Medical care should be safer. Inpatient problems and solutions have received the most attention; this outpatient qualitative case study addresses a gap in knowledge. We describe safety improvements among large physician groups, model the key influences on their behavior, and identify beneficial public and private policies. All groups were trying to reduce medical injury,which was part of the sample design. The most commonly targeted problems are those that are similar across groups: shortcomings in diagnosis, abnormal tests follow-up, scope of practice and referral patterns, and continuity of care. Medical group innovators vary greatly, however, in implementation of improvements, that is, in the extent to which they implement process changes that identify events/problems, analyze and track incidents, decide how to change clinical and administrative practices, and monitor impacts of the changes.

Our conceptual model identifies key determinants: (1) demand for safety comes from external factors: legal, market, and professional; (2)organizational responses depend on internal factors: group size, scope, and integration; leadership and governance; professional culture;information-system assets; and financial and intellectual capital. Further,safety is an aspect of quality (the same tools, decision making,interventions, and monitoring apply), and safety management benefits from prior efficiency management (similar skills and culture of innovation).

Observed variation in even simple safeguards shows that existing safety incentives are too weak. Our model suggests that the biggest improvement would come from boosting the demand for quality and safety from both private and public larger group purchasers. Current policy relies too much on litigation and discipline, which have sometimes helped, but not solved, problems because they are inefficient, tend to drive needed information underground, and complicate needed cultural change. Patients' safety demand is also weak for want of information and market power. Big purchasers' demands, however,quickly influence the internal environment of medical groups, helping managers advance quality safety toward the top of groups' congested decision-making“queues.”

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