Organizing for Action

There was no immediate crisis at Caribou Memorial Hospital in Soda Springs, Idaho. But the small critical access hospital wanted to improve and tighten up procedures and processes around diagnostic error anyway.
Becky Bybee, Caribou’s Senior Administrator of Quality and Regulatory Governance, first raised the idea of improvements in 2020 with Caribou CEO Christina Thomas.
Bybee had experienced being both an employee of and a patient at Caribou. A misread EKG had led to needless tests and procedures that caused her to worry about her own health and that took significant time and resources. In addition, Bybee’s mother had been a lung cancer patient whose radiology test results were once delayed. Bybee’s family had learned firsthand that getting results quickly might not change the outcome of a fatal disease, but it can give loved ones more time to gather and prepare in the face of dire news.
Bybee, an RN with a master’s degree in health care law, was able to communicate to her CEO the personal toll of diagnostic harm events and express the patient-centered need to lessen their occurrence. In this way, she drove both empathy and action at Caribou.
To start, Bybee and Thomas approached the hospital’s Director of Quality, Gavin Hyde, and asked how they could get their arms around the issue of delay in results for diagnostic testing and help everyone understand its importance.
“With being a critical access facility and our size, we don’t get a lot of claims, so there wasn’t a lot we could pull for,” Hyde said. Still, he agreed it was an area the hospital should pursue. 

Diving into the numbers
In an analysis of malpractice claims, Constellation found diagnostic error to be the most costly and third-most frequent allegation made against the organizations it insures. More than half of diagnostic harm events in the outpatient setting involve failures in follow-up systems and care coordination. For patients to receive timely and accurate diagnoses, they need not only skilled diagnosticians, but also systems that make communication of results and means of care coordination with patients easy to achieve.
“Diagnostic errors are one of the most important safety problems to address in the health care industry right now. They are found in 10%–20% of autopsies. That means 40,000 to 80,000 people die each year from diagnostic errors,” said Jan Mangun, a Quality Improvement Consultant with the Society to Improve Diagnosis in Medicine (SIDM). SIDM is the only nonprofit organization in the nation that is solely focused on reducing diagnostic error to improve patient outcomes. Constellation has partnered with SIDM, and through that partnership has been working directly with Caribou on a yearlong quality improvement project.
At Caribou, a group of about two dozen people—made up of everyone from executives to frontline staff and across clinical and nonclinical areas—took Constellation’s online diagnostic error risk assessment. The assessment asked them to rate how the hospital was doing on policies, procedures and systems related to the diagnostic process and communicating with patients. Then, Hyde said, he, Bybee and Thomas went through the results in search of the biggest potential trouble spots.
“That triggered our first audit,” Hyde explained. “We created an internal auditing program. For the top three areas, that is, the top three questions that turned up the highest risk, we decided those would be what our internal audit would address.”
They zeroed in on emergency department (ED) test results and follow-up processes; preoperative testing and result processing; and telephone triage. Caribou staggered its work, focusing on each area in turn throughout the year. (The work in telephone triage, delayed in part because of short staffing due to the COVID-19 pandemic, is ongoing.)

Leaning into change
First up: the ED. Caribou’s Internal Auditor, Sherie Alvari, started by reviewing patient medical records, then gathered her findings and presented them to a group, including the executive team. Next, Hyde, Bybee and stakeholders in the ED created a plan of action to address all 10 of Alvari’s findings.
Alvari signed off on the plan, which addressed variations in processes and took on tasks such as updating policies and standardizing procedures for communicating critical diagnostic results. The plan included training staff on new procedures. And the group monitored and measured their progress, asking: “Are we doing what we said we would do?” “Are we getting the results we aimed for?”
“For example,” Hyde said, “the internal audit showed we didn’t have a great process for care transition after diagnostic testing. We recognized that we have patients come into the ED, and they get radiology or lab tests, and it’s serious. Once they’re discharged, there’s not a great continuity of care from the ED to their care provider. Because of our action plan, now we make sure within the next business day that we’re notifying the patient’s primary care provider of the ED stay. That gives the primary care provider the opportunity to schedule an appointment with the patient.”
The new process makes sense from a patient-centered care standpoint, Hyde said. “If you’re coming to the ED, you likely have something serious enough that you should follow up with your primary care provider.”
Chart audits show that 90% of the time since the new process started, appropriate transition of care and follow-up has happened.
“That’s a big success for us,” Hyde noted. “Before, we left it to the patient to follow up with their doctor. When we take the more proactive approach on our end—we understand patients’ lives are so busy or maybe they don’t understand the seriousness of the situation—that gives the primary care doctor the opportunity to reach out to the patient.”
So far, of the 20 findings from two areas addressed by action plans, 16 have been successfully addressed, Hyde said.
Part of that success has come through working with SIDM and Constellation. Their joint quality improvement (QI) initiative, known as the Collaborative, brought different health care facilities of various sizes and from different parts of the country together in regular virtual meetings to talk about problems and solutions for closing the loop on diagnostic error. SIDM also offered support, such as bringing in an IT expert to address problems the organizations were having in getting good data. That helped spark a realization that IT personnel should be part of their QI teams.
“The Collaborative addressed a combination of quality improvement and risk management—managing risk associated with diagnostic errors by improving quality processes that help to reduce the imperfections, and uncover where the gaps are that are causing diagnostic error to happen,” Mangun said.
At Caribou, the team tasked with bringing about change found camaraderie, support and ideas during their SIDM calls. Getting to see how other organizations were approaching the same issue helped Hyde and his colleagues see through a different lens, he said. “We were kick-starting things we might never have thought of on our own. It was helpful to share ideas. … Each call was like a mini-conference.”

Next steps
Looking toward the future, Mangun is thinking about sustainability. “Making change is one thing,” she said, noting that Caribou was already well-versed in the change process and what QI requires. “Integrating change so it becomes rote is a whole different challenge.”
Plus, change is part of a never-ending cycle, as new ideas or methods require new ways of working, and progress requires maintenance. Just as one area meets goals for improvement, another will need to tackle its own set of problems. So, even as goals are met, more appear on the horizon.
For Hyde, the benefit of tackling big change before a problem occurs reaches deep into the organization.
“I think this internal audit process has improved our collaboration internally,” he said. “In the past, we worked in silos. Being able to look at issues proactively has brought our broader team together. We are more likely to see similarities in areas we might not have known about before, and to bring up strategies to help one another.”
Ultimately, teams at Caribou working together can help reduce the incidence of diagnostic error in the future—and this helps patients, senior living residents and their families as well.
“Through this process, we’ve created a mindset of constant improvement,” Hyde said. SUE CAMPBELL Freelance health care writer and editor