HRO and Dx Mark Graber and Michael Crossey High Reliability and Diagnosis Panel 1 // March 6, 2014 // 2:30-3:45 pm Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 1
Diagnosis and High Reliability Mark L Graber MD FACP Senior Fellow, RTI International Professor Emeritus, SUNY Stony Brook School of Medicine Founder and President, Society to Improve Diagnosis in Medicine www.improvediagnosis.org Michael J Crossey MD PhD Executive Medical Director, TriCore Reference Laboratory CE Disclosure In compliance with the ACCME/NMMS Standards for Commercial Support of CME Mark Graber MD FACP has been asked to advise the audience that he has no relevant financial relationships to disclose or does have relevant financial relationships to disclose which he will disclose here. Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 2
Diagnosis and High Reliability Is diagnosis a high reliability process? What is the reliability of diagnostic support services - The clinical lab and radiology? How can diagnosis achieve higher levels of reliability? Adapting High Reliability Science to Healthcare Leadership commits to the ultimate goal of 0 patient harm Incorporation of all the best principles and practices of a safety culture throughout the organization Widespread adoption and deployment of the most effective process improvement tools and methods High Reliability Health Care Getting There from Here. MR Chassin and J Loeb. Milbank Quarterly 2013. 91:459-490 3
Demonstrating High Reliability on Accountability Measures at The Johns Hopkins Hospital. Pronovost et al. Jt Com Jl Qual Pt Safety Dec 2013 Diagnosis is HARD! PATIENT VARIABLES Stage of disease How it manifests How it is perceived How it is described When help is sought SYSTEM COMPLEXITY Disjointed care Communication barriers Production pressure Tight coupling Access to care & expertise PHYSICIAN VARIABLES Knowledge and experience Access to patient data, tests, consults Skill in clinical reasoning Stress, distractions, mood, time to think 4
How Many Diseases are There? World Health Organization: ICD 1 1893 161 ICD 8 1965 1000+ ICD 9 1979 8000? ICD 101999 12,420 NLM: 8000 MESH terms Growing at 200+/year Estimates of the Diagnostic Error Rate Expert guess Arthur Elstein: 10-15% Patient Surveys Second reviews Standard Patients Look backs Chart review Autopsies One third of patients relate a Dx error that affected themselves, a family member, or close friend Radiology: 10-30% of breast cancers missed Pathology: 1-2% of cancers misread Internists misdiagnosed 13% of patients presenting with common conditions to clinic (COPD, RA, others) Dissecting AAA: 39% delayed diagnosis Cervical cancer: 25-50% of last nl PAP are abnl 1 visit/1000 associated with a dx error and the likelihood of serious harm Major unexpected discrepancies that would have changed the management are found in 10-20% 5
US The toll of Dx Error Your Hospital 40,000 80,000 deaths/yr 1 in 1000 primary care visits involves a preventable dx error causing harm Error-related Harm 10 deaths every year 1 patient harmed every other day in your clinics or ER Diagnostic Error Leape et al. JAMA 288:2405, 2002 Singh et al. BMJ Qual Safety 21: 93-100, 2012 Root Causes of Diagnostic Error 100 cases 535 root causes Graber et al. Arch Int Med 165:1493-9, 2005 BLUNT end SYSTEM Communication, coordination, training, policies, procedures, access to expertise SHARP end Me Patient s Clinical Course Cognitive 6
Error in the Diagnostic Process DIAGNOSTIC ERROR (Wrong, missed & delayed diagnosis) No Fault Causes Silent disease Too early; atypical Patient misleads us Patient doesn t f/u Inconsequential HARM History Physical Exam Hypotheses, Synthesis Tests, Consults Follow Up HARM 7
Breakdowns in the Diagnostic Process Process Step Incidence of Errors Dx testing (lab and radiology) 44% Assessment 32% H&P 10% Referral and consultation 10% Follow-up 10% Schiff et al. 2009; Diagnostic Error in Medicine - Analysis of 583 physician-reported erros. Archives Int Med 169:1881-7 High Reliability Someone owns the process The pieces are integrated Top priority is safety Equivalent actors Performance is predictable Measurement is king Culture: Resilient, safety oriented Results: Six Sigma Diagnosis No one owns the process Independent systems Top priority is fiscal responsibility Independent actors Performance is variable Measurement doesn t exist Culture: Results: One or Two Sigma** DIAGNOSTIC ERROR RATE Medicine, Peds, ER: 10% Radiology: 2-4% Clinical Lab: Analytical phase: Pre- and Post-analytical phases: <0.001% errors 10% errors 8
Diagnostic Error: Reducing Its Impact Through Improving Reliability t r i c o r e. o r g CE Disclosure In compliance with the ACCME/NMMS Standards for Commercial Support of CME Michael Crossey MD PhD has been asked to advise the audience that he has no relevant financial relationships to disclose or does have relevant financial relationships to disclose which he will disclose here. Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 9
A) Correct Diagnosis = Correct Care B) Correct Care = Quality Care C) Quality Care + Safe, Efficient, Cost Effective tricore.org 19 Why The Laboratory? - Lab cost are low, 2-3% of Medicare spend - 60-70% of diagnostic decisions are driven by laboratory results tricore.org 20 10
History Physical Exam Hypotheses, Synthesis Tests, Consults Follow Up Diagnostic Error Diagnosis How to keep patients safe in a complex environment? External Forces tricore.org 22 11
How to keep patients safe in a complex environment? Internal Forces tricore.org 23 How to keep patients safe in a complex environment? tricore.org 24 12
1) Simplify where we can 2) Integrate where we can t simplify tricore.org 25 Do s and Don ts tricore.org 26 13
The Lab Do Don t Simplify the lab ordering process disease state List every test by test name tricore.org 27 The Lab Do Don t Take ownership of the pre-analytic phase Maintain silos tricore.org 28 14
The Lab Do Don t Create interpretive reports Generate data tricore.org 29 As a System Do Don t Put patient safety as a line item on every Hospital Committee P&T, MIC, IC, CPC Create a new patient Safety Super Committee tricore.org 30 15
- Complex patient care requires a team effort - Team efforts require a shared goal with clearly defined strategy and tactics tricore.org 31 What can I do to reduce Dx error? Physicians, NP s, PA s Nurses Labs Healthcare organizations Patients Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 16
Sdkljfgaskjfha;hfas;dhfa s;dflknasd;lfksdfl kasdf lasdkjfas;djfasd l;fksld/ kfj asdjasd jasd Questions? Mark Graber: mgraber@rti.org Michael Crossey: Michael.crossey@tricore.org Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety Collective of the Southwest (PSCS). March 6-7, 2014; Albuquerque, NM 17