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6 Organizational Characteristics, the Physical Environment, and the Diagnostic Process: Improving Learning, Culture, and the Work System
Pages 263-306

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From page 263...
... They will need to tailor the committee's recommendations to their resources and challenges with diagnosis. The first section of this chapter describes how organizational learning principles can improve the diagnostic process by providing feedback to health care professionals about their diagnostic performance and by better characterizing the occurrence of and response to diagnostic errors.
From page 264...
... . These learning health care organizations ensure that individual health care professionals and health care teams learn from their successes and mistakes and also use this information to support improved performance and patient outcomes (Davies and Nutley, 2000)
From page 265...
... Culture L  eadership-instilled culture of learning -- A learning health care organiza tion is stewarded by leadership committed to a culture of teamwork, collabora tion, and adaptability in support of continuous learning as a core aim. S  upportive system competencies -- In a learning health care organization, complex care operations and processes are constantly refined through ongo ing team training and skill building, systems analysis and information develop ment, and the creation of feedback loops for continuous learning and system improvement.
From page 266...
... . Compared to diagnostic errors, other types of medical errors -- including medication errors, surgical errors, and health care–acquired infections -- have historically received more attention within health care organizations (Graber et al., 2014; Kanter, 2014; Singh, 2014; Trowbridge, 2014)
From page 267...
... Improving diagnosis will likely require a concerted effort among all health care organizations and across all settings of care to better identify diagnostic errors and near misses, learn from them, and, ultimately, take steps to improve the diagnostic process. Thus, the committee recommends that health care organizations monitor the diagnostic process and identify, learn from, and reduce diagnostic errors and near misses as a component of their research, quality improvement, and patient safety programs.
From page 268...
... . Medical record reviews can be a useful method to identify diagnostic errors and near misses because health care organizations can leverage their electronic health records (EHRs)
From page 269...
... . Second reviews of diagnostic testing results could also help health care organizations identify diagnostic errors and near misses related to the interpretive aspect of the diagnostic testing processes.
From page 270...
... Some of the data sources and methods mentioned above, such as malpractice claims analyses and medical record reviews, can provide valuable insights into the causes and outcomes of diagnostic errors. Health care organizations can also employ formal error analysis and other risk assessment methods to understand the work system factors that contribute to diagnostic errors and near misses.
From page 271...
... . As health care organizations develop a better understanding of diagnostic errors within their organizations, they can begin to implement and evaluate interventions to prevent or mitigate these errors as part of their patient safety, research, and quality improvement efforts.
From page 272...
... . By leveraging the Medicare conditions of participation requirements and accreditation processes, it may be possible to use the existing oversight programs that health care organizations have in place to monitor the diagnostic process and to ensure that the organizations are identifying diagnostic errors and near misses, learning from them, and making timely efforts to improve diagnosis.
From page 273...
... . In these circumstances, the committee concluded that health care organizations should continue to perform these postmortem examinations.
From page 274...
... Participating health care systems could be required to produce annual reports on the epidemiology of diagnostic errors found by postmortem exams, the value of postmortem examinations as a tool for identifying and reducing such errors, and, if relevant, the role and value of postmortem examinations in quality improvement efforts. These health care systems could also investigate how new, minimally invasive postmortem approaches compare with traditional full body postmortem examinations.
From page 275...
... . To improve the opportunities for feedback, the committee recommends that health care organizations should implement procedures and practices to provide systematic feedback on diagnostic performance to individual health care professionals, care teams, and clinical and organizational leaders.
From page 276...
... There are many opportunities to provide feedback in clinical practice. Methods to monitor the diagnostic process and identify diagnostic errors and near misses can be leveraged as mechanisms to provide feedback.
From page 277...
... . Leveraging Health Care Professional Societies' Efforts to Improve Diagnosis Health care organizations can leverage external input from health care professional societies to inform the organizations' efforts to monitor and improve the diagnostic process.
From page 278...
... These lists were made publicly available as a way of encouraging discussions about appropriate care between patients and health care professionals. Choosing Wisely received national media attention and engaged more than 50 health care professional societies (Choosing Wisely, 2015)
From page 279...
... The committee identified organizational culture and organizational leadership and management as key characteristics for ensuring continuous learning from and improvements to the diagnostic process. Health care organizations are responsible for developing a culture that promotes a safe place for all health care professionals to identify and learn from diagnostic errors.
From page 280...
... Some aspects of culture may promote diagnostic accuracy, such as the intrinsic motivation of health care professionals to deliver high-quality care and the dedicated focus on quality and safety found in some health care organizations. Other aspects of culture may be detrimental to efforts to improve diagnosis, including the persistence of punitive, fault-based cultures; cultural taboos on providing peer feedback; hierarchical attitudes that are misaligned with team-based practice; and the acceptance of the inevitability of errors.
From page 281...
... . Thus, the committee recommends that health care organizations should adopt policies and practices that promote a nonpunitive culture that values open discussion and feedback on diagnostic performance.
From page 282...
... Despite the difficulties one faces in implementing culture change, health care organizations have begun to make changes that can improve patient safety (Chassin and Loeb, 2013)
From page 283...
... IMPROVING LEARNING, CULTURE, AND THE WORK SYSTEM 283 BOX 6-3 Important Cultural Values for Continuously Learning Health Care Systems •  elebration of success. If excellence is to be pursued with vigor and com C mitment, its attainment needs to be valued within the organizational culture.
From page 284...
... . In many health care organizations, organizational leaders have not focused significant attention on improving diagnosis and reducing diagnostic errors (Gandhi, 2014; Graber, 2005; Graber et al., 2014; Henriksen, 2014; Wachter, 2010; Zwaan et al., 2013)
From page 285...
... For example, potential policies and practices could focus on team-based care in diagnosis, the adoption of a continuously learning culture, opportunities to provide feedback to clinicians, and approaches to monitor the diagnostic process and identify diagnostic errors and near misses. All organizational leaders can raise awareness of the quality and safety challenges related to diagnostic error as well as dispelling the myth that diagnostic errors are inevitable (Leape, 2010; Wachter, 2010)
From page 286...
... Thus, organizations can implement changes that ensure a work system that supports the diagnostic process. The committee recommends that health care organizations should design the work system in which the diagnostic process occurs to support the work and activities of patients, their families, and health care professionals and to facilitate accurate and timely diagnoses.
From page 287...
... Health care organizations can consider how to promote these types of opportunities for clinicians to discuss cases and to facilitate more collaborative working relationships during the diagnostic process. For example, some organizations are now situating medical imaging reading stations in clinical areas, such as the emergency department and the intensive care unit (Wachter, 2015)
From page 288...
... . To facilitate the timely collaboration among health care professionals in the diagnostic process, the committee recommends that health care organizations should develop and implement processes to ensure effective and timely communication between diagnostic testing health care professionals and treating health care professionals across all health care delivery settings.
From page 289...
... Additional Work System Elements In addition to improving error recovery and results reporting and communication, health care organizations can focus more broadly on improving the work system in which the diagnostic process occurs. To ensure that their work systems are designed to support the diagnostic process, health care organizations need to consider all of the elements of the work system and recognize that these elements are interrelated and dynamically interact.
From page 290...
... Implementing systematic feedback mechanisms that track patient outcomes over time could also identify diagnostic errors that transcend health care organization boundaries. In addition, payment and care delivery reforms that incentivize accountability and collaboration may alleviate some of the challenges that the fragmented nature of the health care system presents for diagnosis (see Chapter 7)
From page 291...
... Health care professional certification and accreditation standards can be leveraged to ensure that health care professionals within an organization are well prepared to fulfill their roles in the diagnostic process. Health care organizations can also offer more opportunities for teambased training in diagnosis and can expand the use of integrated practice units, treatment planning conferences, and diagnostic management teams (see Chapter 4)
From page 292...
... . RECOMMENDATIONS Goal 4:  Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice Recommendation 4a:  Accreditation organizations and the Medicare conditions of participation should require that health care organiza tions have programs in place to monitor the diagnostic process and identify, learn from, and reduce diagnostic errors and near misses in a timely fashion.
From page 293...
... Goal 5:  Establish a work system and culture that supports the diag nostic process and improvements in diagnostic performance Recommendation 5:  Health care organizations should: •  dopt policies and practices that promote a nonpunitive cul A ture that values open discussion and feedback on diagnostic performance. •  esign the work system in which the diagnostic process D occurs to support the work and activities of patients, their families, and health care professionals and to facilitate ac curate and timely diagnoses.
From page 294...
... 2014b. Patient safety primers: Root cause analysis.
From page 295...
... , Handbook of human factors and ergonomics in health care and patient safety (pp.
From page 296...
... 2013. Explaining the success or failure of quality improvement initiatives in long-term care organizations from a dynamic perspective.
From page 297...
... Joint Commission Journal on Quality and Patient Safety 31(2)
From page 298...
... Joint Commission Journal on Quality and Patient Safety 31(5)
From page 299...
... 2009. Leadership in healthcare organizations: A guide to joint com mission leadership standards.
From page 300...
... 2013. Patient safety strategies targeted at diagnostic errors: A systematic review.
From page 301...
... 2006. Creating high reliability in health care organizations.
From page 302...
... Joint Commission Journal on Quality and Patient Safety 39(11)
From page 303...
... Joint Commission Journal of Quality and Patient Safety 36(9)
From page 304...
... Journal of Patient Safety 6(4)
From page 305...
... 2009. Design of a study on suboptimal cognitive acts in the diagnostic process, the effect on patient outcomes and the influence of workload, fatigue and experience of physician.


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