Creating a Culture of Diagnostic Safety

What follows is an interview with Harry Hoar, MD, med-peds hospitalist, assistant professor of pediatrics, and Director of Clinical Reasoning Education at U Mass Medical School - Baystate.

Why did Diagnostic Excellence become a major priority of Baystate Health’s comprehensive Patient safety program?

As a clinician educator, Dr. Harry Hoar had been teaching about diagnostic error and how to improve clinical reasoning since 2008. When Dr. Doug Salvador, Chief Medical Officer and Chief Quality Officer for Baystate Health, arrived at Baystate six years ago, he brought with him an interest and expertise in diagnostic error from the quality side as well.

“Doug and I soon discovered our shared interest in diagnosis and have been able to combine our respective experience in teaching and quality improvement to generate interest in diagnostic quality and safety throughout Baystate Health,” said Dr. Hoar. “Once diagnostic error rates became a key metric in our institution, it became much easier to convince clinicians, educators, and leaders throughout Baystate Health that diagnostic quality should become a major priority for our institution.”

What tools and resources has Baystate Health developed to improve clinician support in the diagnostic process?

Since 2017, Baystate has applied a diagnostic error filter to every case of patient harm that occurs at Baystate Medical Center to determine if an error in the diagnostic process contributed to the patient harm. If a diagnostic process error has occurred, the case is analyzed using a novel Diagnostic Error Fishbone Diagram to identify the potential sources of error. In cases in which systems issues and/or problems in the “diagnostic environment” have contributed to the error, systems fixes have been put in place that help support clinician decision-making. Baystate has also recently integrated a commercial Clinical Decision Support System (VisualDx) into its EMR to support clinicians.

Baystate’s most innovative intervention has been the development of CaseShare, a novel smartphone app that allows providers to quickly and easily submit a report if they encounter a diagnostic error.

“We noticed that diagnostic errors were rarely being reported via our systemwide safety reporting system (SRS) despite the fact that many of our harm cases and morbidity and mortality conferences featured cases of diagnostic error,” said Dr. Hoar. Many clinicians did not think to report diagnostic errors via SRS or did not feel that the SRS system was the appropriate tool for reporting diagnostic mishaps.

Noticing this disconnect, two members of Baystate’s adult hospitalist team worked with their technology partners to develop CaseShare. The goal was to lower the bar for reporting diagnostic errors with a user-friendly phone app that would only take a few minutes to use. Once errors are reported, they are reviewed by trained clinician reviewers using a validated tool and feedback is provided to the clinicians involved in the case as well as the reporter.

“Several hundred cases have been submitted through CaseShare, far more than were ever reported in the SRS system,” said Dr. Hoar. “In a very exciting development, the app designers are now working on a major upgrade to the app that will allow providers to seek assistance from other providers in our health system by crowdsourcing their real-time diagnostic questions to app users.”

What lessons have you learned? What barriers have you overcome to advance this work?

After years of trying to address diagnostic errors primarily through educational means (lectures to students and residents, Grand Rounds presentations, faculty development/CME activities) Baystate learned, as many others have, that education alone is not particularly effective in changing behaviors or patient outcomes.

“We have had much more success by developing multi-faceted, multi-disciplinary, and inter-professional approaches to diagnostic quality,” stated Dr. Hoar. Baystate has overcome the barriers that all who work in the area of diagnostic quality are familiar with:

a. Defining, identifying, and measuring diagnostic errors
b. Developing effective prevention and mitigation strategies
c. Overcoming the lack of transparency and culture of shame associated with diagnostic errors

“We are pleased to report that we have had some success in overcoming each of these barriers and would be happy to share our experiences with other Coalition members,” said Dr. Hoar.

Tell us about the Clinical Reasoning Teaching Academy. How did it come about, and how has it evolved?

The Clinical Reasoning Teaching Academy (CRTA) is an interprofessional lecture/discussion series for clinician educators who want to improve their teaching skills in clinical reasoning. The CRTA curriculum is based on the recently published Diagnostic Competencies developed by the Josiah Macy Foundation and SIDM and is part of the Macy Foundation/SIDM multi-institutional Learning Collaborative in teaching diagnosis.

The diagnostic competencies include individual, team-based, and systems competencies with a real focus on the collaborative nature of the diagnostic process. During the first year of the curriculum, 68 clinician educators participated, including 35 physicians, 12 nurses, five pharmacists, four respiratory therapists, three nutritionists, three nurse practitioners, two physician’s assistants, two nurse midwives, one occupational therapist, one child life specialist, and one lay community member.

“Initially, the plan had been to dedicate one session to each of the 12 diagnostic competencies, but after some initial discussions it became clear that the primary work of this group should focus on developing effective, non-hierarchical diagnostic teams, improving communication between providers with different skill sets and levels of experience, involving patients in the diagnostic process, and creating a culture of diagnostic safety at Baystate,” said Dr. Hoar.

Unfortunately, the COVID-19 pandemic interrupted the CRTA’s work but Baystate is planning to re-convene virtually and continue the group’s work with the goal of developing multiple projects within multiple disciplines and care areas at Baystate to improve diagnostic teamwork and a culture of diagnostic safety.

How have you engaged the Patient and Family Advisory Council (PFAC) in your efforts?

Baystate has included PFAC members and volunteers in their weekly PI Huddle where cases of patient harm and significant near misses are reviewed and triaged. This meeting began as a work group for the Patient Safety and Risk Management staff and has grown to be a forum for the exchange of ideas on improving care including diagnostic errors.

“Several of our Baystate Health PFAC members attended last year’s Diagnostic Error in Medicine conference and we continue to have conversations with our PFAC about how we can effectively involve patients in the diagnostic process,” said Dr. Hoar. “We hope to include some PFAC members in the next iteration of the Clinical Reasoning Teaching Academy and have discussed training PFAC members to be standardized patients for simulation training for our providers on incorporating patients into the diagnostic process.”

How has the COVID-19 pandemic impacted your ability to focus on improving diagnostic quality and safety?

The pandemic has delayed Baystate’s progress in a number of initiatives related to diagnostic quality and safety. Now that their local surge has passed and they are largely back to regular operations, Baystate will be able to re-focus on diagnosis, including resumption of the CRTA and upgrades to the CaseShare app.

“Recent literature has highlighted the problem of diagnostic errors related to COVID-19 and we have seen examples of these types of errors in our health system as well,” stated Dr. Hoar. “In response to this, our diagnostic error reporting app upgrade will include a specific prompt for reporters to flag cases of errors that they think may have been directly or indirectly related to COVID-19.”

In this way, Baystate hopes to be able to prospectively gather more data on the frequency and types of diagnostic errors that are occurring in relation to the COVID-19 pandemic.

How has participation in the Coalition to Improve Diagnosis helped your work?

Baystate’s participation in the Coalition to Improve Diagnosis has been particularly helpful as a forum to share ideas and get feedback on our current efforts in diagnostic quality and safety. Many of the Coalition members have expressed interest in adopting our diagnostic error reporting app and we have engaged in conversations with our tech team about how we can make the app universally available to other institutions. Particularly during the pandemic, when it has been difficult to focus on anything but the pandemic, our participation in the ongoing Coalition meetings and subcommittee activities has required us to continue to focus on diagnostic quality and safety.

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