level available

EP21EO: Requirement for all ambulatory care areas with a nurse to show patient satisfaction data nationally benchmarked by a national database

New Knowledge, NK6EO: One ambulatory care example • Ambulatory Care NSI Industry Report (performance Innovations, Improvements required for improved outcome in a care improvement strategies for engagement, quality, setting associated with a clinical nurses’ patient satisfaction) involvement in the adoption of technology • Nurse Executive Toolkit* • Scope and Standards of Practice for Ambulatory Care NK7EO: One ambulatory care example Nursing required for improved outcome associated • Scope and Standards of Practice for Care with nurse involvement with design or Coordination and Transition Management redesign of work environment • Scope and Standards of Practice for Professional Telehealth Nursing

*AAACN’s Nurse Executive Toolkit will be released in 2021. AAACN = American Academy of Ambulatory Care Nursing ANCC = American Nurses Credentialing Center requirements adapted from ANCC Magnet Recognition Program Manual (2017) APN = advanced practice nurse CCTM = Care Coordination and Transition Management CNO = chief nursing officer EMR = electronic medical record EP = Magnet Exemplary Professional Practice Component EO = Magnet Empirical Outcomes Component IRB = Institutional Review Board NK = Magnet New Knowledge, Improvements, and Innovations Component NSI = Nurse Sensitive Indicators PPM = professional practice model SE = Magnet Structural Empowerment Component TL = Magnet Transformational Leadership Component

94 March/April 2021 | Volume 39 Number 2 Nursing Economic$

Strategies from the Lived Experience of Ambulatory care entities seeking to adopt the Magnet Model Adoption in an Ambulatory Magnet model as a blueprint for nursing practice Care Setting excellence, along with an inpatient setting or independently as a standalone, benefit from this The following paragraphs provide strategies same process of structural design, ensuring either from the lived experiences of Magnet Program dotted or solid reporting to the organizational Directors and AAACN members. CNO. Many organizations are positioning a CNO over their ambulatory care structures to ensure Transformational Leadership strategies are implemented and sustained. The first and most essential step to authentic Because many nurses in ambulatory care settings integration of the Magnet model starts with do not report directly to a nurse, processes such structural design that positions the CNO in as shared governance or performance oversight connectivity to all settings and roles that practice may not be fully implemented or supported nursing. Ensuring the CNO has a line of nursing without a designated leader to ensure adoption of practice oversight and accountability throughout this approach. Creating a structure that allows for the organization is imperative for all other engagement and empowerment of nursing structures to follow. From this nursing practice practice throughout all practice sites requires ownership position, systems supporting a cultural collaboration with other disciplines and transformation such as shared governance, stakeholders. Furthermore, it may be an activity performance evaluation and peer feedback, that is occurring due to transformation in health strategic planning, policy creation and care in different fields and service lines (Peterson standardization, evidence-based practice and & Lovrien, 2015). research, and strength of professional identity can Much of the Transformational Leadership be integrated. Authentic leadership starting with portion of the Magnet model focuses on the role the CNO can lead to leadership at all levels and of the CNO and other leaders to set strategy and in all settings. It must be approached in mission, create opportunities for resource partnership with other disciplines, not focused advocacy and utilization, as well as succession solely on achieving Magnet designation but on and mentorship activities (ANCC, 2017). Beyond shared priorities related to patient care. the requirements of Transformational Leadership, Often a gap analysis followed by some the Magnet process requires demographic data structured visioning and strategic planning, collection at all levels and practice settings of the conducted from an inclusive approach, with all applicant organization. Nurses with a minimum of clinical specialties and roles represented, can set a bachelor’s degree in nursing must be in the the stage for the following years of needed organizational chart, as managers or directors and structural redesign. Ensuring these activities are higher, cascading from the CNO. They conduct inclusive of both direct-care practitioners and nursing practice oversight, performance administrative nurses will promote collaboration evaluations, support for staffing, and and diminish hierarchy as a flourishing practice empowerment for a shared governance culture environment is pursued. Planning and executing a (ANCC, 2017). Conducting gap analyses and multi-pronged communication and feedback being familiar with the structures required in the process for ongoing improvement through demographic and organizational overview activities such as forums, webinars, development sections of the Magnet process from the earliest activities, and education, in partnership with an moments in an organization’s journey are critical influential and connected shared governance to building nursing excellence throughout (ANCC, structure, can ensure this culture of ownership 2017). and empowerment is hardwired. Promoting activities that develop, mentor, and guide new Structural Empowerment leaders to succeed in their roles as nurses poised Structural empowerment, defined as access to for change management is critical. information, resources, support, and the

March/April 2021 | Volume 39 Number 2 95 Nursing Economic$

opportunity to learn and develop (Kanter, 1993), Exemplary Professional Practice is essential as organizations adopt the ANCC Understanding and integrating a professional Magnet model and seek authentic ownership of practice model (PPM) to guide nursing practice nursing practice in any setting. Aiming to support identity is important as job descriptions, peer nursing practice with access to resources and evaluation, awards, and committee work is tools from specialty professional organizations, pursued (Hossli et al., 2018; IOM, 2010; opportunities to attend continuing education such Wadsworth et al., 2016). Ensuring the ambulatory as webinars or conferences, and leveraging care setting is involved in PPM selection and internal and external expertise to build nursing adoption is an essential part of structural staff’s practice acumen are essential. When empowerment and must be pursued with envisioning shared governance, understanding at subsequent patient outcomes. Ambulatory care the beginning how to operationalize time and settings adopting the Magnet model can create or resources to make it possible is key. Many implement a PPM and utilize it to guide clinical ambulatory care organizations are cohorting like advancement, performance, peer evaluation, and clinics into clinic-based committees that report to other nursing practice activities (Hossli et al., a coordinating or executive-level committee. 2018). Ensuring any structure created in ambulatory care With practice identity enculturated, nurses in is also included in the organization’s shared ambulatory care pursuing Magnet adoption can governance will promote nursing practice seek to work collaboratively with other transformation, collaboration, and heightened stakeholders and nursing departments to support patient service across the continuum, rather than staffing, value-based care delivery, in silos. interprofessional collaboration, and patient Development of policies that support outcomes. Patient outcomes can be tracked at advancing professional development, pursuit of both an internal and national benchmarkable specialty certification, and higher degrees within levels to demonstrate exemplary professional nursing are processes that continue to empower practice. AAACN has contributed to developing nursing staff to be equipped as full partners and nurse-sensitive indicators that support outstanding leaders in any environment. Regular assessment professional practice (Start et al., 2018; Start et al., of learner needs and strategic deployment of 2016). continuing education to meet these needs ensures Mature nursing practice has full ownership nursing is abreast of recent changes to the and accountability for patient outcomes (Clavelle practice environment. Supporting transition to et al., 2016) and is supported by regular, practice throughout all roles and settings, formalized data analysis and dashboard tracking including advanced practice nurses and (Wilbanks & Langford, 2014). Using patient administrative nurses, in addition to new outcomes and related benchmarks can help graduates and other experienced nurses changing develop efficient and value-based staffing in the practice settings, will support retention, ambulatory care setting. Empowering nurses to engagement, and improved patient outcomes pilot and test various care delivery interventions (Goode et al., 2016). and use data to track success or persistent gaps Aligning empowerment structures with expands the critical thinking and research-based community, social, and diversity-based strategies understanding of nursing staff. promotes a nursing staff that is valid in a healthcare setting that is rapidly evolving. Also, New Knowledge, Innovations, and empowerment of staff involves recognition of Improvements exemplary practice and achievement of positive An empowered, flourishing nursing staff is patient outcomes. Seeking meaningful structures accountable for full ownership of the discipline to recognize nursing can support engagement and and utilizes scientific knowledge to promote increased practice ownership (AACN, 2005; Grant evidence-based changes to practice and seeks to et al., 2020).

96 March/April 2021 | Volume 39 Number 2 Nursing Economic$

grow new knowledge where gaps exist (ANA, as new shared governance activities seek to 2010; Clavelle et al., 2016; IOM, 2010). Magnet integrate metrics into their work, is vital to assist applicant organizations must show evidence of at nurses in performance improvement, evidence- least one open nursing research study and one based application, and ongoing tracking of completed nursing research study. Numerous outcomes. other examples of evidence-based practice adoption and promotion throughout the Conclusion organization must be documented. As nurses become more comfortable with scientific inquiry, As healthcare shifts from an acute, disease, searching evidence for answers to practice and episodic-based model to health, community, questions, and improving practice that elicits and continuum-focused interventions, ambulatory positive patient outcomes, new knowledge, care nurses are essential in this transformation improvements, and innovations occur. Supporting and success. Leveraging the ANCC Magnet model a learning and appreciative-based approach to as a blueprint for a journey that leads to improving workflow and redesign of care and the improved patient outcomes and care of the leverage of technology also show nursing staff’s nursing workforce can ensure that transformation willingness to improve and grow discipline- is achieved. Significant support to develop specific contributions to care. structure, connect nursing practice across the Connecting ambulatory care nursing staff to continuum, and empower new generations of resources that exist to support research and nurses into other settings besides acute care has evidence-based practice will promote continuous the potential to propel nurses in ambulatory care improvement in patient outcomes. Support for practice to the full extent of their education and tracking and disseminating best practices can license. This strategy can develop the discipline further the nursing community beyond the and fulfill nursing’s contract with society. $ original healthcare organization’s walls. Strategies such as lean methodology, improving nurses’ ability to conduct business case proposals, and Rachel Start, MSN, RN, NEA-BC, FAAN linking to constant data analysis will promote Director Ambulatory Nursing and Nursing Practice nursing practice improvements that synergize Rush Oak Park Hospital organizational priorities relative to efficiency and Oak Park, IL value (Brown, 2009; Brown et al., 2020). Rebecca Graystone, MS, MBA, RN, NE-BC Vice President Empirical Outcomes American Nurses Credentialing Center The fifth component, Empirical Outcomes, is Silver Spring, MD weaved through the other four components as the NOTE: The “Perspectives in Ambulatory Care” column makes sense of “so what” factor of any nursing structure or today’s changing ambulatory care market. It is written by members of process. Empirical outcomes require pre and post- the American Academy of Ambulatory Care Nursing (AAACN) and data points that prove a nursing intervention, edited by Kitty Shulman, MSN, RN-BC. For more information about AAACN, please visit www.aaacn.org; email [email protected]; or call structure, or process has positive results on (800) AMB-NURS. nursing practice, patient care environment, or patient outcomes (ANCC, 2017). Ambulatory care References nurses working to show evidence of impact American Academy of Ambulatory Care Nursing (AAACN). (2017). through interventions, structures, or processes in American Academy of Ambulatory Care Nursing position paper: The role of the registered nurse in ambulatory care. https://www. the other components should be organized to aaacn.org/sites/default/files/documents/RNRolePositionPaper.pdf collect pre and post-data when initiating work. American Association of Critical Care Nurses (AACN). (2005). AACN Tying metrics to strategy, creating dashboards at standards for establishing and sustaining healthy work environments: A journey to excellence (2nd ed.). clinic, department, service line, and organizational American Hospital Association. (2018). Utilization and volume. In levels can help analyze the impact of ongoing Trendwatch Chartbook 2018 (Chapter 3). https://www.aha. performance improvement. Mentorship, especially org/system/files/2018-07/2018-aha-chartbook.pdf

March/April 2021 | Volume 39 Number 2 97 Nursing Economic$

American Nurses Association (ANA). (2010). Nursing’s social policy Institute of Medicine (IOM). (2010). The future of nursing: Leading statement: The essence of the profession. change, advancing health. National Academies Press. American Nurses Association (ANA). (2013). Framework for measuring Kanter, R.M. (1993). Men and women of the corporation (2nd ed.). nurses’ contributions to care coordination. Basic Books. American Nurses Credentialing Center (ANCC). (2017). 2019 Magnet Lal, M.M. (2020). Innovative nurse-led initiatives improve population application manual. health. The Journal of Nursing Administration, 50(2) 59-60. American Nurses Credentialing Center (ANCC). (2020). Find a Magnet Peterson, L., & Lovrien, K. (2015) The leadership needed for the new organization. https://www.nursingworld.org/organizational- ambulatory enterprise. Becker’s Hospital Review. https://www. programs/magnet/find-a-magnet-organization/ beckershospitalreview.com/hospital-management- American Nurses Credentialing Center. (ANCC). (2021). Facts about administration/the-leadership-needed-for-the-new-ambulatory- the Magnet recognition program. https://www.nursingworld.org/ enterprise.html globalassets/organizational-programs/magnet/magnet- Radley, D., Collins, S. & Baumgartner, J. (2020). 2020 scorecard on factsheet.pdf state health system performance. The Commonwealth Fund. Barnes, H., Rearden, J., & McHugh, M.D. (2016). Magnet hospital Schneider, E.C., Sarnak, D.O., Squires, D., Shah, A., & Doty, M.M. recognition linked to lower central line-associated bloodstream (2017). Mirror, mirror 2017: International comparison reflects infection rates. Research in Nursing and Health, 39(2), 96-104. flaws and opportunities for better U.S. health care. The Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The triple aim: Commonwealth Fund. Care, health, and cost. Health Affairs, 27(3), 759-769. Start, R., Brown, D., May, N., Quinlan, S., Blankson, M., Russel- Brown, R. (2009). The promise of care coordination: Models that Rodriguez, S., & Matlock, A. (2020). Strategies for leveraging the decrease hospitalizations and improve outcomes for Medicare RN role across the continuum in successful care coordination beneficiaries with chronic illnesses. Mathematica Policy and transitions management: Thematic analysis of qualitative Research, Inc. interviews of nurse executive from across the risk sharing Brown, D., Start, R., & Matlock, A. (2020). Creating a business case spectrum. Nursing Economic$, 38(4), 203-217. template for care coordination and transitions management. Start, R., Matlock, A., Brown, D., Aronow, H., & Soban, L. (2018). Nursing Economic$, 38(6), 308-315. Realizing momentum and synergy: Benchmarking meaningful Clavelle, J., Porter O’Grady, T., Weston, M., & Verran, J. (2016). ambulatory care nurse-sensitive indicators. Nursing Economic$, Evolution of structural empowerment: Moving from shared to 36(5), 246-251. professional governance. Journal of Nursing Administration, Start, R., Matlock, A.M., & Mastal, P. (2016). Ambulatory care nurse- 46(6), 308-312. sensitive indicator industry report: Meaningful measurement of Donabedian, A. (1976). The nursing audit: Self-regulation in nursing nursing in the ambulatory patient care environment. American practice (2nd ed.) (Foreword). Appleton-Century-Crofts. Academy of Ambulatory Care Nursing. Donabedian, A. (1978). The quality of medical care: Methods for Stimpfel, A.W., Sloane, D.M., McHugh, M.D., & Aiken, L.H. (2016). assessing and monitoring the quality of care for research and for Hospitals known for nursing excellence associated with better quality assurance programs. Science, 200(26), 836-864. hospital experience for patients. Health Services Research, Emanuel, E.J., Gudbranson, E., Van Parys, J., Gørtz, M., Helgeland, 51(3), 1120-1134. J., & Skinner, J. (2020). Comparing health outcomes of Wadsworth, B., Felton, F., & Linus, R. (2016). SOARing into strategic privileged US citizens with those of average residents of other planning: Engaging nurses to achieve significant developed countries. Journal of American Medical Association outcomes. Nursing Administration Quarterly, 40(4), 299-306. Internal Medicine. https://doi.org/10.1001/jamainternmed. Wilbanks, B.A., & Langford, P.A. (2014). A review of dashboards for 2020.7484 data analytics in nursing. CIN: Computers, Informatics, Freeman, H. (2006). Patient navigation: A community-based strategy Nursing, 32(11), 545-549. to reduce cancer disparities. Journal of Urban Health, 83(2), 139-141. Friese, C.R., Xia, R., Ghaferi, A., Birkmeyer, J.D., & Banerjee, M. (2015). Hospitals in Magnet program show better patient outcomes on mortality measures compared to non-Magnet hospitals. Health Affairs, 34(6), 986-992. Goode, C., Reid Ponte, P., & Sullivan Havens, D. (2016). Residency for transition into practice: An essential requirement for new graduates from basic RN programs. Journal of Nursing Administration, 46(2), 82-86. Grant, S., Davidson, J., Manges, K., Dermenchyan, A., Wilson, E., & Dowdell, E. (2020). Creating healthful work environments to deliver on the quadruple aim. Journal of Nursing Administration, 50(6), 314-321. Haas, S.A., Conway-Phillips, R., Swan, B., De La Pena, L., Start, R., & Brown, D. (2019). Developing a business case for the care coordination and transition management model: Need, methods, and measures. Nursing Economic$, 37(3), 118-125. Hossli, S., Start, R., & Murphy, M. (2018). Implementation and evaluation of an ambulatory care nurse clinical advancement system. Nursing Economic$, 36(3), 149-155.

98 March/April 2021 | Volume 39 Number 2