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7/2/2014
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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
7/2/2014
2
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
7/2/2014
3
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
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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
PHYSICIAN VARIABLES Knowledge and experience
Access to patient data, tests, consults
Skill in clinical reasoning
Stress, distractions, mood, time to think
SYSTEM COMPLEXITY Disjointed care
Communication barriers
Production pressure
Tight coupling
Access to care & expertise
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How Many Diseases are There ?
World Health Organization: – ICD 1 1893 161 – ICD 8 1965 1000+ – ICD 9 1979 8000? – ICD 10 1999 12,420
NLM: 8000 MESH terms
Growing at 200+/year
Estimates of the Diagnostic Error Rate
Expert guess Arthur Elstein: 10 - 15%
Patient
Surveys
One third of patients relate a Dx error that affected
themselves, a family member, or close friend
Second
reviews
Radiology: 10-30% of breast cancers missed
Pathology: 1-2% of cancers misread
Standard
Patients
Internists misdiagnosed 13% of patients presenting with
common conditions to clinic (COPD, RA, others)
Look backs Dissecting AAA: 39% delayed diagnosis
Cervical cancer: 25-50% of last nl PAP are abnl
Chart review 1 visit/1000 associated with a dx error and the likelihood
of serious harm
Autopsies Major unexpected discrepancies that would have
changed the management are found in 10-20%
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Diagnostic Error
Error-related
Harm
40,000 – 80,000
deaths/yr
The toll of Dx Error
Leape et al. JAMA 288:2405, 2002
Singh et al. BMJ Qual Safety 21: 93-100, 2012
1 in 1000 primary care visits involves a
preventable dx error causing harm
US
Your Hospital
10 deaths every year
1 patient harmed
every other day in
your clinics or ER
BLUNT end
SHARP end
Patient’s Clinical Course
SYSTEM
Me
Root Causes of Diagnostic Error
Communication,
coordination, training,
policies, procedures,
access to expertise
Cognitive
100 cases – 535 root causes Graber et al. Arch Int Med 165:1493-9, 2005
7/2/2014
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DIAGNOSTIC ERROR
(Wrong, missed &
delayed diagnosis)
Error in the Diagnostic Process
“No Fault” Causes
Inconsequential HARM
Silent disease Too early; atypical Patient misleads us Patient doesn’t f/u
History
Physical Exam
Tests, Consults
Hypotheses, Synthesis
Follow Up
HARM
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Breakdowns in the Diagnostic Process
Schiff et al. 2009; Diagnostic Error in Medicine - Analysis of 583 physician-reported erros. Archives Int Med 169:1881-7
Process Step Incidence of Errors
Dx testing (lab and radiology) 44%
Assessment 32%
H&P 10%
Referral and consultation 10%
Follow-up 10%
High Reliability Diagnosis
Someone owns the process No one owns the process
The pieces are integrated Independent systems
Top priority is safety Top priority is fiscal responsibility
Equivalent actors Independent actors
Performance is predictable Performance is variable
Measurement is king Measurement doesn’t exist
Culture: Resilient, safety oriented Culture:
Results: Six Sigma Results: One or Two Sigma**
DIAGNOSTIC ERROR RATE
Medicine, Peds, ER: 10% Radiology: 2-4% Clinical Lab: Analytical phase: <0.001% errors Pre- and Post-analytical phases: 10% errors
7/2/2014
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t r i c o r e . o r g t r i c o r e . o r g
Diagnostic Error: Reducing Its Impact Through
Improving Reliability
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
7/2/2014
10
A) Correct Diagnosis = Correct Care
B) Correct Care = Quality Care
C) Quality Care + Safe, Efficient, Cost Effective
tricore.org • 19
Diagnostic Reliability and Patient Safety
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
Diagnostic Reliability and Patient Safety
7/2/2014
11
History
Physical Exam
Tests, Consults
Hypotheses, Synthesis
Follow Up
Diagnosis
Diagnostic Reliability and Patient Safety
Diagnostic Error
tricore.org • 22
Diagnostic Reliability and Patient Safety
How to keep patients safe in a complex environment?
External Forces…
7/2/2014
12
tricore.org • 23
Diagnostic Reliability and Patient Safety
How to keep patients safe in a complex environment?
Internal Forces…
How to keep patients safe in a complex
environment?
tricore.org • 24
Diagnostic Reliability and Patient Safety
7/2/2014
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1) Simplify where we can
2) Integrate where we can’t simplify
tricore.org • 25
Diagnostic Reliability and Patient Safety
Do’s and Don’ts
tricore.org • 26
Diagnostic Reliability and Patient Safety
7/2/2014
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Do
Simplify the lab
ordering process disease state
tricore.org • 27
Diagnostic Reliability and Patient Safety
Don’t
List every test by
test name
The Lab
Do
Take ownership of the
pre-analytic phase
tricore.org • 28
Diagnostic Reliability and Patient Safety
Don’t
Maintain silos
The Lab
7/2/2014
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Do
Create interpretive
reports
tricore.org • 29
Diagnostic Reliability and Patient Safety
Don’t
Generate data
The Lab
Do
Put patient safety as a line
item on every Hospital Committee
P&T, MIC, IC, CPC
tricore.org • 30
Diagnostic Reliability and Patient Safety
Don’t
Create a new patient
Safety Super Committee
As a System
7/2/2014
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- Complex patient care requires a team effort
- Team efforts require a shared goal with clearly defined strategy and tactics
tricore.org • 31
Diagnostic Reliability and Patient Safety
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
7/2/2014
17
Questions?
Mark Graber:
Michael Crossey:
Attaining High Reliability and Safety for Patients –
Collaborating for Change. Patient Safety Collective of the
Southwest (PSCS). March 6-7, 2014; Albuquerque, NM
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