Addressing Biases Through a Think Tank

Children’s Hospital of Philadelphia (CHOP)

What follows is an interview with Andrea Colfer, MSN, RN, CPN, LSSGB, Senior Patient Safety Process Manager at Children’s Hospital of Philadelphia (CHOP); Avram Mack, MD, Associate Chair for Quality and Patient Safety in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at CHOP; and Ursula Nawab, MD, Senior Medical Director of Patient Safety at CHOP.


What drove CHOP to focus on cognitive biases as a part of addressing diagnostic quality?

“We knew that one important contributing factor to misdiagnosis could be cognitive bias,” said Ursula Nawab, MD. “Therefore, we decided to focus on cognitive biases as a part of our patient safety work because it has been well-studied in adult populations, but it’s not often discussed in pediatrics.”

CHOP developed the Cognitive Bias Think Tank, a multidisciplinary program that encourages clinicians at all levels, as well as family faculty, to think about how and why they come to diagnostic decisions. The goal is to prevent diagnostic errors that can come from unconscious biases, such as availability bias, or the tendency to rely on information or ideas that readily come to mind; anchoring bias, the tendency to focus on an initial judgment and use additional information to support that judgment; and more. This training is available institution-wide to all frontline clinicians.

“What’s unique about our program is that we’re focusing on all clinical employees, because we know that each can ultimately affect the plan of care for patients,” said Andrea Colfer, MSN. “I know that as a nurse, the way I present information to a physician may ultimately affect a diagnosis. It’s about teamwork.”


What kind of work do you do with the Cognitive Bias Think Tank?

“The Think Tank offers a way to raise awareness of potential cognitive bias among our staff,” Colfer said. “We host ‘lunch and learns’ on the topic with multiple division representatives in attendance, and we invite both internal and external experts to speak on the topic.”

Recently, the group hosted Annie Duke, a professional poker player, to discuss the principles of thinking through a decision without the benefit of having all of the facts.

“She taught us to think in terms of how you get to the decision, rather than thinking about the outcome of the decision,” Dr. Nawab recalled.

“Our discussions center on common cases that could occur, and coming up with possible interventions,” Dr. Nawab added. “Missed opportunities in diagnosis and cognitive bias are hard things to think and talk about. We want to provide tools to help clinicians reach the best decisions they can. The first step is having a ‘safe space’ for these types of conversations.”


What challenges have you faced in getting clinicians to address cognitive biases?

“One of the difficulties is the presumption that when you’re addressing cognitive biases, you’re discussing how other people think,” explained Avram Mack, MD. “It’s harder to discuss attitudes and decision-making rather than skills and knowledge—it feels personal.”

An important component of work life at CHOP is the concept of psychological safety, which is when clinicians and other staff feel safe to have open dialogue about any issue without fear of punishment. The aim is to make clinicians feel supported through the entire process.

“In my practice, I encourage diagnostic timeouts,” said Dr. Nawab. “It can be challenging on rounds, but on a case-by-case basis, we can sit down and say, ‘These are the things we’re thinking. Why are we thinking that? What are we missing?’ Once we start breaking down our thoughts, it invites better decision-making.”

Throughout the institution there may be best practices to recognize biases and open the door to conversation. Part of the work of the Think Tank is to collect and spread individual best practices, from within CHOP and from other national leaders in this area.


What does success look like for CHOP and what have you learned through this process?

“For us, success is defined as our staff comfortably discussing differences in diagnoses and identifying missed opportunities for diagnosis,” said Dr. Nawab. “We want people to talk about what’s happening. In medicine, it’s hard to express uncertainty, but it’s better for patients and families when we do.”

“Our advice for other organizations is to make sure you create an environment where clinicians feel safe raising issues,” Colfer said. “If they don’t feel comfortable bringing diagnostic opportunities up, then they aren’t going to discuss them in real-time, report them, and then act upon them.”

CHOP is continuing to develop the Cognitive Bias Think Tank with speakers, case studies, tools, and resources. CHOP’s goal this year is to start to use published diagnostic review tools, such as Safer Dx, to help further identify opportunities for improvement.

“It’s about continuous improvement. We want to support clinicians in their aim to make the best diagnostic decisions for their patients,” said Colfer.



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