Coalition Member ACTions
Learn more about the individual actions members of the Coalition to Improve Diagnosis are taking to improve the diagnostic process.
Browse Coalition member ACTions by category:
Convener
The Society to Improve Diagnosis in Medicine (SIDM) catalyzes and leads change to improve diagnosis and eliminate harm from diagnostic error. They work in partnership with patients, their families, the healthcare community, and every interested stakeholder. SIDM is the only organization focused solely on the problem of diagnostic error and improving the accuracy and timeliness of diagnosis. To learn about SIDM’s programs and initiatives, click here.
Resources
- Fellowship in Diagnostic Excellence – SIDM offers an annual fellowship for healthcare professionals with an interest in improving diagnostic safety and quality. SIDM will match you with experienced mentors who are recognized leaders in the fields of diagnostic error education, research, or practice improvement.
- Journal Club – Join researchers in the field to discuss new and emerging research in the area of diagnosis. Journal Club meets a few times a year.
- ImproveDX Newsletter – Learn about developments from the field with original educational articles and with news about SIDM's activities.
- Sharing Stories – We are collecting stories from patients who have experienced a wrong, delayed or missed diagnosis. Share your story with us.
- Diagnosis – Diagnosis is an exciting benefit for SIDM Members only. We are happy to offer our new and existing members free access to the only influential medical journal focused on all aspects of diagnosis in medicine. Diagnosis, published by De Gruyter, is now the official peer-reviewed journal of the SIDM.
Tools
- Clinical Reasoning Toolkit – Diagnostic reasoning is fundamental for any clinician. Access resources that will help you improve your clinical reasoning.
- Assessment of Reasoning Tool (ART) – Use SIDM's Assessment of Reasoning Tool to assess a learner’s clinical reasoning skills and move toward improving diagnosis.
- Patient Toolkit for Diagnosis – The Patient's Toolkit for Diagnosis is created for people who are not feeling well or are visiting their doctor or nurse with a health concern. As patients, we have found that taking an active role in our care can help our doctors and nurses figure out a good “working” diagnosis. Not all diagnoses are correct, which is why we say “working” diagnosis. A diagnosis may be certain or uncertain, and making a diagnosis could be easy or difficult.
- Improving Diagnosis in Medicine Change Package: The Improving Diagnosis in Medicine change package is the result of a collaboration between the Health Research & Educational Trust (HRET) Hospital Improvement Innovation Network (HIIN) team and the SIDM, with contributions of patients and their families. This resource is a tool to help reduce patient safety incidents caused by actions during the diagnostic process.
Clinician
ABIM Foundation supported national experts to develop a set of video learning modules to improve medical students and trainees’ diagnostic reasoning skills.
Through the Choosing Wisely campaign, the ABIM Foundation works with clinical and consumer partners to promote clinician-patient conversations about appropriate care and reduce the use of unnecessary tests, treatments and procedures. This effort helps reduce opportunities for overdiagnosis while ensuring patients get the care they need. The Foundation leads a Choosing Wisely learning network to foster increased awareness and implementation. The learning network is supported through a grant from the Robert Wood Johnson Foundation.
AAP develops and supports a wide variety of resources related to accurate diagnosis in pediatric care. In addition to policy, the AAP provides a variety of opportunities for members to improve their knowledge and skills in preventing diagnostic errors. Their resources offer clinicians who care for children up-to-date, cutting edge information and tools to improve accurate diagnosis in pediatric populations, such as:
- Project RedDE!: A national improvement collaborative aimed at reducing the incidence of pediatric primary care diagnostic errors
- Risk management sessions focused on preventing diagnostic error
- Informational articles and webinars
- National Pediatric Readiness Project (partner)
- National Emergency Medical Services for Children Innovation & Improvement Center (EIIC; key stakeholder)
AANP is educating its members on the importance of diagnostic accuracy and improved diagnosis. AANP is conducting an Educational Session at the 2019 AANP National Conference entitled “Reducing Diagnostic Errors in Practice: A Call to Action for Nurse Practitioners.”
ACEP created the Emergency Medicine Registry to compile quality initiatives of its members who treat over 140 million patients per year in the emergency department, as well as the E-QUAL learning collaborative which provides suggested guidelines in the diagnosis and treatment of emergency conditions including low back pain, opioid prescribing, chest pain, and sepsis. ACEP also participates in the Choosing Wisely initiative and has put forth 10 recommendations on how to diagnose and manage commonly encountered conditions.
For example, for pediatric head trauma, ACEP Choosing Wisely Recommendations promote using the PECARN Head Trauma Guidelines which emphasizes the history and examination with decreased use of CT imaging. ACEP has created a series of bedside point-of-care clinical tools to aid clinicians to promptly diagnose and treat emergency conditions including sepsis, complications of bariatric surgery, and acute pain. ACEP’s CME conferences are packed with sessions on accurately diagnosing the innumerable conditions that present to the emergency department in patients of all ages.
ACP’s goal is to help clinicians optimize their clinical decision-making skills to improve diagnostic accuracy in their daily care of patients. ACP has created and continues to develop resources to help clinicians better understand the diagnostic process and recognize the potential causes and consequences of misdiagnosis. Among the tools available are:
- A resource library available at acponline.org helps physicians improve diagnosis by helping them recognize and avoid common pitfalls.
- Interactive cases serve to encourage thinking around diagnostic decision-making, how problems may occur in that process, and how diagnostic errors may affect both their patients and them in their daily practice of medicine.
To improve diagnostic skills, ACP offers learning opportunities focused on diagnostic reasoning, tools, and techniques, as well as clinical practice and public policy recommendations.
CMSS will convene a CMSS Task Force across their 43 member specialty societies to share best practices and identify collaborative opportunities to address timely and accurate diagnosis. Their goal is to encourage greater focus and collaborative efforts to improve diagnosis across specialty societies.
NAPNAP continues to provide education to its members, who are pediatric-focused advanced practice registered nurses (APRNs) to understand possible personal, system, and patient contributions to diagnostic errors and strategies to improve patient-centered diagnostic outcomes.
The mission of the Primary Care Collaborative (formerly the PCPCC) is to make primary care more robust and patient-centered through advocacy/policy efforts focused on care delivery and payment reforms, including the Patient-Centered Medical Home (PCMH). Such models seek to achieve the vision embodied in the Shared Principles of Primary Care, where primary care is more comprehensive, coordinated, integrated and continuous—which would contribute to improved diagnostic accuracy. An enhanced relationship between patients and primary care clinicians is foundational to better health.
The Society of Bedside Medicine has a program called Improving Bedside Clinical Exam Skills to Reduce Diagnostic Error. In addition to emphasizing traditional physical examination skills, the Society of Bedside Medicine incorporates point-of-care technology such as bedside ultrasound to improve the teaching and practice of bedside skills.
By improving overall clinical exam skills, they expect to improve diagnostic accuracy, decrease cost of care, and improve patient and provider satisfaction with the clinical encounter. They also expect that by empowering their learners with better clinical exam skills, they will spend more time at the bedside engaging in shared discovery with patients, as well as teaching other learners. The Society of Bedside Medicine provides its members with teaching tools to enhance the bedside physical exam skills of learners. At their annual meeting, they will provide members with an opportunity to participate in a U.K.-style assessment of clinical exam skills, with the goal of providing members the skills needed to start their own physical diagnosis teaching and assessment programs at their home institutions.
To address diagnostic error in hospital medicine, SHM’s Hospital Quality and Patient Safety Committee launched the Reducing Diagnostic Error Subcommittee charged with developing strategies, ideas, and resources to address diagnostic error in hospital medicine. In 2017, the subcommittee partnered with SIDM to develop an online CME/MOC learning module that defines and outlines best practices in the realm of diagnostic error as it relates to teamwork, handoffs, incidental findings, and feedback. The module is set to go live in the SHM Learning Portal by Fall 2018 and will be available to SHM and SIDM members free of charge. Participants learn how to:
- Apply TeamSTEPPS language of escalation using “CUS” (I am Concerned, I am Uncomfortable, This is a Safety issue) words
- Describe how the cognitive bias can lead to misdiagnosis
- Explain how TeamSTEPPS practice of “check-back” can aid in patient understanding
- Apply the TeamSTEPPS approach in creating a safe discharge plan
- Understand the role of cognitive bias in perpetuating diagnostic errors during handovers
- Identify patients at high risk for diagnostic errors during handovers
- Describe strategies used to avoid diagnostic errors during handovers
- Recognize how communication failure contributes to diagnostic errors
- Identify how failure to follow up on test results could lead to diagnostic error
- To develop strategies for feedback and its integration into everyday workflow.
Read the Society of Hospital Medicine’s ACT Update feature, “A Multi-Faceted Approach to Diagnostic Improvement,” on their Diagnostic Error Subcommittee and the resources they have developed to improve diagnosis and support clinicians in the diagnostic process.
Healthcare Management
Expanding on the Leading for Safety initiative, the American College of Healthcare Executives and the Society to Improve Diagnosis in Medicine have partnered to create educational programming, including a complimentary webinar that provides healthcare leaders with the knowledge and actions they can take to improve diagnostic safety and quality in their organizations. ACHE’s goal is to educate healthcare leaders on:
- The impact and scope of the issue
- The roles that healthcare systems and processes play in achieving accurate, effective and timely diagnoses
- The tools, resources and best practices available to healthcare leaders and their teams to standardize and improve the diagnostic process
Link: http://safety.ache.org/
ASHRM works with the Society to Improve Diagnosis in Medicine to examine and identify barriers to implementing quality improvement around diagnosis. ASHRM provides education programs to promote enterprise risk management, quality and patient safety. Learn more at www.ASHRM.org/education.
Hospital, Health System or Medical Group
Launched in March 2016, Together 2 Goal® is AMGA Foundation's national campaign that challenges 150 participating medical groups and health systems to improve care for 1 million people with type 2 diabetes. Campaign participants achieved this goal in just 3 years.
AMGA defines “improving care” as either (1) achieving new numerator compliance for at least 1 of the 4 quality measures that make up the bundle measure for the campaign (glycemic control, blood pressure control, statin prescribing, and medical attention for nephropathy), or (2) a new diagnosis of type 2 diabetes. Their immediate objective is to ensure that AMGA members participating in the campaign are able to maintain the gains they have achieved in improved care for people with diabetes, despite disruption of the U.S. healthcare system due to COVID-19. They continue to focus on maintaining and even increasing screening of people at high risk of type 2 diabetes and diagnosis for those who have diabetes.
The importance of diagnosis is emphasized by the fact that fully one-third of the improvements were a new diagnosis of type 2 diabetes. With diabetes being the seventh leading cause of death in the U.S., screening for, and diagnosis of, diabetes are crucial. More than 30 million people in the United States have diabetes, and 1 in 4 don’t know they have it. The T2G campaign will continue through March 2021.
Ballad Health has incorporated diagnostic excellence as an integral part of its journey toward zero-harm, top-decile performance. Since its inception in 2018, Ballad Health’s Clinical Council under its then chair Dr. Amit Vashist, who now serves as the system’s Chief Clinical Officer, launched multiple initiatives aimed at moving the system to a zero-harm state by targeting hospital-acquired infections. The Clinical Council set a series of “30-90” goals, targeting a 30% improvement in hospital-acquired infections in 90 days across the system’s hospitals.
A key focus of this multilayered initiative was improving diagnostic accuracy in order to accurately identify and treat hospital-acquired infections, as well as developing diagnostic algorithms that facilitated appropriate testing of patients with these conditions. The algorithms helped to prevent over-testing and consequent over-diagnosis of these conditions. As a result, Ballad Health has been able to reduce its rates of hospital-acquired C. diff, CAUTI and MRSA by more than 35%.
As part of its zero-harm journey, Ballad Health also initiated system-wide tiered safety huddles to identify opportunities for quality improvement in real time. The safety huddles start with front line caregivers during shift change at 7 a.m. each day and cascade up information to market and system leadership, who act immediately to help resolve any issues that impact safety and quality.
Over the past year, Ballad Health has also worked diligently through its system sepsis committee to identify, diagnose and treat sepsis earlier. Using a robust methodology targeting people, processes and technology, Ballad Health has been able to significantly lower the mortality rates for patients with sepsis, as well as increase its sepsis bundle compliance tremendously.
Baystate Health has made Diagnostic Excellence a major priority of their comprehensive Patient Safety program. They are committed to identifying opportunities to improve the diagnostic process and to implement solutions that will reduce harm from misdiagnosis. In order to achieve that goal, they have organized interdisciplinary teams to study and act in many areas including clinical reasoning education, incident identification and review, electronic clinical decision support, quality improvement activities, and clinical pathway development. Some recent examples:
- Use of a tailored diagnostic error review tool for Root Cause Analysis
- Implementation of a standardized Spinal Epidural Abscess diagnostic algorithm
- Development and implementation of a Diagnostic Errors Reporting System in Hospital Medicine
- Defined Clinical Reasoning curriculum and prioritized in medical school and residency education
- Engagement of Patient and Family Advisory Council in partnering with us to educate patients broadly on the diagnostic process and improvement efforts
CHOP has been educating their clinical staff for several years about cognitive bias, and with their “Cognitive Bias Think Tank” they continue to expand the inclusion of this topic in their safety work. They are fostering increased attention to the risk of diagnostic error that arises through the ways in which clinicians think about and interpret data about patients.
Read the Children’s Hospital of Philadelphia’s ACT Update feature, “Addressing Biases Through a Think Tank,” on their multidisciplinary program that encourages clinicians to think critically about any cognitive biases that may be hindering diagnostic quality.
Geisinger convened a multidisciplinary group of clinical leaders and staff to address the challenge of diagnostic errors. The group known as the “Committee to Improve Clinical Diagnosis” has an extensive agenda but seeks to identify and assess diagnostic errors while making every error an opportunity for broad-based learning through an open and constructive process.
Read Geisinger’s ACT Update feature, “Learning from Diagnostic Opportunities,” on the SaferDx Learning Lab, the Committee to Improve Clinical Diagnosis and other projects they have developed to accelerate diagnostic improvement.
As a learning health system committed to continuous improvement, we are emphasizing communication, shared learning and systems improvement around diagnostic safety. We have expanded our safety event program to enhance the collection of data about opportunities to improve the diagnostic process. Our aim is to support our teams in doing some of the most fundamental work in healthcare: making an accurate and timely diagnosis, with the promise of reducing harm and improving health outcomes.
Read Intermountain Healthcare’s ACT Update feature, “Building a Culture of Diagnostic Quality,” on developing their Zero Harm program and other initiatives under their Office of Patient Engagement to improve diagnostic quality and safety.
The Armstrong Institute Center for Diagnostic Excellence at Johns Hopkins provides a unique, collaborative, transdisciplinary environment for clinicians, researchers, engineers and data experts to work together to improve diagnosis and eliminate patient harms from misdiagnosis. Our focus is on scalable solutions to eliminate serious harms from “the Big Three” (vascular events, infections, and cancer) by leveraging teamwork, training, technology, and tuning to transform diagnosis.
The MedStar Center for Improving Diagnosis in Healthcare is focused on:
- Convening interested clinician, patient and family, and community stakeholders;
- Collaborating to identify and prioritize diagnostic challenges;
- Creating goal-directed strategies and tactics, training, tools and effective improvement interventions; and
- Communicating what they learn with the larger healthcare community through workshops, publications, enhanced training and expanded research.
A number of related incubator processes are currently underway across MedStar, including a clinical reasoning program for medical residents focused on diagnosis, surveys of providers and administrative leaders to identify gaps in awareness and knowledge about diagnostic error and to understand perceptions related to the magnitude of diagnostic issues in the healthcare environment.
The MedStar Health Institute for Quality and Safety (MIQS) faculty and staff are also gathering insights from important MedStar programs such as We Want to Know and Learning from Every Death to quantify how often problems or concerns related to diagnosis are identified. MedStar also has one of six teams from across the nation selected to participate in a prototyping diagnosis improvement collaborative funded by the Gordon & Betty Moore Foundation and organized and led by the Society to Improve Diagnosis in Medicine and the Institute for Healthcare Improvement.
Northwell Health has instituted a teach-back method that instructs providers to go a step further by asking patients to explain the diagnosis back to them. By asking patients to explain the diagnosis, patients often ask another question, clarify information, or remember a piece of medical history that they hadn’t before.
Additionally, Northwell has another project underway where, through education and training, they are teaching physicians how to identify and care for patients who may be at risk of long-term cardiovascular disease.
Read Northwell Health’s ACT Update feature, “Diagnostic Improvement is a Journey,” on developing a teach-back program and other clinician decision support tools to improve the accuracy of diagnosis.
Penn State Health is developing a work flow called Reducing Diagnostic Error in Radiology Resident Reports for Trauma Patients, where it performs 100% audits of all emergency room traumas imaging examinations to determine discrepancies between overnight radiology resident preliminary and final attending subspecialty radiology reports. The reports use natural language processing to identify discrepancies between the two reports and have a standardized scoring system to rate the clinical significance of the discrepancy and failure mode (perception error, knowledge error, communication error, etc.).
For the patients with a clinically significant discrepancy, Penn State Health will perform follow up chart reviews at 24 hours, 30 days, and 60 days to determine if there was patient harm. It will evaluate for trends in errors and use that information to develop e-learning content for residents. With this work flow they plan to:
- Reduce clinically significant discrepancies between the overnight interpretation provided by the radiology resident and the subspecialty trained radiologist to less than the national discrepancy rate between practicing radiologists (1.8%);
- Reduce harm to trauma patients undergoing diagnostic imaging; and
- Improve training of diagnostic radiology residents by targeted intervention on errors made while providing on-call interpretations of trauma studies and rapid feedback on resident diagnostic performance.
The Southern California Permanente Medical Group (SCPMG) developed SureNet under the leadership of Dr. Michael Kanter, now Chair of Clinical Sciences at the Kaiser Permanente School of Medicine. SureNet is a program that uses Kaiser Permanente’s robust electronic health record data to identify patients with test results or symptoms/signs that generally require a next step or follow-up, and flags when the patients haven’t received it.
The automated program scans the EHR to identify potential patient safety issues ranging from drug-disease interaction to delay in follow up on abnormal test results. The goal is to support the care team to initiate appropriate follow-up care, help improve diagnosis, monitor program effectiveness and reduce incidence of harm. Systematic surveillance of KP HealthConnect data through SureNet has reduced outpatient risks, led to earlier diagnosis and detection, and improved medication safety.
SureNet has been so successful that other organizations like Brigham and Women’s Hospital have partnered with Kaiser Permanente to develop similar programs. There are now more than 50 programs within the SureNets of Kaiser Permanente regions nationwide.
Tools/Resources:
Read Kaiser Permanente’s ACT Update feature, “Creating a Diagnostic Safety Net,” on implementing their SureNet program within their network to prevent test results or actions from falling through the cracks, reducing diagnostic errors.
A multidisciplinary team of internists, hospitalists and radiologists are collaborating to reduce diagnostic delay of lung cancer through follow-up of incidental pulmonary nodule findings. We aim to develop a novel system to track and actively monitor incidental pulmonary nodules with a follow-up process that enhances patient communication, reduces in-basket burden for primary care providers and monitors follow-up imaging completion. This process, once developed and tested, may be expanded to other subcritical imaging findings. We are hoping to learn from our colleagues in the Coalition that have already begun spearheading similar work.
Patient
CAPS is collaborating with Compass HIIN to create a change packet regarding the laboratory’s role in diagnostic error. The change packet will provide actionable initiatives for hospitals of all sizes to implement and improve the diagnostic process within their facility.
Sepsis Alliance launched Sepsis: It’s About T.I.M.E™, a national multimedia initiative to raise awareness of the signs and symptoms of sepsis and the urgent need for treatment when symptoms are recognized. The T.I.M.E acronym stands for (1) Temperature – Higher or lower than normal, (2) Infection – May have signs and symptoms of an infection, (3) Mental decline – Confused, sleepy, difficult to rouse, (4) Extremely ill – “I feel like I might die,” severe pain or discomfort. Sepsis Alliance also offers webinars and training modules to healthcare providers to improve sepsis diagnosis and patient outcomes.
Read Sepsis Alliance’s ACT Update feature, “Raising Awareness of Sepsis One Community At A Time,” on educating communities on the signs, symptoms, and urgency of sepsis, and providing healthcare professionals with tools and resources to accurately diagnose sepsis.
Read Sepsis Alliance’s ACT Update feature, “Partnering to Improve Pediatric Sepsis Diagnosis,” on partnering with fellow Coalition to Improve Diagnosis member Children’s Hospital Association in the development of training modules, awards, and webinars aimed at improving the diagnosis of pediatric sepsis cases.
WomenHeart has created resources for dissemination that offer important insights, tips, and recommendations for any woman undergoing cardiac diagnostic testing. The organization aims to highlight women heart patients’ experiences—and the unique challenges they face—when communicating with healthcare providers about their diagnosis and help them to advocate for better policies and practices to address challenges with cardiac diagnostic testing.
Tools/Resources:
- Learn More About Diagnostic Testing
- Cardiac Diagnostic Testing: What Women Need to Know
- Infographic on Cardiac Diagnostic Tests
Read WomenHeart’s ACT Update feature, “Empowering Women Heart Patients,” on empowering and training women heart patients to ensure accurate and timely diagnoses.
Measurement and Assessment
By formalizing the requirement for training in recognition of diagnostic error and diagnostic accuracy, ABIM hopes to raise the profile of these important competencies within the curricula of Internal Medicine Graduate Medical Education.
ABIM will bring “recognizing diagnostic error and diagnostic accuracy” forward to the ABIM Internal Medicine Specialty Board, which oversees training requirements in Internal Medicine, for consideration for inclusion as a training requirement similar to the other six ACGME/ABMS core competencies and/or ABIM procedure requirements.
ABMS works in collaboration with its 24 member certifying boards to maintain the standards for physician certification and to improve the quality of healthcare to patients, families, and communities. The ABMS Member Boards community is involved in a broad spectrum of targeted efforts that support improvement in diagnosis including, formative assessment of knowledge and clinical judgment, lifelong-learning and self-assessment initiatives, directed learning activities, individual case and log reviews, and inter-professional and patient communications skill development.
In addition, the ABMS Continuing Certification Directory includes more than 30 learning activities devoted to improvement of diagnosis and reduction of diagnostic error. The Directory helps physician specialists meet their continuing certification requirements by participating in high-quality, practice-relevant, and ABMS Board-approved programs. ABMS also engages physicians in diagnostic improvement through annual conference sessions and supports research to improve diagnostic accuracy by early-career physician leaders participating in the ABMS Visiting Scholars Program.
Tools/Resources:
Laboratory information is vital to ensuring that patients receive the right diagnosis. Through their standards of accreditation and educational tools, COLA works with physicians, nurses and laboratorians nationwide to strengthen the accuracy of laboratory testing. Lab Testing Matters, COLA's educational forum, is made up of a multi-disciplinary community of experts that share their knowledge and best practices. A diverse range of topics are addressed through the forum, including the role of the laboratory testing in diagnosis; trends in science and technology; the importance of multi-disciplinary care teams; patient stories, and best practices to reduce laboratory errors. COLA's near-patient testing research initiative highlights the value of real-time laboratory information to accurate, timely diagnosis and treatment, as well as the risk to patients, including delayed diagnoses, should access to testing be reduced.
Read COLA's ACT Update feature, "Supporting the Nation's Laboratories," on the role of laboratories in the diagnostic process.
In addition to developing a general framework for measurement of diagnostic quality and safety, NQF is launching a project that aims to develop a framework for chief complaint-based measurement in the emergency department. The goal of the Chief Complaint-Based Quality of Emergency Care project is to lay the conceptual groundwork for measurement approaches that capture the important role of chief complaints in the diagnosis and treatment of patients presenting to the emergency department.
Medical Education and Training
The ACGME implemented the Milestones in 2013 to help residency and fellowship programs improve curriculum and assessment in six Core Competencies. Based on lessons from the first five years of implementation, the ACGME has begun work on Milestones 2.0 for all specialties, which will occur from 2019 to 2022.
Recent data and research have raised awareness of the need to improve clinical and diagnostic reasoning in graduate medical education to reduce diagnostic error. The ACGME is using the Society to Improve Diagnosis in Medicine (SIDM) competency framework in diagnostic reasoning to guide all Milestones 2.0 Work Groups in their development of revised Medical Knowledge and Patient Care competencies. The ACT toolkit will also be included as part of the Supplemental Guide being developed for each Milestones 2.0 set.
The ACGME provides ongoing faculty development in assessment for graduate medical education programs in the United States and in other countries. The assessment of clinical and diagnostic reasoning is a core workshop in the Chicago-based six-day course. The workshop also covers the new SIDM competencies in diagnostic reasoning and the Assessment of Reasoning Tool. ACGME faculty members have partnered with Dr. Andrew Olson, one of the leaders in the development of the SIDM competency framework, to help teach the clinical reasoning workshop. The ACGME is also pursuing research in how developmental assessment like the Milestones and SIDM competencies can facilitate professional development in clinical and diagnostic reasoning.
AAIM contributes to improving diagnosis by educating its members (11,000 faculty and staff in departments of internal medicine at medical schools and teaching hospitals) through conference programming at the APDIM Fall Meeting and Academic Internal Medicine Week.
The AAMC serves and leads the academic medicine community to improve the health of all. Founded in 1876 and based in Washington, D.C., the AAMC is a not-for-profit association dedicated to transforming health care through innovative medical education, cutting-edge patient care, and groundbreaking medical research.
In recent years the AAMC has conducted a range of activities in support of improving diagnostic processes and performance. These activities include learning sessions at several professional development conferences and engaging clinical leaders in timely discussions.
AAMC is currently working with a cadre of experts to develop a toolkit designed to help reduce diagnostic errors and harm by accelerating the ability of hospitals, their leaders, and their teams to address appropriate follow-up for pending laboratory and radiology tests, especially during transitions of care including post-discharge.
Insurers and Payers
Diagnosis-related errors are among the most frequently named causes of action in medical professional liability (MPL) claims. The MPL Association strives to reduce diagnosis-related claims, and through its Data Sharing Project engages in ongoing analyses of diagnosis-related issues as identified in MPL claims data. As a result of this work, the MPL Association develops educational programs and other learning materials to educate MPL insurers and their policyholders (physicians, dentists, hospitals, clinics, and other healthcare providers) about diagnostic errors and associated issues, and also provides guidance to help mitigate diagnosis-related risk.
Quality and Safety
Through the Choosing Wisely initiative, AHQA members strive to reduce unnecessary tests and treatments in healthcare and increase patient empowerment. Launched in 2012, Choosing Wisely is a leading effort to encourage conversations aimed at reducing unnecessary tests and treatments in healthcare. The mission of Choosing Wisely is to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary.
Children’s Hospital Association helps children’s hospitals reduce patient harm by advancing diagnostic safety through data-driven collaboratives focused on areas of greatest impact, such as patient safety practices and hospital onset of severe sepsis:
Child Health PSO is certified by the Agency for Healthcare Research and Quality (AHRQ) to provide federal privilege and confidentiality protections to the safety event reporting and shared learning of 63 children’s hospitals who are focused on the elimination of preventable pediatric patient harm. Their collective data has revealed an urgent need to improve diagnostic safety. They have been collaborating to understand vulnerabilities and actions to implement to mitigate harm, and will soon release a tool highlighting pivotal points of communication in the diagnostic process.
Improving Pediatric Sepsis Outcomes (IPSO), a collaborative of 56 hospitals, is designed to improve pediatric sepsis outcomes through early recognition and diagnosis coupled with timely treatment. The program emphasizes cross-disciplinary communication and collaboration and engages staff throughout the hospital by promoting seven clinical bundles that promote standardization of recognition, diagnosis, and treatment of sepsis. The program goal is to reduce hospital onset of severe sepsis by 25% and reduce sepsis mortality by 25%.
Read the Children’s Hospital Association ACT Update feature, “Partnering to Improve Pediatric Sepsis Diagnosis,” on partnering with fellow Coalition to Improve Diagnosis member Sepsis Alliance in the development of training modules, awards, and webinars aimed at improving the diagnosis of pediatric sepsis cases.
ECRI Institute’s Partnership for Health IT Patient Safety developed a set of solutions, all of which are available free of charge. “Health IT Safe Practices for Closing the Loop,” not only addresses the consequences of failing to close the loop but provides safe practice recommendations and implementation strategies for health IT stakeholders. A podcast series features members of the Partnership’s Expert Advisory Panel. Materials are available online at: www.ecri.org/safepractices.
Health Care Improvement Foundation (HCIF) is an independent non-profit organization that drives high value healthcare through stakeholder collaboration and targeted quality improvement initiatives. HCIF serves as the coordinating center for the Pennsylvania Urologic Regional Collaborative (PURC) collaborative. PURC is a quality improvement initiative established in February 2015 that brings urology practices together in a physician-led, data-sharing and improvement collaborative aimed at advancing the quality of diagnosis and care for men with prostate cancer.
Through its mission, PURC works towards improving the diagnostic algorithm for men with prostate cancer. Recently the HCIF calculated concordance rates between TRUS prostate needle biopsy versus MRI fusion biopsy and final pathology at the time of radical prostatectomy. The findings suggest that MRI fusion plus TRUS biopsies demonstrated higher concordance rates with final pathology at the time of radical prostatectomy than TRUS prostate biopsies alone. Another recently accepted abstract, found that an assessment of high-risk disease increased the odds of detecting clinically significant disease on MRI/US biopsy. In other words, pre-biopsy MRI is important.
PURC is consistently looking at ways to improve the accuracy of diagnosis by improving diagnostic algorithms at time of biopsy and use of MRI in a more standardized manner and reducing variation in techniques by providers.
Through this collaborative, the HCIF’s goals are to:
- Improve increased accuracy in diagnosis of prostate cancer.
- Streamline care for appropriateness of imaging.
- Ensure through patient-provider decision-making that the best treatment option is selected.
- Identify pathways for treating pain post-surgically without additional opioid exposure.
IHI will be hosting three sessions related to diagnostic error during the annual IHI Forum in December 2018: “Reducing Diagnostic Errors: A Practical Workshop,” “Reducing Diagnostic Errors in Clinical Settings,” and “Improving Value; Putting a Strategic Focus on Overdiagnosis.” Additionally, they plan to host sessions on diagnostic error and accuracy at the 2019 IHI Annual Patient Safety Congress.
IHI also created a learning collaborative. Diagnostic error remains an important and unaddressed problem in all care settings. We therefore know where to focus improvement efforts, and why, but not how. This completed work advances a plan to break this cycle of inaction by enabling pioneering healthcare organizations to begin experimenting with interventions and evaluating their relative merits and impact.
Tools/Resources:
- IHI WIHI (February 2018): Practicing More Careful and Thoughtful Diagnosis
- IHI/NPSF (2017): Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era 2017
- IHI WIHI (December 2015): Harnessing Improvement to Reduce Diagnostic Errors and Delays
- IHI WIHI (January 2016) Diagnosis Is a Process: Experts Offer Advice on Diagnostic Error and Delays in Patient Safety
The Maryland Patient Safety Center, a not-for-profit organization committed to improving patient safety in the state and region of Maryland, facilitates an inter-disciplinary and multi-organization advisory council working to develop strategies to improve diagnosis. Through these efforts they are committed to the goal of reducing harm from diagnostic errors. The Maryland Patient Safety Center is focused on developing a database that will be useful in exploring potential diagnostic errors and in educating healthcare workers on the issue.
The Massachusetts Coalition shares studies, resources and presentations of initiatives at their membership meetings. They participate in local collaborations including the PRIDE initiative, to develop and share case studies. They have offered three strategies to test in office practices using a quality improvement approach:
- Partnering with patients to improve follow-up if treatment doesn’t produce expected results;
- Stalling premature closure (“What else could it be?”); and
- Mitigating confirmation bias (“What data don’t fit?”).
They encourage providers to test and share their results. Their continuing approach is to raise awareness of the level of harm and factors contributing to diagnostic errors, and to promote identification and broader adoption of effective strategies in the state through sharing among members and with national organizations.
At the Coalition’s 2019 Annual Patient Safety Forum, there were several presentations on improving the diagnostic process in both the inpatient and ambulatory setting (available at http://macoalition.org/patient-safety-forum-4-2019.shtml) . The Coalition also featured a presentation on the PRIDE initiative at its June 2019 membership meeting.
MAPS hosted a webinar on July 16, 2019 featuring Paul Epner focused on the “MAPS Top 10 Patient Safety Issues for 2019” highlighting Diagnostic Error and Missed Opportunities. A preview of the white paper can be found here: https://www.alliance4ptsafety.org/MAPS-PSO/Purchase-whitepaper.aspx
The Pennsylvania Patient Safety Authority has established a Center of Excellence for Improving Diagnosis to provide leadership, guidance, and support for healthcare facilities and systems, providers, patients, and all interested stakeholders. The Center will gather, synthesize, and share information to broaden awareness and understanding; build partnerships and create new networks to accelerate and scale improvement efforts; and facilitate the development and implementation of novel solutions to improve diagnosis throughout Pennsylvania and beyond.
Tools/Resources:
Washington Patient Safety Coalition, a program of the Foundation for Health Care Quality, chose diagnostic process as a key goal for 2018-2019. Through their Action Planning Subcommittee: Diagnostic Process, they are uniting around three tactics: raising awareness of the burning platform, developing a focus through collaboration and evidence-base, and promoting collaborative diagnosis (including patient/family). They are currently pursuing these through webinars, blog posts, and newsletters focused on diagnostic process, strategic partnerships with those active in this effort including membership with SIDM and collaborations with its staff and board, and a dedicated track at the 2019 Northwest Patient Safety Conference.
Read the Washington Patient Safety Coalition’s ACT Update feature, “A Safe Space to Discuss Diagnostic Quality,” on creating an educational program around the diagnostic process that includes webinars, a podcast, sessions at their annual conference, and a new concept called ‘Safe Table’ to create awareness of diagnostic error.
Testing
AACC launched LabTestsOnline.org in 2001 to help patients better understand the many clinical laboratory tests that play a critical role in diagnosing, monitoring, and treating a broad range of conditions, including cancer, diabetes, heart disease, and infectious diseases. Lab Tests Online content is peer-reviewed and available in 10+ languages through local sites around the globe.
Tools/Resources:
ACS has several programs underway, including:
- A database with reporting tools that enable all AP personnel to provide feedback on all aspects of the process from specimen receipt through final reporting and billing. This database uses QA Tracker software to monitor a structured data set of 236 quality indicators in real time that can also be aggregated for review in a weekly management meeting to identify trends.
- A program of ‘handoffs and transitions’ to maximize communication and minimize errors in anatomic pathology specimen preparation and results reporting. Maximizing patient safety through clear communication is a top priority in any healthcare setting.
- Reports to speed up and improve referral processes in rheumatology at Harris Health. Reports are placed in the patients’ charts and communicated to primary care providers via electronic messages to their personal baskets. Results include increased patient satisfaction and fewer unnecessary tests.
- An elective 20-hour course to medical students on how to use the clinical laboratory. The aim of the course has been to show them how to properly select laboratory tests and understand how to interpret the results.
- A Molecular Tumor Board (MTB) for patient selection and assessment of treatment options. Results suggest that their detection of actionable mutations may be higher due to their careful selection, allowing the focused selection of treatment modalities.
- A review of the potential errors in point-of-care testing (POCT) that may have adverse effects to patients that are associated with patients’ healthcare.
- An implementation of eight different stages of automation and 16 separate process improvements or engineering controls that has reduced the incidence of lost specimens nearly 100-fold.
- A standardization of anatomic pathology reports and automation of grossing templates for common submitted samples.
- An experiment to prove how problematic interpreting laboratory reports, particularly molecular data, can be.
- Inter-professional simulations that allow for students and professionals from many backgrounds to practice teamwork and communication, designed by experts at the University of Alabama.
The American Society for Clinical Laboratory Science provides dynamic leadership and vigorously promotes all aspects of clinical laboratory science practice, education, and management to ensure excellent, accessible, and cost-effective laboratory services for healthcare consumers. The ASCLS formed the Patient Safety Committee, and together began educating its members about their role in patient safety. Staff then realized that laboratorians had been operating in a silo, and that errors were occurring due in part to a lack of understanding about the nuances of laboratory testing.
The ASCLS created educational brochures for patients and families to have the information necessary to have a meaningful conversation with their clinicians, and to teach people how to collect quality samples so that pre-analytical errors don’t impact the diagnosis. The organization developed content not only on appropriate testing, but also on factors that can negatively impact quality results and the correct interpretation of those tests. For example, some dietary supplements or prescriptions can interfere with laboratory testing methods and produce an erroneous result, which has the potential to end in a diagnostic error. To date, ASCLS has developed 14 brochures, all of which are available for download.
Read ASCLS’s ACT Update feature, “Moving Out of the Laboratory Silos,” on developing patient safety tools and educational materials for laboratorians as well as patients and providers.
Federal Liaisons
The Agency for Healthcare Research and Quality’s (AHRQ) Center for Quality Improvement and Patient Safety (CQuIPS) works to improve the quality and safety of the healthcare system through research and implementation of evidence. CQuIPS conducts and supports user-driven research on patient safety and healthcare quality measurement, reporting, and improvement.
AHRQ routinely includes patients and family members in the development of its products. The agency’s focus on broad strategies and its ongoing relationships with patients, clinicians, and researchers has led to widespread implementation of its products. The agency has hundreds of Impact Case Studies that detail what has been achieved with the use of its tools, resources, and data.
Read AHRQ’s ACT Update feature, “A Federal Agency’s Role in Improving Diagnosis,” on their Center for Quality Improvement and Patient Safety (CQuIPS) and the tools they have developed to improve the diagnostic process and safety within healthcare systems.
What ACTion Are You Taking?
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The Coalition to Improve Diagnosis, convened and led by SIDM, is a collaboration of more than 60 leading healthcare organizations focused on ensuring that diagnoses are accurate, communicated and timely.
Coalition Member Features
Want to learn more about members of the Coalition to Improve Diagnosis? Check out our monthly ACT Update Newsletter for member spotlights, event highlights, and the latest developments in the field.