Posted On: April 11, 2012 by Patrick A. Malone

Ambulatory Care Facilities Lack Safety Scrutiny

Most people are aware of the increasing scrutiny of hospital performance in terms of patient safety. Better infection control and attention to readmission rates are among the criteria by which hospitals are measured and, in the case of Medicare, sometimes reimbursed.

But ambulatory facilities don’t fall within traditional hospital oversight, and a recent post on KevinMD by David B. Nash, dean of the Jefferson School of Population Health at Thomas Jefferson University, might raise some helpful consciousness about standards of care at these increasingly popular medical providers.

Ambulatory care facilities provide a range of medical services, including surgery, to outpatients who don’t require overnight care. (See our article, “Same Day Surgery.”)

We reported about one study concerning ambulatory surgery centers, but Nash invokes a report in 2000 by the Agency for Healthcare Research and Quality (AHRQ) noting that very little research actually has been done on medical errors and injuries in ambulatory settings. The AHRQ report made 11 recommendations to stimulate care standards research for ambulatory facilities.

Twelve years later, Nash notes, “almost none” of the recommendations has been implemented. This matters, he says, because a disproportionate and growing number of Americans are receiving care in ambulatory settings. “According to the American Medical Association,” he writes, “300 people are seen in ambulatory settings for every person admitted to a hospital.”

How hospitals care for patients is easier to study than how ambulatory centers do because hospital patients remain hospitalized for a longer period of time. Medical errors such as incorrect medication or the wrong dose of medicine are more difficult to track if the patient isn’t there when the symptoms present or the mistake is realized.

Sharpening the focus on ambulatory quality and safety is challenging because, unlike hospitals, such facilities don’t employ risk managers, compliance officers and chief quality officers to ensure that rules are established and followed. But something must be done, Nash says, because the vulnerability of patients in ambulatory centers was made clear by a recent study of outpatient malpractice claims.

Nash doesn’t say where the study was published, only that in 2009, paid malpractice claims tallied 4,910 for outpatient care and 4,448 for inpatient care. The total amount was higher for inpatient claims, but 2 in 3 of the outpatient claims involved major injury or death.

For the most common outpatient claims:


  • 45 in 100 were for diagnostic problems;

  • 30 in 100 were for treatment problems; and

  • 14 in 100 were for surgical problems.


Nash summarizes the researchers’ recommendations to improve ambulatory patient safety.

1. Conduct a large national study on the epidemiology (the incidence, distribution and control of disease in a given population) of ambulatory patient safety using accepted tools to screen for errors and chart reviews to detect harm in large ambulatory care clinics.

2. Identify and pursue an early and easily achievable goal, such as timely follow-up of abnormal test results.

3. Engage patients, their families and community organizations in ambulatory safety improvement efforts.

4. Link the ambulatory safety agenda to high-profile inpatient safety initiatives; for example, in concert with the initiative for reducing hospital readmissions, emphasize and study the role of ambulatory care clinicians in ensuring patient safety before, during and after hospitalizations.

5. Foster the development of a national system of clinics and practices that function as ambulatory safety “laboratories.”

The AHRQ has earmarked $74 million to research ambulatory quality and safety via health information technology, which signals the importance of increased scrutiny. But patients must be proactive as well.

If you intend to seek care from an ambulatory facility, ask to see its infection control procedures. If it doesn’t have one, go elsewhere. Find out if the providers who will treat you are board-certified in their fields. Research the facility’s medical professionals on your state’s medical licensing board’s website to find any complaints that have been lodged (states vary in their ability to track this activity, and in their ability to organize it for public consumption).

If you’re having surgery, find out the status of the surgery center’s license and certification, which enforce standards of care; just because the surgery center looks clean and professional doesn’t mean it meets professional standards. State health agencies keep a list of licenses for same-day surgery centers.

Ask: Who is giving me anesthesia? What are his or her qualifications? Ensure this person is at least a qualified registered nurse anesthetist, even for sedation.

Of course, if your problem is an emergency you might not have time for advance research. But you should always ask questions and persist until you’re satisfied with the answers.

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