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Because the attention to safety in ambulatory care is long overdue.
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The Time Has Come to Improve Safety in Ambulatory Care

By Madge Kaplan | Wednesday, March 23, 2016

Patient-safety-ambulatory-care-susan-young-photography

More than 30 percent of safety issues for patients in hospitals originate before admission. Many problems are linked to outpatient settings, including primary care.

This is a finding Dr. Mark Jarrett, Senior Vice President and Chief Quality Officer of Northwell Health, learned with his team while tracking hospital harm incidents using IHI’s Global Trigger Tool.

It was a wake-up call, Dr. Jarret explained in a recent episode of WIHI, that spurred Northwell (formerly North Shore-LIJ Health System) to launch an intensive quality program to improve safety in its 450 outpatient settings.

Why now?

Jarrett said the attention to safety in ambulatory care is long overdue and the timing is right. With industry consolidation and a shift away from hospital-based care, ambulatory practices linked to larger medical systems are growing rapidly. It’s never been clearer that providers must focus on safety across the entire continuum of care.   

“There’s a heck of a lot more care delivered in outpatient settings than in hospitals,” Jarrett said. “The acuity might be lower, but the sheer volume of care delivered means higher safety risks.”

Now, Northwell is developing an infrastructure for learning and improvement in ambulatory care facilities with the same rigor as they have for decades in their 21 hospitals.

“We’re just getting started in this journey,” he said.

Where should we begin looking for safety risks?

Staff who are working to improve safety in ambulatory care have to change the perception that there are no safety risks. “I have 180 outpatient facilities and they think they have no safety issues.” one listener commented. “What are the most common errors you see?”

Jennifer Lenoci-Edwards, IHI’s safety director and another panelist on IHI’s audio talk show, said her top concerns would be about workflow. Individual providers often have their own processes for the same work, which means “balls get dropped too easily.” Her other red flags areas:

  • Referral management
  • Test result management
  • Diagnostic errors and delays
  • Care transitions
  • Medication management

Lenoci-Edwards had a medication safety example close to home. Her father was recently prescribed the same drug by two practitioners, an orthopedist and his primary care provider. He didn’t realize it, took the double dose of the nonsteroidal anti-inflammatory, and nearly ended up in the emergency department.

Dr. Tejal Gandhi, President and CEO of the National Patient Safety Foundation (NPSF), stressed patient vulnerability during care transitions. Safety efforts have put a lot of resources into reducing hospital readmissions, she said, but that’s just one common transition. To ensure safety, providers have to look at all of them — nursing home to emergency department, and rehab hospital to home, for example.

Northwell’s Jarrett said one problem is the lack of safety redundancies in ambulatory care. The aviation industry has redundancies throughout — a pilot and a co-pilot, back-up hydraulic systems and electric systems. Hospitals have done the same thing: two signatures before a blood transfusion, time-outs, and surgical checklists. But in outpatient settings, people are often performing tasks on their own without any safety checks.  

How can organizations improve outpatient safety?

Leadership support is critical to building will to address ambulatory safety.

At Northwell, Jarrett’s team had backing from senior leaders to help the organization adopt a new approach to safety. Instead of tracking safety by care setting, they do it through service lines. For example, for the orthopedic surgery patient, they look for gaps throughout the whole patient journey, from pre-op through surgery, recovery, home care, rehab, and long term follow-up.

Panelists agreed that the culture of blame has to change. Dr. Fran Ganz-Lord, Director of Ambulatory Quality at Northwell Health, said providers know there are gaps and near-misses, but they need a forum to discuss their concerns and a learning system to make changes.

Both providers and patients need to overcome their defensiveness to speak up more, especially to one another, to head off mishaps and adverse events. For example, a hypertensive patient who’s not taking her blood pressure medication might not feel comfortable telling her doctor, leading her doctor to increase the dose — and the safety risk.

NPSF’s Gandhi agreed that ambulatory safety is just getting started. Primary care is “just the tip of the iceberg,” she said. All settings require work, including specialty practices, ambulatory surgical centers, nursing homes, and dialysis centers.

Jarrett’s line that seemed to resonate most with WIHI listeners was this advice: “You have to start by getting your leadership to recognize you have a problem.”

Photo credit: Susan Young Photography for IHI.

You May Also Be Interested in:

You’ll find all the information from this WIHI, including slides, audio broadcast, and chat discussion, posted here, in the WIHI Archive. Download this broadcast as a podcast by searching for “IHI” through iTunes or your favorite podcast app.

Read a new report from NPSF, “Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human,” outlining safety experts’ eight recommendations for hospital and outpatient care.

Listen to a recent episode of WIHI focused on the latest research on diagnostic errors and delays.

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