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Outpatients Deserve Patient Safety Improvement Too


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Outpatients Deserve Patient Safety Improvement Too

By Luke Sato, MD, CRICO

Related to: Ambulatory, Primary Care

The current patient safety movement first gained momentum in hospitals (foremost in anesthesiology) but, more recently, the focus has been widening to include outpatient care. As parent health care organizations began to address inpatient safety, they recognized that their outpatient partners needed to be included in the improvement process, and the malpractice claims data bear that out. As health care delivery has shifted more toward outpatient practices, so too have the settings for alleged medical errors. And we know, based on multiple studies of medical error, claims and suits represent just a small proportion of all the preventable adverse events that actually occur.

We know too, the devastating impact an adverse event has on the patients, their families, and also the physicians, nurses, and staff involved. An adverse medical event is often life altering, and when that event is later understood to have involved preventable errors, practice-altering solutions need to be developed, implemented, and spread. The Harvard-affiliated organizations, their associated office practices, and CRICO are committed to that goal. It is an ambitious endeavor.

A Non-organized Network

CRICO-insured office practices are affiliated (often loosely) with a “parent” institution in the Harvard medical system. Those “networks” of practices, however, are not always well organized for making universal improvements at the practice level. The practices within a given affiliation often operate independently in terms of protocols, systems, training, and quality improvement efforts. To achieve a goal of significant patient safety improvement—especially in primary care practices—by relying solely on the already overburdened PCP to address those needs independently is simply too much to ask. Not that the spirit isn’t willing. The hard part of patient safety improvement in the office practice is not motivating dedicated caregivers to do the right thing. The hard part is developing and sustaining an organizational approach that is more efficient and sustainable than each individual practice-based approach. That requires both parties, physician groups and parent organizations, working toward a common goal. The good news is that the CRICO-insured organizations, and their practice affiliates, have begun that work. At the practice level, a great deal is being achieved with grassroots efforts. Through both its research/demonstration project grants, and its Office Practice Evaluation (OPE) program, CRICO has been witness to numerous innovations making a difference in office-based patient safety. But, while that approach serves as a good way to pilot new interventions, it is inefficient for system wide improvements.

We at CRICO have seen the most success, in terms of patient safety improvement, when the relationship between the parent organization and affiliates is built beyond a financial structure. The more both parties can collaborate on mission, systems, and support services, the easier it is to introduce innovations and respond to emerging risks. The parent organizations that strive to accomplish that have developed a more comprehensive network model and are fully committed to providing the outpatient practices with the leadership and resources necessary to sustain and systematize innovations. We hope that the inpatient patient safety improvement experience has shortened the learning curve for outpatient providers. Certainly, clinicians can see that the patient safety movement is not some short-lived concept. They also understand that many techniques and tools developed for hospital patient safety can now be applied to office-practice settings. Of course, office practices cannot individually match the framework and support services of a large hospital on their own. Both sides know that continuous patient safety improvement in the office setting demands greater collaboration. For the individual practice groups, that may mean adopting solutions that were not home grown. For the parent organization, implementation of patient safety improvements in multiple unique settings requires, perhaps, greater patience and more diverse management than for inpatient interventions. An ambitious endeavor indeed.

Recognizing that attention to the office practice is crucial to our mission of decreasing missed and delayed diagnoses (the top area of high-severity malpractice claims); Forum is highlighting the office setting in this issue. We invite you to join the ongoing efforts of CRICO and our guest authors to identify risk, develop and promote risk reduction efforts, and continue to extend patient safety principles into to the office environment.

June 1, 2007
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