CASE STUDY: Lawrence Ward and Rhea E. Powell 

 The healthcare landscape in the United States is dynamic—continuously evolving as the transition from volume to value takes hold under pressure from increasing healthcare costs and a need to deliver better care. This foundational change in the way care is financed has greatly influenced the way care delivery is measured. Although the most acutely ill patients are managed in an acute (inpatient hospital) setting, the vast majority of patients are managed in ambulatory (outpatient) offices. 

The ambulatory setting is where most people, both those in good health and those with acute or chronic illnesses, have frequent contact with the healthcare system; likewise, it is where healthcare providers have the best opportunity to influence healthy behaviors and to prevent future illness. Providers, insurers, and regulatory agencies expect—and are increasingly demanding—to know more about the quality of care delivered in the ambulatory setting, raising the urgency of the need to develop appropriate methods and metrics. This chapter specifically examines the ambulatory based quality and safety landscape, details important trends in this area, and provides an overview of the directions expected in the future.

 The Ambulatory Care Setting Ambulatory care refers to medical services performed on an outpatient basis, without admission to a hospital or other facility. Although the definition is evolving as a result of advances in technology, traditional sites of ambulatory care include primary care and specialty offices, as well as ambulatory surgery centers, urgent care centers, retail clinics, freestanding emergency departments, and work-based clinics (Medicare Payment Advisory Commission 2017). For the purposes of this chapter, we will focus on ambulatory-based providers in both primary care and subspecialist offices. For many years, inpatient settings—such as acute care hospitals, surgical facilities, emergency departments, and other facilities with more acutely ill patients—have been subject to regulation, standards, and inspection by groups such as The Joint Commission, and metrics for performance in such settings have been clearly developed and defined.. .

The Healthcare Quality Book payments and penalties to providers’ performance on the metrics, and these financial incentives have provided motivation for a number of highly developed performance improvement infrastructures, often employing tools from Lean, Six Sigma, and other formal strategies. Historically, ambulatory settings have not been subject to the same level of scrutiny and regulation that inpatient settings have seen, and they have not had the same incentives for improvement. However, given the large volume of patients seen in ambulatory settings and the significant potential for harm that exists, ambulatory settings need to develop a similar infrastructure to spur improvement. Ambulatory settings present unique challenges related to the complexity of practice settings and issues with communication and flow of information. Furthermore, they often have difficulty obtaining critical quality data for such areas as medication errors, adverse drug events, missed/incorrect/delayed diagnoses, and delay of proper treatment or preventive services.

 Additional challenges involve the ambulatory setting’s focus on population-based management—a key difference between ambulatory and inpatient care. Hospitalized patients are tracked for the duration of their admission—and perhaps for some time afterward to reduce the likelihood of readmission—but they are not actively managed for long beyond a single episode of care. Therefore, inpatient quality and safety metrics are often one-time measures—for instance, a measure of whether patients develop a catheter-associated urinary tract infection over the course of a hospital stay. In the ambulatory setting, however, most measures focus on a population of patients seen over a certain period of time. For instance, an ambulatory practice might be responsible for ensuring appropriate colon cancer screening for every patient seen within the previous two years. 

An individual patient might have been seen only once, 15 months earlier, but if the data suggest that a gap in screening care has occurred, the practice is responsible for arranging for the proper screening to occur (or for correcting the data, if the screening has in fact occurred). Thus, an ambulatory practice needs to be able to identify gaps in care when patients arrive in the office, educate patients about the need for care, and arrange for appropriate follow-up. In cases where a patient chooses not to receive the recommended care, the practice needs to implement an efficient mechanism for identification, monitoring, and outreach.