Quality Improvement In Ambulatory Care

Published Date: 02 Nov 2017

Ambulatory care comprises health care services that do not require overnight

hospitalization. Ambulatory care is the predominant mode of health care delivery in the United

States. Physician services are the chief component, however it comprises other outpatient

services like Emergency departments, community health centers, departments of health,

voluntary agencies, and ambulatory surgical centers. In developing countries, both the private

and public sectors provide a substantial proportion of primary health care to low and middle

income groups for communicable and noncommunicable diseases. These providers are

therefore central to improving health outcomes. Perhaps the first sign of quality in the delivery of

healthcare services was during the beginning of the 1980s in the US, when prospective hospital

reimbursement replaced retrospective payment on a national scale through Medicare�s initiation

of the diagnosisrelated

group (DRG) payment system. The new payment system provided

financial incentives to hospitals to decrease the duration of inpatient stays and to increase

service delivery efficiency. Hospitals responded to the new payment system shifting procedures

and services amenable to outpatient delivery from the more expensive inpatient environment to

less expensive and more efficient ambulatory delivery systems.

In general, quality is divided into two perspectives, actual and perceived quality. Actual

quality is the level of quality that is provided by healthcare professionals in ambulatory care units.

Perceived quality is an imaginary romantic perspective held by the customers of healthcare

services when come in contact with these services. If the level of actual quality is equal or higher

than the level of perceived quality, then the ambulatory care units have done a great job, whereas

if the actual quality of services provided were less than the perceived quality hoped for, then

quality should be more stressed on. From a managerial point of view, installing a system of

quality in ambulatory care units requires four main building blocks that should work hand in hand.

The first of which is a system of instructions or an accrediting authorities �to do list� which the

organization needs to consider in order to do services and procedures in the right manner. Two

examples of these accrediting criteria are the Baldrige criteria in the United States, and the

ISO9000

certification internationally. The fourth building block is a tool for measuring the

performance of healthcare professionals in alignment with the business strategy of the

organization. It is accomplished through what is known as a balanced scorecard, and it covers

financial as well as non financial indicators of performance like customer satisfaction, internal

process development, as well as innovation and growth. Between the two building blocks, there

are two other layers of equally important quality tools; mainly lean thinking and six sigma

methodology to create the right culture of performance excellence and process improvement in

the workplace.

All the above building blocks should be there, and should be aligned in order to achieve the

required six aims of quality improvement that were first brought into surface by the famous report

of the Institute of Medicine (IOM), and that is a health care service that is safe, effective, efficient,

timely, patientcentered

and equitable. From the consumer point of view, we will try to highlight

some of the steps that could be done in the ambulatory care setting. To begin with, any

healthcare service faces three main problems; access, quality and cost. Patients always want to

say that the primary health care facility is giving them the help that they want and need exactly

when they want and need. Major ambulatory care facilities now seek to gain the benefits of

increased market share, patient satisfaction, as well as becoming the preferred provider for

referring physicians and insurers that seek to refer patients to practices where access to care is

not obstructed..

In order for more patients to receive better health care services, ambulatory health care

services should install measures to decline in no shows and cancellations for appointments.

They should also ensure effective use of their staff time, by skipping some nonvalue

adding

activities like triaging which consumes personnel time and attention. Effective scheduling of

patients� appointments so that there are minimal or no waiting lists and no backlogs is

necessary. Successful implementation of these process improvements can lead to less

dissatisfied patients who are unable to gain access to ambulatory health care in clinics and

outpatient departments, leading to less onthejob

stress. After the patient is already a part of the

system, the ideal should be that patient�s interactions with the healthcare delivery system be

individualized, where every patient is the only patient.

Putting all of that into place however is not easy. Ambulatory care facilities managers

should pay more attention to forming multidisciplinary teams within every specialized facility to

educate staff as well as future leaders on the importance of continuous improvement in the

workplace. Education should include a wide array of areas like what to do to patients, how to

best do it, roles of paramedical

or administrative workers in the care of patients, as well as what

variations are in the medical service and how to deal with it in a scientific way. Once these

teams are educated and had a solid understanding of the practice and patterns, the focus on

improvement could begin in earnest. The improvement process should allow for rapid change

that occurs by taking small cumulative steps. These teams should choose an area for

improvement in their own department, and start improving by brainstorming solutions, testing the

change, implementing the change if the solution proves successful. For example, to improve

how frontend

employees in a multiclinic

practice managed consultation requests, the team

identified that front end employees had to grapple with a variety of different ways of interacting

with physicians to manage a consult, based on individual physician preferences. Such variations

were time consuming and created a high potential for errors. The root cause was that every

physician�s front endemployee

was doing something different than the other. It was really tough

to keep things consistent and avoid errors if patient access employees have six to seven

variations to everything he did.

Another important issues that are critical to the implementation of quality in ambulatory

health services is the cooperation of physicians and their active participation in the group action

and decision making for short and long term improvements. Other not less critical issues include

comprehensive and balanced (include both financial and nonfinancial indicators) measurement

systems that can be applied to improvement areas for future assessment and followup

of

success. Nonfinancial

indicators include patient satisfaction, employee learning, and growth of

the ambulatory practice, as well as process improvement. For example, patient satisfaction can

be a good indicator of the ability of a public or private clinic to create the least waiting times, or

the least cycle times, or the least checkin

to checkout

times versus the length of time that is

booked in the appointment system, a concept that goes well with what we pointed out earlier

about the actual quality and perceived quality.

Advanced access is the main issue with ambulatory healthcare services these days. For

example, in cardiology practices, one component improved during the transition to advanced

access leads to significant improvements in cycle time for appointment flows. Before the

transition to advanced access, cardiology patients would come in for the first clinic visit,

schedule a second visit for noninvasive

testing, and then schedule a third visit to learn the

results. The cycle timeone

week to two months. Now, patients for these services can get

sameday

scheduling for the clinic visit, move into testing, and get the results in person or via

phoneall

on the same day. The cycle timesame

day, with an average wait time of 24 minutes

and a wait time range of zero to 150 minutes. Backlogs will decrease as a measure of process

improvement, and same day appointments will increase as a measure of patient satisfaction.

A final advice for all healthcare leaders in ambulatory care facilities all over the world is to

seek provider organizations that have put advanced access to the test, contact their CEOs to

ask how those quality measures were implemented. Leaders should base their choices on

sound data not by intuition in order to understand their businesses, and should attend local and

international conferences on quality control measures in healthcare. Once leaders have begun

serious steps on the way to quality control, they should see it as a marathon not as a one track

race. They should educate their staff and form motivated teams that look at improvement

opportunities as a lifetime goal.