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Coalition tackling diagnostic errors gains some traction

Diagnostic errors are one of the most common mistakes in medicine, affecting 1 in 20 adults, according to research published in BMJ. They were also the leading cause of malpractice claims, accounting for about 29% of total suits from 1986 to 2010. Despite the prevalence of such errors, more attention has been paid to other types of clinical mistakes, such as central line and other healthcare-acquired infections.

Health system quality leaders say part of the reason for that is because research is not plentiful, and awareness about the issue is relatively thin. Although the 1999 landmark report To Err is Human mentions diagnostic errors, it doesn’t say much about how to address the problem, and the National Academies of Sciences didn’t publish a stand-alone report on the issue until 2015. The report lays out goals for the industry to improve diagnostic accuracy such as ensuring that technology supports patients and clinicians in the diagnostic process.

But growing cost pressures are another big motivator for health systems to increase the focus on reducing diagnostic errors. The costs associated with additional tests and delays in treatment are difficult to value, but over a 25-year period malpractice claims due to diagnostic errors alone totaled $38.8 billion, according to a 2013 study published in BMJ.

“The wrong diagnosis leads to delays in treatment and increases cost of care,” said Dr. Mark Jarrett, chief quality officer of Northwell Health in New York. “It (diagnostic errors) puts a burden on the healthcare system as a whole.”

And as hospitals are asked to take on more risk-based contracts, controlling costs is becoming even more essential. “One of the pillars of the healthcare system is value, and value is the quality of care, efficiency of care and the cost of care,” Jarrett said.

To tackle this pressing problem, Northwell along with 46 other healthcare organizations have joined the Coalition to Improve Diagnosis to work together on best practices that address the leading causes of diagnostic errors. The coalition is led by the Society to Improve Diagnosis in Medicine, a not-for-profit organization established in 2011; its leader hopes the society will catalyze standardized practices and solutions to diagnostic errors.

“There are a lot of systematic things that we understand are problems, but we aren’t very good at implementing solutions,” said Paul Epner, CEO and co-founder of the SIDM. “In terms of having standard solutions, we are early.”

The SIDM established a similar coalition in 2015 with 14 organizations, and re-energized the effort last September when more than 40 groups opted to join after the coalition received additional funding.

Epner touts the coalition as the only one that focuses solely on diagnostic errors. Along with several health systems including Johns Hopkins Medicine and Geisinger, coalition members include the American Academy of Family Physicians, the ECRI Institute, Leapfrog Group and the National Quality Forum.

The SIDM doesn’t require organizations to pay a fee to be part of the coalition. Instead they must pledge to work on ways to address diagnostic errors. “We didn’t want costs to be a reason for not joining,” Epner said.

All of the organizations have submitted action plans to the SIDM about what they’re doing or plan to do to decrease diagnostic errors. “We know that most organizations would say it’s on their radar screen, but organizations can only cover two or three things well,” Epner said. “We want to change that. We think it belongs in the top three.”

The coalition is largely supported by a $2.45 million grant from the Gordon and Betty Moore Foundation through the end of 2019. The Moore Foundation wanted to help increase awareness about diagnostic errors. “We think this is a new frontier of safety and quality we want to be part of,” said Dr. Daniel Yang, program officer of patient care at the Moore Foundation.

Yang said the foundation’s funding has helped the SIDM establish the coalition including additional support staff and a marketing campaign. The foundation hasn’t yet discussed if it will continue funding the coalition after this year, but Yang said the hope is that the coalition will eventually be self-sustaining.

Epner said he’s hopeful the society will receive more grant funding to continue the coalition after this year.

Right now, the SIDM is checking in with member organizations on their work thus far and planning a structure for the members to share their work and collaborate on any challenges. “We want to be a convener, a partner-maker and a switchboard for this issue,” Epner said.

Barriers to accurate diagnosis

The coalition’s steering committee has identified six barriers to accurate diagnosis: incomplete communication during care transitions; lack of measures and feedback; limited support to help with clinical reasoning; limited time; the complexity of the diagnostic process; and lack of funding for research.

Each coalition member has selected which of the barriers it wants to address.

For instance, Northwell is beginning to develop quality measures to identify and track diagnostic errors.

“We don’t have good metrics for this and that is a major problem. … We need metrics, or we don’t know if we made a difference,” Jarrett said.

Six barriers to diagnostic accuracy Poor communication during care transitions: When patients are transferred between facilities, physicians or departments, there is potential for important information to slip through the cracks.Lack of measures and feedback: There are no standardized measures to understand performance in the diagnostic process, to guide improvement efforts or to report diagnostic errors.Limited support to help with clinical reasoning: Clinicians need timely, efficient access to tools and resources to assist in making diagnoses.Limited time: Providers often report feeling rushed during patient appointments, which impedes their ability to gather a complete history that’s essential to formulating an accurate diagnosis. It’s complicated: There is limited information available to patients about the questions to ask or whom to notify when changes in their condition occur. It’s also often unclear who is responsible for closing the loop on test results and referrals, and how to communicate follow-up.Lack of funding for research: The total impact of inaccurate or delayed diagnoses on healthcare costs and patient harm isn’t clear.Source: The Society to Improve Diagnosis in Medicine
Northwell has assembled a team to develop measures, but it hasn’t made meaningful headway yet because the problem is so complex. “It’s a new science and you don’t want to do it inaccurately—we are a little bit of a distance from seeing the metrics we want,” Jarrett said.

That’s not enough to keep members from trying to improve now. Christine Goeschel, assistant vice president for quality at Columbia, Md.-based MedStar Health, which is also part of the coalition, said the lack of quality measures is the biggest barrier to establishing best practices for better diagnosis, “but that shouldn’t stop us from improving the things that we can see while we are waiting for the best measurement.”

Goeschel said there are improvements that can be made to how clinicians speak with patients about their conditions. Too often, patients aren’t involved enough in their treatment plans or appropriately educated about their conditions, so they are left confused about next steps, which can lead to diagnostic errors, she said.

MedStar is currently leveraging its patient and family advisory councils to understand how clinical staff can better communicate with patients when talking about their diagnosis and treatment plans. “It’s about changing the mindset that it’s the doctor that makes the diagnosis,” Goeschel said. “It comes from communication from all of us. It’s learning from patients and families about what it would look like if their voices were valued.”

Educating teachers

Hospital leaders are trying to change how physician residents are trained to think about the diagnostic process. “We don’t teach physicians clinical reasoning. We don’t tell them about biases that enter into their work. We don’t give them much time to reflect. They get 10 minutes with a patient and half the time they spend documenting,” Epner said.

Physicians can make a wrong diagnosis for many reasons, including personal biases toward patients and conditions or from being overworked.

The ability to make an accurate diagnosis is also a point of deep pride for physicians, so when a mistake does happen, it can be devastating, said Dr. Tim Mosher, chairman of the radiology department at Penn State Health in Hershey, Pa., who helped develop a course at Penn State College of Medicine focused on diagnostic errors. Penn State Health is part of the coalition.

“It hits them to the core. It makes them question, ‘Am I a good physician?’ And that has been a barrier,” Mosher said. “On some of the system errors, we realize there is a workflow process we can design to reduce these errors. But when it’s a cognitive error, that is very personal and it’s going to take a while to work through that.”

Penn State College of Medicine established the elective course last year and roughly 18 students have taken the class so far. Penn is currently petitioning other schools to establish a similar course, Mosher said.

“Our goal is to make the students more aware of the issue of diagnostic errors and being able to develop practices in their own workflow that helps them reduce the harm from diagnostic errors,” he added.

Epner said the SIDM can’t do its work alone. It’s relying on its partners to spread the word about the prevalence of diagnostic errors. And although best practices around the issue are a work in progress, the goal is for every segment of the industry to adopt safeguards to protect against diagnostic errors, he added.

“Every patient deserves an accurate and timely diagnosis for their problem,” Epner said. “It doesn’t matter if they live in a rural area, urban, going to a big hospital or a family clinic; there is nothing that should stop us from providing that. We just have to figure out for every setting what is the best way.”