Providing the right care in the right setting has long been advocated to improve health care quality, patient experience and cost. Often that setting is the ambulatory environment with a strong foundation of primary care and collaboration with specialty care. The volume and dollars are now starting to catch up with the advocacy.

The American Hospital Association’s 2019 Hospital Statistics report noted an increase of 12% in outpatient revenue, at $472 billion compared to $498 billion in inpatient revenue. That increase in revenue has led to increases in oversight from regulatory agencies and payers. Health care leaders, now more than ever, need to accelerate improving the quality, experience and cost in the ambulatory environment. Our work over the last four years with academic medical centers engaged in the Transforming Clinical Practice Initiative (TCPi)* funded by a CMS cooperative agreement, has provided several important lessons about how improvement varies in the ambulatory setting. 

Yes, you have heard it over and over again, leadership engagement is the starting point from where all change and improvement pivots. It’s no different in the ambulatory space. What is unique, however, is that there are many leaders managing different areas of care at multiple sites, with a variety of reporting structures. Therefore, identify an executive champion who can drive that change as it impacts each of those areas of care; who is passionate about your improvement ideas and has accountability to achieve results driven by the strategic plan.

Following are six purposeful interventions to accelerate improvements in the ambulatory space.

Dedicated time available for improvement is in short supply so you must focus efforts. Getting the frontline staff and clinicians involved requires significant planning to minimize disruption to patient care. Gather a group of key stakeholders to determine and agree upon the project scope and get leadership agreement before launching. Utilize available data to understand current performance and make sure you can obtain meaningful data at the clinician and clinic level to add focus. This will often take support from your IT team to beef up data collection and reporting methods. Start with small, short, attainable goals and limit to one to two initiatives at a time depending on the bandwidth of the group. Too much at once and teams grow weary and ineffective, losing momentum for future work.

As you navigate a project you will find plenty more opportunities for improvement and will be tempted to add them along the way. Don’t do it. Ambulatory care is busier than ever with diminishing access to care, primary care clinician shortages, tight budgets and the shift from fee for service to value-based care. There is no time or energy available to boil the ocean.

To truly understand how to provide better care in the ambulatory space, involve the patient and family. You would be remiss if you did not define the value of services in the eyes of the customer. Patient and family advisors bring a whole new perspective to your team on how to solve a problem. We have had the pleasure of being witness to brave organizations who fully embraced pulling patients and families into their improvement efforts. It is amazing how willing patients and families are to dedicate their time to become a part of a team making improvements. In many organizations, Patient and Family Advisory Councils dedicated to ambulatory care are an excellent resource for accelerating improvement.

The larger the organization, the bigger the challenge to eliminate siloes. This is magnified in ambulatory and how naturally decentralized it is. Despite efforts to move toward an integrated system of care, there remains an inclination to function independently. Duplicative efforts create confusion and waste. Breaking down the siloes allows for synergies to occur. First step, pull together key stakeholders to launch improvement work. Second, establish communication methods to share projects and progress obtained. Develop a way to communicate improvement such as a repository to log projects. Connected projects will create a synergy that would not have been otherwise discovered. A repository is a fabulous tool to scale and spread as well. Some may argue that letting go of current state is the most difficult part of change; we would suggest that communication is just as difficult … if not more so.

Recognize the difference between primary and specialty care. Each specialty has different priorities and emphasis; one-size doesn’t fit all. Improvement in ambulatory is limited without crossing over the care continuum. Cooperation for improvement between primary and specialty care occurs by coordinating care for the patient through referral management, compact agreements and creating access. When you do not consider the differences and synergies between the two, you risk disenfranchising one or the other and can lose momentum and support for your project(s).

Our experience with TCPi revealed a lack of established improvement methodologies in the ambulatory space. Acute care has a long history of dedicating resources and using improvement methods to achieve change. Improvement methodologies such as Plan-Do-Study-Act, Rapid Cycle Improvement, Lean and Six Sigma accelerate improvement. The key is to choose one that aligns with your system and ambulatory bandwidth. Train teams and start using it! 

Data in the ambulatory setting is most meaningful when aggregated at the clinic and clinician level. Transparently sharing data via visual management boards keeps the current condition and performance readily visible to all staff and clinicians in an understandable format. Expectations are communicated by setting targets and goals. Driving visual management down to daily metrics for each clinician is helpful to understand yesterday’s performance and what focus is needed today to meet targets. Conversations at the visual management board daily in the form of a patient centric huddle serves to surface and solve problems in real time. Your teams will need to be creative as to how to engage staff and clinicians in these regular conversations about the improvement work while juggling a busy clinic schedule. Lastly, stand up huddles with executives every two to four weeks keeps leadership abreast of the progress and engages support needed.  

While many aspects of accelerating improvement are conceptually the same regardless of the location of care, we have found that execution of these concepts needs to be uniquely different and creative in meeting the needs of ambulatory care clinicians and staff. We have outlined the differences in six key areas: focus improvement, involve patients and families, breakdown siloes, recognize differences, establish improvement methods, and provide transparent data. How well are you leading your ambulatory care improvement efforts in these six key areas? What changes do you need to make to accelerate improvement in your ambulatory environment? 

*The TCPi project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Center for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The Vizient Practice Transformation Network is 100% funded with Federal U.S. Department of Health and Human Services (HHS) funds, provided by the Center for Medicare and Medicaid Service.

Tina Whited, Quality Improvement Advisor, Transforming Clinical Practice Initiative. Tina Whited has been in the health care industry for more than 30 years, with experience in various areas including ICU, medical surgical care, maternal child and pediatrics, clinics, occupational health, outpatient surgery, nursing education, home health care and infusion, wound centers and quality. She is an experienced quality professional; most recently as a TCPi Quality Improvement advisor. She is Lean Six Sigma Green Belt-trained and has worked with both primary and specialty care practices on quality and process improvement as they transition their practices from a fee-for-service to value-based purchasing model. A subject matter expert in the regulatory policies that impact practices as they move toward value-based care (MACRA, MIPS and APMs, and PCMH), Whited is passionate about quality, transforming practices and improving the patient experience.

Maureen Sullivan, Senior Consulting Director. With more than 35 years of experience in the health care industry, Maureen Sullivan’s areas of expertise include facilitation and training of quality and strategy deployment, process improvement, and management systems including coaching of leaders at all levels of the organization. She has consulted with a variety of organizations including small rural hospitals, large academic medical systems, primary and specialty clinics, quality networks and health care facility architects. Prior to her years in consulting, Sullivan filled a variety of leadership roles directing quality and Lean process improvement in a community hospital and as part of a larger health system. In addition, she also held advancing leadership roles in nursing management and medical surgical nursing within a not-for-profit teaching facility.

Published: December 10, 2019