May 2013
PSOMediumClarity PSO Learning Series
Topic #2: Ambulatory Safety
About the Clarity PSO Learning Series

As one of the nation's first and most trusted Patient Safety Organizations, we understand the importance of knowledge sharing in order to improve the quality of healthcare delivery. For this reason, Clarity PSO has developed a series of educational reports that focus on the risk-quality-safety (RQS) issues we have spotted through our incident reporting data collection and analyses. Each of the reports will include our findings on a given topic and our recommendations on how to use knowledge to mitigate risk and improve patient safety. The second topic in this series is Ambulatory Safety


NOTE: For the purpose of this report and the related data, the term "ambulatory" is defined in a broad sense as healthcare services delivered in non-hospital settings including surgical centers, outpatient care centers and office practices.

Historically, quality and safety efforts have primarily revolved around the care provided in the traditional hospital setting and much less around the care beyond the hospital walls. While healthcare providers, risk managers, insurers, legislators, executives and administrators work together to make progress toward creating safer care delivery models, dramatic shifts in the healthcare landscape demand that we broaden our efforts to reach beyond the traditional hospital settings and truly begin to incorporate the entire continuum of care. According to a June 2011 article in The Journal of the American Medical Association, there are nearly 30 times more outpatient visits than hospital discharges annually(1). It is clear that the landscape is changing, and now more than ever, there is a critical need to better understand the risks associated with care in the ambulatory setting.
While there are many comparisons that can be made between safety events in hospital and ambulatory settings, in order to appropriately address patient safety in ambulatory care, it is essential to acknowledge and understand that differences do exist. Concern for patient safety and quality care is directly aligned with the physician's role as a primary care provider. Yet resources, infrastructure and expertise related to improving patient safety and quality are often directed to the inpatient setting, and are often limited in the ambulatory setting.
Since August 2012, Clarity PSO has been conducting a pilot study (The Ambulatory Safety Initiative) with two of our larger client health systems. The main goals of the study are to identify and learn from the following:
  • Improve the awareness of those areas of greatest risk in delivering ambulatory care
  • Provide a means to create and implement tools and strategies that improve the overall care delivered in the ambulatory setting
  • Identify opportunities (both similar and dissimilar) between hospital and ambulatory settings to improve quality and safety across the entire health system
In order to meet these goals, we have reviewed and analyzed three aspects of data that highlight risky behaviors and practices in ambulatory settings. From our analyses, we have been able to draw inferences and recommendations for improvement to various safety areas at each of the pilot systems. The three aspects of data include:
  1. Review of professional liability claims history
  2. Results from a self-reported online Office Practice Survey (OPS) assessment
  3. Safety events reported to their incident reporting system (in this case, Clarity's Healthcare SafetyZone� Portal) under the Ambulatory Safety Module (ASM)
What We Learned: Historical and New
Professional Liability Claims 
It is fairly well known that there are a few areas in ambulatory care that make up the majority of claims filed against providers. These areas include:
  • Missed or delayed diagnoses
  • Delays in proper treatment
  • Not providing/recommending preventative services leading to care/treatment delays
  • Medication errors/ADEs
  • Hand-offs: Ineffective communication and poor information flow
Office Practice Survey
In addition to the claims activity, the Office Practice Survey (OPS) revealed that providers feel that there are opportunities to improve their follow-up and hand-offs/communication. Here are a few instances of where this was identified through the survey:
  • A patient who is transferred to another physician's care has his/her medical record noted with the clinician's name who has accepted care and the date the transfer of medical information and care was completed
  • Patient compliance with obtaining consultations is tracked and noted in his/her medical record
  • Information provided to covering physicians is documented in the medical record
  • Patient education information is provided that discusses the importance of screening and preventative testing
  • A process is in place to flag unexpected returns to the office so the medical record can be reviewed
These sorts of gaps in care are the kinds of practices that can result in missed or delayed treatment/diagnosis, improper treatment management and communication barriers. 
Event Reporting
What we have learned from the event reporting so far:
  • A "Reporting Culture" is not as prevalent in the ambulatory areas of a healthcare organization
  • Physicians did not typically participate in event reporting, but they want to!
  • The pilot groups adopted the ASM of their event reporting system (Healthcare SafetyZone Portal). This module was designed to capture safety events specific to ambulatory care settings
  • Education was provided to help the staff in the ambulatory areas to understand what can be reported and how to do so effectively. Spending the appropriate time with the providers in small group settings allowed for the culture to evolve in two very important ways:
    • The ASM tool was developed for this particular setting
    • The events were reported to Clarity PSO so that the information was protected and further fostered a culture of safety
Based on our experience and knowledge gained in analyzing these data through the Ambulatory Safety Initiative Pilot, the following are a few recommendations to address a number of the areas of safety in ambulatory care delivery. What is central to each recommendation is that reliance on the Electronic Medical Record alone is not always sufficient without a workflow analysis to support the particular practice:
  • Implement screening and tracking processes for test results, referrals/consultations, follow-ups and monitoring patient compliance
  • Ensure physician/practice coverage and communication
  • Employ general documentation practices
  • Incorporate processes into established health screening guidelines, tracking and compliance
  • Track patient compliance with obtaining referrals/consultations
  • Maintain an updated medication list
  • Review and revise the protocol for missed appointments to include follow-up and medical record documentation
  • Implement documentation processes for physician review of reports and procedures, test results and consultations
  • Develop a standardized system for documenting allergies
  • Document and periodically update advance directives
  • Develop or revise protocols for tracking prescribed tests/procedures and recommended follow-up appointments
  • Continue to encourage the use of an incident reporting tool and provide feedback on what is being done with the data
Establishing practices for the capture of data from ambulatory settings is a start to understanding this environment. The next step is to use the knowledge gained from the data analysis and implement the appropriate policies and procedures to address any gaps in the culture of safety. This is also an opportunity to inform and raise awareness about how the issues of potential risk exposure are interrelated with outcomes, resource utilization and financial reimbursement. As the healthcare landscape evolves and we continue to experience greater reliance on ambulatory settings, our practices must ensure and reflect due diligence in the self-regulation of unsafe conditions, near misses and medical errors for both the population health and financial health of our care delivery system. We will continue to monitor the results of the Ambulatory Safety Initiative as this moves to full implementation. 

1. Bishop, T., Ryan, A., & Casalino, L. (2011). Paid Malpractice Claims for Adverse Events in Inpatient and Outpatient Settings. JAMA, 305(23), 2427-2431.
To learn more about patient safety in the ambulatory setting, read Clarity's white paper, Risk-Quality-Safety Beyond the Traditional Hospital Setting: The Time for Awareness is Now
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This information is provided for informational and educational purposes only and should not be construed as financial, medical and/or legal advice. Specific questions regarding this information should be addressed to local advisors and legal counsel. � 2013 Clarity Group, Inc. All rights reserved.