Learning from Diagnostic Opportunities

What follows is an interview with Dennis Torretti, MD, associate chief medical officer of the Geisinger Medical Center, chairman emeritus of the Division of Medicine, and chair of the Committee to Improve Clinical Diagnosis, and Divvy Upadhyay, MD, MPH, researcher-in-residence and co-investigator of the Safer Dx Learning Lab and scientist in the Division of Quality, Safety and Patient Experience at Geisinger.

Geisinger is committed to making better health easier for the more than 1.5 million consumers it serves. Founded more than 100 years ago by Abigail Geisinger, the system now includes 13 hospital campuses, a 600,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With 32,000 employees and 1,800 employed physicians, Geisinger boosts its hometown economies in Pennsylvania and New Jersey by billions of dollars annually.

 

Why did diagnostic quality become an important facet of Geisinger’s work and research?

“I believe that the diagnostic process is the cornerstone of everything that we do in medicine,” said Dennis Torretti, MD. “The Geisinger leadership team agrees that maintaining the integrity of the diagnostic process is essential to our mission as a health system.”

In 2014, the chief transformation officer and chief quality officer of Geisinger convened a group of leaders to explore the topic of diagnostic error and diagnostic safety. Dr. Torretti subsequently led a work group that evolved from the initial discussions.

“I think the fact that Dr. Torretti led the initiative gave it a certain level of cachet and encouraged other senior leaders to get on board,” said Divvy Upadhyay, MD, MPH. “Having key clinical and operational leadership interested, invested, and passionate was a key factor in our initial and continued success.”

 

How did this exploratory group transition to Geisinger’s Committee to Improve Clinical Diagnosis (CICD)? What does the CICD do and what are its goals?

“To make significant progress in improving diagnostic quality, the exploratory group needed a more formal role within Geisinger,” said Dr. Torretti. “We named the group the CICD, and we expanded the membership to include representation from all major disciplines to ensure that we were looking at the issue broadly.”

The CICD developed a charter and identified four key components to improving diagnostic quality at Geisinger, all hinging on creating a culture of learning and improvement within the system.

In an effort to refine its initiatives, Geisinger invited Dr. Hardeep Singh, an international expert on patient safety and health information technology issues, to visit and discuss the problem of diagnostic error. Before they could enhance the safety and accuracy of the diagnostic process, they first needed to overcome the challenge of defining and measuring diagnostic error, especially across multiple care settings.

That is how the Safer Dx Learning Lab—a three-year project funded by the Gordon and Betty Moore Foundation to leverage institutional data, provider reporting, data analytics, and electronic health records to measure patient safety, reduce diagnostic errors, and share best practices for quality improvement with industry stakeholders—was born.

“This partnership with Dr. Singh paired his extensive research with Geisinger’s operational capabilities to create a unique learning opportunity for the field,” said Dr. Torretti.

 

What other steps has the CICD taken to accelerate diagnostic improvement at Geisinger?

“We asked our directors, ‘What could the CICD do, in the short term, that would have a positive impact on the diagnostic process?’ and the majority noted the importance of developing a process for feedback on diagnostic errors,” said Dr. Torretti. “As a result, we created a process for identifying diagnostic opportunities in order to provide feedback to clinicians.”

Dr. Torretti and Dr. Upadhyay knew that providers would only share instances of potential diagnostic improvement if they felt comfortable and safe, so the CICD framed the request as an opportunity to learn rather than be criticized.

“In fact, we use terms like ‘diagnostic opportunities’ rather than ‘diagnostic error,’ and ‘share’ instead of ‘report,’” said Dr. Upadhyay. “We emphasize that as healthcare professionals, our patients trust us to continuously improve our processes and advance patient care, so sharing diagnostic opportunities reflects a commitment to improvement.”

The CICD reviews all incidences of diagnostic improvement that are submitted, and if the group agrees that there is a learning opportunity, the case is forwarded to the department director and the quality director of that respective area, who are asked to respond accordingly:

1. Provide feedback to the individual provider(s) involved and have a discussion.
   If there is a significant learning opportunity, expand it beyond the individual by discussing or presenting it at an appropriate forum, such as a departmental meeting or a clinical staff conference.
2. If there are local process issues that need to be addressed to prevent recurrence, develop an action plan.
3. If there are system issues that need to be addressed to prevent recurrence, elevate the issue to the CICD for further exploration.

“There must be an open, transparent, constructive, and non-punitive dialogue between all parties in order to have a shared understanding of the context and issues that drove the decision-making,” said Dr. Torretti.

 

What are some challenges you’ve faced in implementing this feedback process?

“It is time-consuming, because we’re facilitating provision of extensive feedback to providers on a case-by-case basis,” said Dr. Upadhyay. “But it is also condition and disease agnostic, so we’re not constrained by the silos that tend to impede system-wide learning.”

Dr. Torretti and Dr. Upadhyay believe that the time investment is justifiable because when taken together, the cases paint a full picture of system-wide improvement opportunities. Geisinger’s providers seem to appreciate the process: since June 2018, more than 220 cases have been shared with the CICD, and about 50 percent were shared as learning opportunities.

“We believe that this effort facilitates broader, system-wide learning and moves us closer to a culture of safety,” said Dr. Torretti.

 

Resources

• Early Lessons & An Action Plan to develop learning and exploration of diagnostic excellence (LEDE) organizations such as Geisinger
• About the Safer Dx Learning Lab
• Video: A Learning Health System Improving Diagnosis at Geisinger

If you would like to share your experiences or discuss this work with Dr. Torretti or Dr. Upadhyay, please email Coalition@ImproveDiagnosis.org and we would be happy to connect you.