Understanding Quality and Safety Problems in the
Ambulatory Environment: Seeking Improvement With
Promising Teamwork Tools and Strategies

John S. Webster, MD, MBA; Heidi B. King, MS, CHE; Lauren M. Toomey, RN, BSBA, MIS;
Mary L. Salisbury, RN, MSN; Stephen M. Powell, BA, ASO; Brigetta Craft, RN, MSN, DNP;
David P. Baker, PhD; Eduardo Salas, PhD





Abstract
Despite 1.2 billion ambulatory visits in 2005, from a health care quality and safety perspective,
the ambulatory setting has been less subject to research and scrutiny, compared to high-risk
inpatient areas like surgery, perioperative and perinatal care, and the emergency department
(ED). The ambulatory environment is prone to problems and errors that include missed/delayed
diagnoses, delay of proper treatment or preventive services, medication errors/adverse drug
events, and ineffective communication and information flow. Once there is clarity about the
nature of outpatient errors, evidence-based teamwork tools, strategies, behaviors, and principles
can be implemented as countermeasures to elements of the error chain. From the resources of the
TeamSTEPPS™ initiative, six effective and evidence-based tools and strategies are offered for
use by clinicians in the ambulatory setting to improve the quality and safety of patient care by
improving teamwork and communication.

Introduction: Realities and Harm in the Ambulatory
Care Setting
Patients and health care providers have become increasingly aware of medical error and system
problems causing poor outcomes in high-risk inpatient environments, including surgery,
perinatal care, intensive care, and the emergency department (ED). In contrast, care provided in
the ambulatory setting has received less scrutiny and is often perceived as safe and routine,
focusing on relatively healthy patients. The volume of care within the United States for
outpatient services is estimated at 1.2 billion visits to physician offices, clinics, and emergency
rooms in 2005,1 a rate of four visits per person annually.
Trends indicate increasing numbers of outpatient visits for primary and specialty care over the
past decade, with similar trends in ambulatory procedures, which numbered 31.5 million in
1996.2 Compared to inpatient hospital care, the outpatient environment often is dispersed
geographically and lacks infrastructure support. For patients, this potentially creates problems
with continuity of care and confusion.

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A better understanding of the quality, safety, and system problems clinicians face while
providing outpatient care will allow focused application of an increasing array of patient safety
solutions, including effective communication and teamwork.3 Recently developed medical error
taxonomies4, 5, 6 for the ambulatory care environment create structured, meaningful categories
and bring greater clarity and understanding to this previously understudied area.
Quality and Safety Problems Experienced by Providers and Patients
in the Ambulatory Care Setting
Missed or delayed diagnoses. One of the leading allegations in liability lawsuits is that the
clinician “failed to diagnose” a significant condition (e.g., cancer), a claim made in nearly
75 percent of radiology cases, 64 percent of pediatric cases, and in about 50 percent of cases
involving family medicine providers and internists.7 Analyses of this problem have focused on
the frequency, impact, causes, and potential for prevention of missed/delayed diagnoses.
Analysis of closed-claim cases identified common factors, including failure to have or adhere to
a cancer screening protocol, failure to include cancer in the differential diagnosis, and inadequate
followup.8
In the ambulatory setting, a review of 307 closed claims9 revealed that 59 percent of diagnostic
errors harmed patients; of those, 59 percent caused serious harm, and 30 percent resulted in
death. In these cases, common process problems included failure to order an appropriate test,
create a proper followup plan, obtain an adequate history, or perform an adequate physical
examination, as well as incorrect interpretation of diagnostic tests. Further analysis revealed
judgment error (79 percent), failure of vigilance or memory (59 percent), knowledge deficit (48
percent), patient-related factors (46 percent), and handoffs (20 percent) as causal factors. The
authors comment that no “silver bullet” can solve such complex problems. Instead, successful
interventions focused on improving quality and safety will most likely target portions of the error
chain.9

A literature review and collaborative project,10 “diagnosing diagnosis error,” formulated
potential solutions to include reengineering processes for followup of abnormal tests, delineating
“red flag” and “do not miss” diagnoses and situations, and standardizing the interpretation of
tests/imaging, particularly after hours and in residency programs. These authors acknowledged
the relationship of diagnostic errors with the cognitive process and complexity of the problem.
Cognitive errors and the decisionmaking process can be seen as failures in perception, failed
heuristics, and decisionmaking biases, as recently popularized by Groopman in his book, How
Doctors Think.11 These failures are further explained in detailed articles,12, 13 with thoughtful
analysis recommending countermeasures to known biases and the useful suggestion to routinely
ask during the diagnostic process, “What else might this be?”
Despite the seemingly esoteric view of cognitive failures, often problems seen in offices and
clinics are as mundane as misfiled papers, unavailable charts and records, poorly distributed
workload, ineffective communication, and reports not acted upon—system defects that can lead
to potentially tragic outcomes for patients. Available solutions should address the human factors
issues, system problems, ineffective communication, and information flow.

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Delay in proper treatment or preventive services. Certainly, if there is substantial delay in
diagnosis, there may be a corresponding delay in initiating proper treatment. However, treatment
delays have many causes, some of which may or may not be preventable. Patients may not seek
care in a timely manner; system issues can delay appointments, testing, or notification of results;
or communication may fail along a potentially convoluted continuum of care (e.g., patient to
primary care provider to diagnostic testing to and from specialists). According to The Joint
Commission (2005),14 root causes of sentinel events specifically related to delay in treatment
focused on the top four problems: communication, patient assessment, procedural compliance,
and continuity of care. Recent statistics reveal that only 2.7 percent of sentinel events reported to
The Joint Commission occurred in the ambulatory setting, not including the ED.14 However,
underreporting is frequent outside of the hospital environment.
Similarly affected is the delivery of preventive services, such as mammograms, PAP smears,
fecal occult blood testing, colonoscopies, and other monitoring/screening functions that are
performed in the ambulatory setting. The failures15 may be related to faulty processes,
information technology support, time pressures, inadequately trained personnel, financial
constraints, organizational culture, teamwork, and communication, as well as ineffective
communication with the patient and family, which may be secondary to language and literacy
issues. Solutions must address ineffective communication, lack of teamwork principles, clinical
leadership failures, the apparent normalization of ineffective processes, patient-clinician roles
and responsibilities, failure to followup, and mutual understanding/decisionmaking.
Problems with medications: Adverse drug events (ADEs). Extensive work has been done in
the area of medication errors, including a recent comprehensive evaluation of the evidence and
recommendations, broadly applicable across all domains of health care, for actions to prevent
these errors.16 The evidence for harm is extensive, with estimates in one study of 27 ADEs per
100 adult ambulatory patients, of which 13 percent were serious, 28 percent ameliorable, and
11 percent preventable.17 For older individuals, the rate of ADEs was 50 per 1,000 person-years,
of which nearly 14 percent were preventable, and 38 percent were considered serious, life-
threatening, or fatal.18 In this group, the medications most involved with preventable ADEs were
cardiovascular drugs, diuretics, nonopioid analgesics, hypoglycemics, and anticoagulants.
Recommended prevention strategies have focused on the prescribing and monitoring stages of
pharmaceutical care.
Misunderstandings between patients and doctors were identified in a study of general practice
medication use in the United Kingdom. This report19 revealed multiple modes of failure on the
part of both the physician and patient in sharing information, beliefs, and decisionmaking. A
national surveillance study20 of ED visits identified ADEs from the outpatient setting, which
represented 2.5 percent of ED visits, 6.7 percent of hospitalizations for unintentional injuries,
and an extrapolated annual national estimate of more than 700,000 individuals treated in EDs for
unintentional problems related to medications.
Additional investigations focused on interventions and strategies in primary care and ambulatory
practices to reduce the incidence and severity of ADEs,21, 22, 23 but the systematic review24
concluded that these interventions had little measurable effect, except for weak evidence that
pharmacist medication reviews were effective in reducing hospital admissions due to ADEs.
Stronger evidence16 identifies fewer ADEs with electronic prescribing, particularly with built-in

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decision support and technology-based checks for allergies, drug-drug interactions, dosing, and
patient-specific information.
Solutions must address inaccurate understanding, the communication process, medication
reconciliation, and interactions among providers and other health care professionals, particularly
nurses and pharmacists. In addition, the human limitations to vigilance and the presence of
complacency, even with high-alert medications, must be considered. The possibility of using
back-up behaviors, mutual support within the care team, and standardized communication
techniques may offer partial solutions.
Communication and information flow processes. The following are problem areas that can
lead to medical error in the ambulatory setting:
• Ineffective communication between patient/family and clinician and among office/clinic staff
members.25
• The communication chain: patient primary care provider specialty or subspecialty
referral.26, 27, 28
• Primary care to hospital and hospital to primary care.29, 30
• Handoff communications along the continuum of care.31, 32, 33, 34
• Missing reports35 from laboratories, imaging and other tests, consultants, procedures, and
correspondence.
These problem areas would benefit from structured handoffs, proactive sharing of the patient
care plan, improved feedback, and standardized processes for information handling. In addition,
clinical leadership has opportunities to set expectations, use the whole team to focus on quality
communication and process improvement, and expand the definition of the care team to include
consultants, ancillary services, and the patient and family.

Approaches to Improve Quality and Safety
in Ambulatory Care
Many organizations have developed and published important concepts, approaches, metrics, and
recommendations for improving care in the outpatient setting, all ideas that deserve close
attention from those trying to improve quality and safety of care. These excellent resources are
summarized in Figure 1:
• AHRQ Conference on developing a strong research agenda for ambulatory patient safety.36
• The Joint Commission: 2008 Ambulatory National Patient Safety Goals.37
• National Quality Forum: National Voluntary Consensus Standards for Ambulatory Care.38
• American College of Physicians (ACP), an online continuing medical education series39 on
patient safety, providing seven modules:40 Systems, Medication Errors, Idealized Office
Design, Electronics, Communication, the Role of the Patient, and Human Cognition.

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Figure 1. Diagram of resources designed to improve health care quality and safety.


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• Focus on measures and reporting:41 AQA Alliance,42 a collaborative of the ACP (and the
American Academy of Family Physicians (AAFP), America’s Health Insurance Plans
(AHIP), and Agency for Healthcare Research and Quality (AHRQ).
• Extensive redesign and “New Model of Practice” from The Future of Family Medicine
Collaboration.43
• Institute for Healthcare Improvement’s “Planned Care Innovation Community,”44
championing a comprehensive redesign of office-clinic practices based on a reliability
concept that “…every patient should have a plan for his or her care.” Changes in four key
elements of care delivery are required: (1) the care team, (2) patient activation to participate
in their own care, (3) effective clinical information system, and (4) leadership.
• Enhancing interdisciplinary team collaboration45 to improve primary/ambulatory care46 and
promote a culture of safety,47 often by implementing patient safety projects and initiatives.48
Relationship of Change Initiatives to Teams and Teamwork
Three important aspects of teams and teamwork in health care must be identified and clarified in
order to recognize potential applications to the ambulatory care setting for quality and safety
improvements:
• Improvement teams: Interdisciplinary teams have long worked together on improvement
projects and problem solving, for example, using the PDSA (plan-do-study-act) model cycle
to improve processes of care delivery. This would involve identifying a problem and bringing
a team together (e.g., physician, nurse, practice manager, physician assistant, and technician)
to solve the problem, such as inaccurate lab report handling. The goals might be to ensure
that a laboratory report is received accurately and delivered to the provider; its information is
properly acted upon; the patient is notified; the report information is recorded/documented;
and appropriate decisions and plans are made. The impact could be studied for 3 to 6 months;
the results could be analyzed, tracked, and evaluated; and a decision could be made about
further lab report handling changes or about moving on to another problem for the team to
evaluate and solve.
• Care provision team:49 A multidisciplinary team within a clinic or practice that
collaborates, for example, on the chronic care of a patient (or group of patients) with diabetes
and comorbid conditions. This group effort—focused on diagnostic, therapeutic, preventive,
and social dynamics—can be seen as effective teamwork, when the members are
interdependent, proactively share information, collaborate in the decisionmaking process, and
successfully relate to each other respectfully, with each having an expertise to bring to the
table. This team might include the patient, family, physician, office nurse practitioner,
nutritionist, social worker, home care nurse, foot care specialist, and specialty consultant(s).
In fulfilling a dual mission, these team members could certainly combine their wisdom, clinic
data, and process improvement knowledge to function as a diabetes care improvement team
for all clinic patients with diabetes, in addition to providing daily care.50
• Science of teamwork: Based on solid behavioral research on effective teamwork, the
primary focus of this article pertains to the application of evidence-based tools, strategies,
behaviors, and principles of care provided in the ambulatory environment. Seemingly
neglected in most of the studies on the effectiveness51 of interdisciplinary teams on the
quality of delivered care are two very basic questions: (1) whether the care providers (in the

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studies) were actually using effective teamwork skills and (2) whether they were practicing
in a climate that fostered effective teamwork. Recent adaptation of the Safety Attitudes
Questionnaire52 (SAQ-A) to the ambulatory arena has improved the ability of researchers to
explore the safety culture and climate in offices and clinics. This third aspect of teamwork is
starting to be valued as teamwork experts “team up” with medical experts and identify
opportunities to augment medical knowledge with principles based on the science of human
factors,53 system and reliability theory, and team performance.54, 55, 56 The benefit in turning
a team of experts into an expert team on behalf of patient care quality and safety is
significant.

Six Promising Tools and Strategies to Improve Quality
and Safety in Ambulatory Care
Based on collective experience over the past 3 years of using TeamSTEPPS™ materials within
the Department of Defense (DoD) and a broad range of institutions around the world, the
following strategies, tools, behaviors, and principles, selected from dozens within the initiative,
are offered as potentially the most useful for making an im
heir
pact in the ambulatory setting. T
selection was based on these factors and considerations: usability, implementation effort,
understandability, acceptance, rationale, usefulness, potential positive impact on quality and
safety, ability to improve communication and team performance, im
aff satisfaction,
pact on st
role in meeting regulatory goals, leadership support, and patient satisfaction.
Team Events: Briefs, Huddles, and Debriefs
Briefs. To create a shared mental model that enables all team members to “be on the same
e,”
pag
a leader conducts a briefing: bringing team members together, sharing important information,
seeking input from others, and creating a plan for
c
an event, procedure, shift, or day. The classi
example for a briefing would be a “preflight” brief in aviation. Important information shared
with all team members includes environmental cond

itions, status of the crew and plane, a clearly
stated plan for primary mission and destination, a
a
nd contingency plans. This translates well to
(pre-procedure) brief prior to a surgical case, outpatient procedure, clinical shift, or review of
patients to be seen in the offi
lin
ce/c
ic that day. Discussion may include expectations, the plan,
and any contingencies or risks.
It is important to note that a brief is not a meeting, and it must efficiently focus on the quality
and safety of patients, roles and responsibilities of team members, input from
nd
the leader, a
pertinent contributions from team members. Typically, when a brief does not occur, staff
members presume what is going to happen; new or inexperienced team members miss an
opportunity for learning and planning; and the case, shift, or day unfolds as it ma —more
y
reactive than proactive, more on “autopilot” than with adaptive decisionmaking.
Initial responses among staff about conducting briefs could include negative comments,
cynicism, and resistance related to time constraints, scheduling issues, and questionable added
value. Possible strategies for managing this resistance include an educational event focused on
patient safety, medical error, and harm in the
l of the leadership
ambulatory setting; portraya
vision; stories or data from the practice; and agreement on a trial period.

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Compelling reasons for conducting briefs should focus on the premise that “as is” needs to
change, and time spent performing the brief will be seen as an investment. The resultant payoffs
are efficiencies based on clarity of the plan and team roles, fewer reworks, better
communication, less confusion, and improved staff satisfaction, resulting in retention of
personnel.
Several publications clarify successes from briefing interventions,57, 58, 59, 60, 61 and one clearly
identifies the opportunity for “next steps” in spreading the briefing project to the ambulatory care
setting. Specifically within the DoD, ambulatory clinical leaders almost always choose the
briefing tool as the starting point for their teamwork and communication interventions. When
roles and responsibilities are clarified, problems are identified/prevented/mitigated, all of the
professionals are clear about patient plans, contingencies are considered, accuracy is emphasized,
information is gathered from all sources, the climate is conducive to questioning and clarifying,
the outcome is enhanced quality and safety for patients in the ambulatory setting.
Huddles. Huddles differ from leadership-driven briefs, in that any member of the team may call
a huddle to address new or changing circumstances and to problemsolve about adapting the
earlier plan. There may be urgency with an emergent patient, workload issues, unpredicted
staffing challenges, environmental problems related to weather or traffic, or unexpected delays in
clinic/office operations. In any case, a new plan is needed, and it generally takes a very short
amount of time once “the right people” (generally multidisciplinary) gather for a “huddle.”
The focus might be on developing quick evaluation plans for some patients. This is not rocket
science, and most ambulatory staff members already do meet to solve problems. Giving it a
name, clarifying the purpose, making it a standard process in the work day, distinguishing it from
a “meeting” or “brief,” and mimicking the speed and efficiency of a sports huddle allow people
to trust that it will be ultrafocused and ultrabrief, yet effective in solving the problem(s).
Much that is written about huddles does not distinguish the rapid huddle, just described, from a
pre-procedure briefing, a short safety meeting,62 a process-improvement PDSA event,63 or a
brief prior to a shift, case, or day. Some authors have used the term huddle for the time-out prior
to a procedure, as per the Universal Protocol.64 This interdisciplinary event, immediately prior to
the procedure, verifies the correct patient, correct site/side, the intended procedure and possibly
the correct implant. It is useful to distinguish among a brief, huddle, and time-out, each of which
adds significant value to the care quality and safety for patients in many venues, including
ambulatory settings.
The team huddle is powerful and effective, but the keys are: short, patient-focused, efficient,
problemsolving, information sharing, and action oriented. The huddle is a tool for getting the
team to work together effectively; it is easy to implement and a great team-builder. Huddles can
change a practice, improving teamwork and communication on behalf of patient care quality and
safety. These team events become partial solutions to the ambulatory error chain by proactively
sharing information, clarifying patient care issues, providing back-up behaviors with nurses,
technicians, and providers, and helping each other with error avoidance.
Debriefs. The debriefing process is central to improving team performance, yet it is seldom used
in health care, in marked contrast to other high-reliability teams and high performance teams, for

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which debriefing is expected and used routinely. Although supervisors typically give individual
performance feedback to employees as a managerial function, the idea of high quality feedback,
in real time, focused on team performance, is foreign to most health care team operations, with
the exception of code team or resuscitation team debriefs.
When communication and feedback are open, fair, respectful, and focused on team performance
improvement, the enhanced learning environment creates remarkable opportunities for the team
to improve. A report describing benefits of the debriefing process65 in the operating room and
intensive care unit settings, indicated a rapid spread to hospitalwide implementation following a
grand rounds and information campaign. In aviation, the crew debriefs after every flight so as to
incorporate lessons learned in real time. In health care, there is great opportunity to increase use
of debriefs with very little burden, with the benefits being improvement in team performance.
In the ambulatory environment, making these team events—briefs, huddles, and debriefs—the
usual way of working together could result in improved care, decreased error, learning from
mistakes and near misses, and possible disruption of the error chain for the problems of missed
diagnoses, medication errors, and ineffective communication that are so prominently presented
in the literature and medical-legal arena.
Communication: Closed loop and structured techniques. Communication skills are the
lifeblood of teamwork, yet communication failures66, 67 are the root cause of nearly 70 percent of
sentinel events reported to The Joint Commission.68 When information is critical, it should be
verified so that both the sender and receiver clearly have the same understanding of the situation.
For the pilot cleared by the air traffic controller to ascend to 35,000 feet, the “check-back”
includes an exact identifier for that specific plane/flight and a restatement of what was heard,
“cleared to three-five thousand feet.”
For medication orders—given verbally in an emergency or written for routine orders, even in the
ambulatory setting69—an exact repeat of the patient, medication, dose, and route of
administration and a further acknowledgment of accuracy by the original sender complete the
verification process. After the order, the nurse says, “Let me repeat that. Mrs. Getta Medication,
ID number (stated) to receive 40 (four-zero) milligrams of drug X-Y-Z subcutaneously now.”
“Yes, that’s correct.” This process is easy to do but requires some discipline. Institutionalizing
the process in one’s practice avoids some of the problems with wrong medication, wrong dose,
wrong person, and wrong route problems that may result in ADEs.
For telephone orders, actually writing down the exact order then reading back what is written and
verbally acknowledging accuracy completes the “read-back” and ensures accuracy of the
information exchange. Read-backs have also been effective in giving and receiving critical lab
values70 and other reports, with minimal time investment. Simple advice: agree as a team what
key operational orders will be checked/read back, practice doing this, and take pride in checking
back and verifying that what was heard was exactly what was said. Another part of success with
this process is for the receiver to speak up if there is any concern with the order creating a quality
or safety problem.
In many organizations, staff members use a tool known as the “two-challenge rule,” in which the
receiver states two times, if necessary, the safety concern, and the sender is obligated to

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acknowledge the concern. Typically, a misstated dose or erroneous drug order results from a
momentary lapse or slip, and the sender is appreciative of the assistance and avoidance of error.
This is particularly true when the team has agreed to the process, practiced it, and all members
see the direct benefit to patient care quality and safety by taking the “ego problem” and hierarchy
out of the interaction. Using these methods of closed-loop communication methods, check-backs,
and read-backs offer the benefits of redundancy and engagement to decrease medication errors.
Structured communication and handoffs: SBAR. A key lesson from high-reliability
organizations is to standardize processes to decrease error and improve performance. SBAR
(Situation, Background, Assessment, and Recommendation) is a structured communication
technique that allows information to be packaged in an expected and accepted format, which is
concise, pertinent, and well-framed for the receiver of the information. SBAR is a superb tool71
for updating clinical circumstances or relating patient information. In the ambulatory setting,
among DoD personnel, SBAR has been used effectively in emergency transport settings,
provider-to-provider, nurse-to-provider, technician-to-provider, and telephonically in nearly
every clinical scenario.
The following is an example of a telephonic communication using SBAR:

S
SITUATION: This is (medic) John Smith in the field. I’m calling about a patient we are

dressing and splinting for transport shortly to your clinic with an apparent isolated open

B
fracture of the left ankle. BACKGROUND: Mr. XXX is 22 years old, otherwise healthy,

who was playing basketball, twisted his ankle and fell. ASSESSMENT: Open fracture of
A

the ankle. The alignment is satisfactory, and the pulses and sensation are normal, and the
R
pain level is tolerable, now that the splint is on. RECOMMENDATION: We will keep
the patient from eating, have the leg at neutral elevation, run the IV at 100cc/hour, and
transport in the next 5 minutes to your location. Tetanus status is up to date, but on
arrival, suggest IV antibiotics, immediate x-ray, repeat neuro-circ checks, and immediate
orthopedic consultation for wound and fracture care. We’ll monitor for any other injuries.
This is a tool that allows concise, focused transfer of information. SBAR may need to be
expanded with disease-specific, age-specific, or circumstance-specific agreed upon data sets for
handoffs and referrals for more complicated patients. Clinicians in both inpatient and outpatient
settings are designing handoff and referral forms based on SBAR or the mnemonic I PASS THE
BATON.72 For the perioperative arena, including ambulatory surgery, the Association of peri-
Operative Registered Nurses (AORN) has provided online examples of handoff tools prepared
by its members.73
Clinical Team Leadership and Membership
The major goals of health care teamwork are to reduce clinical error, enhance patient outcomes,
improve process outcomes, raise the level of patient and staff satisfaction, and reduce

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