Improving Diagnosis in Health Care
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- Priscilla Webster
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1 WATER SCIENCE AND TECHNOLOGY BOARD Improving Diagnosis in Health Care
2 The IOM Quality Chasm Series
3 Committee Members JOHN R. BALL, MD, JD (Chair) American Society for Clinical Pathology and American College of Physicians, Emeritus ELISABETH BELMONT, JD MaineHealth ROBERT A. BERENSON, MD The Urban Institute PASCALE CARAYON, PhD University of Wisconsin Madison CHRISTINE K. CASSEL, MD National Quality Forum CAROLYN M. CLANCY, MD Department of Veterans Affairs MICHAEL B. COHEN, MD University of Utah School of Medicine PATRICK CROSKERRY, MD, PhD, FRCP (Edin) Dalhousie University THOMAS H. GALLAGHER, MD University of Washington CHRISTINE A. GOESCHEL, ScD, MPA, MPS, RN, FAAN MedStar Health MARK L. GRABER, MD RTI International HEDVIG HRICAK, MD, PhD Memorial Sloan Kettering Cancer Center ANUPAM B. JENA, MD, PhD Harvard Medical School ASHISH K. JHA, MD, MPH Harvard School of Public Health MICHAEL LAPOSATA, MD, PhD University of Texas Medical Branch at Galveston KATHRYN MCDONALD, MM Stanford University ELIZABETH A. MCGLYNN, PhD Kaiser Permanente MICHELLE ROGERS, PhD Drexel University URMIMALA SARKAR, MD University of California, San Francisco GEORGE E. THIBAULT, MD Josiah Macy Jr. Foundation JOHN B. WONG, MD Tufts Medical Center IOM Staff Erin Balogh Study Director Bryan Miller Sarah Naylor Kathryn Ellett Celynne Balatbat Patrick Ross Laura Rosema Beatrice Kalisch Patrick Burke Roger Herdman Sharyl Nass
4 Study Sponsors Agency for Healthcare Research and Quality American College of Radiology American Society for Clinical Pathology Cautious Patient Foundation Centers for Disease Control and Prevention College of American Pathologists The Doctors Company Foundation Janet and Barry Lang Kaiser Permanente National Community Benefit Fund at the East Bay Community Foundation Robert Wood Johnson Foundation
5 Study Charge Evaluate diagnostic error as a quality of care challenge Examine the epidemiology, burden of harm, economic costs of diagnostic error, and current efforts to address the problem Propose solutions and devise recommendations for stakeholders on topics such as: Clarifying definitions Education and cognitive processes Culture, teamwork, and systems engineering Health IT Measurement Research Payment and medical liability
6 Key Report Themes Diagnostic errors are a significant and underappreciated health care quality challenge Patients are central to the solution Diagnosis is a collaborative effort
7 Areas for Improvement Education and training Health IT Research Identification and learning Work system and culture Collaboration Areas where more evidence is needed Payment Medical liability Measurement for accountability
8 Getting the right diagnosis is a key aspect of health care: it provides an explanation of a patient s health problem and informs health care decisions Yet Diagnostic errors persist through all settings of care and harm an unacceptable number of patients In every research area, diagnostic errors were a consistent quality and safety challenge
9 It is likely that most of us will experience at least one diagnostic error in our lifetime, sometimes with devastating consequences.
10 Committee s Conceptual Model Definition of Diagnostic Error Overview of the Diagnostic Process Work System Factors that Influence the Process Outcomes from the Diagnostic Process
11 Definition of Diagnostic Error The failure to: (a)establish an accurate and timely explanation of the patient s health problem(s) or (b) communicate that explanation to the patient
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15 Identifying and learning from diagnostic errors is important, but a sole focus on reducing diagnostic errors will not achieve the extensive change that is necessary. A broader focus on improving diagnosis is warranted.
16 8 Goals to Improve Diagnosis and Reduce Diagnostic Error GOAL 1 GOAL 2 GOAL 3 GOAL 4 Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families Enhance health care professional education and training in the diagnostic process Ensure that health information technologies support patients and health care professionals in the diagnostic process Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
17 8 Goals to Improve Diagnosis and Reduce Diagnostic Error GOAL 5 GOAL 6 GOAL 7 GOAL 8 Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses Design a payment and care delivery environment that supports the diagnostic process Provide dedicated funding for research on the diagnostic process and diagnostic errors
18 GOAL 1 More effective teamwork in the diagnostic process
19 RECOMMENDATION 1 1A: Health care organizations should ensure that health care professionals have the appropriate knowledge, skills, resources, and support to engage in teamwork in the diagnostic process. This includes: Interprofessional and intraprofessional teamwork. Collaboration among pathologists, radiologists, and treating health care professionals to improve diagnostic testing.
20 RECOMMENDATION 1 1B: Health care professionals & organizations should partner with patients and their families as diagnostic team members. They should: Create environments where patients and their families can learn and engage in the diagnostic process and share feedback and concerns. Ensure patient access to EHRs, including clinical notes and diagnostic testing results. Include patients and their families in efforts to improve the diagnostic process.
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22 GOAL 2 Enhance health care professional education and training in the diagnostic process
23 RECOMMENDATION 2 2A: Educators should ensure that curricula and training programs across the career trajectory address performance in the diagnostic process and include evidence from the learning sciences: Clinical reasoning Teamwork Communication Diagnostic testing Health IT 2B: Certification and accreditation organizations should ensure that health care professionals have and maintain these competencies.
24 GOAL 3 Ensure that health information technologies support patients and health care professionals in the diagnostic process
25 RECOMMENDATION 3 3A: Health IT vendors and ONC should work together with users to ensure that health IT used in the diagnostic process: Demonstrates usability Incorporates human factors knowledge Integrates measurement capability Fits well within clinical workflow Provides clinical decision support Facilitates the timely flow of information among patients and clinicians
26 RECOMMENDATION 3 3B: ONC should require health IT vendors meet standards for interoperability by C: The Secretary of HHS should require health IT vendors to: Submit products for independent evaluation Notify users about adverse effects on the diagnostic process related to product use. Support the free exchange of information about user experiences with health IT used in the diagnostic process.
27 GOAL 4 Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
28 RECOMMENDATION 4 4A & 4B: Accreditation organizations and the Medicare Conditions of Participation should require that health care organizations: Monitor the diagnostic process Identify, learn from, and reduce diagnostic errors and near misses. Provide systematic feedback on diagnostic performance to health care professionals, care teams, and clinical and organizational leaders
29 RECOMMENDATION 4 4C: HHS should provide funding for a designated subset of health care systems to conduct routine postmortem examinations on a representative sample of patient deaths. 4D: Health care professional societies should identify opportunities to improve accurate and timely diagnoses and reduce diagnostic errors in their specialties.
30 GOAL 5 Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
31 RECOMMENDATION 5 5: Health care organizations should: Promote a non-punitive culture that values open discussion and feedback on diagnostic performance. Design the work system to support patients, their families, and health care professionals in the diagnostic process. Ensure effective and timely communication between diagnostic testing health care professionals and treating health care professionals across all health care settings.
32 GOAL 6 Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses
33 RECOMMENDATION 6 Reporting 6A: AHRQ or others should encourage and facilitate the voluntary reporting of diagnostic errors and near misses. 6B: AHRQ should: Evaluate the effectiveness of PSOs as a major mechanism for voluntary reporting and learning from diagnostic errors and near misses Modify the PSO common formats to include diagnostic errors and near misses.
34 RECOMMENDATION 6 Medical Liability & Risk Management 6C: States and others should promote a legal environment that facilitates timely identification, disclosure, and learning from diagnostic errors. Adoption of Communication and Resolution Programs Demonstration projects of alternative approaches to the resolution of medical injuries Administrative health courts Safe harbors 6D: Professional liability insurers should collaborate with health care professionals to improve diagnosis through education, training, and practice improvement.
35 GOAL 7 Design a payment and care delivery environment that supports the diagnostic process
36 RECOMMENDATION 7 7A & 7B: CMS and other payers should: Provide coverage for evaluation and management (E&M) activities, including time spent by pathologists, radiologists, and others in advising clinicians on diagnostic testing. Reorient relative value fees to more appropriately value the time spent with patients in E&M activities. Modify documentation guidelines to improve the accuracy of information in the EHR and to support decision making in diagnosis. Assess the impact of payment and care delivery models on the diagnostic process & diagnostic error.
37 GOAL 8 Provide dedicated funding for research on the diagnostic process and diagnostic errors
38 RECOMMENDATION 8 8A: Federal agencies (HHS, VA, and DOD) should: Develop a coordinated research agenda on the diagnostic process and diagnostic errors by the end of Commit dedicated funding for implementation. 8B: The federal government should pursue and encourage opportunities for public private partnerships among a broad range of stakeholders to support research on the diagnostic process and diagnostic errors, such as: PCORI Foundations Diagnostic testing and health IT industries Health care organizations Professional liability insurers
39 Improving the diagnostic process is not only possible, but it also represents a moral, professional, and public health imperative. Achieving this goal will require a significant re-envisioning of the diagnostic process and a widespread commitment to change.
40 To download the report and view more resources, visit: nas.edu/improvingdiagnosis
41 Video featuring patient experiences with diagnosis
42 Communication Resources
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45 Dual Process Theory and Diagnosis
46 Feedback on Diagnostic Performance and Calibration
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