Process breakdowns in diagnosis

Bruno, Michael mbruno at HMC.PSU.EDU
Fri Dec 2 13:31:31 UTC 2016


Hi Bob,

Thanks for your note below.

As I am someone who is involved in process improvement quite frequently, it struck me that your comment to the effect that a focus on process is going to be useful only when one actually has a method to improve the process is profoundly correct. Another aspect of this idea is that in order to improve a process, one typically must first draw a process map—a graphic construct which is, in essence, a theoretical model of the process itself.  Without a solid process map, you don’t even know what to measure and cannot even begin to improve the process.

I don’t think we’re at a point yet with the process of diagnosis where we can actually map or model it, although thanks to the SIDM’s research agenda and many of our amazing colleagues on this list-serve I think we’re moving toward that goal in encouraging ways.  But we’re clearly very far from having an actual method to improve the process.

All the best,

[cid:image004.png at 01D112FF.F77F98B0]
Michael A. Bruno, M.S., M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality & Patient Safety
Chief, Division of Emergency Radiology
Penn State Milton S. Hershey Medical Center
• (717) 531-8703  |  • mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>  |  6 (717) 531-5737
[https://infonet.pennstatehershey.net/documents/396359/10678301/Medical+Center+Two+Color/4ea2250e-2e29-4b9f-8d2e-2911ed1af1ea?t=1456671057665]

From: Bob Swerlick [mailto:rswerli at GMAIL.COM]
Sent: Thursday, December 01, 2016 10:58 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
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.



________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/



--
Bob Swerlick

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

To unsubscribe from the IMPROVEDX:
mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

For additional information and subscription commands, visit:
http://www.lsoft.com/resources/faq.asp#4A

http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20161202/f0596300/attachment.html> ATTACHMENT:
Name: image001.png Type: image/png Size: 2281 bytes Desc: image001.png URL: <../attachments/20161202/f0596300/attachment.png> ATTACHMENT:
Name: image002.png Type: image/png Size: 14098 bytes Desc: image002.png URL: <../attachments/20161202/f0596300/attachment-0001.png>


More information about the Test mailing list