Health systems are actively working to bolster quality and safety practices in outpatient settings as more care historically only performed in hospitals moves to ambulatory facilities.
CMS recently finalized the phase-out of its inpatient-only list as part of its 2026 hospital outpatient payment rule. The list has historically limited Medicare reimbursement for certain procedures to only when they’re performed in hospital inpatient settings. The new rules remove 285 procedures from the list and add 289 to the ASC covered procedures list, marking a dramatic acceleration of surgical care to outpatient settings.
Clinical leaders say the shift demands more robust quality and safety monitoring infrastructure across ambulatory networks. In recent conversations with Becker’s, executives shared how their organizations are building capabilities to track outcomes, coordinate care and ensure staff readiness as increasingly complex procedures move outpatient.
Clear protocols and comprehensive screening
The movement of complex procedures to outpatient settings requires rigorous patient evaluation before care is delivered, leaders said.
“We have to have a mature pre-procedure optimization process, such as doing frailty assessments, getting cardiac clearance, and having standardized discharge and observation requirements,” said Gena Lawday, BSN, RN, chief quality officer of UVA Community Health, part of Charlottesville, Va.-based UVA Health.
While ASCs already have patient selection processes in place, the acceleration of more care to these settings means protocols need to become more comprehensive and refined. This is critical to ensure patients are appropriate candidates for outpatient procedures and that care teams are prepared to manage complications as they arise, leaders said.
“While it sounds wonderful to have more flexibility with scheduling complex procedures in the ambulatory space or the acute ASC environment, we have to balance that with the risk and resource implications,” said Niti Armistead, MD, chief quality and clinical officer at Greenville, N.C.-based ECU Health.
These concerns reflect broader industrywide discussions about the need to balance ambulatory expansion with appropriate site-of-care determinations. Elimination of the inpatient-only list and recent expansions of site-neutral payment policies have sparked conversations across the industry about ensuring medical judgement not being overridden as more procedures become eligible to be performed outpatient.
While expanding outpatient eligibility can improve access and convenience, health system leaders have cautioned it must not come at the expense of clinical discretion about where individual patients can safely receive care. As procedures shift to settings where reimbursement tends to be lower, leaders stress that payer coverage decisions must account for patient-specific factors beyond the procedure type itself.
“The worst case scenario, to me, would be a high-risk patient getting a procedure in an ambulatory ASC environment, having complications and not having the resources for rescue,” Dr. Armistead said.
Staff training and accountability
Health systems are also enhancing staff training across their ambulatory networks to ensure frontline teams are prepared to handle an influx of services moving to outpatient settings.
“Organizations will have to be a bit more mindful of these outpatient care sites and ensure that we have the right training for the staff, because they potentially will be doing procedures that have traditionally only been done in hospitals,” Ms. Lawday said.
In any care setting, quality and safety should be front and center, Dr. Armistead said, but building a culture where that reality lives out starts at the top. At ECU Health, C-suite leaders routinely emphasize a commitment to high reliability principles, which help drive quality across the enterprise, she explained. Practices that align with those principles are embedded into workflows across sites of care, such as daily huddles and systems where staff are encouraged to report and escalate safety concerns.
The health system also embeds ambulatory quality measures — including hypertension control — into its enterprise goals, reflecting leadership’s commitment to ensuring outpatient care meets the same standards as inpatient services.
“You can have all the strategy, policies and governance, but what really needs to happen is for every team member who’s showing up to deliver care to understand their critical role in preventing harm and having accountability,” Dr. Armistead said.
Beyond staff readiness, leaders said robust patient education will become increasingly important as procedures move to settings where patients leave shortly after care is delivered. Patients need clear guidance on what to expect during their recovery, medication management and when complications require immediate attention — all of which are critical to prevent adverse outcomes and unnecessary readmissions.
“Because of the fact that patients will be leaving so quickly after the procedure, I think you can never say enough about excellent education for patients,” Ms. Lawday said. “Patients need to understand what is truly a complication and what is something that’s expected to happen.”
Leveraging data and technology to support care coordination
As care becomes more dispersed across settings, modernized data infrastructure will be essential for systems to coordinate care effectively. Keeping track of patient records across multiple sites and reaching out to patients proactively requires closing data silos that currently fragment information, Dr. Armistead said.
“Data fragmentation and care coordination, or lack thereof, becomes an entirely different challenge in an ambulatory environment. How to get organized and be able to coordinate the care of these complex patients as they go from primary care to specialist — maybe to a specialist that is not within your group or on your EMR — it really does take an active effort and building a system of care to be able to do that for patients,” she said.
Dr. Armistead and Ms. Lawday both emphasized the increasing role technology will play in supporting strong patient outcomes. Organizations should consider expanding remote monitoring capabilities and look to implementing automated follow-up systems to check in on patients after their procedures, Ms. Lawday said. These types of tools can help identify which patients need clinical intervention, with algorithms designed to route concerns to clinicians based on severity.
Remote patient monitoring, in particular, can help patients manage their conditions between visits, enabling early intervention and potentially preventing emergency department visits, Dr. Armistead said.
“A lot of the quality work has to happen in between visits” in the ambulatory space, she said.
“The gaps that we need to close on this front is to break out of the mentality of care only being rendered at the time of the visit, and having mechanisms to be able to provide care and shore up quality between visits by leveraging technology — and our teams and the reimbursement models, of course, have to recognize that and help us be able to do that.”
Building internal governance as regulatory gaps persist
Peter Pronovost, MD, chief quality and clinical transformation officer at Cleveland-based University Hospitals said the health system has implemented a standardized quality and safety program across all of its ambulatory sites to address broader gaps in regulatory oversight.
The effort started by creating a management oversight committee responsible for defining quality and safety functions across all relevant domains, including medication safety, infection prevention, environmental safety and employee safety. This committee helped map out the functions for each domain, clarify governance structures and determine who is responsible for conducting audits at each site. The health system uses standardized self-assessments and auditing processes to maintain consistent quality and safety standards across its ambulatory footprint.
University Hospitals’ approach reflects a broader challenge facing large health systems as ambulatory care expands: an uneven regulatory landscape. While ASCs face oversight comparable to hospitals through CMS certification requirements, Dr. Pronvost said many other outpatient sites operate with significantly lighter regulatory frameworks. Physician office practices, urgent care centers and other ambulatory venues often lack the external quality mandates that hospitals navigate, leaving systems to build their own governance structures.
For other health systems looking to strengthen their ambulatory safety infrastructure, Dr. Pronovost said the starting point is having a complete picture of ambulatory operations — a level of visibility that many systems lack.
“Systems have grown from acquisitions and often, there may not be a single person who has an understanding of the entire portfolio,” Dr. Pronovost said.
He advises health systems to map their full ambulatory footprint — including physician practices, ASCs, home care sites — then examine governance structures to determine who is responsible for what at each site.
“We have a really simple rule that says if you really want to have a management system, you have to be able to map board to bedside who are the main people over each of those units,” Dr. Pronovost said. “Trying to reduce ambiguity about responsibility and roles as much as possible is going to do a lot to improve safety.”
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