Team synergy: A collaborative playbook to improving ambulatory care

September 9, 2024

Embracing the trend of growing outpatient health services, UK HealthCare - the academic health system of the University of Kentucky comprised of 9,000 healthcare professionals - has built a winning team to improve ambulatory care through persistence and trust.

By Randena Hulstrand, Vizient

Like any successful coach, Patty Hughes, chief nursing officer-ambulatory at UK HealthCare, has a clear vision on how to lead a team - and win.

A 40-year career in nursing and leadership - built around in-patient care as well as oncology service lines - prepared for her latest role that involved growing culture to improve patient-centered care.

"After I joined the ambulatory services team in 2015, we embarked on this journey toward our second Magnet designation [the gold standard of nursing excellence by the American Nurses Credentialing Center]," Hughes said. "We had a lot of nurses and clinical activity in our ambulatory space - comprised of 120 clinic locations across Fayette County and contiguous counties in Eastern Kentucky. But we realized there wasn't standardized supervision of the activity."

Here, Hughes shares strategies from her playbook on how she - and her synergetic team - are taking the offense in their ambulatory performance improvement game.

Step 1: Build a winning team.

While achieving the designation was the initial guiding principle, Hughes said the risk to quality patient care took center field.

"It went much deeper for us," she said. "I knew the best way to make healthcare improvements was with a team. So, building one became my mission."

In 2019, she hired Marianne Hutti, a nurse scientist for ambulatory services - one of the nation's first nurse scientists in the ambulatory space. The following year, she rounded out her cadre with Brittney Dees, staff development specialist, and Sara Wellman, clinical nurse specialist.

"Then COVID hit," Hughes said. "But it didn't stop our work. With fewer activities in our clinics, it was the perfect time to huddle together, build trust and help our nurses identify what areas we could help them improve on. We knew there were a lot of talented nurses in the ambulatory space, and they had great ideas; we just had to help guide and support them in a different way."

Step 2: Develop evidence-based practices.

Tactic: As part of the standardization process, the team leaned heavily into industry evidence-based practices such as reviewing literature searches and finding opportunities for their own scholarly work.

"We looked closely at best practices behind what should occur in our ambulatory space so we could educate our staff and encourage them to think outside the box to create some new evidence," Hughes said.

Hutti, who also serves as a liaison between the UK College of Nursing and ambulatory services, led the charge by helping Dees and Wellman develop quality improvement and research projects.

"I tried hard to get nurses in the clinics to engage research in the beginning," Hutti said, "But it wasn't until Brittney and Sara came that I got the 'in' to help create more scholarship. Nursing is a team sport. Sara put me in touch with nurses interested in scholarly activity, and Brittney helped me with educating the staff about the value of that work. Each of us could make changes in isolation, but we make such better change working together."

Outcomes: The results have been impressive and building year upon year. They completed six quality improvement projects in 2021 and are on track to disseminate 20 projects in 2024, with more in the works for 2025.

"We've also showcased our successes at numerous national conferences," Hutti said. "Many of these nurses have never presented before. It's so exciting to see them blossom."

Step 3: Identify gaps.

Tactic: As the "eyes and ears in the clinics," Wellman looked closely for gaps in their ambulatory practice.

"I round with the nurse managers and clinical staff and look for areas of care that might not be working so well," she said.

She's created dashboards accessible in real-time, conducted protocol developments, standardized rooming processes and improved quality measures. Among the measures, she reviewed patient pain scores, blood pressure rechecks, fall screenings and depression screenings.

Outcomes: "One of the biggest wins was improving our pain score documentation. I identified early on that our policy says we need to get a pain score on every patient, every time they come in, but we weren't doing it consistently," Wellman said. "So, I teamed up with Brittney to talk through why we were missing this and built training around it. As a result, our scores improved from 14% in 2019 to 95% in 2023."

Hughes emphasizes that from a sustained improvement perspective, real-time reporting through dashboards is key.

"We can monitor individual clinics and then focus on the specific areas of improvement needed," she said. "The data helps us empower nurse managers to hold their staff accountable. This not only standardizes work from one clinic to the next but allows for long-term improvements."

She says this work also is important to ensure that a patient does well after discharge, regardless of their social determinants of health.

"A patient may have an issue that they wouldn't otherwise discuss if it weren't for us asking appropriate questions," she said. "We're then able to connect them to resources they need such as food or transportation to best manage their conditions in the long run."

Step 4: Coach through education and support.

Tactic: The other complementary - and necessary - component to the team's success is education.

Dees - whose primary role is onboarding the clinical staff for all 120 clinics and growing (they are on target to open four more clinics this year) - meets with every new staff member and their manager regularly through the orientation process.

"Staff are eager to be involved in the work they do every day and want professional development resources," she said. "Investing time in the individual employee so they are happy and engaged when taking care of the patients every day is a win-win."

Additionally, she's implemented a tiered skills acquisition model, pain score documentation, skills day for ambulatory medical assistants and vaccine education.

Outcomes: "This really has standardized and upped the quality of care our nursing staff provide, which has been a game changer," Hughes said, adding that while they've long had a Vizient/AACN Nurse Residency Program™ at UK HealthCare, they recently expanded the program specifically for ambulatory nurses. "That's been really important for us because we now can recruit from nursing schools straight into ambulatory as well as from acute care."

She also says looking at education gaps helps identify opportunities to support their nursing staff - such as through certifications, professional development and advanced degrees - which in turn helps to promote their workforce culture and staff engagement.

"We increased our national certifications from zero ambulatory specialty certified nurses in 2019 to 110 in 2023 and have been able to offer paid course study each year," Hughes said. "We want to see our clinical staff be successful. We are all their biggest cheerleaders."

The collaborative team Hughes built is realizing multiple championship seasons.

"Our accomplishments are directly the result of the tight-knit relationship the four of us have," she said. "We don't silo our work. We draw on each of our skills and strengths to ensure we attain the biggest triumphs for both our staff and patients."

Learn more about the Vizient/AACN Nurse Residency Program™and other solutions to help optimizeyour workforce.