THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 1

Ambulatory Care as an Alternative Revenue Source for Hospitals

Theoretical Framework and Annotated Bibliography

Student’s Name

Institutional Affiliations

Course Code and Course Name

Instructor Details

Date
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Theoretical Framework and Annotated Bibliography

Search Strategy

In identified the required resources for the project, a search were conducted to identify

key literature on the topic. The search terms to use include:

(Ambulatory care service or Ambulatory surgical centers or Urgent care clinics or

outpatient care) and (hospital revenue or income or financial performance or returns

or profits) and (quality of care or patient outcomes or patient experiences).

The search terms will be run in the following databases:

PubMed Central,

PubMed,

UpToDate,

Digital Commons Network, and

PLos.

Change Theory – The Change Theory of Nursing

Change can take many forms and one of the change theories that guide a change

process is the change theory of nursing developed by Kurt Lewis. According to this theory, a

change process will take on three key steps; breaking down the old tasks/activities, moving

towards new tasks/activities, and establishing the new activities as a routine (Batras, Duff, &

Smith, 2016). A status quo must be attained and this involves two opposing forces; driving

and restraining forces, in which case the driving forces must overcome the effects of

restraining forces thereby driving change (Batras, Duff, & Smith, 2016).
THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 3

Literature on Application

Kurt Lewis change theory is one of the oldest and most used in initiating and maintain

change in the healthcare system. For instance, in a study conducted by Harrison et al. (2021)

investigating models of change management demonstrated that the application of Lewin’s

change theory in nonsurgical trauma admission rates was associated with between 3%and

30% reduction in these rates. The same study also demonstrated that in health gain change

process, using this model increased team engagements, discussions, and teamwork which was

associated with reduced resistance and improved performance. In another study by Archer et

al. (2019) that sought to develop and implement a standardized EMS feedback tool, evidence

indicated that the application of this model resulted in the adoption of a feasible standardized

EMS feedback tool for stroke program that had a 90% response rate. When initiating a

system change, evidence from these studied confirm that applying Kurt Lewis change theory

guarantees success and complete adoption of a change process, tool, or activity.

Conceptual Definitions

The change theory described has three key concepts: the equilibrium, driving forces,

and restraining forces (Batras, Duff, & Smith, 2016). The driving forces are the factors that

push an organization to change. In adopting ambulatory care services model, the driving

forces include desire to boost revenues, increase quality of care, and promote patient-

centeredness. Restraining forces are factors that prevent a change process (Batras, Duff, &

Smith, 2016). Some of these forces include resources scarcity, employee resistance to change

and organizational culture. To achieve change, the effects of the driving forces must

overcome those of the restraining forces. However, an organization will attain equilibrium, a

state in which these forces are equal and change cannot occur. If the effects of driving forces

overcome those of restraining forces, a change process will be initiated through the

unfreezing, moving, and refreezing (Batras, Duff, & Smith, 2016).

THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 4

Application

The goal of the project is to initiate a change in which the organization will

implement ambulatory care services as a strategy to improve its performance in matters

related to quality of care and revenues. The change model is therefore critical in this project

as it will allow us to explore a change process by evaluating the extent to which restraining

and driving forces influence the change process and how ambulatory care services will help

increase revenues for the organization. It provides a pathway to implementing ambulatory

care services as an alternative to generating revenues for the organization.

Conclusion

The theoretical framework presents a simplified search strategy that identifies key

articles for the proposal, a description of Kurt Lewis change theory as the guiding model,

evidence of using this model, and its relevance in the project.

THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 5

References

Archer, M., Fuller, M., Cox, K., & Swearingen, N. (2019). Regional Stroke Program

Coordinator Nurses Standardize EMS Feedback Utilizing Kurt Lewin’s Change

Model. 50(1), https://doi.org/10.1161/str.50.suppl_1.WMP114

Batras, D., Duff, C., & Smith, B. J. (2016). Organizational change theory: implications for

health promotion practice. Health promotion international, 31(1), 231-241.

https://doi.org/10.1093/heapro/dau098

Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H.

(2021). Where Do Models for Change Management, Improvement and

Implementation Meet? A Systematic Review of the Applications of Change

Management Models in Healthcare. Journal of healthcare leadership, 13, 85–108.

https://doi.org/10.2147/JHL.S289176
THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 6

Annotated Bibliography

Akinleye, D. D., McNutt, L. A., Lazariu, V., & McLaughlin, C. C. (2019). Correlation

between hospital finances and quality and safety of patient care. PloS one, 14(8), e0219124.

https://doi.org/10.1371/journal.pone.0219124

This study investigates the correlation between quality and safety of patient care and hospital

finances. Results from the study confirm that there is a direct relationship between

organizational finances and its ability to provide quality and safe care. It is associated with

improved patient experience. The findings suggest that hospital should find ways to maintain

financial stability as a way of ensuring that they have the capacity to maintain and improve

the quality of care through its systems.

Alarcon-Ruiz, C. A., Heredia, P., & Taype-Rondan, A. (2019). Association of waiting and

consultation time with patient satisfaction: secondary-data analysis of a national

survey in Peruvian ambulatory care facilities. BMC health services research, 19(1),

439. https://doi.org/10.1186/s12913-019-4288-6

The study evaluated the relationship between consultation and waiting time with the level of

patient satisfaction in ambulatory settings. The findings indicate that ambulatory care was

associated with better patient experiences, a key metric in measuring quality of care.

Therefore, the study will be used in the current research as it provides a critical analysis of

factors that influence patient experiences. In designing an ambulatory care strategy, the

findings will be essential as it gives the required guide on areas of importance.

Baynouna Al Ketbi, L. M., Al Kwuiti, M. M., Abdulbaqi, H., Al Kwuiti, M. H., Al Alawi, S.,

Al Zarouni, A., Al Awadhi, F., Al Bloushi, D., Al Harbi, A., Saadon, B., & Al Jabri,

O. (2018). Integration of a Patient-Centered Medical Home into Ambulatory Health

Care Services Centers in Abu Dhabi. The Journal of ambulatory care management,

41(3), 158–170. https://doi.org/10.1097/JAC.0000000000000242

THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 7

The study investigates the value of ambulatory care services on health promotion, access to

healthcare, and quality of care. The researchers aimed at determining whether ambulatory

healthcare was beneficial or not with findings indicating that ambulatory care was associated

with an increase in quality of care and accessibility. Therefore, the findings from this study

would be paramount in supporting the research as they provide evidence that support

ambulatory healthcare as a pathway to improving quality of care.

Creps, J., & Lotfi, V. (2017). A dynamic approach for outpatient scheduling. Journal of

medical economics, 20(8), 786-798. https://doi.org/10.1080/13696998.2017.1318755

Loss of productivity is associated with patient no-show and as demonstrated by this study,

improving patient scheduling through ambulatory healthcare services would enhance

productivity. Proper scheduling increases efficiency and clinic utilization. Therefore, it

results to optimal resource utilization and increased revenue generation through continuous

patient visits. The study provides evidence that supports the significance of ambulatory care

services in ensuring optimal resource utilization resulting to cost cutting, and increased

patient visits which translates to income.

Dong, G. N. (2015). Performing well in financial management and quality of care:

evidence from hospital process measures for treatment of cardiovascular disease. BMC

Health Services Research, 15(1), 1-15. https://doi.org/10.1186/s12913-015-0690-x

This study explores the relationship between quality of care and healthcare organization’s

financial performance. Findings from the study demonstrate that hospital profitability,

operating efficiency, and asset liquidity directly improve the hospital’s capacity to provide

quality care. The findings form this study is important as they help create rational for

adopting a new strategy to boost an organization’s revenue thereby improving its capacity to

provide quality care.

THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 8

Geraedts, M., Krause, S., Schneider, M., Ortwein, A., Leinert, J., & de Cruppé, W.

(2020). Patient safety in ambulatory care from the patient's perspective: a retrospective,

representative telephone survey. BMJ open, 10(2), e034617.

https://doi.org/10.1136/bmjopen-2019-034617

One of the measures of quality of care is the level of safety associated with such services.

This study found that patient safety problems in ambulatory settings are many. It also

identified key interventions that could prevent these problems. Therefore, while the study

provides evidence against ambulatory care services when considering safety, it also provides

evidence on ways to address these issues. The article will therefore be of great importance in

supporting the implementation of the strategy with minimal safety issues which will translate

to success.

Hamad, M., & Connolly, V. M. (2018). Ambulatory emergency care - improvement by

design. Clinical medicine (London, England), 18(1), 69–74.

https://doi.org/10.7861/clinmedicine.18-1-69

The study acknowledges ambulatory care services as critical in ensuring continuity of care

despite the high bed occupancy. It also ensures that bed pressures are alleviated for patients in

these settings. Therefore, it targets two areas of importance cost cutting, and healthcare

service improvement. The study is therefore important as it helps answer the research

question and support the proposed solution as it is viable in improving organizational

revenues and quality of care.

Hodgson, K., Deeny, S. R., & Steventon, A. (2019). Ambulatory care-sensitive conditions:

their potential uses and limitations. BMJ Quality & Safety, 28, 429-433.

http://dx.doi.org/10.1136/bmjqs-2018-008820

The study explores the importance of ambulatory care services. According to this study,

ambulatory care services help reduce emergency admissions and longer hospital stays. These
THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 9

effects translate to better quality of care, reduced resource strain, and cost saving. Therefore,

findings from the study are important in this research as they reinforce evidence of why a

hospital should implement ambulatory healthcare services within its system to improve

patient healthcare outcomes and cut on associated costs thereby improving its income.

Rumball-Smith, J., Shekelle, P., & Damberg, C. L. (2018). Electronic health record "super-

users" and "under-users" in ambulatory care practices. The American journal of

managed care, 24(1), 26–31. https://www.ncbi.nlm.nih.gov/pubmed/29350506

The study explored the use of electronic health record systems in ambulatory care practices

and its significance. Study findings demonstrate that with EHR, ambulatory care facilities can

deliver high-quality care. Adopting EHR in ambulatory healthcare services enhances

efficiency improving quality of care while reducing the cost of operations. The study is

therefore important in providing evidence on how best an organization can shift to

ambulatory care services through inclusion of EHR.

Thorakkattil, S. A., Nemr, H. S., Al-Ghamdi, F. H., Jabbour, R. J., & Al-Qaaneh, A. M.

(2021). Structural and operational redesigning of patient-centered ambulatory care

pharmacy services and its effectiveness during the COVID-19 pandemic. Research in

social & administrative pharmacy : RSAP, 17(1), 1838–1844.

https://doi.org/10.1016/j.sapharm.2020.06.017

The study explores the implications of operational and structural changes in ambulatory care

services during the pandemic. According to this study, medical home deliveries, pharmacy

call-center, online health application services, and remote area pickup locations have

maintained ambulatory pharmacy services. While these enhance patient experiences, they

have a cost attachment which translates to improved revenue sources for hospitals. Therefore,

the findings support the financial need of shifting towards this area of service delivery. There
THEORETICAL FRAMEWORK AND ANNOTATED BIBLIOGRAPHY 10

is also a quality improvement as the risk of infection reduces as patients have no direct

contact with other patients who might be infectious.

Tuot D. S. (2018). Better Patient Ambulatory Care Experience: Does It Translate into

Improved Outcomes among Patients with CKD? Clinical journal of the American

Society of Nephrology : CJASN, 13(11), 1619–1620.

https://doi.org/10.2215/CJN.11260918

The study demonstrate that ambulatory care services promote effective communication,

electronic consultations, and patient-centeredness. All these translate to better experiences

and improved quality of care. Therefore, this study is of importance as it supports the need

for these services as they promote patient-centered services which are linked to quality and

safety.

Volk, A. S., Davis, M. J., Abu-Ghname, A., Warfield, R. G., Ibrahim, R., Karon, G., &

Hollier, L. H. (2020). Ambulatory Access: Improving Scheduling Increases Patient

Satisfaction and Revenue. Plastic and Reconstructive Surgery, 146(4), 913-919.

https://doi.org/10.1097/prs.0000000000007195

The study examined the effects of different initiatives in increasing appointment use, clinic

capacity, and ease scheduling. The study findings demonstrate that optimizing clinic

availability and standardizing sessions increases hospital revenues and improves patient

experiences. Therefore, the findings not only address the quality aspects of the current

research but also justify the revenue aspect of ambulatory care services. The study findings

are therefore important in the current study as they provide the basis for shifting towards

ambulatory care. Ambulatory care services have a positive impact on the organization’s

revenue and quality of care. Therefore, the findings will be used to support the

implementation of the required change from quality and revenue perspective.

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Wright, B., Potter, A. J., & Trivedi, A. N. (2017). Use of Federally Qualified Health Centers

and Potentially Preventable Hospital Utilization Among Older Medicare-Medicaid

Enrollees. The Journal of ambulatory care management, 40(2), 139–149.

https://doi.org/10.1097/JAC.0000000000000158

The study found that patients who receive healthcare services from FQHC have lower

ambulatory care sensitive conditions compared to those who do not. Evidence indicates that

hospitalization rates and emergency department visits were fewer in this case implying that

the practice or use of these services was associated with improvement in patient outcomes.

The findings will be instrumental in determining the strategy to apply in the implementation

of ambulatory care service model for the facility.