Overview

Diagnostic errors affect an estimated 12 million Americans each year, and most likely cause more harm to patients than all other medical errors combined.

This three half-day virtual conference will highlight the alarming impact diagnostic error has on patients, residents, care teams and organizations. It will energize teams to identify opportunities for improving diagnostic processes in their own organization by sharing best practices and successes from industry experts. Additionally, it will highlight the importance of communication when a harm event does occur.

Who should attend?

Executive leaders, physicians, administrators, patient safety/risk personnel, system engineers, quality leaders and practice leaders from hospitals, clinics, senior living and long-term care organizations.

There is no registration fee for this conference.

Participants will have the opportunity to join a new collaborative dedicated to improving the diagnostic process; a year-long group whose focus will be on reduction in patient harm and the subsequent financial burdens, while supporting the implementation of new strategies and shared experiences.

To register:

First-time users will need to create an iCompass Academy account.

  • Requests to join the Academy will be approved immediately
  • New registrants will receive an email with login instructions
  • After logging in, navigate to the Events tab, select Working Together to Improve Diagnosis and select Take Course to complete your registration. You will receive a registration confirmation email.

Speakers

Agenda

8:30 – 9:45 AM 
KEYNOTE: DEFINING THE LANDSCAPE AND SETTING THE AGENDA FOR DIAGNOSTIC ERRORS: WHAT WILL IT TAKE TO ACHIEVE DIAGNOSTIC EXCELLENCE

David Newman-Toker, Director, Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins Medicine, Baltimore, MD 

Diagnostic errors are almost certainly the most common, most costly and most catastrophic of medical errors. Despite this, they were largely ignored for the first two decades of the patient safety movement era. Over the past five years since the publication of the National Academy of Medicine report on Improving Diagnosis in Healthcare, this has finally begun to change. In this session, the speaker will review the scope of the problem, the complexity of causes and the need for multi-faceted solutions at provider, organizational and system levels.

  • Summarize the public health burden and financial impact of diagnostic error and misdiagnosis-related harms.
  • List common causes and prioritize targets for diagnostic error reduction and quality-improvement initiatives.
  • Discuss solutions at provider, organizational and system levels that can contribute to diagnostic excellence.
10:00 – 11:00 AM
EXPLORING SOLUTIONS TO ADDRESS DIAGNOSTIC ERROR

Dana Siegal, RN, CPHRM, CPPS, Director, Patient Safety Services, CRICO Strategies, Boston, MA

Diagnostic errors are typically driven by two primary causes: cognitive failures and system failures. In this session, Dana Siegal will share national Medical Professional Liability (MPL) claims data illustrating the prevalence of these challenges in diagnostic error cases, and present solutions to both sources of error, including raising awareness regarding cognitive biases and highlighting decision support tools to aid in this process. She will also present systems-based solutions for closing loops in referral and test result management processes. 

  • Identify primary cognitive- and systems-based drivers of diagnostic error.
  • Discuss the burden of those drivers on providers and care teams through the lens of medical professional liability claims.
  • Identify specific solutions to address cognitive- and system-based drivers of diagnostic error.
11:15 AM – 12:00 PM 
THE EMOTIONAL AND ORGANIZATIONAL COST OF HARM

Julia Prentice, PhD, Research Director, Betsy Lehman Center for Patient Safety, Boston, MA 

Medical error can have significant emotional, financial, physical and socio-behavioral impacts, including reduced healthcare trust and avoidance. The Massachusetts Betsy Lehman Center for Patient Safety fielded a statewide survey to increase their understanding of how patients and families experience medical error. This session will review the data examining the long-term impact of medical error, discuss the relationship between open communication and long-term impacts and identify current tools for communication and resolution best practices.

  • Identify long-term risks of medical error including emotional harm and 
  • healthcare aversion.
  • Assess the impact of transparent communication about the medical error on long-term risks.
  • Identify available communication and disclosure tools. 
8:30 – 9:45 AM 
KEYNOTE: THE POWER OF PARTNERSHIP:  HOW PATIENTS CAN – AND DO – PARTNER TO IMPROVE DIAGNOSIS IN MEDICINE

Suzanne Schrandt, Senior Engagement Advisor, Society to Improve Diagnosis in Medicine, Evanston, IL

This session will describe current practices in patient engagement to improve diagnosis in medicine. Patients, particularly those who have been affected by a diagnostic error, have a critical role to play in eliminating diagnostic error through research, policy, patient education and quality improvement. Drawing from their lived experience, patient partners can provide insights that no one else in the healthcare ecosystem can. Appropriately involving and facilitating the involvement of patient partners can yield important gains in this critical work.

  • Describe the concept of patient engagement and how patients are/have been involved as partners in various facets of the healthcare ecosystem.
  • Give tangible examples of the impact patient partners have had on changing the diagnostic error landscape in research, policy and care delivery.
  • Identify tips and tools available, including those that SIDM offers, for learners to use as they work to engineer patient engagement solutions in their work.
10:00 – 11:00 AM 
CANDOR: NORMALIZING COMPASSIONATE HONESTY AFTER UNEXPECTED HARM

Timothy McDonald, MD, JD, Chief Patient Safety and Risk Officer, RLDatix, Chicago, IL Professor of Law, Loyola University and Bruce Lambert, PhD, Professor, Department of Communication Studies, Director, Center for Communication and Health, Northwestern University, Evanston, IL

Candor is a powerful tool that works to maintain open and honest communication with patients and families after an unintended harm event occurs. During this highly experiential session, attendees will learn about the evolution of approaches to the response to patient harm. Empathic and honest communication including the disclosure of mistakes or errors if they have occurred will be discussed. Attendees will also gain a clearer understanding of issues surrounding the emotional angst for members of the care team. 

  • Outline ways to coach a healthcare team through the critical phases of the open communication process.
  • Discuss how to provide initial emotional first aid to clinicians following an adverse medical event.
  • Develop a comprehensive approach to patient harm that includes care for the caregiver.
  • Describe the approach to determining appropriateness of care following patient harm events.
  • Describe the comprehensive, principled and systematic approach to harm from event through resolution.
11:15 AM – 12:00 PM
PANEL DISCUSSION: EVOLUTION OF APPROACHES TO PATIENT HARM HEAL/CANDOR

Moderator: Tom Evans, MD, FAAFP, President and CEO, Iowa Healthcare Collaborative, Des Moines, IA

Panelists: Timothy McDonald, MD, JD, Chief Patient Safety and Risk Officer, RLDatix, Chicago, IL, Professor of Law, Loyola University, Chicago, IL; Bruce Lambert, PhD, Professor, Department of Communication Studies, Director, Center for Communication and Health, Northwestern University, Evanston, IL; Shelly Davis, JD, BSN, Director of Early Intervention, Constellation, Minneapolis, MN and Laurie Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation, Minneapolis, MN

This panel discussion will focus on the evolution of approaches to the response to patient harm. Honest communication including the disclosure of mistakes or errors if they have occurred and the support that clinicians and patients need after a diagnostic error leads to a harm event will be discussed. Panel members will bring patient and clinician perspectives after a diagnostic error leads to a harm event. They will also share what brought them to the work on CRP programs and consider ways to move forward after a harm event. 

  • Discuss what brought the panel members to work on CRP programs.
  • Describe how this work is making a difference for patients, residents, their families, care teams and organizations.
8:45 – 9:45 AM 
KEYNOTE: FROM PRINCIPLE TO PRACTICE: HOW COMMUNICATION, PATIENT ENGAGEMENT, AND LEARNING CAN PREVENT AND RESPOND TO DIAGNOSTIC ERRORS

Thomas H. Gallagher, MD, Professor, Department of Medicine, Professor, Department of Bioethics and Humanities, University of Washington, Seattle, W

Experts on improving diagnosis in medicine have long recognized the important role that effective communication, patient engagement and learning can play in preventing diagnostic errors. Communication and Resolution Programs (CRP) are similarly emphasizing how transparent communication, collaboration with patients and families and accountable learning are critical to responding when care has gone awry. Bringing the Improving Diagnosis and CRP communities together could enhance the effectiveness of both streams of work. Yet both fields also suffer from the challenges of turning these principles into highly reliable practices. This presentation will review how the integration of concepts around improving diagnosis, high reliability and CRP can substantially accelerate the progress of these critical and related areas.

  • Describe the common barriers that hinder turning principles of improving diagnosis and CRP into highly reliable practice.
  • Recognize how a focus on communication, patient engagement and learning can facilitate the success of efforts both to prevent and respond to diagnostic errors.
  • Summarize how learning collaboratives and new tools can accelerate progress in both the improving diagnosis and CRP fields.
10:00 – 11:00 AM 
FOLLOW-UP SYSTEM FAILURES: STOP DROPPING THE BALL 

Laurie C. Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation, Minneapolis, MN; Missy Lindow, Director of Clinic Operations and Access, Lakewood Health System, Staples, MN; Mary Theurer, Lakewood Health System Board, Staples, MN and Andrew Olson, MD, Associate Professor, University of Minnesota Medical School

Follow-up system failures contribute to over half of Constellation’s outpatient diagnostic error malpractice claims. Even when appropriate clinical steps are taken to lead to a correct diagnosis, diagnostic errors due to failures in follow-up and care coordination still persist. This session will provide an overview of Constellation’s malpractice claim data and how Lakewood Health System used co-design to create a new process with community members and patients to minimize the possibility of test result follow-up system failures upon discharge from the emergency department. 

  • Discuss the causes and contributing factors of breakdowns in diagnostic care processes and follow-up systems that lead to patient injury, malpractice claims and poor business performance.
  • Examine Lakewood Health System’s experiences and learned best practices in engaging with a rural community to gather input as they developed new workflow processes for test results communications.
  • Identify Lakewood Health System’s operational point of view on co-designing new workflow processes. 
11:15 AM – 12:00 PM 
TAKING ACTION TO CLOSE THE LOOP ON DIAGNOSTIC ERROR: A CONSTELLATION AND SIDM COLLABORATIVE

Gerry Castro, MPH, Quality Improvement Program Manager, Society to Improve Diagnosis Medicine, Evanston, IL

The Collaborative is a joint effort of Constellation and the Society to Improve Diagnosis in Medicine (SIDM) focused on improving the diagnostic process during two of the three key stages of the diagnostic process; tests and results processing and follow-up and coordination. This session will provide information and details for organizations interested in improving the diagnostic process in their community. 

  • Recognize that almost half of diagnosis-related malpractice claims involve test follow-up system failures and that accurate and timely diagnosis depends nearly as much on the healthcare team and systems as it does on the diagnosticians themselves.
  • Identify how to join the Constellation and SIDM Collaborative to work on a diagnostic process quality improvement project via an expert-led virtual community.

Taking Action to Close the Loop on Diagnostic Error Collaborative

This virtual Collaborative is a joint effort of Constellation® and the Society to Improve Diagnosis in Medicine (SIDM) focused on improving the diagnostic process during two of the three key stages; tests and results processing and follow-up and coordination.

What is the Collaborative?

The Collaborative is a virtual community managed by SIDM to share work, update on progress, raise questions, and join conversations improving the diagnostic process and reducing preventable harm.

Who should join the virtual Collaborative?

Clinic, hospital, or health system teams interested in improving the diagnostic process in your organization. Quality improvement (QI) teams could include physicians, quality and safety leaders, department managers, nursing, lab or HIT personnel.

When?

This is a year-long Collaborative.

  • Space is limited; Apply by May 7, 2021
  • Kick-off meeting & intro calls: Week of June 1, 2021

How?

Submit an email to Collaborative@ConstellationMutual.com. Early applicants will be given priority as space is limited.

Cost for participation in the Collaborative is valued at $2,000. Due to the financial constraints on health care organizations in the COVID-19 environment, Constellation is now waiving the fee for participation.