If it could be said that the Age of Hospital Quality dawned with the 1999 Institute of Medicine's seminal report, "To Err Is Human," then the Age of Outpatient Quality may finally be dawning now.
I've counted eight reasons why the safety movement is rapidly accelerating in the ambulatory care arena, inspired by one major reason: the American Medical Association devoted a 194-page report to the topic just before the holidays.
The group's review lists the stumbling blocks as well as the possibilities of improvement through better research, better definitions of what constitutes poor quality, and improved measurement tools for community clinics, office practices, and surgical centers.
"I think there's definitely momentum now," says Matt Wynia, MD, an internist at the AMA's Institute for Ethics and the Center for Patient Safety, the report's lead author. "The number one thing I keep repeating is that there are 300 patients seen in ambulatory settings for every one person admitted to a hospital, and [there are] a hugely disproportionate number of encounters that take place in ambulatory settings."
Of course, one wonders why it's taken 12 years for quality leaders to focus on outpatient errors, and there are just about that many long-winded and complex explanations. For starters, there's no infrastructure to lead the way as there is in acute care facilities, with chief quality and compliance officers to make sure rules exist and are followed.
Nevertheless, the period that Wynia and co-author David Classen, MD, called in a recent journal commentary "the lost decade in ambulatory safety" is about to find its way.
So here, culled from a variety of sources including the AMA report, are eight reasons why quality measures to prevent outpatient mishaps—from prescription drug errors to delayed or missed diagnoses—will soon be a much bigger issue on the ambulatory provider's radar.
1. Outpatient Visits More Numerous, Complex
The setting for more complex procedures, with greater potential for harm, has been rapidly shifting from inpatient to outpatient. And errors that take place in these settings may elude detection for longer periods.
"The things that lead to bad outcomes in ambulatory settings are more dispersed, they're harder to keep track of. An error takes place in one setting, but isn't discovered until the patient goes to another setting," Wynia says.
In the hospital, patients remain in one place long enough for providers to see and attribute the cause of medical mishaps within minutes or days. But the consequences of an outpatient's wrong dose of medication may not be noticed for days or weeks.
2. Patients' Responsibility in Preventing Errors
Providers are increasingly aware the patient may not follow their course of care. And more now than ever, the provider is accepting the blame. The patient may be insufficiently informed, cognitively unable to grasp concepts, have limited language skills or simply be unwilling to take a prescription because of a perceived drug side-effect or lack of money.
"Patients are also expected to explain their symptoms to clinicians accurately and completely and to provide other essential information for diagnosing and tracking the progression of their conditions," the AMA report explains.
When they don't, a medical error can result. The AMA report says that one challenge to studying patients' roles in their care "has been the inherent difficulty in classifying whether a patient made an 'error' versus a bad choice."
Even the forthcoming ICD-10 coding system reflects this distinction, offering eight codes for patient noncompliance, including one for "patient's intentional under-dosing of medication regimen due to financial hardship." The current coding system, ICD-9 has only one.
Wynia says that providers have been "really reluctant to say the patient made an error. After all, the patient is there for your help," and some say it's the provider's job to ensure that the patient knows how to manage themselves when they go home. "Yet in all these studies, the patient's role was a very important factor in (many) ambulatory care adverse outcomes."
3. Reducing Readmissions via Continual Care
There's a big push to see medical treatment as an episode lasting more than just the initial visit. Think accountable care models or medical homes, where the physician, hospital, pharmacist, clinic, and in-home support team all keep track of what each other does for and with the patient over weeks to years.
Now, instead of handing off a patient to the next provider as if care is no longer their responsibility, outpatient clinicians hold each other accountable for what happens to that patient for a much longer term. If something goes wrong, they all will be tracking back to see why.
4. EMR
The emerging use of electronic medical records can link all hospitals, physicians, and nurses with the patient's files, and at least in theory, can prevent errors and speed timing of care.
According to the AMA report, EHRs can maintain allergy lists, alert in cases of potential drug-drug or drug-allergy reactions, e-prescribe, provide a patient encounter summary after each visit the patient and family can refer to if memory of what was said fails.
5. Value-Based Purchasing Programs
The Centers for Medicare & Medicaid Services must prepare a value-based purchasing incentive plan for ambulatory surgical centers, under provisions of the Patient Protection and Affordable Care Act of 2010.
Last April, CMS said it intends to propose sometime this year a rule implementing an ambulatory surgical quality reporting program. Eventually, it may reduce annual payments to facilities with higher rates of adverse events such as falls, wrong-site surgeries, surgical site infections, and blood clots.
6. Infection Control Guidelines from the CDC
The Centers for Disease Control and Prevention in July issued a set of guidelines to prevent transmission of infectious diseases in ambulatory care settings through better hand hygiene protocols and personal protective equipment use among providers. The CDC called for a trained infection control professional to be on staff or regularly available in ambulatory care settings, and to help write infection control policy for the facility.
7. Follow Abnormal Test Results
An often overlooked category of serious adverse outcomes is when the physician neglects to tell the patient about an abnormal test result, delaying or preventing appropriate treatment. "Logistical barriers may also impede prompt follow-up on the part of patients if they are not able to receive timely appointments or obtain the requisite insurance coverage for recommended tests," the AMA report says.
Wynia says an abnormal report should sound an alarm if it's the first one, but when patients routinely get abnormal results because of other factors, providers tend "to become inured to all the alerts and warnings and sirens that are going off all the time."
8. The AHRQ's Recommendations
The AMA report lists 11 recommendations stemming from the Agency for Healthcare Research and Quality's consensus conference several years ago on ways to spend money to measure and improve ambulatory care. Jeff Brady, AHRQ's patient safety portfolio lead, says the agency has embarked on a number of projects with research grants.
For example, he says, $74 million has been dedicated to research ambulatory safety and quality through health information technology. Still other strategies include communication improvement courses to build teamwork, and the creation of blameless ambulatory care cultures that encourage providers to speak out about problems.
Wynia says there's still a paucity of research. "If one does a PubMed search for the words, patient, safety, and hospital, "you get 25,000 articles. But if you search for patient, safety, and ambulatory, you get only 1,800."
Ambulatory quality is going to be a tough process to measure, to be sure, because it means monitoring outcomes from much less invasive procedures over the long haul. But the drive to keep outpatients out of the hospital, in much lower acuity settings, must also police itself better, to make sure errors in care don't become mishaps that force these patients back in.