Editor’s note: Richard Ricciardi is the associate dean for clinical practice and community engagement and the executive director of the Center for Health Policy and Media Engagement at the George Washington University. He has served as the director of the Division of Practice Improvement and senior advisor for nursing at AHRQ, and he maintains a part-time clinical practice at Mercy Health Clinic. We spoke to him on patient safety in office-based settings.

Sarah Mossburg: Welcome, Dr. Ricciardi. Please tell us a little bit about yourself and your current role.

Ric Ricciardi: I am currently serving as the associate dean for clinical practice and community engagement at The George Washington University School of Nursing. In that role, I seek ways for the university to build collaborations with health systems and external partners to address the healthcare delivery gaps and to build entrepreneurial opportunities to improve educational, research, clinical, and policy practices. I also serve as the executive director for the Center for Health Policy and Media Engagement, where we are committed to increasing the visibility of nurses and their invaluable expertise and unique perspectives in media, policy, and research. I am passionate about amplifying the voice of nursing. Research has shown that the nurse’s voice is missing in the media. One study found nurses were identified as the source in only 2% of quotes in health news stories and were never sourced in stories on health policy.¹ This lack of media engagement hasn’t changed in over 15 to 20 years from the original Woodhull study conducted in 1997. I work with professional organizations, with health systems, and with individuals to develop and operationalize strategies that improve nurses’ voices in the media.

Prior to being an associate dean at GWU, I was at the Agency for Healthcare Research and Quality (AHRQ) for 8 years. I served as the director for the Division of Practice Improvement, where most of our work was exploring methods to improve quality, safety, human factors, workflows, and efficiencies in the implementation of evidence-based practices across ambulatory settings. I had the opportunity to work with many great colleagues at AHRQ, and within Health and Human Services to improve quality and safety nationally in ambulatory settings. We developed a model where quality and safety and practice improvement fall under the larger umbrella of health services research. Addressing the gaps in quality and safety in primary care requires interprofessional quality improvement teams and a team science approach to conduct research.

Sarah Mossburg: You’re currently working as a nurse practitioner as well, right?

Ric Ricciardi: I work on Wednesdays at Mercy Health Clinic, which is a clinic that serves only uninsured individuals. Almost all are migrants from different countries who are here to try to make a better life for themselves, or they’re escaping some very horrific conditions in the country they migrated from. All the patients I see in clinic are uninsured and from underrepresented populations. As you can imagine, safety net clinics that provide care for uninsured populations have a whole gamut of issues that influence quality and safety. These issues are different from the health systems that care for the insured, where they have comparatively larger infrastructure and resource streams.

Sarah Mossburg: Could we step back from there just to touch on context? For a long time, patient safety has been focused on inpatient settings or acute care. And now, office-based settings in general, like medical offices, ambulatory care, clinics like the one that you’re talking about, are getting more focus in the safety literature. Could you talk about why that matters, and what’s the difference between office-based care settings versus acute care that necessitates its own focus and approach to patient safety?

Ric Ricciardi: I agree with you that traditionally, up to maybe 10 years ago, the main focus and investments on quality and safety were on developing strategies and methods to mitigate risks in acute care settings. Errors or unsafe practices in acute care settings were more readily visible and were an immediate concern to health systems, healthcare professionals, and the public.

Thanks to the good work of AHRQ, particularly the Center for Quality Improvement and Patient Safety, we see a shift to expand the focus to include ambulatory areas and to invest in ways to improve quality and safety in ambulatory settings, because the kinds of unsafe conditions that happen in the ambulatory settings were happening much more frequently than in acute care. Over time, these lapses in quality and safety cause significant morbidity, and perhaps even mortality. It was important for AHRQ, and HHS, for that matter, to lead efforts to provide resources to strengthen quality and safety practices in ambulatory care.

Unfortunately, we don’t have a high-functioning integrated healthcare system in the United States. What we do have is a series of primary care and ambulatory practices that are disconnected and underresourced by the current reimbursement structure. Continuity of care and care coordination is a big challenge, and technology has not lived up to its potential. Starting out at the time when the electronic health record thrust was to improve quality and safety, to improve interoperability, that didn’t really happen to the extent that we expected from the meaningful use incentive program. Moving toward an integrated health system like those of Kaiser Permanente, the Mayo Clinic, or the Veterans’ Affairs, with interoperability of information platforms and systems, will greatly benefit primary care. Quality and safety challenges arise due to gaps in continuity of care, transitions in care, and communication between specialty care and primary care.

Another element that makes primary care so challenging is that many individuals within the United States do not have a primary care provider. They don’t have a "go-to” health professional to build a relationship with and who can incorporate the patient’s values and preferences into a whole-person care plan. Follow-up and follow-through on the patient’s health and health issues are key to building trust and relationships that support sustained behavior change and healthy lifestyle behaviors. And that lack leads to risks and quality and safety gaps.

Ultimately, the big reason I think there are lots of challenges in quality and safety in the ambulatory setting is because we don’t have an integrated primary care system, and many people don’t have access to a primary care provider. The way I look at it, and I learned this from a patient, care is really broken into three brackets. Care to me or care delivered in the acute care setting, in which healthcare professionals are primarily responsible for delivering care to someone who is not fully capable, perhaps physically or mentally, to take on the role of caring for themselves.

And then in the ambulatory settings, my patient said, it’s care with me. In these settings, healthcare professionals and primary care teams are partnering with the patient to deliver care, engaging the patient, and incorporating the patient’s values and preferences, to put together a care plan that is tailored for that individual patient. And, as you know, when you see one patient, you only see one patient, because even though we’re more than 99% genetically equal as humans, our determinants of care and our health and lifestyle habits are different. Both of those have a significant impact on health. So how you integrate those determinants of care and the patient’s health habits in a plan is very much individualized for a patient, taking a whole-person approach.

And then the third bucket, it’s care by me. An individual is responsible for their own healthcare, and that’s where you get into the concept of healthy lifestyle habits. Do you smoke or use tobacco products? How much alcohol do you drink? Do you eat healthy? Do you exercise? Do you get sufficient sleep and take time for yourself to relax? Do you take on some responsibility for your own health and well-being, and for your mental health? And are you socializing? Do you have healthy relationships?

These quality and safety risks have very different conceptual areas and approaches in each of those three buckets: care to me, care with me, and care by me. For instance, the patient in the care by me bucket is responsible for leading the effort to mitigate their own quality and safety risks because that involves changes to the activities of everyday living and their unique lifestyle.

Sarah Mossburg: Could you speak to what types of safety issues are likely to arise in the office-based setting through that lens?

Ric Ricciardi: The biggest issues involve communication risks between the patient and the primary healthcare team and communication between teams of teams. Communication is the cornerstone of relationship-based care, and good communication will establish and sustain trust. Do you trust your healthcare provider team? Can you tell them what’s really going on in your life, with your health, and also day-to-day factors that influence health and well-being? All of these determinants of health impact health and well-being greatly. And then, it is critically important to have good communication between teams and within teams. I’ll give you an example, a real-world example. When we built the TeamSTEPPS for ambulatory care, we hosted an annual meeting where we had a large group of healthcare professionals and patient advocates from all disciplines. During the meeting, attendees would talk about the TeamSTEPPS program, the tools and materials, and how they could integrate those in their practice. I was talking to this individual, and he said, “I’m a radiation oncologist.” And I’m thinking, why would a radiation oncologist be coming to this TeamSTEPPS meeting? I said, “Well, what brought you here?” And he replied that he had a patient who had a head and neck tumor, and a cancer that was being treated. The standard treatment protocol required both chemotherapy and radiation therapy, and he was delivering the radiation therapy. And this patient was coming into their clinic for 6 or 7 weeks, and then finally a nurse asked the patient, “How is your chemotherapy going?” And the patient replied, “I’m getting it here.” And the nurse said, “No, I mean the medication you get orally, or IV, besides the radiation.” And the patient said, “I’m not really getting anything else; I’m not going anywhere else. I’m coming here, and I’m getting my radiation.” So this patient was not getting their chemotherapy; they were only getting their radiation, which greatly affected their treatment response and outcome. And the meeting participant said, “I need TeamSTEPPS because we’re not communicating. I need to figure out a better way that we can communicate among providers and teams.”

We sometimes make huge assumptions in primary care, that people are getting what they need when they’re not with us in the other settings. Those assumptions and the lack of real data could lead to quality and safety errors. That is one real-world example.

Sarah Mossburg: That example speaks to the potential for missed care because of challenges and communication. I’m curious about the flip side of that. Unnecessary tests and procedures can sometimes harm patients. Are those problems found in office-based care settings?

Ric Ricciardi: Those problems are important and occur every day in large numbers. They are a focus of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. It is also an issue for the primary care provider team not to have access to prior diagnostic studies due to lack of access to health information, which causes risks to patients and systemwide inefficiencies.

The lack of continuity in diagnostic testing can lead to additional trauma to patients because there’s a physical trauma of needing to have repeated diagnostic or preventative testing and screening. Many diagnostic procedures are very uncomfortable, but there’s also a psychological trauma of wondering whether you have some significant illness while you are waiting for the results. There’s also risks associated with radiation. If you’re getting a CT scan and you’ve already had one, and you go to an emergency room and they say, “We don’t have time to find the old CT scan, we’ll just give you another one.” Then you’re getting radiation again from a second CT scan.

Sarah Mossburg: Another area that is a potential patient safety issue in office-based settings is related to medication safety events. Could you talk a little bit about medication-related safety events?

Ric Ricciardi: The risk of medication error occurs at many points throughout the system. One point is a prescribing error. Prescribing errors can be mitigated by the pharmacist and electronic health records. For example, I prescribed a medication for a patient and the pharmacist called me and asked, “Did you know this patient was on this other medicine?” I did not know this. It’s important for us to have a relationship with the pharmacy where the patient gets their medicines because they have a record of what this patient is on.

It could also be a dosage error in the prescribing of the medication. This error particularly happens more frequently in pediatrics, where you have weight-based dosing. If you have people who are not familiar with weight-based dosing, you could have a decimal point error that can have serious effects.

And then you have communication errors, where you have teams within teams caring for patients and a lack of interoperability or access between electronic health records. The patient is not clear on what medications they are taking, and then you prescribe a medication that may put the patient at risk for adverse events or be harmful.

Sometimes, patients don’t have the money to purchase the medications, and they don’t have adequate health insurance. I’ve had patients say, “I’m only taking a light dose of that” or “I take it every other day because I can’t afford to take the full dose.” Or they don’t pick up their prescription at all because they don’t have money to. Patients in the ambulatory setting have to make very difficult choices, especially if they’re caring for someone else. Many patients are caring for a loved parent, partner, or child and they often put those individuals’ needs ahead of their own.

If we had an integrated healthcare system where all the patient’s medications are tied into the pharmacy system and tied into the health record, where it’s automated and visible to all healthcare providers and teams, then risks of errors would be reduced. Yes, medications are a big source of potential safety errors. Quality includes access and cost issues where patients are not getting what they need because they can’t afford their medicines or do not have access to healthcare.

Sarah Mossburg: I’m curious about any strategies or tools that providers working in office-based care settings use to improve the safety of care for their patients. You alluded to TeamSTEPPS earlier, and you mentioned interventions to mitigate medication errors. Do you have any other examples?

Ric Ricciardi: Nursing is the largest workforce in healthcare, and nurses are key to improving quality and safety in office-based care settings. Since Florence Nightingale, we have trained and educated nurses to work primarily in acute care settings. I think the role of the registered nurse needs to be expanded dramatically to where the registered nurse is working in office-based settings to do the kinds of follow-up and continuity that would mitigate some of these safety issues we’ve mentioned. Whether it’s going to the patient’s home or calling them, or video conferencing, and really following up on the care and treatment plan. I believe there’s a significant role for the registered nurse, along with care team members such as community health workers and public health nurses as they establish themselves within community-based environments that serve as the liaison across the community, the patient, the family, and the primary care team. The registered nurse could take on multiple practices in primary care. Maybe it’s a small primary care practice that only has one or two providers in it, and they can’t afford to hire a registered nurse all the time. But if we had a virtual registered nurse or if we had registered nurses who were integrated and working with that practice and other practices, then that registered nurse could fill a variety of roles to improve safety and quality. Perhaps they could do follow-up, community assessments, and medication reconciliation after the patient has picked up the medicine. Or the registered nurse could support the patient in trying to change some lifestyle behavior, whether it’s smoking, drinking, or increasing activity, thereby improving their behavior as well as serving as a navigator and advocate for the patient in the healthcare delivery system. Because we know the concept of self-efficacy is critical in primary care and for people to have real, meaningful change, they have to believe that they can do it, and are they are supported. Patients and families should have someone on their medical team whom they trust and count on to help them with the barriers and roadblocks in the healthcare system as well as the treatment plan.

I think one of the biggest possible improvements and mitigators for safety is having registered nurses move front and center into primary care. In my opinion, if nursing doesn’t do it, eventually, I believe the healthcare system is going to find a new provider. But quite honestly, I don’t think we need a new provider. I think that nursing is the perfect provider to improve quality and safety and address communication, health literacy, and system barriers while also integrating the patient’s values and preferences into an implementable plan of care. Also, I think leveraging technology could help improve safety. And probably the biggest potential gain is practicing from a team-based care perspective where, if there are safety issues, you have more eyes on that patient and a better capacity to identify potential safety issues before they happen.

Sarah Mossburg: Well, thank you very much for this conversation. This was really interesting.

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