A Prognosis for Primary Care

With outpatient treatment on the rise, could better teamwork guard against error — and the accompanying malpractice suits?

May 29, 2019

| by Áine Doris


Medical equipment is pictured on the wall of an examination room. Credit: Reuters/Mike Blake

How can we improve the quality of outpatient care? New research suggests better teamwork could mean better outcomes. | Reuters/Mike Blake

Around 900 million people are treated by medical staff outside of hospitals in the U.S. every year. Outpatient — or primary — care is one of the fastest-growing spending segments in the country, outpacing hospital spending. And it’s where the bulk of the very important work in screening for illness and disease happens.

But how much do we actually know about the quality of the care provided? What are the risks to patient safety beyond hospital walls?

Anecdotal evidence points to a range of challenges: poor information gathering and sharing; missed or delayed diagnoses; inconsistencies in organizational structure and regulatory requirements.

And the problems are manifest. In 2018, the vast majority of malpractice claims originated from the outpatient setting. In the same year, no fewer than 100,000 deaths were attributed to medical errors in primary care.

One of the biggest challenges in tackling these problems is a general lack of understanding around the mechanisms that underpin this kind of care, with the bulk of research in the area limited to hospital settings.

But a study by Stanford’s Sara Singer sheds new light on this.

She and her colleagues have unearthed an important link between the team dynamics among medical personnel and patient safety in primary care.


The more practitioners felt they were working in a high-functioning team, the more they felt they had psychological safety, and the better equipped they felt to do their jobs efficiently and keep their patients safe.
Sara Singer

“We’ve found that robust care coordination makes providers feel their practice is prioritizing safety and delivering more reliable care,” she says. “This includes things like improving the processes of care delivery and patterns of behavior such as closing communication loops, confirming that critical tests are completed, or following up abnormal test results.”

Testing Communication

Outpatient care happens sequentially, Singer says. A patient visits a testing center, which runs analyses, and other parts of the chain manage results and make referrals. These handoffs create what is known as “open loops” — points in the communication chain where care can break down. That patient might not receive sufficient follow-up after abnormal tests, for example, or might not connect to a referral.

Together with Karen J. Blumenthal and Alyna T. Chien of Harvard Medical School, Singer wanted to test the idea that improving team dynamics would bolster overall care. They wanted to know if tactics like regular meetings, team huddles prior to patient visits, and enhanced support for teamwork would drive improvements in coordination — better communication, more thorough test follow-up, and so on.

The researchers conducted a large-scale, cross-sectional survey of 1,716 personnel — attending clinicians, resident physicians, nurses, and other patient-facing staff. These participants worked in 19 practice sites that had established team-based outpatient care between 2010 and 2014 and were part of the Harvard Academic Innovations Collaborative, an initiative formed to improve patient safety, particularly in breast and colorectal cancer screening.

The researchers surveyed practitioners for their perceptions across three core constructs: team dynamics, care coordination, and safety culture. Using a 5-point Likert Scale to indicate strength of agreement or lack thereof, respondents were asked to rate all three to capture how well they thought they were doing in each.

The results were clear. For every 1-point increase in overall team dynamics, the researchers found a 0.76-point increase in respondents’ perceptions of safety culture.

“In other words, the more practitioners felt they were working in a high-functioning team, with clarity around roles and responsibilities, clear lines of communication, and with high levels of trust and respect between team members, the more they felt they had psychological safety,” says Singer, “and the better equipped they felt to do their jobs efficiently and keep their patients safe.”

Wider Implications

These findings are highly relevant given the growth of outpatient care and an increasing nationwide shift to team-based models, Singer says. And they imply clear recommendations for decision-makers.

“The transition to team-based frameworks in primary care in the U.S. is promising,” she says. “Our research shows that in order to capitalize on this promise, decision-makers should be focused on making these teams work better. There are different measures that can be taken to drive this, from registration systems that assign patients to different team members, to addressing hierarchical issues by talking though roles and responsibilities and giving greater responsibility to different people.”

What is key, she stresses, is supporting teams with systems that close open loops and ensure follow-up.

“Collaboration and training are essential, but primary care teams also need the time and the resources to improve team dynamics and coordination,” Singer says. “In order for teams need to function well, systems and processes that empower them need to function optimally.”

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