September 2013
PSOMediumClarity PSO Learning Series
Topic #3: A Continued Exploration of Ambulatory
   Safety in Modern Healthcare Systems

In this edition of the Clarity PSO Learning Series, we continue to explore the topic of Ambulatory Safety in healthcare systems. Recall that a number of changes in the healthcare industry are fostering an increase in healthcare services rendered in ambulatory settings, making this topic extremely important in the overall discussion of patient 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.


Today, the ambulatory sector is experiencing tremendous growth, stemming from a continued shift in delivery of care from inpatient to outpatient settings, an increase in the integration of various delivery models under single providers, and the change from volume- to value-based pricing structures. Due to these and other factors, the ambulatory sector is demanding significant attention as it relates to the quality and safety of care delivery.


Whether it's a walk-in clinic, a physician office, a rehab facility or even your own home, the challenges toward patient safety and quality of care are uniquely different from the traditional inpatient settings. In order to improve patient safety in these settings, it is important that we identify the differences and develop strategies specifically for these given areas. 


Differences in Emphasis on Patient Safety

Patient Safety beyond the Hospital, Gandhi, TK, Lee, TH

N Engl J Med 2010; 363: 1001-1003, Sept 9, 2010

With each setting having its own patient safety needs, physicians are presented with a variety of challenges as they try to maintain quality throughout the entire continuum of care. The sheer vastness of the ambulatory arena and the number of services rendered exposes patients to an assortment of safety and quality concerns. According to the National Center for Health Statistics, August 2012, there are nearly 1 billion visits to physician offices as compared to 36 million hospital discharges annually. Also consider that in an office setting, a primary care physician can process more than 900 laboratory results per week, making it extremely difficult to track significant abnormal results amidst the sea of normal values(1). The result is that the signal-to-noise ratio is much lower in ambulatory settings: a physician may see 100 patients with chest pain before seeing one who is actually having a heart attack(2).


In our last edition of the Clarity PSO Learning Series, we discussed a pilot study taking place among Clarity PSO (The Ambulatory Safety Initiative) and two of our large client health systems. During the study, we reviewed and analyzed three aspects of data: professional liability claims history, results from an Office Practice Survey (OPS) and safety events reported to the participants' incident reporting system (in this case, Clarity's Healthcare SafetyZone� Portal) under the Ambulatory Safety Module (ASM).


Our Ambulatory Safety report published in May of 2013 focused primarily on the types of errors that we typically see in ambulatory settings as a way to enhance the awareness of reporting and how communication is critical in mitigating the factors that contribute to those events. For this report, we looked at the mindset of the care providers who practice in ambulatory settings and the unique circumstantial challenges that make practicing in these setting so different from working in the traditional inpatient settings.

What We Learned:

As part of the Ambulatory Safety Initiative, we administered an Office Practice Survey (OPS) to help gauge the climate of safety at our participating healthcare organizations. As we drilled down into the survey and began interviewing the individual providers, we began to see the need for a more cohesive effort toward patient safety practices. The following describes what the providers discussed through their participation in the initiative:

  • Physicians have not typically participated in event reporting and review
  • Physicians are very interested in knowing about patient safety events in their offices and trends across the system
  • The physician environment is different from hospitals; having a reporting tool that is meaningful is important
  • Defining who needs to follow-up on events and when helps get follow-ups done. Measuring and reporting the follow-up process also helps
  • A simple reporting tool is best
  • The creation of a "Learning from our Mistakes" forum would be helpful
Based on the reporting data collected and sentiments gleaned from the OPS, a picture of ambulatory safety began to unfold:
  • The need for having a system-wide process (electronic, preferably) to capture events from all aspects of the healthcare system is an important consideration and runs parallel to and separate from electronic medical record (EMR) structures
  • As awareness of events grows, the ability to bring risk-quality-safety (RQS) resources of the hospital to bear on working on reducing harm in the ambulatory settings increases
  • Working through the PSO brings the whole organization into an awareness of harm reduction and fosters collaboration across the entire system of care
Overall, through our Ambulatory Safety Initiative, we learned that physicians and other healthcare providers in those settings are, in fact, quite interested in participating in quality/safety efforts. We also learned that the practice environments between hospitals and ambulatory settings can be quite different. Therefore, in many ways it makes sense to have separate systems for reporting. In our program, it was also very clear that in ambulatory settings there isn't always dedicated staff to manage the reporting process. Even without dedicated staff, actions such as follow-up documentation and investigation must still be conducted. Creating a streamlined process with the proper tools is important for closing the loop and tracking performance over time.    

Though historically the focus has been on the hospital setting, we realized that when good systems are designed by and for ambulatory provider settings, the awareness and eagerness to engage in these processes is greatly improved. This suggests that our design of the initiative was created appropriately - simple, easy-to-use templates specifically for ambulatory settings that focus on getting to the root of issues quickly. Additionally, a clearly defined method for event investigation is also very helpful in determining who will follow up, what items need immediate attention, how follow-up will be documented, and when it should be completed.


Lastly, creating a forum to reflect back on issues and what can be done better next time is also very important. Providers expressed that having a venue to talk through issues was helpful in two ways: (1) identifying the root of problems; and (2) stress relief when care delivery is not optimal despite our intentions. This is a key element to conducting such work under the auspices of a PSO. In essence, create a learning lab so that the provider can freely discuss concerns, issues and improvements in a legally protected environment. Fostering the development of a "learning lab" such as this is critical because it gives providers a sounding board in a setting where they won't feel isolated. This helps avoid a silo-type environment because now we have fostered communication and a culture of safety from the very beginning. This will make integrated care easier and potentially allow for more complex issues to be addressed and handled more quickly and efficiently.


1. Poon EG, Et. Al., Arch Intern Med, 2004; 164(20): 2223-2228

2. Gandhi, TK,, N Engl J Med 2010; 363:1001-1003 (Sept 9, 2010

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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