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Quality indicators for academic nursing primary care centers.

Executive Summary

* Academic Nursing Centers (ANCs) provide a unique environment that serves patients, students, and faculty.

* As a result, performance measures of quality and efficacy must be broadly defined to meet their clinical, fiscal, research, and educational objectives.

* The University of Texas Health Services ANC defines measures within the following areas in their plan for performance management:

-- Multidisciplinary quality assurance committee and process

-- Financial stability

-- Billing and insurance systems

-- Participation levels from students and faculty in the ANC

-- Research activities

-- Patient care processes

-- Administrative organization

-- Marketing efforts

-- Medical information management

-- Credentialing and continuing education

-- Facilities and care environment

-- Health education and wellness services

-- Patient/corporate satisfaction feedback

-- Faculty and staff management

ACADEMIC NURSING centers (ANCs) involved in primary care provide a forum by which schools of nursing achieve a number of goals including community service, clinical opportunities for students and faculty, and data for research projects (Aydellote & Gregory, 1989). Regardless of the ANC's objectives, the issue of quality is paramount. The purpose of this article is to propose an evaluation tool for measuring the overall quality of a primary care ANC. Further, it is to stimulate thoughts on how to improve the overall quality of a primary care ANC clinic. It is not the intent to discuss quality care delivered by individual practitioners or quality related to specific health care conditions.

History of Academic Nursing Centers

The American Nurses Association's definition of a nursing center is a center in which a nurse occupies the chief management position; accountability and responsibility for client care and professional practice remains with the nursing staff; and nurses are the primary providers seen by clients visiting the center (Lockhart, 1993). Holthaus (1993) traces the beginnings of nursing centers back to Lillian Wald in 1893. Other examples of nursing centers through time have been the Frontier Nursing Service and community nursing centers funded by local, state, and federal monies, and by foundations such as Robert Wood Johnson and W.K. Kellogg. Planned Parenthood clinics most certainly fit the description of nursing centers, as do many college health services across the country. In the late 1970s Pace University in New York became one of the early leaders of ANCs.

Current accurate data on the number, diversity of missions, economic status, quality, and other issues of ANCs are not available. The National League for Nursing provided an excellent forum for those involved in ANCs in the late 1980s and early 1990s. However, that forum is no longer active. Important current forums for ANCs include the American Association of Colleges of Nursing (AACN) and the recently developed Penn Macy Fellowship program at the University of Pennsylvania. Nurse researchers involved with these two organizations are actively looking at ways to gather data that will identify the varied types and activities of ANCs.

Review of Literature on Quality of Care at ANCs

The literature is anemic and confusing with regard to quality issues in ANCs. However, Davis (1993) discusses the various issues of accrediting bodies for primary care settings (protocols, quality assurance, and risk management programs) and indicates that accreditation is one means to assure excellence of care in an ANC. Chickering Group (Ferran, 2001) raises the issue that the quality of a health care service is viewed differently by patients, providers, administrators, insurance/managed care companies, and in some cases students (student health services). Patients often define quality in terms of convenience and service expectations. Providers define quality in terms of process and outcomes. Administrators define quality as "no complaints" and cost effectiveness. Researchers typically evaluate quality of care by assessing the structures, processes, and outcomes of care (Rosenfeld & Wenger, 2000).

Definition of Terms

Just as patients, providers, and researchers measure and define quality in various ways, they also differ in the meaning of other terminology surrounding the issue of quality. For the purposes of this article the following terms are defined.

Quality refers to the degree of excellence. In this article it refers to the degree of excellence of a particular center, program, or other service pertaining to an ANC.

A quality indicator is a policy, program, protocol, standard, guideline, assessment measure, or other evaluation tool that shows there is reason to believe measures are in place to assure a high level of care is provided.

Quality assurance is defined by Mosby (Anderson, 1994) as "any evaluation of services provided and the results achieved as compared with accepted standards" (p. 1319).

A standard is an "evaluation that serves as a basis for comparison for evaluating similar phenomena or substances such as a standard for a practice" by a professional (Anderson, 1994, p. 1475). In this case we refer to standards not just for a professionals but also for ANCs. Standards and guidelines are developed over time by organizations and professionals who present the highest levels of achievement in a particular area such as clinical practice or health care management. Standards are also recommendations by which an individual or organization can achieve goals.

A quality assurance program is a systematic "review of selected hospital medical/nursing records by medical/nursing staff members, performed for the purposes of evaluating the quality and effectiveness of medical/nursing care in relation to accepted standards" (Anderson, p. 1319).

Quality assessment is a method that can be used to obtain information related to the provision of health services that should subsequently lead to appropriate action to safeguard and enhance the quality of these services. Quality assessment is achieved by identifying and describing the structural characteristics of a setting, examining the activities or processes involved in the provision of services, and measuring the effects of services that result when the identified structures and processes are combined (Salazar, Graham, & Lantz, 1999).

A quality assessment measurement is a "formal, systematic, organizational evaluation of overall patterns or programs of care, including clinical, consumer and systems evaluation" (Anderson, p. 1319). Typically, quality measurements evaluate structures, processes, and outcomes.

National Organizations and Quality

Accreditation from a national organization such as The Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and the Community Health Accreditation Program (CHAP) may or may not be appropriate depending on the individual ANC's make up. Protocols, however, are frequently mandated by state law and, if properly written, will address health care issues from a "clinical standards" viewpoint. One example of a quality assurance program is that of Pace University Health Care Unit. This program includes peer review of charts, diagnosis-based chart review, review of high-risk client encounters, monitoring of equipment, systematic disposal of expiring medications, adherence to the Occupational Safety and Health Administration (OSHA) and Department of Environmental Control standards for environment, client satisfaction surveys, followup file for client surveys, and followup of missed appointments (Davis, 1993).

Four organizations that provide a framework for assessing quality in the primary care setting are AAAHC, JCAHO, CHAP, and the American Academy of Ambulatory Care Nursing (AAACN). AAACN first developed and published standards for ambulatory care nursing practice and administration in 1985 and has since revised them (AAACN, 2000). These standards come closest to defining appropriate quality indicators for ANCs. AAACN's nine standards are accompanied with rationale and measurement criteria by which any ANC could evaluate itself for quality issues. These standards are:

1. Structure and organization of ambulatory care nursing standards of professional performance.

2. Staffing standards of professional performance.

3. Competency standards of professional practice.

4. Ambulatory nursing practice standards of professional performance.

5. Continuity of care standards of professional practice.

6. Ethics and patient rights standards of professional performance.

7. Environment standards of professional performance.

8. Research standards of professional performance.

9. Quality management standards of professional performance.

Despite the comprehensiveness of these standards, they still do not fully address some of the more important quality indicators of an ANC.

Quality Indicator Recommendations

AAAHC, JCAHO, CHAP, and AAACN are all concerned with multiple areas of service (see Table 1). Although they address the typical quality indicators of primary care centers, none of them directly addresses the unique issues of academic nursing centers.

The following 14 recommendations are based on AAAHC, JCAHO, CHAP, and AAACN recommendations and guidelines with the addition of other quality indicators unique to academic practices. These recommended indicators are based on 12 years of practice at The University of Texas Health Services ANC.

A highly qualified primary care academic nursing center will possess:

1. Quality assurance (QA) program. The QA program will have committee members representative of clinic personnel from various areas including administration, providers, and clerical staff. The committee will also be multidisciplinary. The program will be organized as evidenced by holding regular meetings, developing and implementing a plan of action, and systematically reviewing areas represented by its members. Finally, it will have and audit a compliance program addressing state and federal regulations (for example, Health Insurance Portability & Accountability Act or HIPAA, Medicare, Medicaid, and managed care organizations).

2. Financial stability. Financial stability will be evidenced by a collection rate above 90%; accounts receivable (AR) for greater than 120 days at less than 18% of total AR; ability to track accuracy of billing; financial self-sufficiency (income exceeds expenses); reserve funds equal to 10% of annual income; administrative costs no greater than the national mean according to the practice type (see national data from Medical Group Management Association); and diverse funding sources such that less than 50% of funding comes from a single source.

3. Educational opportunities for students. A specified number (or percent) of students receive educational opportunities in the center. Faculty from the school of nursing have the opportunity to use the ANC for faculty practice opportunities. Faculty preceptors receive orientation (Fay et al., 2001). At least 50% of clinic faculty/staff are significantly involved in teaching students. Clinic personnel are from different disciplines (for example, nursing, medicine, pharmacy, social work).

4. Research efforts. Faculty from the ANC and the academic unit are actively engaged in research and publishing. Students regularly use ANC clinical data for dissertations, theses, and clinical projects. Institutional review board protocols are followed. ANC resources (funds, space, computers, release time) are available for research purposes. ANC administration encourages interdisciplinary research efforts.

5. Patient care processes. The ANC has appropriate referral and consultation patterns (Mackey, Cole, & Veeser, 1999). Laboratory, radiology, physical therapy, and other outpatient care services are offered and monitored for quality and service. Clinic pharmaceuticals are regularly monitored for dates of expiration. Tracking systems are in place to document care processes including handling of inpatient admissions and of laboratory, radiology, and other test results. There is an interdisciplinary approach to patient care including arrangements for nutrition, pharmacy, mental health, social, physical and occupational therapy services. Emergency drugs and procedures are in place. Patient wait times are less than 15 minutes (Mackey et al., 1999). The ANC has arranged for 24/7 call. There is a phone triage process in place. Universal precautions are provided for and followed by all clinic staff and faculty.

6. Billing and insurance systems. The clinic possesses or uses a billing system that is accurate, timely, cost effective, efficient, and customer friendly as evidenced by satisfaction surveys. The ANC accepts third-party insurance payers as appropriate for that particular center's patient population.

7. Administration and governance. Policies and procedures are established, documented, and regularly updated. Outside consultants are used for process improvement efforts and audits. The ANC has a long-range plan that is regularly updated. Staff meetings are held regularly with agenda input from all staff and faculty. The ANC posts and adheres to a statement of patient rights. There is a balanced interface and support among the ANC operations, the parent academic unit, and university administrative departments.

8. Marketing efforts. There is a detailed marketing plan with a budget and staff resources to support the marketing efforts. Outcomes of the marketing efforts are tracked, and the plan is updated regularly.

9. Clinical records and information systems. The systems are comprehensive (medication list, flow sheets, allergies, problem list, SOAP format, confidentiality issues, health maintenance), retrievable, and achievable. These systems are integrated and used by all ANC faculty and staff. Appropriate backup systems are in place.

10. Credentialing and continuing education efforts for faculty and staff. Personnel records verify current licensures and certifications. The center has adequate library references. All faculty and staff maintain and document current CPR certification. Continuing education is encouraged through available funding and release time. Credentialing and certifications of laboratory and radiology services used are verified and current. The ANC is in compliance with CLIA regulations and other appropriate regulations (for example, pharmacy services).

11. Facilities and environment. Facilities and environment should be conducive to patient convenience (for example, hours of operation, patient parking); regulatory adherence (for example, fire inspections, ADA compliance, emergency evacuation plan, personal protective equipment and medical safety data sheets in compliance with OSHA standards); and efficient operations should be maintained (for example, appropriate and up-to-date diagnostic, treatment, and electronic equipment; and routine equipment inspections).

12. Health education and wellness services. Personnel should be trained in health education and wellness type services. A documented program plan should include a needs assessment for targeted populations. There should be personnel training for the plan's implementation. Documentation of these services should be found in patient charts.

13. Patient/corporate satisfaction feedback. A regular feedback mechanism is in place as well a mechanism to receive and act on complaints.

14. Faculty and staff issues. Pre-employment (for example, security checks, immunizations, health screenings) and orientation plans (for example, team approach to patient care, clinic policies and procedures, job duties, expectations) should be implemented. Employee satisfaction (for example, benefits, retention rates) should be monitored and issues addressed. Where appropriate, nurse practitioners should have faculty status and the school of nursing should employ the staff. Faculty and staff have security clearance before starting employment.


ANCs, by definition, deliver more than clinical services to patients and communities. The unique identifier that separates ANCs from other primary care/ambulatory care centers is the educational service they offer to students and other faculty in the school of nursing to which they belong. Therefore, measuring the quality of an ANC must include a measurement of the educational properties that it possesses in addition to the usual quality measurements by such organizations as AAAHC, JCAHO, CHAP, and AAACN. Unless these properties are included and measured by an ANC, it becomes difficult to justify the existence of such a clinic within a school of nursing.

ANCs are encouraged to develop quality evaluation programs aimed at evaluating the educational aspects as well as the administrative and clinical aspects of their operations.
Table 1.

Common Survey Areas of Major Accrediting Agencies *

Administrative Activities               Clinical Activities

Administration                          Records
Facilities and Environment              Diagnostic Imaging
Governance                              Emergency Services
Managed Care Professional               Health Education and Wellness
Delivery Organization
Patient Rights                          Immediate/Urgent Care
                                        Occupational Health
Professional Improvement                Overnight Care
Quality Management                      Pathology and Laboratories
Quality of Care Provided                Pharmaceutical
Teaching and Publication Activities     Research Activities

* Accreditation Association for Ambulatory Health Care Guidelines

* Joint Commission on the Accreditation of Healthcare Organizations

* Community Health Accreditation Program Guidelines

* American Academy of Ambulatory Care Nursing Standards


American Academy of Ambulatory Care Nursing. (2000). Ambulatory care nursing administration and practice standards. Pitman, NJ: Author.

Anderson, K. (Ed.). (1994). Mosby's medical, nursing, and allied health dictionary (4th ed.). St. Louis: Mosby.

Aydellote, M., & Gregory, M. (1989). Nursing practice: Innovative models. Nursing centers: Meeting the demand for quality health care (Publication No. 21-2311). New York: National League for Nursing.

Davis, E. (1993). Establishing a nurse-managed health center: Assuring excellence. Nurse Practitioner Forum, 4(3), 151-157.

Fay, V., Feldt, K., Greenberg, S., Vezina, M., Flaherty, E., Ryan, M., & Fulmer, T. (2001). Providing optimal hands-on experience: A guide for clinical preceptors. Advance for Nurse Practitioners, 9(3), 71-74, 110.

Ferran, E. (2001, Spring). Quality in student health: Do we need a new quality initiative? Student Health Spectrum. Cambridge, MA: Chickering Group.

Holthaus, R. (1993). Nurse-managed health care: An ongoing tradition. Nurse Practitioner Forum, 4(3), 128-132.

Lockhart, C. (1993, June). Community nursing centers: An analysis of status and needs. New Brunswick, NJ: Robert Wood Johnson Foundation.

Mackey, T., Cole, F., & Veeser, P. (1999). Nurse practitioner referral patterns in primary care/occupational health care settings. The Internet Journal of Advanced Nursing Practice, 2(2). Retrieved July 19, 2001 from:

Rosenfeld, K., & Wenger, N. (2000). Measuring quality in end-of-life care. Clinics in Geriatric Medicine, 16(2).

Salazar, M., Graham, K., & Lantz, B. (1999). Evaluating case management services for injured workers: Use of a quality assessment model. AAOHN Journal, 47(8), 348-354.

THOMAS A. MACKEY PhD, NP-C, is a Professor of Clinical Nursing, Director, The University of Texas Health Services, University of Texas Health Science Center at Houston School of Nursing, and Director, Occupational Health for Nurses Program, Houston, TX.

NANCY O. McNIEL, PhD, is Associate Professor of Clinical Nursing and Associate Dean for Management, University of Texas Health Science Center at Houston, School of Nursing, Houston, TX.
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Author:Mackey, Thomas A.; McNiel, Nancy O.
Publication:Nursing Economics
Geographic Code:1USA
Date:Mar 1, 2002
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