Improving Quality in Outpatient Services

Visit the link below to download the full version of this book:
https://cheaptodownload.com/product/improving-quality-in-outpatient-services-ful
l-pdf-docx-download/
Improving Quality in
Outpatient Services

Carole Guinane, RN, MBA

Noreen Davis, RN, MPH

Foreword by Kevin M. Fickenscher, MD

CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2012 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20110727

International Standard Book Number-13: 978-1-4398-9526-9 (eBook - PDF)

This book contains information obtained from authentic and highly regarded sources. Reason-
able efforts have been made to publish reliable data and information, but the author and publisher
cannot assume responsibility for the validity of all materials or the consequences of their use. The
authors and publishers have attempted to trace the copyright holders of all material reproduced in
this publication and apologize to copyright holders if permission to publish in this form has not
been obtained. If any copyright material has not been acknowledged please write and let us know so
we may rectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying, microfilming, and recording, or in any information
storage or retrieval system, without written permission from the publishers.

For permission to photocopy or use material electronically from this work, please access www.
copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc.
(CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organiza-
tion that provides licenses and registration for a variety of users. For organizations that have been
granted a photocopy license by the CCC, a separate system of payment has been arranged.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and
are used only for identification and explanation without intent to infringe.
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents

Foreword.................................................................................................... xi
Preface......................................................................................................xiii
About the Authors................................................................................... xvii
Acknowledgments.................................................................................... xix

1 Defining Outpatient Healthcare........................................................ 1

Outpatient Quality.................................................................................. 1
National Health Statistics Reports........................................................... 2
Outpatient Quality Initiatives................................................................. 5
CMS Outpatient Initiatives (HOP QDRP)............................................. 7
Clinical Performance Measures for Ambulatory Care.............................. 8
ASC Quality Collaboration..................................................................... 9
American Medical Association (AMA).................................................. 10
Safe Injection Practices Coalition.......................................................... 10
Safe Practices for Better Healthcare....................................................... 11
Summary and Key Points...................................................................... 12
Sources.................................................................................................. 12
2 Creating a Structure for Quality and Safety.................................... 15
Simplicity Is Best................................................................................... 15
Tie Your Quality Strategy to Your Mission, Vision, and Values............. 16
Appoint a Governing Body.................................................................... 16
Leader Selection..................................................................................... 18
The Medical Staff, Nurses, and Allied Health Professionals................... 24
Meetings, Minutes, and Keeping a Calendar......................................... 26
Quality Program Topics......................................................................... 30
Summary and Key Points...................................................................... 31
Sources.................................................................................................. 32

v
vi ◾ Contents

3 Engineering the Customer Connection............................................ 33

Quality Function Deployment............................................................... 35
Kaizen................................................................................................... 37
Plan, Do, Check, and Act (PDCA) and Six Sigma................................. 38
Three Types of Waste............................................................................. 38
CSP Number 1: Keep Wait Times to a Minimum.................................42
CSP Number 2: Make a Good Impression............................................ 43
CSP Number 3: Be Open and Honest...................................................44
CSP Number 4: Don’t Blame the Customer.......................................... 45
CSP Number 5: Ask Questions.............................................................46
CSP Number 6: It’s Not a Meat Market................................................46
CSP Number 7: Follow Through........................................................... 47
CSP Number 8: No Medical Mumbo Jumbo........................................ 47
CSP Number 9: Work as a Team........................................................... 48
CSP Number 10: Relate to the Person................................................... 48
Summary and Key Points...................................................................... 48
Sources.................................................................................................. 49
4 Policies, Procedures, and Plans........................................................ 51
Staying True to Your Mission, Vision, and Values.................................. 51
Creating Lean and Useful Documents................................................... 52
Regulatory Requirements for Documents.............................................. 52
The Users of Policies, Procedures, and Plans.......................................... 53
Use Reference Manuals and Association Books..................................... 53
Document Format................................................................................. 55
Documents to Create and Have on Hand.............................................. 56
Reviewing and Revising Your Documents............................................. 56
Summary and Key Points...................................................................... 59
5 The Human Resource Factor............................................................ 61
Overview............................................................................................... 61
Quality and the HR Factor.................................................................... 62
Creating Complete HR Files..................................................................64
Health Care Quality Improvement Act (HCQIA) of 1986.................... 69
Vendor and Contract Files..................................................................... 69
Clinical Contract Employee Requirement and Files.............................. 70
Monitoring, Collecting, and Analyzing Data........................................ 72
HR Training to Promote Safety and Quality......................................... 74
Audits and Auditors............................................................................... 79
Summary and Key Points...................................................................... 79
Sources..................................................................................................80
 Contents ◾ vii

6 Measuring Quality and Safety......................................................... 81

Measurement......................................................................................... 81
Induction, Deduction, and the Scientific Method.................................. 82
Case Study............................................................................................. 83
Scorecards for Outpatient Services......................................................... 87
Rewarding Based on Performance......................................................... 92
Summary and Key Points...................................................................... 93
Sources.................................................................................................. 93
7 Medication Safety............................................................................. 95
Safety Overview..................................................................................... 95
Formulary, Consulting Pharmacist, and Tools....................................... 96
High-Alert Medications......................................................................... 98
Look-Alike Sound-Alike Medications (LASAs)................................... 100
Contrast Media.................................................................................... 100
Anticoagulants..................................................................................... 101
Insulin................................................................................................. 101
Chemotherapy..................................................................................... 102
Injection Safety and Multiuse Medication Vials.................................. 102
Labeling Medications and Containers................................................. 103
Medication Reconciliation................................................................... 103
Sample Medications............................................................................. 104
Storing and Securing Medications....................................................... 105
Medication Safety Reporting............................................................... 106
Adverse Drug Reaction Reporting....................................................... 106
Summary and Key Points.................................................................... 109
Sources................................................................................................ 109
8 Infection Prevention in the Ambulatory Setting.............................111
Infection Prevention and Control.........................................................111
Infection Control and Prevention Structure......................................... 112
Disaster Planning and Outbreak Investigation.................................... 113
Infection Control and Prevention Committee..................................... 114
Infection Control and Prevention Plan................................................ 114
Surveillance..........................................................................................115
Bloodborne Pathogens..........................................................................117
Sharps: Engineering Safety Mechanisms.............................................. 118
Multiuse Vials and Single-Use Vials.................................................... 118
Environmental Cleaning and Disinfection...........................................119
Sterilization, Disinfection, and Cleaning............................................. 120
Recommended Sterilization Resources................................................. 121
viii ◾ Contents

Measurement....................................................................................... 121
Mandatory Staff Training in Infection Prevention............................... 124
Hand Hygiene............................................................................ 124
Isolation Considerations............................................................. 124
Multidrug-Resistant Organisms (MDRO)................................. 125
Infection Prevention Resources............................................................ 125
Summary and Key Points.................................................................... 126
Sources................................................................................................ 126
9 Clinical Documentation................................................................. 129
History................................................................................................ 129
Meaningful Use................................................................................... 130
Electronic Health Records (EHRs)...................................................... 132
Meaningful Use Quality Implications................................................. 133
The Purpose of Clinical Documentation.............................................. 134
Authentication and Completion of Medical Records........................... 135
Problem Lists....................................................................................... 138
Allergy and Sensitivity Documentation............................................... 139
Ambulatory Surgery Center Documentation....................................... 140
Communication.................................................................................. 143
Security and Retention of Medical Records......................................... 144
Regulatory Requirements..................................................................... 145
Summary and Key Points.................................................................... 145
Sources................................................................................................ 145
10 Risk Management and Safety......................................................... 147
Introduction........................................................................................ 147
Challenges and Opportunity in the Ambulatory Setting..................... 148
Common Causes of Errors in the Ambulatory Setting......................... 148
Patient Care Errors..................................................................... 148
Communication Errors............................................................... 149
Medication Errors....................................................................... 150
Ambulatory Surgical Errors.........................................................151
Care Transition Errors................................................................ 153
Building Your Safety Program............................................................. 154
Patient Safety Culture.......................................................................... 154
National Patient Safety Goals...............................................................155
Goal: Patient Identification..........................................................155
Goal: Communication.................................................................155
Goal: Improve Safety in the Use of High-Alert Medications
and Medication Safety................................................................ 156
 Contents ◾ ix

Goal: Reduce the Risk of Healthcare-Associated Infection......... 156

Goal: Medication Reconciliation................................................ 156
Universal Protocol............................................................................... 157
Surgical and Anesthesia Safety............................................................. 157
Airway Maintenance............................................................................ 158
Malignant Hyperthermia..................................................................... 158
Postanesthesia Monitoring................................................................... 158
Environmental Safety.......................................................................... 158
MRI Safety.......................................................................................... 159
Radiation Safety.................................................................................. 160
Surgical Fires....................................................................................... 160
Work Flow Analysis and Redesign....................................................... 160
Safety Program Training...................................................................... 160
What to Do If You Experience a Safety Event..................................... 161
Use of RCA and FMEA Tools............................................................. 161
Summary and Key Points.................................................................... 164
Sources................................................................................................ 164
11 Licensing, Deemed Status, Accreditation, and Certification......... 165
Defining Licensing, Deemed Status, Accreditation, and Certification......165
Why Become Accredited?.................................................................... 167
Certification of Programs..................................................................... 169
Ambulatory Accreditation and Certification Programs........................ 170
Survey Preparation............................................................................... 170
Accreditation Listing........................................................................... 170
Summary and Key Points.................................................................... 173
12 Practice Makes Perfect................................................................... 177
Why Practice?...................................................................................... 177
PDPC and FMEA............................................................................... 177
5 Whys: Why, Why, Why, Why, Why................................................ 180
Medication Error........................................................................ 180
Cancer Diagnosis Delay.............................................................. 180
Using Checklists to Improve Safety and Quality................................. 181
Codes and Drills.................................................................................. 183
Emergency Carts or Boxes for Outpatient Settings..................... 186
Scenario Training................................................................................ 186
Scenario Example for Endoscopy......................................................... 189
Operative Report............................................................... 191
Summary and Key Points.................................................................... 192
Sources................................................................................................ 192
x ◾ Contents

Appendix A: Checklist on Policies, Procedures, and Plans

for an Outpatient Setting................................................... 195
Appendix B: Quality Glossary................................................................ 207
Appendix C: Quality Reporting Measures.............................................. 215
Appendix D: Infection Prevention Plan Example................................... 231
Appendix E: Risk Assessment.................................................................. 237
Appendix F: Medical Record Review Criteria Audit............................... 241
Appendix G: Safety Management Program............................................ 247
Appendix H: Root Cause Analysis and Corrective Action Plan.............. 253
Appendix I: State Contacts for Ambulatory Licensing and Standards.......257
Appendix J: Patient Education Pathway Example................................... 271
Foreword

Improving Quality in the Outpatient Setting

As a student of the healthcare management literature and a physician execu-
tive involved in leading healthcare organizations, I’m always searching for prag-
matic materials that provide a roadmap for the path forward in our complex and
changing healthcare environment. I’m also interested in “thought leadership”
pieces that help all of us to frame our approach on the three critical issues of
our time: increasing quality, enhancing service, and reducing the cost of health-
care. These are the prime objectives that face our industry now and into the
foreseeable future. Unfortunately, too much of the literature provides a concep-
tual framework without the practical elements. Improving Quality in Outpatient
Services hits the mark as both a roadmap and practical guide.
First and foremost, Carole Guinane and Noreen Davis bring a wealth of prac-
tical experience to the table which is amply displayed in each chapter. Their nurs-
ing backgrounds coupled with their strong business and public health experiences
in ambulatory care provide a foundation for understanding critical segments of
the industry where change is sweeping through the care delivery model.
As we all know, the advent of comprehensive, coordinated care (C3) models
are becoming the norm, primarily because of the efficiency and effectiveness
of the approach in providing healthcare services. The major component of all
such models is an effective ambulatory care model, which has been woefully
underestimated and underinvested under traditional approaches. We should all
anticipate that ambulatory care will become the primary focus for care delivery
extending from chronic congestive heart failure patients to the usual acute care
problem. Guinane and Davis bring us a wealth of pragmatic advice on how to
traverse the complexities of ambulatory care in the new environment of health-
care reform.
Whether you are pursuing an accountable care organization (ACO), primary
care medical home (PCMH), bundled payments, or other similar model, the

xi
xii ◾ Foreword

clear challenge in the future will be on how to best organize and deliver quality
ambulatory care services. It is the diligent attention to standards, guidelines, and
protocols in the outpatient setting that will provide the roadmap forward, and
Improving Quality in Outpatient Services provides the foundation for moving
from rhetoric into reality.
From the opening chapter, where the authors describe the fact that “the qual-
ity canvas is changing,” to the Appendices, where detailed information is pro-
vided on where and how to apply for certification, the authors have provided a
credible overview of the elements of ambulatory care management.
Improving Quality in Outpatient Services provides not only a broad visionary
direction for where we need to go in outpatient care management, but also pro-
vides the details that must be considered as part of our efforts to lead the future
of healthcare delivery. Ambulatory and outpatient care are the fastest growing
segments of the healthcare industry, and it’s not just about healthcare reform.
As leaders in healthcare, we increasingly recognize that the provision of care on
a more efficient and effective basis is the norm to which we must aspire. Simply
admitting people to institutions does not meet that standard. As a result, we
must consider alternative delivery models—most of which are ambulatory in
nature.
Guinane and Davis provide the path for moving forward. The ambulatory
environment has been captive to a cottage industry model which is no longer
sustainable. We need standards. We need models. We need to embrace care
delivery requirements. Improving Quality in Outpatient Services establishes the
critical foundation for how we—as leaders in healthcare—can carry forward an
approach to care delivery that meets and exceeds the requirements of consumers
across the nation.
There are ample checklists and “to do” items included in this pragmatic book
on outpatient care and management. We need to accept their challenge that
ambulatory care is the future and requires our involvement. We have a significant
distance to go in our quest for increasing the quality of care, let alone enhanc-
ing service and decreasing cost. Starting with ambulatory care would be a good
place to begin. Guinane and Davis provide the roadmap. We need to implement
their ideas and embrace the changes they suggest.

Kevin Fickenscher, MD
Washington, DC
December 2010
Preface

Apprehension, uncertainty, waiting, expectation, fear of surprise, do

a patient more harm than any exertion.
—Florence Nightingale

Overview
Two bigger-than-life myths exist—that outpatient care is easy and safe and that
anyone can do it.
In all fairness, if an outpatient program does not invest in quality and safety
programs, or attempt to understand licensing and regulatory requirements, and
loosely oversees the service, then it would appear to be easy, safe, and that any-
one could do it.
With this book, we strive to shed some light on the opportunities that
abound in outpatient services and to debunk these two myths. Outpatient care
is rich with quality offerings, accrediting agencies, and leadership credentialing
to promote excellence. However, what is needed is investment in stronger over-
sight, mandatory licensing, leadership expectations, and standards across states
and outpatient service lines.
Maybe someday outpatient quality and safety programs will be prolific and
patients will enjoy transparency of information from all care channels and the
myths will have taken the path of dragons and fairy tales. Finally, it’s our belief
that if consumers had a choice, they would not select the care pathway from
those that run mythical outpatient programs.

xiii
xiv ◾ Preface

Bad Apples and Apple Pie

An analogy that comes to mind when thinking about healthcare quality has
to do with apple pie and bad apples. It’s easy to take the bad apple approach,
reacting only to errors, egregious acts, and horrific outcomes. This fosters a crisis
management quality method. On the flip side, if the good apples are discovered
and used, the apple pie created would be desired by all, hopefully decreasing the
need to invest so much time with bad apples.
Choose the good apple approach to grow and prosper, but know that bad
apples do exist, requiring specific interventions to ameliorate these situations.
Bad Apple Quality can be described as:

1. Punitive and secretive

2. Poor communication
3. Fostering a culture of fear
4. Ostrich quality—burying one’s head in the sand to avoid tough issues
5. Doing only what’s needed to get by
6. Not having a passion for the work and outcomes
7. Living in a bubble
8. Groupthink behavior
9. Mavericks, heroes, and silos
10. Ceasing to learn or to think that others may do something better

Apple Pie Quality can be described as:

1. Prevention is practiced
2. Patients come first
3. Process oriented
4. Innovative and passionate, but realistic
5. Knows the value of system thinking
6. Deconstructs silos
7. Creates a synergistic culture of quality and safety
8. Huddles daily with staff
9. Believes in measurement and understands variation
10. Benchmarks against the best of the best

Chapter Summaries
This book consists of twelve chapters. Chapter 1 delivers an overview of out-
patient healthcare, a high-level view of opportunities, existing national quality
 Preface ◾ xv

programs, and the challenges we face. Chapter 2 outlines the governance, medi-
cal staff, and quality structures required to create, implement, and maintain
strong outpatient quality programs. Chapter 3 explores the world of human con-
nections, and concentrates on the importance of taking care of our customers.
Chapter 4 provides an outline of needed policies, procedures, and plans, and
stresses the importance of the written word to deliver quality healthcare services.
Chapter 5 discusses the human resources (HR) factor, and what’s essential to
properly address the needs of the people who serve our patients in outpatient
care settings. Chapter 6 describes measurement examples, and delves into scien-
tific methods and analytic tools.
Chapter 7 introduces medication management strategies, and Chapter 8
delivers infection prevention quality and safety applications for outpatient ser-
vices. Both are highly complex, but if not implemented appropriately would
contribute to potentially deadly outcomes for our patients. Chapter 9 covers
clinical documentation and the steps needed to create a comprehensive approach
to telling the patient’s story.
Chapter 10 continues with safety themes by concentrating on risk preven-
tion and error elimination, thus stirring our thinking about what we can do
to enhance our safety programs for all who touch outpatient care. Chapter 11
enters the world of licensing, accreditation, deemed status, and certification for
ambulatory programs. Chapter 12 encourages practice, drills, and planning for
worst case scenarios.
Appendices augment the chapter information, delivering tools for medi-
cal record review, policy and procedure checklists, measurement, and state
resources. A glossary covers key terms for outpatient quality and safety.

Purposeful Omissions
Excellent references and teaching tools already exist to help healthcare profes-
sionals with their journey. Therefore, the wheel was not created once again. It
isn’t our aim to retool quality theory or patient safety foundations. Rather, we
chose to stimulate the reader with practical applications, stories, and outpatient
quality and safety examples.
Caregivers want to drive the way we take care of our patients. We want to wrap
our processes around their needs. To drive the care delivery processes requires
knowledge of available evidence-based literature and studies. We did not spend a
great deal of time on evidence-based medicine. We do think there is value in this
knowledge, but didn’t feel this book was the proper venue for this information.
Even though we won’t cover evidence-based information, we do want to
emphasize the importance of reducing variation in care processes. Variation in
xvi ◾ Preface

healthcare contributes to a great deal of cost associated with care. We encour-

age outpatient leaders to hold weekly meetings to address variation. Map out
the process and study the findings. Make it safe to ask questions and to work
collegially. We do not cover the theory of transactional leadership as it pertains
to physician relationships and variation. We don’t believe that physicians are
motivated by reward and punishment and a clear chain of command. Physicians
do not cede authority for their care delivery decisions to a manager. Instead, we
look at partnering with physicians, leaders, and caregivers as the way to reduce
unnecessary variation.
We also acknowledge that a what’s in it for me (WIIFM) mentality can
and does exist. WIIFM, fondly known as the radio station of caregivers, is
common when anything new is presented in the healthcare arena. We have
to attempt to tune in to the needs of the population of caregivers and clearly
articulate what’s in it for them. There are scores of books dedicated to change
management and how to get people to buy in. Once again, that’s not the pur-
pose of this book.
We have concentrated on what we believe to be the most pertinent sources
for references at the end of chapters, with some imbedded in the chapters or the
appendices. It’s our hope that this book, along with the references, will ignite a
passion for quality and safety application for those who directly and indirectly
influence the care of our patients. It’s also our hope that our selected omissions
do not deter from the path we all need to take to make a difference and to
achieve world-class status in all avenues of ambulatory care delivery.
About the Authors

Carole Guinane RN, MBA. Carole’s quality journey began in 1989 as a

senior leader and Vice President at Parkview Episcopal Medical Center in
Pueblo, Colorado. Parkview’s success story was published in 1992 by The Joint
Commission, with the foreword of the book written by Donald M. Berwick,
MD. The book, Striving for Improvement: Six Hospitals in Search of Quality,
shared the process, methods, and rewards that our leadership team, employ-
ees, and physicians experienced. It was magical. Applying quality principles to
clinical processes was new to healthcare at the time, but groundbreaking results
occurred. Carole took the lessons learned from those early days and continued to
grow her knowledge base for operational and clinical improvement application.
Carole has worked as Chief Clinical and Compliance Officer for an ambu-
latory surgery center company, Vice President of Medical Staff Services and
Quality for a healthcare system, Vice President for Applied Business Science
and Education for a specialty hospital and healthcare system, Consultant and
Clinical Improvement Director for a Center for Continuous Improvement
and Innovation, and Vice President for Ambulatory Clinical Improvement
and ASC Clinical Operations for an integrated healthcare system. She has
had the pleasure of building and growing quality and clinical operations
programs for large healthcare systems, small and rural hospitals, ambulatory
surgery centers, insurance companies, and ambulatory entities. Carole is a
trained Six Sigma Black Belt. She has published books and journal articles
on clinical pathways, quality tools, Six Sigma, clinical operations, and con-
sumer-driven healthcare.
Noreen Davis RN, BSN, MPH. Noreen earned her BSN from St. Louis
University and her master’s in ­public health from the University of North
Carolina in Chapel Hill. Her healthcare journey began in cardiovascular care
and heart and lung transplantation. As a trained Six Sigma Black Belt, she is an
experienced healthcare quality and operations executive. She has worked as a
quality consultant for ambulatory programs, and has experience in assisting with

xvii
xviii ◾ About the Authors

National Committee for Quality Assurance (NCQA) accreditation. Noreen

has several years experience supporting outcomes measurement and analysis for
both hospitals and outpatient facilities.
Her management experience includes positions with direct responsibility for
transplant, clinical research, patient safety, performance improvement, accredita-
tion for hospital and ambulatory care settings, infection prevention and control,
and clinical case management. Her current responsibilities include management
and development of evidence-based shared baselines across all service lines for a
large healthcare system in conjunction with the development of comprehensive
electronic medical records (EMRs) and computerized order entry for ambula-
tory and acute settings. Noreen has published articles on healthcare quality and
Six Sigma.
Acknowledgments

We are greatly indebted to Kristine Mednansky, senior editor at CRC Press, a

Taylor & Francis Group. No one helped us more, as this book was brought to
life because of her belief in our vision for outpatient quality.
Our gratitude is extended to Marsha Pronin, our project coordinator at
Taylor & Francis. As an eagle eye proofreader and editor, she made our job so
much easier.
Our sincere thanks are due to Kidist Kassahun, MHA. Chapter 11 and
Appendix I required painstaking research, and she exceeded our expectations.
Her exhaustive work and prudent skills contributed significantly to the book,
and we are grateful.
We can’t possibly list all of the people who have touched our lives in the
healthcare and quality world. There have been so many teachers along the way.
We are eternally grateful to the quality champions and leaders that really do get
it. To these heroes and patient safety warriors, thank you.

From Carole
When Kris and I first talked about the possibility of this book, I spent several
months living with the idea of outpatient quality and what it means. What
motivated me most of all were my grandchildren, as I want their healthcare jour-
ney to be awesome and free from life-changing errors and devastating events.
They are often touched by outpatient services and healthcare practitioners. They
deserve the absolute best and I will champion this cause for as long as I live.
More recently, Coumadin errors nearly killed a loved one. To make matters
worse, the physician blamed the patient for the errors, which was not the case.
Poor follow-up for this new medication, a lack of lab testing to monitor levels,
and blaming the patient while he was in the cardiac care unit (CCU) all spell fail-
ure. Why did this have to happen? Mythical outpatient care—promoting errors,
insensitive care practices, and lack of an embedded outpatient quality program.

xix
xx ◾ Acknowledgments

I must thank my husband, Tom. Many weekends were spent on the

c­ omputer, locked away in my home office, and he kept me sane by providing
support, nourishment, and encouragement. My daughter Carissa and I bounced
around ideas, and she never seemed to lose her enthusiasm for the spirit of this
book. Just talking to her helped to clarify my thinking. Thanks to my son,
Jordon, for believing in me. As always, my family offered unending sources of
inspiration. Thanks to Noreen, my writing partner and friend. I couldn’t have
done it without her.
This book is dedicated to my grandchildren, Darcy Elizabeth, Carolyn Rose,
William Alexander, and Rowan Grace, with love.

From Noreen
My healthcare journey began as a teen at the hospital where my mom coached
and mentored many nursing students. I was not sure I could possibly be as
skilled as she was in caring for her intensive care patients. After twenty-five years
in healthcare, I have learned that knowledge and skill are not just taught, but
are acquired over time from lessons learned along the way. Hopefully this book
shares some of those pearls of wisdom.
I want to thank Carole, my true friend, who knows all of my strengths and
weaknesses. She inspired me to take this journey and I am truly grateful for the
chance to write this book. It is rare to find someone who shares the same passion
for life and work.
I also want to thank my husband for his never-ending patience and sup-
port in the past year. Many challenges in family and work life have taken time
away from us and yet he never questioned my desire to write and spend time
on this project.
This book is dedicated to my three children Connor Michael, Brenna
Catherine, and Cara Elizabeth Davis.
Chapter 1

Defining Outpatient
Healthcare

I believe strongly and passionately that every American has a right

to good health care that is effective, accessible, and affordable, that
serves you from infancy through old age, that allows you to go to
practitioners and facilities of your choosing, and that offers a broad
range of therapeutic options.
—Andrew Weil, MD

Outpatient Quality
Outpatient healthcare is growing rapidly and there continues to be movement
of care from inpatient to outpatient locations. It can be said that the majority of
care delivered to patients in the United States is provided in the outpatient set-
ting. According to the National Quality Forum, more than one billion outpa-
tient encounters occur ever year.
The outpatient market produces wide variation in quality practices.
Inconsistent oversight by regulatory, licensing, accreditation, and benchmarking
agencies contributes to variation, as do many other variables. Outpatient quality
programs rely on the honor system for the most part.
Economic prosperity for outpatient programs depends on reducing varia-
tion, improving efficiencies, and implementing predictive care models within

1
2 ◾ Improving Quality in Outpatient Services

a challenging reimbursement system. Healthcare reform initiatives beg that

we think about efficiency and effective care models for outpatient services.
Accountable care organizations (ACOs), if successful, will push inpatient and
outpatient entities together in a collaborative model to share in Medicare reim-
bursement. It comes down to savings for Medicare. The jury is out as to whether
this will be successful, and what outcomes of care will materialize. Regardless,
the quality canvas is changing.
Building and delivering a culture of quality and safety is absolutely necessary
if true prosperity is to occur and if we are to make outpatient programs afford-
able and accessible.
For the purpose of this book, the following definition will be used when
speaking about outpatient healthcare:

Outpatient services consist of treatment performed without requiring an

inpatient stay.
Outpatient care is also called ambulatory care.

The patient may be treated in a variety of settings, including, but not limited to:

◾◾ Ambulatory surgery centers (ASCs)

◾◾ Minute clinics
◾◾ Urgent care facilities
◾◾ Physician practices
◾◾ Imaging centers
◾◾ Oncology centers
◾◾ Dialysis centers
◾◾ Homecare
◾◾ Freestanding emergency centers
◾◾ Endoscopy centers
◾◾ Chiropractors
◾◾ Aesthetician and health spas
◾◾ Emergency departments

National Health Statistics Reports

The Centers for Disease Control and Prevention (CDC), National Center for
Health Statistics (NCHS), Division of Health Care Statistics conducts sur-
veys of healthcare providers and facilities such as hospitals, ambulatory surgery
centers, and physicians. Encounters are tracked, along with the characteristics
of those who seek encounters. This “family” of surveys is called the National
Health Care Survey (NHCS).
 Defining Outpatient Healthcare ◾ 3

Table 1.1 provides a snapshot of data gleaned from the Ambulatory Medical
Care Utilization Estimates for 2006 survey. Clearly, ambulatory visits overall are
increasing, demonstrating a steady climb in numbers since 1996. Medication
therapy goes hand in hand with ambulatory visits, presenting a need to manage
patient medications across the continuum. Information on medication safety
can be found in Chapter 7. Spend some time reviewing your medication prac-
tices in your facility, as errors abound in the sector. Volume alone dictates a need
for attention to medication practices.
An astounding 300 percent increase in freestanding ASC visits from 1996 to
2006 was explained in the Ambulatory Surgery in the United States, 2006 report.
Table 1.2 displays key findings from this report. The migration from hospital
ambulatory surgery programs to freestanding centers demonstrates a health-
care transformation that is underway. This trend will continue to escalate, and

Table 1.1 2006 Ambulatory Medical Care Utilization

Ambulatory Medical Care
Utilization Results

Rate of visits 1.1 billion visits to physician offices, EDs,

and hospital outpatient departments—
resulting in 381.9 visits per 100 persons
annually in 2006.

Visit rates to medical 29% increase from 1996 to 2006.

specialty offices

Hospital outpatient Went from 25.4 per 100 persons in 1996 to

department visits 34.7 visits per 100 persons in 2006.

Emergency department Increased from 34.1 per 100 persons in 1996

visits to 40.4 visits per 100 persons in 2006.

Ambulatory care visits 18.3% of all visits in 2006 were for

conditions such as routine checkups and
pregnancy exams.

Medications Seven out of ten ambulatory care visits

had at least one medication provided,
prescribed, or continued in 2006.
Amounted to 2.6 billion drugs overall.

Analgesics Accounted for 13.6 drugs per 100 drugs

prescribed, most often in primary care and
ED visits in 2006.