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Ambulatory Safety Nets: The Power of Collaboration and Co-Design

Why It Matters

Ambulatory safety nets not only safeguard against diagnostic errors, they also encourage collaboration, support health care providers, and break down competitive barriers for the greater good of patient safety.


It is every patient’s nightmare: A delayed cancer diagnosis. Too many people are familiar with the consequences, which can include a prolonged and tougher course of treatment, increased likelihood of recurrence, emotional suffering, and even death.

A delayed cancer diagnosis is also every care provider’s nightmare. Recognizing that delays in cancer diagnoses resulting from lapses in communication pose a significant risk to patient safety, an effort known as ambulatory safety nets — a model pioneered by Kaiser Permanente — is underway in Massachusetts to safeguard against these errors.

Based on the Institute for Healthcare Improvement (IHI) Breakthrough Series Collaborative Model, the effort in Massachusetts is funded by CRICO, the company that provides professional liability insurance coverage for Harvard medical institutions and their affiliates. CRICO assembled, facilitated, and continues to assist and guide this ambulatory safety net implementation collaborative, which includes seven organizations across the CRICO network.

The participating teams:

  • Create registries for patients who have abnormal colorectal, breast, lung, and prostate screening tests;
  • Develop standard workflows to systematically identify those overdue for recommended follow-up; and 
  • Help patients close the loop on their care through support from patient navigators. 

By co-designing with patients and promoting cooperation between participating organizations, the first phase of the implementation collaborative has led to scheduled or completed colonoscopies for more than 1,300 patients who had been lost to follow up and at risk for a delayed colorectal cancer diagnosis.

Learn more about the IHI Breakthrough Series College

Matthew Germak, MD, MPH, Chief Quality & Safety Officer, Beth Israel Lahey Health Primary Care (Boston, Massachusetts, USA), is a participant in the Ambulatory Safety Net Collaborative and leads the Ambulatory Safety Net program for Beth Israel Lahey Health. In a recent interview, IHI asked Germak about the challenges of bringing organizations from different health systems together in a competitive health care market. While he noted that participants had to reconcile varying strategic plans and priorities and accommodate different levels of experience with the work, he was pleased that they rapidly coalesced around a common sense of purpose. “We quickly started to zero in on our shared vision and patient-centered approach,” Germak recalled.

The collaborative approach to learning has fostered cooperation and communication. Participants have also seen the practical advantages of sharing perspectives, tools, scripts, and best practices. “Those [benefits] far outweigh any background climate of competitiveness,” Germak noted, “because ultimately everyone who’s involved cares about improving patient safety, quality of care, and equity, and mitigating risk for their patients and the people in the communities they serve.”

Patient Advisors: Critical for Co-Design and Equity

Designing the ambulatory safety nets with patients — and not just for patients — has been essential. The involvement of patient advisors has helped ensure a patient-centered focus. As Germak comments, “[Patient advisors] always help us broaden our lens as we’re looking at a particular issue.”

Germak described a sometimes underappreciated aspect of co-designing improvement with patients. “I try to always foster as much psychological safety as possible in meetings and on teams,” he noted, “so everyone feels comfortable to contribute and offer important perspectives.” In addition to addressing power imbalances between clinicians and patients, developing psychological safety is also important between colleagues and across disciplines.

One example of the impact of cultivating psychological safety and incorporating co-design into the ambulatory safety net work involved Beth Israel Lahey Health’s analysis of their colorectal cancer screening data. One of the team’s patient advisors had wondered aloud whether their patient navigation approaches were inadvertently hindering certain patient groups from receiving equitable care. His insights encouraged the team to scrutinize the potential unintentional biases and inequities in their patient outreach strategies. Specifically, they delved into their data and considered factors such as educational disparities, language barriers, access to technology, and potential reasons for patient hesitancy. This became a catalyst for reflection that challenged the team to reassess and modify their patient outreach and navigation model. “Fortunately, our patient advisors have grown to be comfortable on our team,” Germak commented. “We try to be intentional about welcoming their perspective in any conversation we’re having because patients’ insights can inform and drive the way we deliver care.”

Hopes for the Future

Germak is hopeful that the collaborative's success in addressing cancer diagnoses will open the door to tackling other challenges beyond the current initiative. He is also optimistic that the acceleration of integration across Beth Israel Lahey Health resulting from the ambulatory safety net initiative will be a long-lasting benefit of the collaborative.

In a health care landscape full of challenges, ambulatory safety nets have emerged as a demonstration of the power of partnerships, co-design, and patient-centered care. This approach not only addresses diagnostic errors but also establishes a model for organizations to collaborate effectively, support health care providers, and break down competitive barriers for the greater good of patient safety and well-being.

Editor’s note — Dr. Germak and CRICO would like to thank the participants in the Ambulatory Safety Net Collaborative: Atrius Health, Beth Israel Lahey Health, Boston Children's Hospital, Cambridge Health Alliance, Dana Farber Cancer Institute, Mass General Brigham, and MIT Health.

You may also be interested in:

Join us at the IHI Patient Safety Congress (May 14–16, 2024)

Patient Safety Awareness Week is March 10–16, 2024.

Diagnostic Excellence - free webinar on Thursday, March 14, 2024. Register here.