Transferring Patient Safety Progress to the Ambulatory Setting

March 14, 2019
Stanford Health Care’s Lisa Schilling says ambulatory safety is more important because increasingly complex care is being provided outside of hospitals

This week there have been several announcements and events tied to Patient Safety Awareness Week. For one, the ECRI Institute rolled out its annual list of the Top 10 Patient Safety Concerns. For another, the nonprofit Institute for Healthcare Improvement (IHI) hosted a webinar highlighting the importance of broadening the focus of patient safety efforts to the ambulatory setting.

Noting that patient safety improvement efforts have historically focused on inpatient settings, IHI brought together some patient safety experts to discuss the challenges around addressing the serious safety risks that are present in ambulatory settings.

IHI also noted that as increasingly complex care is being provided outside of hospitals and in patients' homes, it is important to consider how to advance patient safety in ambulatory settings and across the entire care continuum, including in the home and in skilled nursing facilities.

Tejal Gandhi, M.D., M.P.H., IHI’s chief clinical and safety officer, said the organization wants to help clinicians, patients and families mitigate threats and improve patient safety in the ambulatory setting. She said that involves moving from a reactive approach to initiatives that focus on foundational things such as teamwork, safety culture and patient engagement. Ambulatory operations do not have the infrastructure for patient safety that inpatient settings do, so a systems approach is going to be relevant to transferring learnings to outpatient settings.

Lisa Schilling, R.N., M.P.H., vice president of quality, safety and clinical effectiveness at Stanford Health Care in California, began her presentation by citing a 2014 report from AHRQ that estimated that 5 percent of adults in the United States, more than 12 million individuals, experience a serious diagnostic error in the outpatient setting every year. Meanwhile, the number of outpatient surgical procedures in the U.S. is expected to grow from 129 million in 2018 to 144 million by 2023.

She began by asking a series of questions: How do the issues and trends in patient safety transfer over to ambulatory spaces? In particular, when we think about the drivers of patient safety, what are the considerations across different types of structures for improving safety and ensuring safety? If you work in a small group of clinics, you don’t have the same infrastructure as large integrated systems, so how can you leverage existing systems to ensure safety? 

“Healthcare has changed dramatically, even over the last five years,” said Schilling, who was previously Kaiser Permanente’s national vice president for quality and clinical effectiveness. She used Stanford Health Care as an example. It has a large academic medical center, with a new hospital building opening this year — a very high-acuity academic center. But it also has more than 50 locations with many primary care and specialty care clinics, and even integrated centers for services, such as an integrated cancer center, where they do procedures but do not have inpatient beds.

 “The definition of ambulatory care has changed dramatically, and so has the experience around safety and injury and risk, and it will continue to change in the future,” Schilling stressed. “Diagnostic error has been largely what we focused on in the ambulatory setting for many years. It is difficult, because unless you are a fully integrated system, you deal with hand-off issues and the inability to follow up. The solution is leveraging partnerships with hospitals and other clinics, and the use of care management resources. Care coordinators can follow up with people after they leave the hospital. Those solutions have to be leveraged more in the ambulatory setting.”

 But Schilling implored the audience not to forget what is coming. “Fifteen years ago, we gave people a lot of opiates for surgeries, we put them in bed and didn’t let them get up and about much, and we gave them several days to recover from surgery,” she said. “Today we are using many alternatives to opioids for pain management, and people are ambulating very quickly, keeping their nutrition up, and we have people going home from a total hip replacement the same day as the surgery. But that does mean that the risk and safety issues are significant both in the ambulatory setting and in the home setting.”

 Schilling brought up a list of the types of events that happen in the ambulatory space: diagnostic issues, medication errors, falls, equipment, behavioral, communication, and perioperative/procedural. “The challenges remain care coordination and transitions of care. But we now have resources in quality and care management across sites that we can leverage to improve safety,” she said. “Do I have case management structures in place where we are coordinating care because we are an ACO?  Do we have a call center where we do appointment reminders and medication refills? How can we leverage those to ask the right questions and pinpoint the right opportunities? If you don’t use patient engagement methods like Open Notes and co-design of your interventions with patients, teach back, and shared decision-making, now is the time to do that.”

 “Historically we know that the patient has been the coordinator of care,” she added. “But today with the patient acuity as high as I have ever seen it in the ambulatory setting, we have to prepare people for the right conversations and have them be well-versed on how to call us and when to call us to seek help, because we are not in their environment all the time.”

Knowing that many of the drivers are the same as for the inpatient environment, Stanford has been working to transfer what is evidence-based into the ambulatory environment. "We know that we train people in teamSTEPPS in the inpatient environment. We do safety culture assessments in the inpatient environment," Schilling said. "How do we do that in an ambulatory environment? We need to do teamSTEPPS and a patient survey. How do we give the clinic operational staff information about how they are doing and how many events there are? I have found that we focus more on the populations in need.” She said a primary care or chronic care clinic is going to focus on things that are higher risk such as diabetes, heart failure, polypharmacy, ObGyn, and anybody who has been hospitalized or goes to the emergency room more often. “We don’t have the resources in a smaller environment to look at everything every day, but we can pinpoint the populations most at risk.”

When it comes to structure and oversight, Schilling said there are four things to look at:

• Who monitors overall performance of safety and issues that come up?

• Who is going to monitor event reporting and how the follow-up occurs?

• What is your operating structure to assure safety?

• How are you going to develop capabilities for safety and improvement? How would you think about teaching people about the culture of safety and how performance improvement fits into that?

In integrated health settings, she said, if you can get a service line structure where you have inpatient and ambulatory services connected from an administrative level, then you can have quality councils or committees that can oversee the continuum of safety, including ambulatory.

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