Skip to main content

Currently Skimming:

4 Diagnostic Team Members and Tasks: Improving Patient Engagement and Health Care Professional Education and Training in Diagnosis
Pages 145-216

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 145...
... In terms of the committee's conceptual model of the diagnostic process, the focus of this chapter is on two of the elements of the work system: diagnostic team members (health care professionals, patients, and their families) and the tasks they perform in the diagnostic process (see Figure 4-1)
From page 146...
... However, at the other end of the spectrum, the diagnostic process could be quite complex and involve a broad array of health care professionals, such as primary care clinicians, diagnostic testing health care professionals, multiple specialists if different organ systems are suspected to be involved, nurses, pharmacists, and others. Even though some diagnoses continue to be made by individual c ­ linicians working independently, this solitary approach to the diag­ ostic n
From page 147...
... . To manage the increasing complexity in health care and medicine, clinicians will need to collaborate effectively and draw on the knowledge and expertise of other health care professionals, as well as patients and families, throughout the diagnostic process.
From page 148...
... . Another study found that surgical teams that did not engage in teamwork had worse patient outcomes, including a higher likelihood of death or serious complications (Mazzocco et al., 2009)
From page 149...
... Teamwork in diagnosis is likely to be somewhat distinct from the teamwork that occurs after a diagnosis is made, in part due to the fluid, or unstable, collection of health care professionals involved in the diagnostic process. Fluid team membership has been recognized as a strategy to deal with fast-paced, complex tasks such as diagnosis where preplanned coordination may not be possible and where communication and coordination are a necessity (Bushe and Chu, 2011; Edmondson, 2012; Vashdi et al., 2013)
From page 150...
... In recognition that the diagnostic process is a dynamic team-based activity, health care organizations should ensure that health care professionals have the appropriate knowledge, skills, resources, and support to engage in teamwork in the diagnostic process. Ensuring that individuals participating in the diagnostic process have the appropriate resources and support extends beyond the purview of this chapter and requires a systems approach to diagnosis, including consideration of health information technology (health IT)
From page 151...
... that can contribute to diagnostic errors (see Chapter 2)
From page 152...
... 152 FIGURE 4-3  An example of diagnostic teamwork and the potential participants in the diagnostic process. The arrows in the figure illustrate the importance of communication among team members.
From page 153...
... The depiction in Figure 4-3 of the various ways that patients and health care professionals interact during the diagnostic process is likely an idealization of clinical practice. For example, patients and their families will often take on a significant burden of care coordination because of the fragmentation of the health care system, a lack of interoperability of patients' electronic health records (EHRs)
From page 154...
... Thus, the committee recommends that health care organizations should facilitate and support collaboration among pathologists, radiologists, other diagnosticians, and treating health care professionals to improve diagnostic testing processes. This includes collaboration throughout the testing process, including the ordering of appropriate tests or images, analysis and interpretation, the reporting and communication of results, and subsequent decision making.
From page 155...
... potential diagnostic errors. Nurses facilitate patient engagement in the diagnostic process by communicating with patients about their history, actively listening to patients' descriptions of their reasons for a visit, documenting patients' symptoms, assessing vital signs, and conveying this information to other clinicians.
From page 156...
... In the 5 years since the report's release, there has been increased awareness of and growing support for these recommendations in nursing schools, health care professional societies, and health care organizations. For example, AARP and the Robert Wood Johnson Foundation recently launched the "Future of Nursing: Campaign for Action," an initiative designed to drive implementation of the report's recommendations.2 D ­ espite these efforts, progress in the implementation of these recommendations has been uneven.
From page 157...
... -- have recently been implemented across the country as a means to improve patient care coordination and increase communication among health care professionals (see Chapter 7)
From page 158...
... . Treatment planning conferences are often held for specific types of cancers, and their participants may include surgeons, medical oncologists, radiologists, radiation oncologists, pathologists, nurses, and other collaborating health care professionals.
From page 159...
... conferences are forums that bring clinicians together to review cases involving medical errors and adverse events that have occurred. M&M conferences have been used to better understand how errors occur and to help health care organizations identify work system failures and develop interventions to address these failures 3  Personal communication, M
From page 160...
... They provide an opportunity for health care professionals to learn how other health care professionals approach medical issues and to interact with health care professionals from different disciplines. Multidisciplinary rounds have been associated with improvements in care quality, shortened length of stays, and enhancements in resident education (O'Mahony et al., 2007)
From page 161...
... •  ot always take their own problems seriously enough N •  ack understanding of the health care system or opportunities to become L involved •  ncounter inexperienced health care professionals E •  ave language and health literacy barriers H •  e unsure how to seek resolution to a problem when issues are not B r ­ esolved at the point of care Health care professionals may: •  ismiss patients' complaints and knowledge D •  ct on implicit or explicit biases and stereotypes A • ncorrectly assume that a patient does not want to be involved in his or her I care Health care systems may exhibit: •  isjointed care through a lack of coordination and teamwork D •  reakdowns in communication among health care professionals B •  ailure to transmit information to patients F •  ailure to adequately review or follow up on diagnostic testing results F •  ack of disclosure or apology after diagnostic errors L SOURCE: McDonald et al., 2013. Adapted by permission from BMJ Publishing Group Limited.
From page 162...
... . These barriers have also been associated with diagnostic errors (Flores, 2006; Marcus, 2003; Price-Wise, 2008)
From page 163...
... . In the United States more than 80 million adults have a poor level of health literacy, which has been defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (AHRQ, 2011, p.
From page 164...
... . The use of EHRs may also lead to problems with patient engagement, as health care professionals may be distracted from communicating with patients as they enter information in the EHR (O'Malley et al., 2010; Spain, 2014)
From page 165...
... . In cases where there is poor care coordination and communication among clinicians, patients and their families may need to convey their information among their health care professionals.
From page 166...
... Health care professionals need to embrace patients and their families as essential partners in the diagnostic process, with valuable contributions that can improve diagnosis and avert diagnostic errors. Thus, the committee recommends that health care professionals and organizations should partner with patients and their families as diagnostic team members and facilitate patient and family engagement in the diagnostic process, aligned with their needs, values, and preferences.
From page 167...
... Thus, the committee recommends that health care professionals and organizations should create environments in which patients and their families are comfortable engaging in the diagnostic process and sharing feedback and concerns about diagnostic errors and near misses. Health care organizations will need to carefully consider whether their care delivery systems and processes fully support patient engagement and work to improve systems and processes that are oriented primarily toward meeting the needs of health care professionals rather than patients and their families.
From page 168...
... 3. Keep Good Records: •  eep your own records of test results, referrals, and hospital admissions.
From page 169...
... Reprinted, with permission, from the National Patient Safety Foundation and Society to Improve Diagnosis in Medicine. Ask Me 3 is a registered trademark of Pfizer Inc.
From page 170...
... 170 IMPROVING DIAGNOSIS IN HEALTH CARE BOX 4-5 Smart Partners About Your Health SMART CHECKLIST • Symptoms  ell your clinician what's currently wrong .
From page 171...
...  alk about other treatment plans or options. T • Be sure to ask for your after-visit summary • Follow all your clinician's instructions or let them know if you can't SOURCE: Reprinted, with permission, from Kaiser Permanente.
From page 172...
... Supportive health care environments are places where patients and families feel comfortable sharing their concerns about diagnostic errors and near misses and providing feedback on their experiences with diagnosis. As discussed in the education section of this chapter, providing feedback to health care professionals about the accuracy of their diagnoses can help improve their diagnostic performance.
From page 173...
... If health care organizations make it easier for patients and families to navigate, understand, and use health care services, then patients and their families can become more engaged in the diagnostic process. In addition, health care professionals and organizations can ensure that health care environments reflect cultural and language competencies (AHRQ, 2012)
From page 174...
... ncludes populations served in the design, implementation, and evaluation I of health information and services 5.  eets the needs of populations with a range of health literacy skills while M avoiding stigmatization 6.
From page 175...
... . Thus, the committee recommends that health care professionals and organizations should ensure patient access to EHRs, including clinical notes and diagnostic testing results, to facilitate patient engagement in the diagnostic process and patient review of health records for accuracy.
From page 176...
... . Thus, the committee recommends that health care professionals and organizations should identify opportunities to include patients and their families in efforts to improve the diagnostic process by learning from diagnostic errors and near misses.
From page 177...
... . HEALTH CARE PROFESSIONAL EDUCATION AND TRAINING There are indications that health care professionals may not receive adequate preparation to function optimally in the diagnostic process (Brush, 2014; Dhaliwal, 2014; Durning, 2014; Richardson, 2007; ten Cate, 2014; Trowbridge et al., 2013)
From page 178...
... Although this section's emphasis is on diagnosticians, the challenges and solutions are relevant to many health care professionals who participate in the diagnostic process. Educational Approaches The learning sciences are an interdisciplinary field that studies learning methods and principles in an effort to understand how to optimize learning (Torre et al., 2006)
From page 179...
... SOURCE: Sawyer, 2006. dents with authentic practice; for example, a majority of graduate medical education (GME)
From page 180...
... . Feedback is an integral part of continuous learning and can help health care professionals understand how well they are performing (Croskerry, 2000b)
From page 181...
... . The result is a continuing education system that does not meet the needs of health care professionals in practice; for example, didactic activities such as lectures are large components of continuing education, even though participatory learning opportunities may be more appropriate (Hager et al., 2008)
From page 182...
... . Though many programs are beginning to initiate changes that better align with current knowledge about health care professional education, a larger focus on aligning education with the learning sciences is warranted across the career trajectory.
From page 183...
... . As discussed in Chapter 2, health care professionals have an ethical responsibility to improve clinical reasoning skills in order to improve diag­ ostic performance and avert diagnostic errors (Stark and Fins, 2014)
From page 184...
... Improved understanding of diagnostic uncertainty can help clinicians make decisions about whether further diagnostic testing or treatment is warranted. This could also facilitate improved collaboration with other health care professionals and better communication with patients and their families about the nature of a working diagnosis.
From page 185...
... . This includes a focus on the work system factors that can contribute to diagnostic errors, such as communication and collaboration challenges among diagnostic team members; health IT tools that are not supportive of clinical reasoning activities; cultural, organizational, and physical environmental factors; and the impact of reporting, medical liability, and payment.
From page 186...
... Developing clinical reasoning skills is important for practicing health care professionals who are beyond formal education and training settings. Continuing health care professional education can be leveraged to develop clinical reasoning skills as a lifelong competency.
From page 187...
... . The goals of the interprofessional education programs varied, but most aimed to familiarize students with the roles of other health care professionals (89 percent)
From page 188...
... This training may include an emphasis on basic communication skills and also on BOX 4-8 Situation-Background-Assessment-Recommendation Tool to Improve Communication Among Health Care Professionals Before you call, be prepared! Be clear, concise, focus on the problem and only report what is relevant to the current situation!
From page 189...
... Diagnostic Testing Diagnostic testing has become an integral component of the diag­ nostic process, yet medical school curricula have not kept pace with the advances in diagnostic testing and with how these advances affect diagnosis (Hallworth, 2011; Laposata and Dighe, 2007; Smith et al., 2010)
From page 190...
... . Similar surveys completed several decades ago found that many health care professionals had trouble applying statistical methods and understanding statistical concepts, suggesting that this may be a longstanding gap in health care professional education (Berwick et al., 1981; Casscells et al., 1978)
From page 191...
... . Thus, health care professionals need improved education and training on the appropriate use of diagnostic tests and the application of these results to subsequent decision making.
From page 192...
... . As health IT becomes increasingly integrated into all aspects of health care, clinicians will likely rely more on it to facilitate diagnostic decision making and communication and collaboration among health care professionals and ­ atients (Thibault, 2013)
From page 193...
... . Accreditation Council for Continuing Medical Education evaluates and a ­ ccredits institutions and organizations offering continuing medical education for physicians and other health care professionals (ACCME, 2015)
From page 194...
... . Organizations responsible for health care professional licensure and certification can help ensure that individual health care professionals have achieved and maintain competency in the skills essential for diagnosis.
From page 195...
... . Initial certification of health care professionals is important, but it may be insufficient to ensure sustained diagnostic competency throughout the career trajectory.
From page 196...
... The committee concluded that oversight organizations, including accreditation organizations and professional licensure and certification bodies, can play an important role in improving diagnostic performance. Thus, the committee recommends that health care professional certification and accreditation organizations should ensure that health care professionals have and maintain the competencies needed for effective performance in the diagnostic process, including • Clinical reasoning • Teamwork • Communication with patients, their families, and other health care professionals • Appropriate use of diagnostic tests and the application of these results on subsequent decision making • Use of health IT RECOMMENDATIONS Goal 1: Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families Recommendation 1a: In recognition that the diagnostic process is a dynamic team-based activity, health care organizations should en sure that health care professionals have the appropriate knowledge, skills, resources, and support to engage in teamwork in the diagnos tic process.
From page 197...
... Goal 2: Enhance health care professional education and training in the diagnostic process Recommendation 2a: Educators should ensure that curricula and training programs across the career trajectory: •  ddress performance in the diagnostic process, including A areas such as clinical reasoning; teamwork; communication with patients, their families, and other health care profes sionals; appropriate use of diagnostic tests and the applica tion of these results on subsequent decision making; and use of health information technology. •  mploy educational approaches that are aligned with evi E dence from the learning sciences.
From page 198...
... . ACGME (Accreditation Council for Graduate Medical Education)
From page 199...
... BMC Medical Education 4:20. Berkhof, M., H
From page 200...
... Christensen (eds.) , Clinical reasoning in the health professions (pp.
From page 201...
... 2015. Diagnostic errors in a PICU: Insights from the morbidity and mortality conference.
From page 202...
... 2009. Improving critical thinking and clinical reasoning with a continuing education course.
From page 203...
... Medical Education 39(9)
From page 204...
... 2014. Focus on diagnostic errors: Understanding and prevention.
From page 205...
... 2015. Teaching health center gradu ate medical education (THCGME)
From page 206...
... 2014. Graduate medical education that meets the nation's health needs.
From page 207...
... 2014. Diagnostic errors -- Patient safety.
From page 208...
... 2011. The integration of pathology into the clinical years of undergraduate medical education: a survey and review of the literature.
From page 209...
... 2011. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education?
From page 210...
... 2014. Diagnostic errors.
From page 211...
... 2009a. Towards effective evaluation and reform in medical education: A cognitive and learning sciences perspective.
From page 212...
... Medical Education 36(4)
From page 213...
... 2014b. Diagnosis and diagnostic errors: Time for a new paradigm.
From page 214...
... 2012. Continuing medical education and quality improvement: A match made in heaven?
From page 215...
... Input submitted to the Committee on Diagnostic Error in Health Care, November 25, 2014, Washington, DC. Thibault, G
From page 216...
... 2013. Patient engagement and patient safety.


This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More information on Chapter Skim is available.