Process breakdowns in diagnosis

Jason Maude jason.maude at ISABELHEALTHCARE.COM
Fri Dec 2 11:56:40 UTC 2016


It’s hard but I don’t accept that it’s impossible and, in fact, there could be quite a lot that could be implemented relatively easily by the CEO and CMO that really wanted to improve standards that would likely make a big difference. For example:

  1.  Trigger when a patient returns for same problem within a few days
  2.  Trigger for patients admitted where no diagnosis made after 48 hours
  3.  Notes to contain a ddx

These are just a very few but should be simple to introduce. However, the most important part is having the CMO monitor and ensure that it happens. This will need good man management, support from senior clinicians and probably some difficult conversations with detractors. In any change of this type 1/3 of people will be very supportive and wonder why you didn’t do this before, a 1/3 will not be bothered and just follow along and the final 1/3 will be tough and not want to change. The CMO and CEO will have to be prepared to lose those people for the sake of the direction the institution has chosen to follow.

As the standard is raised and set then the culture will change and gradually all these other issues will probably just fall into place. The secret is just good man management.

Regards

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>

From: Bob Swerlick <rswerli at gmail.com<mailto:rswerli at gmail.com>>
Date: Friday, 2 December 2016 03:57
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org<mailto:IMPROVEDX at list.improvediagnosis.org>>, JASON MAUDE <jason.maude at isabelhealthcare.com<mailto:jason.maude at isabelhealthcare.com>>
Subject: Re: [IMPROVEDX] Process breakdowns in diagnosis

It is hard (and perhaps impossible) to be in charge of quality of a process which by all accounts defies measurement.

When diagnosis is flat out and spectacularly wrong, the process may be easy. For example, when someone presents with profound anemia with renal cell carcinoma and is misdiagnosed as having a non-existent stomach ulcer or is accused of being crazy.

However, the diagnostic process involves being wrong at many points in the process and as I see it the process itself is about getting less wrong over time. Think of a differential and most of the things on the list are going to turn out wrong diagnoses! When in the process does being wrong constitute a misdiagnosis and when is that considered simply part of the process?

Focus on process is useful when one has a method to improve the process. You have to ultimately know if the process works and in order to do so, you have to be able to measure whether whether such a process yields better diagnostic results and provide feedback to those making diagnoses in a time frame which allows them to change and improve. This may exist somewhere in healthcare but I am not sure where that might be.

Bob Swerlick

On Thu, Dec 1, 2016 at 1:34 PM, Jason Maude <jason.maude at isabelhealthcare.com<mailto:jason.maude at isabelhealthcare.com>> wrote:
This is a really important question- who is responsible for the quality and standard of diagnosis quality in an institution? Shouldn’t the CMO be responsible for the overall standard of clinical care which includes diagnosis? If there isn’t this clarity, as implied below, then that’s where the problem starts. There has to be somebody who is responsible to drive the process forward.

Regards

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886<tel:+44%201428%20644886>
Tel: +1 703 879 1890<tel:(703)%20879-1890>
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>

From: "Hess, Dr. Donald" <dhess at SUSQUEHANNAHEALTH.ORG<mailto:dhess at SUSQUEHANNAHEALTH.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Hess, Dr. Donald" <dhess at SUSQUEHANNAHEALTH.ORG<mailto:dhess at SUSQUEHANNAHEALTH.ORG>>
Date: Thursday, 1 December 2016 12:15
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Process breakdowns in diagnosis

Greetings Mark:

Thanks for your important reminder that diagnosis is a process. Even though we tend to think of it as a noun, one that reduces to an ICD number, it is essentially a verb.

The diagnostic process is deeply embedded into other organizational processes, e.g. patient throughput, standardized protocols, EHR documentation, etc. More importantly, it is also blended into the interpersonal information exchange amongst clinicians, patients & families. Perhaps this “hiddenness” explains why it has taken so long to recognize the importance of the diagnostic process relative to the quality of care.

Who owns the process? It is broadly distributed.

Who defends the integrity of the process? To the extent that ownership is broadly distributed, likewise the responsibility.

For example, when a quality improvement initiative is being planned, who will ask: “What are the potential adverse consequences to the diagnostic process”?

Regards, Don

Dr. Donald Hess

From: Mark Graber [mailto:graber.mark at GMAIL.COM]
Sent: Wednesday, November 30, 2016 2:22 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Process breakdowns in diagnosis

One of the major messages in the IOM report was that diagnosis is a PROCESS.  Quality improvement work then becomes possible by examining and addressing the process breakdowns that contribute to errors and harm.

The attached article from Saul Weingart & associates is a terrific illustration of how much can be learned from this approach.  With permission of the publisher, its our pleasure to forward this article, and an accompanying editorial by Hardeep Singh, in advance of their appearing online (soon !) in the Joint Commission Journal.   Both of these articles have important messages.



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Bob Swerlick

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