1. No category

Objectives
Utilizing the QSEN Framework to Structure :
Registered Nurse Care Coordination
Co
and
Transition Management
S h e i l a H a a s , P h D, R N , FA A N
B et h A n n Swa n , P h D, C R N P, FA A N
Tra c i H ay n e s , M S N , R N , BA , C E N
Background and Significance
ƒ Health care delivery is shifting from
inpatient to outpatient and
community settings.
ƒ Need for care coordination and
management of transitions between
types of care, providers and settings
is often overlooked, episodic, follows
specialty rather than primary care.
ƒ Describe development of the care coordination and transition
management (RN-CCTM) model.
ƒ Discuss dimensions and outcomes of the RN-CCTM model.
ƒ Describe the use of QSEN to standardize role expectations,
education, and evaluation of the RN-CCTM model.
ƒ Discuss use of RN-CCTM dimensions, competencies, and
evidence-based tools and methods to impact patient
outcomes.
Roles of RNs:
National Nursing Initiatives
ƒ American Academy of Ambulatory Care Nursing
(AAACN)
ƒ Expert Panels
ƒ Core Curriculum for Care Coordination and
Transition Management
ƒ In the context of the interprofessional care team
ƒ Care coordination and transitions
occur with no one accountable for
coordinating care or managing
transitions.
Method
Roles of RNs:
National Nursing Initiatives
ƒ Develop RN Evidence-Based Competencies for Care Coordination
and Transition Management
ƒ Expert Panel 1
ƒ Tap into expertise of ambulatory and acute care nurse leaders
ƒ Expert Panel 2
ƒ A cost effective, expeditious approach to bring leaders together
ƒ Expert Panel 3
ƒ Opportunities to dialogue and build on each individual leader’s
knowledge, skills and experience
ƒ Expert Panel 4
ƒ Use data summary techniques to capture and share outcomes
achieved by each Expert Panel
First Expert Panel
ƒ Provided with results of a search in MEDLINE,
CINAHL Plus, and PsycINFO that yielded 82 journal
articles plus white papers available on line from
major organizations
ƒ 26-member panel worked in dyads and abstracted
data to a table of evidence (TOE)
‰
‰
Each dyad reviewed four to five articles and needed to
reach consensus on items for TOE
Then abstracted the information onto the template table
of evidence
Table of Evidence Template
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Authors of Study Column
Study Title Column
Research Questions Column
Research Design Type Column
Setting and Sample, Inclusion/Exclusion Criteria Column
Methods, Intervention and/or Instruments
Analyses Column
Key Findings Column
Recommendations Column
List dimension or dimensions identified with activity or activities that are
supporting and/or contributing to care coordination and transition
management
Second Expert Panel
ƒ 16-member panel was charged with:
‰
‰
Defining the dimensions, identifying core competencies
Describing the activities linked with each competency for
care coordination and transition management in ambulatory
settings
ƒ Using focus group methods online, the expert panel
identified nine patient-centered care dimensions and
associated activities of care coordination and
transition management
First Expert Panel (cont’d.)
ƒ Expert Panel represented:
‰
‰
‰
Practice and Education;
Public, Private, Military, and
Veterans Organizations;
15 States in East, West, North,
South, and Central United States
Literature Review Team
Table of Evidence (TOE)
Competencies:
Knowledge, Skills and Attitudes
Second Expert Panel
Outcome identified nine dimensions:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Support for self-management
Education and engagement of patient and family
Cross setting communication and transition
Coaching and counseling of patients and families
Nursing process including assessment, plan, implementation/intervention,
and evaluation; a proxy for monitoring and intervening
Teamwork and collaboration
Patient-centered care planning
Decision support and information systems
Advocacy
ƒ The Quality and Safety in Education in Nursing (QSEN)
format was used for each care coordination and
transition management dimension identified
(Cronenwett et al., 2OO7)
ƒ Panelists were also asked to identify the knowledge,
skills, and attitudes identified in the literature, and if
absent to use expert opinion to specify each
This panel also identified competencies needed for each dimension including
knowledge, skills, and attitudes.
13
Dimensions, Activities, and Co
Competencies for Care Coordination
and Transition Management
Third Expert Panel
ƒ Reviewed, confirmed, and created a table of dimensions,
activities, and competencies (including knowledge, skills,
attitudes) for ambulatory care RN care coordination and transition
management
ƒ After much discussion, they determined the original 8th
dimension of decision support and information systems, as well
as, telehealth practice were technologies that support all
dimensions
ƒ Population Health Management became the new 8th dimension
given:
‰
Dimensions of Care Coordination
Coord
and
Transition Management
Expert Panel 3:
Expert Panel 2:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Support for self-management
Education and engagement of patient
and family
Cross setting communication and
transition
Coaching and counseling of patients and
families
Nursing process including assessment,
plan, implementation/intervention, and
evaluation; a proxy for monitoring and
intervening
Teamwork and collaboration
Patient-centered care planning
Decision support and information
systems
Advocacy
8.
Advocacy
Education and engagement of patients
and families
Coaching and counseling of patients and
families
Patient-centered care planning
Support for self-management
Nursing process: proxy for monitoring
and evaluation
Cross setting communications and
transitions
Teamwork and collaboration
9.
Population Health Management
1.
2.
3.
4.
5.
6.
7.
The prominence it is assuming in outpatient care even though there was
little discussion of it in the literature reviewed
Care Coordination
Definition “Care coordination is the deliberate organization of
patient care activities between two or more participants (including
the patient) involved in a patient’s care to facilitate the appropriate
delivery of health care services. Organizing care involves the
marshaling of personnel and other resources needed to carry out all
required patient care activities and is often managed by the
exchange of information among participants responsible for
different aspects of care.”
(McDonald et al., 2007 in AHRQ Care Coordination Measures Atlas, 2010, p. 4)
Naylor s Definition of
Naylor’s
Transitional Care
Transition Management
“Transitional care comprises a range of time-limited
services that complement primary care and are designed
to ensure health care continuity and avoid preventable
poor outcomes among at-risk populations as they move
from one level of care to another, among multiple providers and across settings.”
ƒ Definition:
‰
(Naylor, 2000)
“the ongoing support of patients and their families over time
as they navigate care and relationships among more than
one provider and/or more than one health care setting
and/or more than one health care service. The need for
transition management is not determined by age, time,
place, or health care condition, but rather by patients' and/or
families' need for support for ongoing, longitudinal
individualized plans of care and follow-up plans of care within
the context of health care delivery.“ (Haas, Swan, & Haynes, 2014,
p. 3)
Challenges with Care Coordination and
a
Transition Management in the 90s
Nurses in ambulatory care were performing Care
Coordination and Transition Management role dimensions,
but until this study (Haas et al., 1995) there was no
evidence of their work or contribution
ƒ Nurses typically did not chart in ambulatory on paper or EHR
ƒ With advent of EHR, there are few documentation screens
for nurse documentation
ƒ There are no indicators to track impact that RNs make on
processes or outcomes of patients in ambulatory care
Growi
Growing
owing Demand for Care
e Co
Coordination
oo
and
an
nd
d TTr
Transition
ransition Managem
Management
mentt
for
orr High Risk Chronic Care
e Populationss (cont.)
ƒ Chronic disease combined with co-morbid mental illness present
challenges in self-management, treatment adherence and cost
effective care
http://www.healthintegrated.com/Portals/0/ELS%20Presentations/Susan_Norris_Marc
h%202013.pdf
ƒ Individuals with multiple needs are often unable to navigate the
complex and fragmented health care.
ƒ Care providers recognize the need for better coordinated care that
leverages community resources and aligns social determinants
such as food, housing and safe environments, but payment
structures in the health care system do not allow such alignment
(Freeman, 2006).
Growing Demand for Care Coo
Coordination
and Transition Management
for High Risk Chronic Care Populations
ƒ Health care spending in the United States is disproportionate,
half of U.S. health care dollars are spent on five percent of the
population (Conwell & Cohen, 2002).
ƒ 78% of health care spending is for persons with chronic
conditions
http://www.healthintegrated.com/Portals/0/ELS%20Presentation
s/Susan_Norris_March%202013.pdf
ƒ Many struggle with multiple illnesses combined with social
complexities such as, mental health and substance abuse,
extreme medical frailty, and a host of social needs such as social
isolation and homelessness (Berwick, Nolan & Whittington, 2008).
New Role Development
Deve
in Healthcare
ƒ Involves:
‰
‰
‰
Responsiveness to a need within healthcare
Grounding in and integration of best evidence-based
practice
Specification of Role Dimensions: ‘major areas of
responsibility and accountability’
• Activities that comprise each dimension
• Performance Expectations or Competencies needed within each
dimension:
 QSEN – Knowledge, Skills and Attitudes (KSAs) was chosen
New Role Development
Deve
in Healthcare
Vision for RN
N-CCTM
N
-CC
CCTM Model
Mode for
Ambulatory Care Nurses
ƒ Involves:
Is consistent with recommendations of IOM (2011) Report Future of Nursing: Leading Change Advancing Health
‰
Methods to specify the Role:
• Position description with reporting relationships
‰
• Development of standardized educational resources
• Evaluation plan for competencies prerequisite to role performance
including:
‰

Plan for national recognition of competence

Plan to evaluate outcomes of performance in the role
Developing linkages between dimensions within the role and interface of
role dimension practice with other members of the interprofessional
healthcare team
AAACN CCTM Experts
Karen Alexander, MSN, RN, CCRN
Thomas Jefferson University
Janine Allbritton, RN, BSN
Baylor University Medical Center
JoAnn Appleyard, PhD, RN
University of Wisconsin, Milwaukee
Jilll Arzouman, MS, RN, ACNS, BC, CMSRN, AMSN Treasurer
University Medical Center Tucson
Diane Kelly, DrPH, MBA, RN
Duke University Cooperatives
Lisa Kristosik, RN, MSN
VNA of Cleveland
Cheryl Lovlien, MS, RN-BC
Mayo Clinic
Rosemarie Marmion, MSN, RN-BC, NE-BC
AAACN
Deborah Aylard, MSN, RN
Core Physicians
Deanna Blanchard, MSN, RN
UW Health University of Wisconsin
Elizabeth Bradley, MSN, RN-BC
VA Pasco OPC
Stefanie Coffey, DNP, MBA, FNP-BC, RN-BC
The Villages, VA Outpatient Clinic
Sandy Fights, MS, RN, CMSRN, CNE
AMSN President
Jan Fuch, MBS, MSN, NEA-BC
Cleveland Clinic
Patricia Grady, BSN, RN, CRNS, FABC
Lahey Clinic Medical Center
Jamie Green, MSN, RN
Kaiser Permanente
Denise Hannigan, RN-BC, MSN, MHA
Cedars-Sinai
Clare Hastings, RN, PhD, FAAN
NIH Clinical Center
Anne Jessie, MSN, RN
Carillon Clinic
Sheila Johnson, RN, MBA
Dartmouth-Hitchcock Accountable Care Programs
CDR Catherine McNeal Jones, MBA, HCM, RN BC
USN Family Practice Clinic
Nancy May, RN-BC, BSN, MSN
Scott White Health
Sylvia McKenzie, MSN, RN, CPHQ
University of Washington
Kathy Mertens, RN, MN, MPH
Harborview Medical Center
Shirley Morrison, PhD, RN, OCN
Texas Women’s University
Janet Moye, PhD, RN, NEA-BC
George Washington Univ. Center for HC Quality
Donna Parker, MA, BSN, RN-BC
James H. Quillen VA Medical Center
Carol Rutenberg, RN-BC, C-TNP, MNSc
Deborah Smith, DNP, RN
Georgia Health Sciences University
Debra Toney, PhD, RN, FAAN
Federally Qualified Health Center
Barbara Trehearne, PhD, RN
Group Health
Linda Walton, MSN, RN, CRNP
Orlando Health Physician Group
Stephanie Witwer, PhD, RN, NEA-BC
Mayo Clinic
Table 3. Cross Walk of Dimensions for Care Coordination and Transition
Management with Core Competencies
Dimension RN Care
Coordinator and
Transition Manager (RNCCTM)
Quality and Safety Education
for Nurses (QSEN) Core
Competencies
www.qsen.org
Support Self-Management
Patient-centered Care
Education & Engagement
of Patient & Family
Cross Setting
Communication and
Transition
Coaching and Counseling
of Patients and Families
Nursing Process:
Assessment, Plan,
Intervention, Evaluation
Teamwork and
Collaboration
Patient-Centered Planning
Patient-centered Care
Patient-centered Care
Public Health Nursing Competencies
http://www.resourcenter.net/imag
Interprofessional Education
es/ACHNE/Files/QuadCouncilCompe
Collaborative Core Competencies tenciesForPublicHealthNurses_Sum
http://www.aacn.nche.edu/educat
mer2011.pdf
ion-resources/ipecreport.pdf
Interprofessional Communication
Patient-centered Care
Evidence-based Practice Quality
Improvement
Roles and Responsibilities
Teamwork and Collaboration
Teams and Teamwork
Patient-centered Care
Values/Ethics for Interprofessional
Practice
Population Health
Management
Quality Improvement
Informatics
Advocacy
Patient-centered Care
Safety
Nurses should practice to the full extent of
their education and training.
2) Nurses should achieve higher levels of
education and training through an improved
education system that promotes seamless
academic progression.
3) Nurses should be full partners, with physicians and other health
care professionals, in redesigning health care in the United States.
1)
Plan to educate for the Role:
Domain #3: Communication Skills
Domain #4: Cultural Competency
Skills
Domain #1: Analytic Assessment
Skills
Domain #8: Leadership and System
Thinking Skills
Domain #1: Analytic Assessment
Skills
Domain #5: Community Dimensions
of Practice Skills
Domain #6: Basic Public Health
Sciences Skills
Domain #2: Policy
Development/Program Planning
Skills
4)
Effective workforce planning and policy making require better data
collection and an improved information infrastructure.
Wagner Model
Reprinted with permission from the American College of Physicians. Wagner EH. Chronic disease
management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998; 1:2-4.
QSEN Competenc
Competencies
tenc
encccies Are a Direct
Match with RN
N-CCTM
Dimensions
ƒ Patient Centered Care
ƒ Quality
ƒ Safety
ƒ Teamwork
ƒ Evidence-based Practice
ƒ Informatics
RN
N-CCTM
N
-CC
CCTM needed not
only in ambulatory care
ƒ Affordable Care Act (ACA) 2010 calls for coordination of
care and management of transitions in all sites of care.
ƒ Nurses are most likely to provide CCTM in many settings.
ƒ However, CCTM is within the scope of practice of other
professionals.
ƒ Complex chronically ill individuals routinely move
between care settings even on a daily basis.
Affordabl Care Act
Affordable
Fosters:
ƒ Care Coordination and Transition Management
ƒ Patient-centered Care that is grounded in best EBP,
but tailored to patient goals, values and preferences
ƒ Teamwork, with an emphasis on Interprofessional
Collaboration and Teamwork
ƒ Emphasis on high quality, safe care
ƒ Tracking of processes and outcomes via
documentation in EHR using informatics techniques
Logic Models
Use of Logic Model
Have been used in Program Evaluation and Econometric Modeling to:
Vision for the
RN Care Coordination
Coordi
& Transition Management Model
1.
Delineate vision/purpose for a project
2.
Surface assumptions, environmental issues and needed knowledge, skills and
attitudes
3.
Specify relationships among program goals, objectives, activities, outputs, and
outcomes.
4.
Clearly indicate the theoretical connections among program components;
activities involved, who carries out the activities and specification of short,
medium and long term outcomes.
5.
Set up evaluation by assisting with development of the measures used to
determine if activities were carried out (process and output measures) and if the
program's objectives are met (outcome measures).
https://www.bja.gov/evaluation/guide/pe4.htm retrieved 8/11/2013.
RN
NN-CCTM
Logic Model
Provide structure and content for:
Assumptions
ns:
ns
1. Education of RNs to work within the CCTM role
ƒ CCTM Logic Model guided development of
2. Employer position descriptions
3. Employer performance evaluation that uses QSEN
KSAs specified in the RN-CCTM dimensions
4. Outcome measurement of impact of CCTM
dimensions within and across organizations
ƒ Patients will use primary care settings
ƒ Patients will access RN-CCTM providers
ƒ Patients will be engaged in care processes
ƒ Providers will collaborate, work in teams, develop and use
patient centered care plans
ƒ Organization will have EHR that operates across settings
ƒ Outcomes are often not discipline specific, but shared by team
RN
NN-CCTM
Logic Model
Assumptions
ƒ ACA fosters use of care
coordination and evidence-based
practice
ƒ CCTM is needed by patients with
complex chronic illnesses
‰
‰
Risk stratification needed to identify patients who will benefit
most from CCTM
Risk stratification must use social determinants as predictors
of risk level
ƒ RN’s can do CCTM in ambulatory care, acute care,
home health care, rehabilitation etc.
External Factors:
ƒ Slow development of interdisciplinary team education and
practice
ƒ Changes in reimbursement and penalties for Never Events
ƒ Decreasing revenue
ƒ Slow implementation of EMRs that are operable across
settings
ƒ Slow development of model for care plan that moves
between settings.
Value Proposition for RN
NN-CCTM
Definitions:
Value is an outcome of nursing practice
(Edelbauer, Vlasses, & Rogers, 2013)
Value = Outcomes Achieved Per Dollar Spent
(Porter, 2010)
Proposed Method of Developing
Deve
eve
elloping an
Estimate of Value for RN
N-CCTM
ƒ If summative indicators are developed for these last
three columns and they are imbedded in RN-CCTM
documentation, as well as, documentation of other
members of the interprofessional team
ƒ And these indicators are coded in standardized language
in an EHR, then:
‰
‰
‰
The documentation data sets can be queried
Processes and outcomes can be mined from electronic
documentation
There will be real-time demonstration of processes done,
outcomes achieved and value gained
Value
alue
e Proposition
Propo
for
RN
N-CCTM
ƒ Proposed method of developing an estimate of value
for RN-CCTM:
‰
Challenges:
Challenges
ss:: Ar
Areas
reas Where
KSAs Need to be
b De
Developed
and Implemented
ƒ
Using the RN-CCTM Logic Model,
• The first column on the left specifies the dimension
• Second column specifies activities/interventions included in the
dimension
• This column specifies who does the activities
• While the last three columns to the right specify short, medium and
long term outcomes
• Short term outcomes can also been considered processes as can
medium term outcomes
Standardization of Commun
Communication
during Transitions of Care
ƒ BOOST® Better Outcomes by Optimizing Safe Transitions
ƒ Introduction:
‰
‰
‰
ƒ
ƒ
ƒ
ƒ
ƒ
Developing and using Position descriptions that incorporate CCTM
Competencies
‰
Developing education and evaluation methods that foster CCTM
Competencies involving QSEN KSAs within and across professions
Developing staffing models to support/resource the interprofessional team
Building human resources/team configuration to support CCTM
Creating an environment (physical and cultural) to support CCTM
Developing/standardizing communication methods for communication
across settings and between interprofessional team members
Developing, testing and using process and outcome indicators to track the
impact and value of RN-CCTM
Project BOOSTT ®
ƒ Improving the hospital discharge care transition,
Project BOOST ® aims to:
http://www.hospitalmedicine.org/Web/Quality___Innovation/Mentored_Imple
mentation/Project_BOOST/About_BOOST.aspx
ƒ Identify patients at high risk of rehospitalization and
target specific interventions to mitigate potential
adverse events
Advantages to BOOST®
ƒ Reduce 30 day readmission rates
Developed by: Society of Hospital Medicine
Purpose: Assist in stratification of risk as well as assessment of needs
• Goes beyond patient physical and psychological problems
• Goes beyond history of readmission and ED use
• Provides evidence-based predictors of risk that include social
determinants
Project BOOSTT ® (cont.)
ƒ Improve flow of information between hospital
and physicians and providers across the
continuum
ƒ Improve communication between providers
and patients
ƒ Optimize discharge processes and transitions
http://www.hospitalmedicine.org/Web/Quality___Innovation/
Mentored_Implementation/Project_BOOST/About_BOOST.aspx
ƒ Improve patient satisfaction scores and H-CAHPS
scores related to discharge
What are soc
social determinants
of health?
http://www.who.int/social_determinants/sdh_definition/en
ƒ The social determinants of health are
the conditions in which people are born,
grow, live, work and age. These
circumstances are shaped by the
distribution of money, power and
resources at global, national and local levels.
ƒ The social determinants of health are mostly responsible for
health inequities - the unfair and avoidable differences in health
status seen within and between countries.
Social Determinants
http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health
ƒ In addition to the more material attributes of “place,” the
patterns of social engagement and sense of security and
well-being are also affected by where people live.
ƒ Resources that enhance quality of life can have a
significant influence on population health outcomes.
‰ Examples of these resources include:
•
•
•
•
•
safe and affordable housing,
access to education, public safety,
availability of healthy foods,
local emergency/health services,
environments free of life-threatening toxins.
Exemplars
ƒ Interprofessional-Collaborative Redesign and Evaluation for
Population Access to Health (I-Care Path.) Vlasses, Hackbarth,
Burkhart, Haas (Co-PD/consultant), Kouba and Michelfelder,
Health Researches and Services Administration. NEPQR Grant #
UD7HP26040
‰
‰
‰
‰
Education and training of PCMH staff on RN-Care Coordination and
Transition Management Model, IPEC competencies and TeamSTEPPS®
Immersion training site for interprofessional students
Use of the RN-CCTM Logic Model to guide development of process and
outcome indicators for development of documentation screens in the EHR
Use of BOOST ® to guide care interventions for complex diabetic
populations and to standardize communication among interprofessional
team members and across settings of care
Exemplars
Ambulatory Care Translational Research, Quality Improvement
Initiative: Application of the Project BOOST® 8Ps Tool for Risk
Identification and Stratification in Multidisciplinary Care
Planning. Jessie, Anne. Capstone Project
ƒ Methods:
‰
‰
‰
‰
Stratification using NY State Heart Failure Classification, Modified
LACE, BOOST ® for identification of care needs and stratification
BOOST ® provides focus on social determinants (Health Literacy,
support) and interventions, i.e., med rec and psychological issues
EHR tracking of Health Literacy, Self Management, Medications
Boost ® Gap Analysis Tool
Electronic Health
He
Record (EHR)
Challenges
1. Patient Protection and Affordable Care Act
mandates use of:
ƒ Evidence-based accepted guidelines, but
implementation is slow and there is a great lag time in:
‰
‰
‰
‰
‰
Getting evidence-based protocols into the EHR
Development of documentation screens in EHR
Development of process and outcome indicators for use in
EHR documentation
Development of Decision Support in EHR
Use of EHR interprofessional documentation methods
References
Referencess (cont’d)
Edelbauer, A., Vlasses, F., & Rogers, J. (2013). The Value Proposition
in Nursing. Presentation at the International Nursing Administration Research
Conference, Baltimore, MD.
Haas, S., Hackbarth, D., Kavanagh, J., & Vlasses, F. (1995). Dimensions of the
staff nurse role in ambulatory care: Part II – Comparison of role dimension in four
ambulatory settings. Nursing Economics, 13(3), 152-164.
Haas, S., Swan, B.A., & Haynes, T. (Eds.) (2014). Care Coordination
and Transition Management Core Curriculum. Pitman, NJ: Anthony J. Jannetti.
McDonald et al., 2007 in AHRQ Care Coordination Measures Atlas, 2010, p. 4.
https://innovations.ahrq.gov/qualitytools/care-coordination-measures-atlas
Haas, S. & Swan, B.A. (2014). Developing the Value Proposition for
Registered Nurse Care Coordination and Transition Management Role in
Ambulatory Care Settings. Nursing Economic$, 32(2), 70-79.
Naylor, M. & Sochalski, J. (2010). Commonwealth Fund Issue Brief - Scaling
Up: Bringing the Transitional Care Model into the Mainstream. retrieved 3/19/15
Haas, S. & Swan, B.A. (2014). Emerging care coordination models for
achieving quality and safety outcomes for patients and families. In Lamb, G.
(Ed.), Care Coordination the Game Changer. Washington, DC: American
Nurses Association.
Haas, S., Swan, B. A. & Haynes, T. (2013). Developing ambulatory
care registered nurse competencies for care coordination and transition
management. Nursing Economic$, 30(1), 44-49, 43.
http://www.commonwealthfund.org/Publications/Issue-Briefs/2010/Nov/ScalingUp-Transitional-Care.aspx
Porter, M. J. (2010). What is value in health care? New England Journal of
Medicine, 363, 2477-2481.
Swan, B. A., Haas, S. A., and Chow, M. (2010, October). Ambulatory care
registered nurse performance measurement. (AHRQ grant HS18885). Nursing
Economics, 28(5), pp. 337-342.