Ambulatory Care Quality Improvement Model. Moving from Retrospective to Prospective-based Quality Improvement. Probabilistic risk analysis (PRA) is ...
Sustainable Quality Improvement in Ambulatory Care International Forum on Quality and Safety in Health Care, 21- 23 April 2009, Nice, France
Robert J. Borotkanics
Background & History
Ambulatory Care Quality Improvement Model
The complexity and scope of ambulatory care has increased over the past couple decades. This has been due to changes in technology, changing patient demographics and financing. For instance, in the United States: • The rate of emergency department visits has risen dramatically. • Ambulatory surgical centers are the fastest growing provider type participating in Medicare, increasing by 61 percent from 2000 to 2009. • The rate of visits to physician offices has increased only slightly over the past 20 years, but patients being treated for one or more chronic conditions have increased. • Medical regimen complexity has increased; e.g., outpatient diabetes management. The U.S. Institute of Medicine (IOM), an accepted authority in U.S. and international health care, considers ambulatory care peppered with many risks that contribute to patient harm: Highlighted the risks of medication use in the ambulatory setting and across transitions in care.
Characterized emergency departments as high-risk ambulatory care sites.
Throughout the world, ambulatory care is highly distributed, with many organizations participating in many care processes at many points. While ambulatory care is technologically less complex than inpatient care, it is often more complex logistically. Transitions between care sites are also moments of increased risk of adverse events. To improve ambulatory care quality via PRA, first requires an appreciation of organizational behavior: 1. Distributed environments are characterized by different levels of cooperation, shifting responsibilities, varying priorities, different conditions, autonomy, variability and independence of each organization and their supporting technologies. 2. Organizations exhibit defined, recognizable spatial and temporal characteristics. People come together and do things over finite periods of time. Health care organizations, in particular, are based on highly specialized knowledge, skills and expertise. 3. Organizations also have defined psychological traits. The activities of the organization are a source of feeling that deepens the organization’s identity. At the invisible borders of an organization, it meets the environment. Interaction with other organizations results in instability, because processes that span organizational borders, result in a broader distribution of power and responsibility. 4. Work processes that go through multiple organizations are more variable and require more deliberate installation and reinforcement of repeatable processes and common values.
Identified ambulatory care as a priority area for improving the nation’s quality.
Patient safety systems have traditionally detected risk and harm retrospectively: adverse event reports or chart review. These reports are then used to make changes by distilling the information of the event and feeding it back into the system. This approach is self-limiting for several reasons: 1. Identifies latent harm only after it becomes active. 2. Depends on rational situation assessment. Participants involved in adverse events typically do not behave rationally. 3. Feedback mechanisms are often lacking. Related, quality improvements often result from empirical study; variable X is modified and the resulting change in variable Y is measured. Associations and relationships are clarified; however, it assumes a sort of professional and intellectual Tabula rasa. The approach is also inefficient and assumes that all health services across all organizations are standardized (e.g., hospital A does things the same way as hospital B). Each variable requires study under controlled conditions and measurement using classical, statistical tools. Donnabedian chipped away at the empirical model, with the ‘structure, process, outcome’ model, but most quality improvements continue to rely on the empirical model.
Ambulatory care can implement PRA-based practices to reduce potential patient harm, but when implementing improvements where the patient receives care across multiple organizations, specific best practices must be put into action:
I. Practice Boundary Maintenance 1. The staff of the organization must be aware of their organization’s boundaries and be able to clearly articulate them to the staff of other organizations. 2. The ambulatory center must be open to inspection and mutual validation of its boundaries. 3. Organizations must establish exchange agreements in which standards for processes and information exchange are clear, carried out reliably and maintained. 4. Promote cross-training.
The tradition of John Locke continues, “As people are walking all the time, in the same spot, a path appears.”
II. Conduct Risk Analyses Using Diverse Teams It is critical that problem solving using PRA tools occurs in a team environment and that these teams include a diverse range of skills, background and expertise: 1. Thorndike noted that groups perform better at problem solving than individuals, particularly when the tasks are complex and require the consideration and integration of many components. 2. Group decisions reached through cooperative and respectful deliberation are consistently superior to decisions made by individuals or groups operating via majority rule.
Moving from Retrospective to Prospective-based Quality Improvement Probabilistic risk analysis (PRA) is emerging as an alternative to reduce risk of harm to patients. PRA is a systematic way to evaluate risks associated with a complex work. The IOM and the National Academies has noted its potential value to health care: The report noted the importance of a systems approach to improving the quality of health care, including the use of risk analysis, failure modes and effects analysis, simulation, and human-factors engineering. Within the risk analysis toolkit are many methods to identify potential hazards. A popular and easily accessible approach is failure mode and effects analysis (FMEA). At its most basic level, FMEA seeks to identify the effect of a component failure. Since these failures have not yet occurred, they are expressed in probabilistic notation of likelihood and significance of impact. The method can be used retrospectively or prospectively. For example: University Hospitals, Geneva, improved the safety of the cancer chemotherapy process and used FMEA to conduct a comparative risk analysis of decentralized to centralized pharmacy production processes, each process of which had varying IT capabilities. Bonnabry and team reduced criticality indexes by almost half, formalizing production protocols, automating calculation-based tasks and implementing production controls in the creation of chemotherapy products (2006). The quality improvements reduced potential risk for patient harm and also demonstrated a favorable cost value (Figure 1).
3. Effective problem-solving groups are characterized by formulating the objective of their work, open expression of differences, examination and comparison of differences and alternatives, and finally, the group members listen to and support one another. 4. Leadership support is critical. Without the ownership engendered by such team efforts facilitated by leadership, the possibility of effective action to eliminate or minimize risks and hazards is greatly reduced.
III. Focus Quality Improvements on Prevention Hazard Elimination: It is the most effective quality improvement; e.g., automation of dosing calculations in a pharmacy eliminates the risk of human calculation errors. Build in Protective Measures: A redundant system of checks can reduce chances of patient miss-identification. Substitution: Exchange existing materials, processes or practices for safer ones; e.g., geographically distinct labs serving a common region adopting the same materials and processes for INR determination.
Eliminate Hazard
Most Desirable
Build in Protective Measures
Isolation: What is known and can be handled.
Figure 1
From: Bonnabry, et al., IJQHC, 2006
Many other successes have also been realized using PRA mostly in inpatient settings and serial clinical processes.
Successful use of PRA tools in the ambulatory setting requires a nuanced, deliberate approach account for the distributed and multi-organizational character of ambulatory patient care.
Administrative Controls: Putt into practice policies and procedures; e.g., hand hygiene and barrier practices to reduce HAIs. Reinforcement is conducted via training and boundary setting. Workers must know proper operating procedures and safety guidelines. Supervisors need to know the equipment and processes they are responsible for. Supervisors need to be knowledgeable and informed of hazardous processes, operations and materials for which they are responsible and also know when and under what circumstances to request assistance for problem solving potential problems or risks.
Substitution
Isolate
Administrative Least Desirable Controls
