title: Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  To assess staff and administrator perceptions of safety and malpractice risk in ambulatory settings.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: *Harvard School of Public Health †Harvard Medical School ‡Mongan Institute for Health Policy, Massachusetts General Hospital §Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA ∥Bureau of Health Care Safety and Quality, Massachusetts Department of Public Health, Boston, MA ¶North Shore Medical Center, Salem, MA #Center for Surgery and Public Health, Brigham and Women's Hospital, Boston **Institute for Healthcare Improvement, Cambridge, MA ††Massachusetts Coalition for the Prevention of Medical Errors, Burlington, MA.
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Singer
authors.forename: Harry
authors.initials: H
authors.lastname: Reyes Nieva
authors.forename: Namara
authors.initials: N
authors.lastname: Brede
authors.forename: Judy
authors.initials: J
authors.lastname: Ling
authors.forename: Nicholas
authors.initials: N
authors.lastname: Leydon
authors.forename: Joel S
authors.initials: JS
authors.lastname: Weissman
authors.forename: Don
authors.initials: D
authors.lastname: Goldmann
authors.forename: Paula
authors.initials: P
authors.lastname: Griswold
authors.forename: Catherine
authors.initials: C
authors.lastname: Yoon
authors.forename: E John
authors.initials: EJ
authors.lastname: Orav
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
authors.forename: Madeleine
authors.initials: M
authors.lastname: Biondolillo
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Schiff
mesh_terms: D000288:Administrative Personnel / Q000706:statistics & numerical data; D000328:Adult; D000553:Ambulatory Care / Q000592:standards / Q000706:statistics & numerical data*; D001291:Attitude of Health Personnel; D003142:Communication; D005260:Female; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008318:Malpractice / Q000706:statistics & numerical data*; D008404:Massachusetts; D008875:Middle Aged; D061214:Patient Safety / Q000592:standards / Q000706:statistics & numerical data*; D010564:Personnel, Hospital / Q000706:statistics & numerical data; D011159:Population Surveillance; D017751:Safety Management / Q000706:statistics & numerical data*