Getting Started on Ambulatory Safety

Even within a small team you can model the communication and transparency necessary to advance a safety culture.

What would you say is the biggest patient safety challenge in ambulatory settings? Medication reconciliation? Diagnostic error? How about managing transitions or procedural safety?

Those are all big issues that certainly need attention. But, to my mind, the biggest issue in ambulatory patient safety is the lack of a safety infrastructure. For the most part, ambulatory settings often lack the foundational resources, tools, and mechanisms to adequately implement and manage safety initiatives. Trying to improve any aspect of safety without those key ingredients in place may yield some initial results, but long-term improvement or practice change will be difficult to sustain.

After years of attention to safety in hospitals, and some real progress, there is now wide agreement that we need to step up efforts across the continuum of care. Most health care happens in outpatient settings — about a billion encounters each year in the US — so the potential for patient harm is arguably higher than in hospitals. IHI’s recent survey found that of all people who reported experiencing a medical error, only about one-third occurred in hospitals.

While acuity may be lower in outpatient care than in hospitals, the sheer diversity of ambulatory settings complicates the challenge. Think about how different the workflow and practices are in primary care, ambulatory surgery centers, dialysis centers, urgent care clinics, and outpatient pharmacies, not to mention the home itself.

So, if you work in ambulatory care, and you want to begin or improve upon your safety program, where do you start? Here are three things to consider:

Assess Your Safety Culture — Efforts to improve patient (and workforce) safety need to start with a frank look at factors such as how safe people feel speaking up about safety risks and whether, for example, they view the culture as punitive. This is important to consider even in outpatient clinics that are part of a larger system. As research has shown, overall organizational culture does not necessarily translate to the department or unit level and vice versa. Leaders — at both the organizational level and at the unit level — greatly influence the culture of any group. So, while it is critical for executive leaders to make safety a core value of their organizations, you don’t need to be the CEO to have an impact. Even within a small team you can model the communication and transparency necessary to advance a safety culture.

Tools such as the AHRQ surveys on patient safety culture — which measure factors such as teamwork, organizational learning, and processes and standardization — can help you assess culture and monitor it over time. Versions have been developed for outpatient settings such as ambulatory practices, nursing homes, and ambulatory surgical centers.

Move from a reporting system to a learning system — Learning systems are those that have in place standard improvement methods and measures, share data transparently, and apply evidence-based practices, all with the goal of collecting and learning from reports of what has gone well or not so well.

It’s not enough to ensure that staff are encouraged and feel safe reporting risks. You also need to ensure that they know what kinds of things to report and how. Equally important is clarity around what happens to the reports — whose job is it to review them, analyze the information, respond with a systems approach, and follow up?

Ambulatory settings need to build capability in systems thinking, human factors, root cause analysis, and other areas so they have the expertise to learn and improve. Reporting doesn’t help anyone; it’s the learning experienced through reports that help guide future actions to, hopefully, reduce or eliminate risk of harm.

Ensure Transparency and Collaboration — Hospitals have long used mechanisms such as peer-review processes and Mortality and Morbidity Reviews to allow for discussion about unexpected or poor outcomes, as well as a growing number of multi-hospital collaboratives. Ambulatory settings can implement similar strategies in their own contexts.

In addition, the federal Patient Safety Organization program encourages health care organizations to collaborate with peers, by region or specialty, for example, to share information and learning. One of the benefits for small practices is that a PSO aggregates data from all its members, allowing more opportunities to share and learn from each other about solutions that work.

More and more care is shifting beyond the hospital walls, and we owe it to patients to have robust mechanisms in place to ensure that they will have safe care wherever they are getting care.