Efforts to improve quality and patient safety have historically focused on the inpatient setting. But as more care moves outside of hospital walls, health systems are beginning to craft structures and processes to better measure and improve safety in ambulatory settings.
"We have to focus on outpatient safety because it's just going to come up more, as more care that would have traditionally been dealt with inpatient moves outpatient," said Esme Singer, MD, senior vice president of Philadelphia-based Temple Health's physician enterprise and chief medical officer of Temple Faculty Physicians.
While inpatient settings have long benefited from standardized safety protocols and rigorous reporting mechanisms, ambulatory care has often lacked the same level of structure and oversight. Now, leaders at major health systems are working to bring the same disciplined approach to outpatient settings, where an increasing share of care is delivered.
Outpatient volumes are projected to increase 17% by 2034, driven by more surgeries shifting to ambulatory settings and the growing demand for chronic disease management, according to a forecast report from Vizient company Sg2.
When Dr. Singer joined Temple about six months ago, one of the first major projects she was tasked with was building out an outpatient safety program that is aligned with inpatient safety but exists as a distinct entity within the system. In hospitals, there are robust structures in place to capture data and inform quality and safety initiatives, with care teams keenly aware of what is being measured and where there are opportunities for improvement.
"On the outpatient side, it does often get a little murkier or at least a little less complete," Dr. Singer said, noting that one of her goals for this year is to increase reporting of potential safety issues in outpatient settings. "Then we can actually work on making improvements in a data-driven way and really start to see where we have opportunities."
Temple is working to develop Epic dashboards to provide clinicians with specialty-specific quality and safety metrics. For instance, a breast surgeon would have the ability to see data that is meaningful to them, such as the average time it takes between a patient having a lesion identified, and having surgery to remove it. Similarly, an endocrinologist would have a view of how many of their patients have hemoglobin A1c levels less than 7%, a treatment target associated with lower risk of complications among diabetic patients.
"It's important to get it into Epic because that's where providers are living," Dr. Singer said.
April Taylor, vice president and COO of The Johns Hopkins Hospital in Baltimore, said work to elevate quality and safety in outpatient settings began during the COVID-19 pandemic. As more care began to move to the outpatient setting, peers across health systems began having conversations surrounding the need to ensure quality and safety metrics were captured in outpatient settings, and what to measure in the first place.
"There's been a lot more discussion around things like diagnostic accuracy," Ms. Taylor said.
With telemedicine's growth, systems are also looking more closely at how to best determine when an in-person visit is most appropriate.
"How do we look at when you need one versus the other, and the quality outcome associated with that," she said.
Durham, N.C.-based Duke Health integrates outpatient safety into daily operations through a huddle structure. Daily huddles occur across all ambulatory practices, with care teams discussing progress on quality and safety projects that they developed.
"These quality and safety projects are designed by the people doing the work" said Angelo Milazzo, MD, chief medical officer of integrated practice at Duke Health. "We're not pushing down ideas; they're bubbling up from the people who are hands-on with patients, who are seeing where the opportunity lies."
The daily huddle structure in outpatient practices originally launched in 2017, though was disrupted during the pandemic and has regained momentum over the past year. While quality projects across ambulatory practices often align with national patient safety goals, care teams also focus on locally relevant challenges.
"If we're in a pediatric office, we may be looking at reconciliation of immunization status. If we're in a psychiatric practice, we may be looking at screening for depression or suicidal ideation. If we're in a surgical practice, we may be looking at post surgical wound infection," he said. "We try to make it context dependent and context specific."