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Introduction   

The outpatient setting, also termed ambulatory care, provides health care assistance to individuals in clinics, provider offices, specialty centers, laboratories, and more. Ambulatory care has expanded in its scope over the past ten years as patient care has become more complex [5].  

Healthcare professionals in outpatient settings are tasked with providing care to a growing number of patients who are increasingly ill. A primary goal of healthcare is to equip individuals with the tools to safely maintain their health away from the hospital. The provision of high-quality care in the outpatient setting is vital as the public relies heavily on outpatient services.  

What Is the Difference Between Inpatient and Outpatient Care? 

The patient’s level of acuity marks the primary distinction between inpatient and outpatient care.  

Inpatient care is provided to patients with acute illnesses and life-threatening conditions who need close monitoring. Inpatient settings include acute hospitals (including psychiatric hospitals) and some surgery centers [5]. Inpatient settings provide care that typically leads to longer length of stays. 

Outpatient care is appropriate for individuals who do not need prompt/emergent medical attention or close monitoring. Settings include primary care offices, specialty clinics (such as dialysis centers), long-term care facilities (such as nursing homes), and private homes. Often, same-day or routine services are provided in outpatient settings.  

What Is Quality Care? 

Quality care has many definitions. The Institute of Medicine (IOM), now the National Academy of Medicine, defines quality care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (para. 3) [11]. According to the World Health Organization, quality of care is determined by how well health services apply current evidence-based knowledge and practice to care, increasing the likelihood that people will achieve their desired health outcomes [14]. 

Among the many definitions, a main theme resides quality care relies on current evidence to improve patient outcomes. All care, no matter the setting, should include the following six domains of quality healthcare, as outlined by the IOM [3]. 

• Safe: Avoiding harm to patients from the care that is intended to help them. 
• Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively). 
• Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. 
• Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care. 
• Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy. 
• Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. 

The IOM’s framework can be simplified into the following three categories [2]: 

• Care that protects patients from medical errors and does not cause harm (safe) 
• Care that is proven to work or get results (effective and efficient) 
• Care that is responsive to a patient’s needs and preferences (patient-centered, timely, and equitable). 

What Are Quality Care Goals in Outpatient Care? 

Quality care in outpatient settings requires coordination from interdisciplinary teams to meet the high care demand. The Agency for Healthcare Quality and Research, the lead Federal agency for improving the safety and quality of healthcare for Americans, established three goals for improving the quality of care for individuals in outpatient settings [5]: 

• Establish a culture of patient safety 
• Improve the safety of care transitions 
• Identify techniques, tools, and strategies for clinicians to improve teamwork and performance 

While these goals may apply to all care settings, improving the safety of care transitions is particularly appropriate to the outpatient setting as care transitions occur frequently, quickly, and across multiple care environments. This includes provider-to-provider, provider-to-laboratory services, provider-to-diagnostic services, and provider-to-insurance services, among others. 

What Are Care Transitions? 

A care transition is the process of moving care from one healthcare setting or provider to another for continuity of care. A common example is the care transition from a hospital to a home health service (the discharge process). Another example is the care transition from a primary care provider to a specialty provider, such as a surgeon (referral). Healthcare transitions pose a safety risk to patients.  

Unsafe care transitions are associated with poor communication between healthcare team members, insufficient follow-up, and suboptimal patient education [15]. Healthcare leaders have attempted to manage this problem through policy by penalizing hospitals for readmitting patients soon after discharge. These changes place an extra burden on nurses working in home health and long-term care as they must ensure they receive a proper nursing report from hospital nurses, which may not always happen. Additionally, outpatient care nurses must provide extensive health education to patients to keep them out of the hospital. 

While much of the research regarding care transitions is inpatient-focused, the principles may be applied to outpatient care. However, researchers argue that scaling these changes to settings outside of the hospital may result in suboptimal outcomes as the implementation process is highly challenging [15]. 

How Is Quality Care Measured? 

Quality measures are findings that determine if care provided is of high quality. Nursing leaders in various care settings review a facility/organization’s data, documentation, and survey results to establish these measures. For example, if several patients with pressure injuries are admitted to a skilled nursing facility and the wounds worsen during their stay, the argument can be made that the care provided by the skilled nursing facility is suboptimal.  

The percentage of patients with worsened pressure injuries is considered a quality measure as it proves the care is suboptimal. Worsening pressure injuries are just one of the many examples of quality measures in healthcare.  

Other quality measures in healthcare include [1]: 

• Number of new disease cases 
• Number of hospital admissions 
• Percentage of medication errors 
• Use of electronic medical records and medication order entry systems 
• Proportion of board-certified providers 
• The ratio of providers to patients 
• Rate of healthcare-associated infections 
• Patient satisfaction survey results 

These measures help healthcare leaders identify how well a facility or organization is providing quality care to its patients. 

How Is Quality Care Measured? 

Quality measures are findings that determine if care provided is of high quality. Nursing leaders in various care settings review a facility/organization’s data, documentation, and survey results to establish these measures. For example, if several patients with pressure injuries are admitted to a skilled nursing facility and the wounds worsen during their stay, the argument can be made that the care provided by the skilled nursing facility is suboptimal.  

The percentage of patients with worsened pressure injuries is considered a quality measure as it proves the care is suboptimal. Worsening pressure injuries are just one of the many examples of quality measures in healthcare.  

Other quality measures in healthcare include [1]: 

• Number of new disease cases 
• Number of hospital admissions 
• Percentage of medication errors 
• Use of electronic medical records and medication order entry systems 
• Proportion of board-certified providers 
• The ratio of providers to patients 
• Rate of healthcare-associated infections 
• Patient satisfaction survey results 

These measures help healthcare leaders identify how well a facility or organization is providing quality care to its patients. 

How Can Nurses Improve the Quality of Care in Outpatient Settings? 

Outpatient care nurses work in multiple care environments including primary provider offices, long-term care facilities, and patients’ homes. Quality measures in these settings are associated with wound care, emergencies, medication management, and provider-patient communication [4].  

The following are ways outpatient nurses can improve the quality of care for their patients [4]: 

Managing Wounds 

Chronic wounds affect 2.5% of the U.S. population [12]. While these wounds are often seen among the elderly, recent studies have shown an increase in the incidence of chronic wounds among individuals under age 65 [8]. Chronic wounds are on the rise due to the aging population, diabetes, obesity, and persistent infections [12]. Many of these wounds will require care from an outpatient nurse.  

Rather than focusing on healing the wound, which is typically the primary focus, a reasonable goal for nurses is to prevent the wound from worsening. This includes the correct identification and familiarization of the stages of pressure injuries as well as signs a wound is worsening.  

In this case, the focus is less on performing wound care and more on assessing the wound characteristics during wound care. With proper assessments and prompt reports to the primary provider, interventions can be modified right away to halt the worsening of the wound and reduce the frequency of wound-related visits to the emergency room. 

Preventing Emergencies 

A primary goal of home health services is to limit patient visits to provider’s offices, outpatient clinics, or emergency rooms for any type of emergency. In a 2022 systematic review, heart disease, chronic obstructive pulmonary disease, and septicemia/other infections were the primary reasons for hospital readmissions [6].  

Rather than primarily focusing on the disease process during teaching, highlight signs and symptoms to report and what patients should do to prevent the need for emergent care (identifying early signs of infection, taking medications as prescribed, etc.). Many patients are often eager to know more about their medical situation [6].  

Another unconventional approach is to cultivate great working relationships with nursing ancillary staff, such as aides and assistants. Oftentimes, nursing aides/assistants encounter patient conditions that require reporting to the nurse. Teamwork and mutual respect between the nurse and ancillary staff can contribute to a safe working environment in which the aide/assistant can feel comfortable reporting a concerning finding regarding a patient. 

Managing Medications 

The prevalence of medication errors in the outpatient setting is high. While most errors in these settings are related to prescribing and dosing, medication errors can also occur during transcribing of the provider’s order, dispensing of the medication, administration, monitoring of the patient post-administration, and documentation [13]. 

While teaching about medications is vital, the nurse might consider prioritizing performing a thorough medication review. This involves reviewing the medication order, asking the patient what medications and supplements they are taking, obtaining a thorough medical history, identifying allergies, and asking about food intake. The nurse can use this information to screen for medication contraindications, unsafe dosing, drug interactions, and other precautions.  

While pharmacists can identify medication allergies and contraindications for patients, the nurse might identify additional precautions after performing a thorough medication review. For example, the therapeutic effects of some medications may be altered when taken with certain supplements, beverages, or diets (such as alkaline, high-fat, or high calorie) [7]. After completing a medication review, the nurse is better prepared to teach the patient about their medications. 

Improving Communication 

A quality measure used in outpatient care involves the provider-patient relationship. The quality of communication between providers and patients correlates with the quality of care perceived by the patient. However, researchers argue that simple communication skills may be not enough to maintain a great provider-patient relationship [9]. Good communication between the provider and patient may not be feasible at times due to various reasons, including personality clashes, lack of interpersonal skills, and mistrust. Some studies have shown patients were not happy with the way their providers communicated with them even though the providers felt their communication was good or excellent [9]. 

While nurses are not responsible for improving the communication between the patient and the provider, filling in the communication gaps by serving as a liaison/advocate is ideal. Asking the patient if they understood what the provider explained and reiterating the education as needed is a great practice. However, nurses might also consider cultivating a positive professional relationship with the provider. While this may not change the communication dynamics between the provider and patient, effective provider-nurse collaboration and teamwork, including mutual respect, trust, and joint decision-making, has been shown to improve the quality of care for patients [10].  

Conclusion

In final, “How can nurses improve the quality of care in outpatient settings?” The answer is simple, but the solution is complex. Providing quality care in these environments may be challenging due to limited resources, such as funding, staff, and supplies. Nurses can improve assessment skills, provide situation-appropriate patient education, perform medication reviews, and cultivate great relationships with providers and ancillary staff. Yet, nurses can only provide the best care possible if allotted the best resources. Poor quality of care is not an individual nurse problem, nor is it a general nursing problem. Improving the quality of care is a systems problem. The solution involves collaboration from all fields of healthcare. 

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