The problem of diagnostic error is not new to healthcare, yet it still has not received its due attention. In its 2015 report, the
National Academy of Medicine (NAM) concluded that "most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences."1 Despite a recognized need for more work in this area to improve processes and prevent harmful events, the breadth of the issue makes it challenging to find a place to start. Solutions are rarely "one size fits all," and in some cases they may not yet exist.
Institute for Healthcare Improvement (IHI) recommends approaching challenges with a comprehensive Model for Improvement2 to guide efforts from goal-setting through iterative small changes using
Plan, Do, Study, Act (PDSA) cycles.3 This model provides a tested, standard method for performance improvement work.
Daunting patient safety challenges can be viewed as learning journeys that invoke a spirit of welcoming new and creative ideas and allow room for experimentation. With this approach, hospital project leaders and change agents ("project leaders") set the creative context and help the team move to action more quickly through small trials, with an expectation of learning and adaptation along the way.
In this article, we share a conceptual framework that can be used to tackle any big patient safety challenge. This is not an alternative to the IHI Model for Improvement and PDSA but a supportive framework that can be used in conjunction with them. We also share our story of working together to decrease diagnostic error in Pennsylvania as an example of our conceptual framework in action (see "The Conceptual Framework in Action to Decrease Diagnostic Error in Pennsylvania").
Understand the Nature of the Challenge
With a broad, complex patient safety challenge, attempting to clarify every detail can impede progress. Instead, teams can first focus on understanding the nature of the challenge.
In "The Practice of Adaptive Leadership: Tools and Tactics for Changing Your Organization and World," Heifetz and colleagues explain that challenges can be technical or adaptive in nature, and in some instances, have elements of both.4 For technical problems, solutions and expertise already exist; the work is in applying and implementing known solutions. Conversely, adaptive challenges require shifting of attitudes and priorities, adopting new habits, and letting go of old beliefs that support the status quo. The people experiencing the challenge must take action to solve their problem and not rely on others to provide solutions.
One key skill of a project leader is the ability to diagnose technical challenges versus adaptive ones. The approach and tools best suited to address the challenge may differ. Coaching and supporting improvement teams is greatly enhanced when they can assess the nature of the challenge as technical or adaptive and bring the best tools to the table to accelerate change. Without this early phase of understanding the nature of the challenge, efforts can be impeded as teams take an ill-suited approach. Attempting to solve adaptive challenges with technical solutions can bring frustration and inertia to performance improvement efforts.
An ideal place to start in making this determination is to look at the current state and what is happening daily in the context of the challenge. In this stage, we can step back and look at the steps in a process, how individuals relate and communicate, as well as positive attributes—what is working well? All the observations and additional information gathered will support efforts of the team in understanding the nature of the challenge and determining their best strategy.
Determine the Current State
To understand the technical and adaptive characteristics of a challenge, it is important to "go and see" what is happening day to day. Policies and protocols may tell us how work should be done, but not how it is
actually done. Braithwaite and colleagues describe this as
work-as-imagined, how we think work occurs on the front line, and
work-as-done, what is actually happening.6 Work-as-imagined cannot capture the complexities and decision-making necessary in the moment in real life. Without going to observe and learn how the work is actually accomplished on the front line, we are likely to miss the true nature of the challenge we are trying to solve.
By going to the front line and using all senses (watch, listen, feel), we can observe how the process really works. This allows real-time identification of challenges in real-world settings: how work is accomplished in a high-stress environment; how providers from various disciplines interact; and how communication does or does not occur. Valuable performance improvement tools such as process mapping and failure mode and effects analysis can assist in understanding the process. Here, potential interventions may start to take shape and align with the
Plan phase of the PDSA method.
It is also helpful to gather perspectives about the challenge and processes from frontline staff members working in different roles. These conversations offer a window to the shared attitudes and beliefs of individuals operating within the system, both at a unit or departmental level and as part of the larger organization. This is an opportunity to observe who is doing the work and who might provide valuable insights and perspectives. This can also set the stage for identifying key stakeholders for further project work.
Ensure All Voices are Heard
If we view a challenge in terms of the process steps involved, we can more easily identify the individuals who should be included. When forming a project team, a broader discussion provides perspectives across different roles from which the problem is viewed. At the unit level, physicians and nurses are rarely overlooked when requesting participation. On the other hand, support staff, who contribute greatly to unit culture, are often not asked to participate yet can offer an important perspective. For example, environmental services staff may have relevant, valuable input for keeping hallways clear or improving infection control practices.
Everyone looks at aspects of the process through their own lens and may "see" barriers or assets missed by others. Ensuring diverse representation from all interested stakeholders will provide the best opportunity to unleash new ideas.
Most people are familiar with conventional team meetings, which have a set agenda and a meeting leader who speaks at the participants. These familiar environments may not help generate creative thinking and fresh ideas. It can also be intimidating for some individuals to speak up and offer their perspective. How the environment of the meeting itself is designed and structured by project leaders can accelerate the move toward new, actionable ideas. Project leaders can benefit from building their own skills in designing and running meetings. These skills are just as important, and should be as foundational to improvement work, as knowledge of policies and best practices.
Skills in utilizing many tools and techniques for developing this expertise can be taught and many are available publicly with directions on implementation. One set of techniques, coined "Liberating Structures," is described by its creators as, "Easy-to-learn microstructures that enhance relational coordination and trust. They quickly foster lively participation in groups of any size, making it possible to truly include and unleash everyone."7
With information gathered to this point, project leaders can coach the team to narrow the focus. To get started, identify a piece of the overall process where it is possible to take actionable steps and identify short-term opportunities for intervention.
By acting, rather than continuing to simply discuss the issue in committees, the team forms an iterative process from which to learn and shape next steps (the
Do phase of the PDSA method). New information will reveal new opportunities as the improvement work advances.
Project leaders should anticipate hesitance to act among the team when there is lack of clarity on the path forward. Teams often become "stuck" in the development phase and may feel unready to launch or roll out changes. The key is to gather just enough information to get started and then move to action with small but meaningful tests of change, making sense of what is learned, and continuing to adapt and move forward down a path with bends and curves.
Learn and Adapt
At this stage, teams begin to straighten out the bends in the path to change, by processing what they have learned and deciding what to do next (the
Act phases of the PDSA method). Improvement work is an iterative process. Project leaders should allow time for analyzing data and studying themes that have been observed in small tests and interventions. These discussions should be lively and held in an environment that encourages interactive dialogue and creative problem solving. Although untraditional structures may give the false impression of being "too loose," it is up to the project leader to allow for fun and excitement while maintaining focus on the objectives—action, learning, and new possibilities.
In addition, returning to the front line ("go and see") where the work is occurring provides the best understanding of the effects of small process changes. Teams can also broaden the assessment to ask what is working well and capitalize on existing solutions that might have otherwise gone unrecognized. With new understanding, the team focuses on establishing the next steps, rather than the final steps, as the cycles continue.
This conceptual framework can overlay any improvement process in any discipline, offering wider context for tackling complex challenges. Getting started—somewhere, on some piece of the process, where even small but meaningful change can occur—builds momentum for the journey. The skills needed throughout the framework can be taught and built upon. We recommend professional development for anyone in the role of project leader, change agent, or coach.
This framework is laid out in stages, each building on the previous and offering new information to overcome inertia by focusing on what needs to be done next rather than the long, looming road ahead. What ties the steps together, and perhaps can be seen as the peak of a hill, is bringing diverse voices together and capitalizing on the synergy when real face-to-face conversations occur.
Project leaders create the environment and extend the invitation to frontline experts—who may already have solutions for aspects of the larger challenge—building a culture that promotes learning and adapting to new information and creative ideas as possibilities for sustainable change.
- National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington (DC): The National Academies Press; 2015. Available:
- Institute for Healthcare Improvement - how to improve. [internet]. Boston (MA): Institute for Healthcare Improvement; [accessed 2018 Aug 29]. [2 p]. Available:
- The W. Edwards Deming Institute - PDSA Cycle. [internet]. Ketchum (ID): The W. Edwards Deming Institute; [accessed 2018 Aug 29]. [5 p]. Available:
- Heifetz R, Grashow A, Linsky M. The practice of adaptive leadership: tools and tactics for changing your organization and the world. Boston (MA): Harvard Business Press; 2009.
- Heath C, Heath D. Switch: how to change when change is hard. New York (NY): Crown Publishing Group; 2010 Feb. 305 p.
- Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care. 2015 Oct;27(5):418-20. Also available:
http://dx.doi.org/10.1093/intqhc/mzv063. PMID: 26294709
- McCandless K, Lipmanowicz H. Liberating structures - introduction. [internet]. Liberatingstructures.com; [accessed 2018 Aug 10]. [9 p]. Available:
This project has created what I hope will be a sustainable workflow to change patient outcomes. Having the technologists, management, and ED providers working together has resulted in better overall communication between teams.
—Hospital Team Leader
In 2016, the Pennsylvania Patient Safety Authority and the Health Care Improvement Foundation ("project team"), under the Hospital and Healthsystem Association of Pennsylvania (HAP) Hospital Improvement Innovation Network (HIIN), launched a multiyear project focused on diagnostic error related to imaging in the emergency department (ED).* In year one, the project team developed a set of measures to be tested in year two with a group of Pennsylvania hospitals. Now approaching the end of year two, the project team has identified important insights for healthcare organizations seeking to address the problem of diagnostic error.
Understand the Nature of the Challenge
The project team focused on imaging in the ED because of the many challenges and opportunities for improvement in these clinical areas. The ED is an inherently risky environment with many distractions and coordination challenges. Imaging is often critical to accurate and timely diagnosis, yet radiologists may not be engaged as full members of the diagnostic team. In addition, silos often exist between the ED and radiology, and processes between the two departments involve individuals in many roles located in different parts of the hospital.
The project team sought to understand the nature of the challenges related to diagnosis in these clinical areas. Given the disparate nature of the process and necessary coordination between individuals and departments, it was clear the project would involve some adaptive, nontechnical challenges, thus requiring different approaches to find solutions. The project team anticipated and planned its work throughout the project to create the space and interactions needed to challenge assumptions and unleash new ideas along the way.
Determine the Current State
The project team focused on narrowing the scope to specific clinical areas. A project team leader visited several Pennsylvania hospitals to observe processes in the ED and radiology in real time and obtain frontline staff members' perspectives. The project team leader sought to identify areas of variation or discrepant understanding of the process. The following themes emerged:
The pitfalls and opportunities to improve the diagnostic continuum identified by ED physicians and advanced practice providers were very different from those identified by radiologists.
Many of the ED nurses did not view their roles as being significant to the diagnostic process (although some said they should "trust their gut" and speak up more often when they have concerns).
Not only did the observations and interviews provide valuable information, but they allowed new relationships to be formed with hospital teams for future participation in the project.
Ensure All Voices are Heard
Collaboration is essential to spark new ideas and foster sharing across disciplines, as well as refine scope and prioritize areas for further study and evaluation. The project team gathered diverse stakeholders including radiologists, emergency medicine physicians, radiologic technologists, nurses, a patient representative, patient safety experts, invited expert speakers, professional organization leaders, and department leaders from hospitals across Pennsylvania for a full-day collaborative event.
In planning the meeting, the project team focused on who should be invited and what was to be accomplished. By viewing diagnosis as a multifaceted process, they identified key players with direct knowledge of different aspects of the process. The project team also used interactive methods to achieve the objectives. After presentations by invited subject matter experts, facilitated and interactive discussion allowed for connection and deeper discovery of themes in creative ways.
Many participants commented that they learned things that day that challenged their assumptions about processes in other departments. The activity was captured by a graphic recorder (Figure 1).
By the end of year one, the project team achieved consensus among participants, deciding to focus on communication of incidental findings.† The goals were to improve providers' communication with patients about incidental findings and verify patients' understanding of follow-up recommendations. The project team developed a preliminary toolkit that included a data-collection tool and resources to help hospital team leaders with implementation.
In year two, 12 hospital teams piloted the measures as a demonstration project. Participating hospitals represented all regions of the state, including metropolitan and rural, teaching and non-teaching, and profit and not-for-profit hospitals. Upon enrollment, hospital teams agreed to implement a process to identify patients whose ED imaging studies reflected incidental findings requiring follow-up or treatment; to test measures through data collection and submission; and to provide input on the toolkit and data collection tools. Program activities, such as webinars, one-on-one calls, and collaborative check-ins, provided additional support and assistance to hospital teams. The project team took care to maintain the context for hospital teams moving into year two—that trying new things might not always unfold smoothly nor go as planned but learning and adapting to new information would continue, through collaborative activity, on the road to change.
During early collaborative discussions, hospital teams described their intended processes for capturing data on the measures. During the months that followed, hospital teams shared process modifications to improve data capture, reduce burden, and improve communication between departments. During that time, the project team regularly supported hospital teams to understand and express to their staff that ongoing learning and adaptation is an expectation and not a sign of failure.
Hospital team leaders shared challenges related to process variation among clinicians in reporting of incidental findings in radiology reports and communication between departments. These discussions allowed the groups to share new ideas and interventions to address local barriers.
Learn and Adapt
Some key findings among hospital teams included inconsistency in use or location of the term incidental finding in radiology reports, causing concern that this important information is not easily seen. This led some hospital teams to standardize use of the term. Others standardized the format of their radiology reports.
Hospital teams also identified gaps in communication between departments and among providers. Some hospitals in the project have deployed strategies to decrease final radiology report turnaround time, so ED providers can communicate results to patients prior to discharge. Another hospital implemented a voice recognition service that has improved the speed at which final reports are completed and made available to the ordering physician.
Processes and methods of communicating incidental findings to patients vary across hospitals and may be based on resources and workflow; methods include electronic, paper, in-person, and by telephone. In one hospital, the radiologist has face-to-face conversations with the ED providers about all incidental or other significant findings, while others have chosen to use real-time electronic communication between departments that allow for immediate follow-up on any issues. Reaching patients after discharge remains a challenge, so the ideal aim is to communicate this information before patients are discharged from the ED.
The next step in this journey is to explore potential measures to determine whether the patient follows and receives recommended follow-up. The project team continues to expand this work in Pennsylvania and is planning collaborative efforts with hospital teams to address the next steps in this challenging yet rewarding process.
* The analyses upon which this publication is based were performed under contract number HHSM-500-2016-00066C, entitled, "Partnership for Patients Hospital Improvement Innovation Network Contract, sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services."
† For this project, an incidental finding is defined as "an imaging finding that is unrelated to the patient's presenting complaint(s) or to the clinical indication(s) for the imaging examination that was performed."