Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys

Ambulatory practices deliver most health care services and contribute to malpractice risk. Yet, policymakers and practitioners often lack information about safety and malpractice risk needed to guide improvement.

To assess staff and administrator perceptions of safety and malpractice risk in ambulatory settings.

We administered surveys in small-sized to medium-sized primary care practices in Massachusetts as part of a randomized controlled trial to reduce ambulatory malpractice risk.

Twenty-five office practice managers/administrators and 482 staff, including [physicians, physician assistants, and nurse practitioners (MD/PA/NPs)], nurses, other clinicians, managers, and administrators.

Surveys included structured questions about 3 high-risk clinical domains: referral, test result, and medication management, plus communication with patients and among staff. The 30-item administrator survey evaluated the presence of organizational safety structures and processes; the 63-item staff survey queried safety and communication concerns.

Twenty-two administrators (88%) and 292 staff (61%) responded. Administrators frequently reported important safety systems and processes were absent. Suboptimal or incomplete implementation of referral and test result management systems related to staff perceptions of their quality (P<0.05). Staff perceptions of suboptimal processes correlated with their concern about practice vulnerability to malpractice suits (P<0.05). Staff was least positive about referral management system safety, talking openly about safety problems, willingness to report mistakes, and feeling rushed. MD/PA/NPs viewed high-risk system reliability more negatively (P<0.0001) and teamwork more positively (P<0.03) than others.

Results show opportunities for improvement in closing informational loops and establishing more reliable systems and environments where staff feels respected and safe speaking up. Initiatives to transform primary care should emphasize improving communication among facilities and practitioners.