health professions education research, held in conjunction with The RTT Collaborative A large group is very difficult to prepare for and then keep focused on the task at hand. .. of having an incredibly important relationship not . Session II: Who REALLY Goes into Primary Care? (Mark Deutchman). Professor, Vice Provost for Inter-professional Education and Development. Oregon Health & Science CVS Caremark, Woonsocket, RI. ROBERT E. CAMPBELL . high-quality, patient-centered, and equitable health care services. We believe. The biomedical model has formed the foundation and defined the character of contemporary American medical practice and education. There is a growing.
Though the infrastructure for peer review in radiology is still evolving, there are now frameworks specific to radiology for identifying and learning from diagnostic errors Allen and Thorwarth, ; Lee et al.
In addition to the use of peer review in identifying errors, there is an increasing emphasis on using peer review tools to promote peer learning and improve practice quality Allen and Thorwarth, ; Brook et al.
Patient surveys represent another opportunity. Eliciting this information via surveys may be helpful in identifying errors and near misses, and it can also provide useful feedback to the organization and health care professionals see section below on feedback.
For example, a recent patient-initiated voluntary survey of adverse events found that harm was commonly associated with reported diagnostic errors and the survey identified actions that patients believed could improve care Southwick et al.
In addition to identifying diagnostic errors that have already occurred, some methods used to monitor the diagnostic process and identify diagnostic errors can be used for error recovery. Error recovery is the process of identifying failures early in the diagnostic process so that actions can be taken to reduce or avert negative effects resulting from the failure IOM, Methods that identify failures in the diagnostic process or catch diagnostic errors before significant harm is incurred could make it possible to avoid diagnostic errors or to intervene early enough to avert significant harm.
By scanning medical records to identify lapses in care, the SureNet system supports error recovery by identifying patients at risk of experiencing a diagnostic error Danforth et al. Beyond identifying diagnostic errors and near misses, organizational learning aimed at improving diagnostic performance and reducing diagnostic errors will also require a focus on understanding where in the diagnostic process the failures occur, the work system factors that contribute to their occurrence, what the outcomes were, and how these failures may be prevented or mitigated see Chapter 3.
If a health care organization is evaluating where in the diagnostic testing process a failure occurs, the brain-to-brain loop model may be helpful in conducting these analyses, in particular by articulating the five phases of testing: It is also important to determine the work system factors that contribute to diagnostic errors and near misses. 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. Root cause analysis is a problem-solving method that attempts to identify the factors that contributed to an error; these analyses take a systems approach by trying to identify all of the underlying factors rather than focusing exclusively on the health care professionals involved AHRQ, b.
Maine Medical Center recently conducted a demonstration program to inform clinicians about the root causes of diagnostic errors. They created a novel fishbone root cause analysis procedure, which visually represents the multiple cause and effect relationships responsible for an error Trowbridge, Organizations and individuals can also take advantage of continuing education opportunities focused on using root cause analysis to study diagnostic errors in order to improve their ability to identify and understand diagnostic errors Reilly et al.
The cognitive autopsy is a variation of a root cause analysis that involves a clinician reflecting on the reasoning process that led to the error in order to identify causally relevant shortcomings in reasoning or decision making Croskerry, These can be useful, especially if they are framed from a patient safety perspective rather than focusing on attributing blame.
Other analytical methods used in human factors and ergonomics research could also be applied in health care organizational settings to further elucidate the work system components that contribute to diagnostic errors see Chapter 3 Bisantz and Roth, ; Carayon et al. 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.
To date, there have been relatively few studies that have evaluated the impact of interventions on improving diagnosis and reducing diagnostic errors and near misses; three recent systematic reviews summarized current interventions Graber et al.
These reviews found that the measures used to evaluate the interventions were quite heterogeneous, and there were concerns about the generalizability of some of the findings to clinical practice.
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Health care organizations can take into consideration some of the methodological challenges identified in these reviews in order to ensure that their evaluations generate much-needed evidence to identify successful interventions.
The Medicare conditions of participation and accreditation organizations can be leveraged to ensure that health care organizations have appropriate programs in place to identify diagnostic errors and near Page Share Cite Suggested Citation: The Medicare conditions of participation are requirements that health care organizations must meet in order to receive payment CMS, a. State survey agencies and accreditation organizations such as The Joint Commission, the Healthcare Facilities Accreditation Program, the Accreditation Commission for Health Care, the College of American Pathologists, and Det NorskeVeritas-Germanischer Lloyd determine whether organizations are in compliance with the Medicare conditions of participation through surveys and site visits.
Some of these organizations accredit the broad range of health care organizations, while others confine their scope to a single type of health care organization. Other accreditation bodies, such as the National Committee for Quality Assurance NCQAprovide administrative and clinical accreditation and certification of health plans and provider organizations.
Accreditation processes, federal oversight, and quality improvement efforts specific to diagnostic testing can also be used to ensure quality in the diagnostic process see Chapter 2.
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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. Thus, the committee recommends that accreditation organizations and the Medicare conditions of participation should require that health care organizations have programs in place to monitor the diagnostic process and identify, learn from, and reduce diagnostic errors and near misses in a timely fashion.
As more is learned about successful program approaches, accreditation organizations and the Medicare conditions of participation should incorporate these proven approaches into updates of these requirements. Postmortem Examinations The committee recognized that many approaches to identifying diagnostic errors are important, but the committee thought that the postmortem examination also referred to as an autopsy warranted additional committee focus because of its role in understanding the epidemiology of diagnostic error.
Postmortem examinations are typically performed to determine cause of death and can reveal discrepancies between premortem and postmortem clinical findings see Chapter 3.
One of the contributors to the decline is that in The Joint Commission eliminated the requirement that hospitals conduct these examinations on a certain percentage of deaths in their facility—20 percent in community hospitals and 25 percent in teaching facilities—in order to receive accreditation Allen, ; CDC, Insurers do not directly pay for postmortem examinations, as they typically limit payment to procedures for living patients.
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Medicare bundles payment for postmortem examinations into its payment for quality improvement activities, which may also disincentivize their performance Allen, Given the steep decline in postmortem examinations, there is interest in increasing their use. For example, Hill and Anderson recommended that half of all deaths in hospitals, nursing homes, and other accredited medical facilities receive a postmortem examination.
Lundberg recommended reinstating the mandate that a percentage of hospital deaths undergo postmortem examination, either to meet Medicare conditions of participation or accreditation standards. The committee concluded that a new approach to increasing the use of postmortem examinations is warranted. The committee weighed the relative merits of increasing the number of postmortem examinations conducted throughout the United States versus a more targeted approach.
In these circumstances, the committee concluded that health care organizations should continue to perform these postmortem examinations. In addition, the committee concluded that it is appropriate to have a limited number of highly qualified health care systems participate in conducting routine postmortem exams that produce research-quality information about the incidence and nature of diagnostic errors. Thus, the committee recommends that the Department of Health and Human Services HHS should provide funding for a designated subset of health care systems to conduct routine postmortem examinations on a representative sample of patient deaths.
A competitive grant process could be used to identify these systems. This approach will likely provide better epidemiologic data and it represents an advance over current selection methods for performing postmortem examinations, because clinicians do not seem to be able to predict cases in which diagnostic errors will be found Shojania et al. The data collected from health care systems that are highly qualified to conduct routine postmortem examinations may not be representative of all systems of care.
However, the committee concluded that this is a more feasible approach, given the financial and workforce demands of conducting postmortem examinations. Findings from the health care systems that perform routine postmortem examinations can then be disseminated to the broader health care community.
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. Less invasive approaches include the use of medical imaging, laparoscopy, biopsy, histology, and cytology. For example, instead of conducting a full body postmortem exam, pathologists could biopsy tissue samples from an organ where disease is suspected and conduct molecular analysis van der Linden et al.
These youth are more likely to engage in health care if they feel comfortable disclosing their non-binary gender identity in an affirming environment to providers with a basic understanding of gender diversity.
In this webinar, Alex S. Keuroghlian, MD MPH, will review concepts and terminology related to non-binary gender identities, including correct names and pronouns. The webinar will also focus on best mental health clinical practices and how to create an inclusive and affirming health care environment for youth with non-binary gender identities.
January 25, Faculty: LGBT Health Education Center, School-Based Health Alliance Engaging transgender clients in exploring sexuality — including intersectionality with gender identity and shifts in attraction associated with medical affirmation—is integral to the larger, clinical goal of affirming transgender identities and providing competent care.
In this webinar, Dr. Alex Keuroghlian, MD MPH, will review recent research as well as existing best behavioral health practices and therapeutic considerations for sexual health among transgender clients, including the following topics: Attention is given to providing a transgender-affirming frame and discussing sexual health risk within the context of psychosocial stressors, including challenges related to gender affirmation and experiences of transphobia.
December 11, Faculty: The National LGBT Health Education Center This program discussed clinical issues and health disparities facing the transgender community, and suggested how they can be improved through educational and organizational change. Sample topics include developing a better understanding of transgender identities and lives; creating a welcoming and gender-affirming environment for transgender patients and staff; and learning ways to use and document patient names and pronouns in clinical records.
December 10, Faculty: This advanced webinar is geared towards providers of transgender medical care and therefore assumes that participants will have, at minimum, a baseline understanding of transgender medical terms and care guidelines.
October 28, Faculty: The National LGBT Health Education Center A growing number of clinicians are facing the challenge of caring for pediatric patients with fluid gender identities and with dysphoria about discordance between their gender identity and birth sex.
Stewart Adelson and Dr. They review specific health and mental health needs in gender dysphoric children and adolescents, and will provide viewers with effective and innovative ways to support their gender dysphoric patients. Additional resources will be provided. February 17, Faculty: The National LGBT Health Education Center Research suggests that the number of transgender people seeking gender affirming surgical procedures is increasing, and this is accelerating in the US with the lifting of insurance exclusions.
Behavioral health providers are seeing more transgender patients seeking referrals to surgeons, and are seeking guidance on the standard practice with each patient.
June 10, Faculty: The webinar will include videos of leaders in the transgender community who describe their perceptions of what high quality care means to them and ways in which providers can offer sexual health care and HIV prevention that is based on trust and understanding.
July 16, Faculty: Because of this, national guidelines recommend that transgender men with a cervix follow the same screening protocol as non-transgender women. However, a recent research study found that Fenway Health patients who identify on the female-to-male FTM transgender spectrum have over 10 times higher odds of having an inadequate Papanicolaou Pap test compared to female patients. In this webinar, experts in the fields of medicine and research will share primary and secondary cervical cancer prevention strategies and will identify strategies that providers can use to address barriers to optimal screening and prevention in FTM patients.
October 22, Faculty: Jennifer Hastings of Planned Parenthood Mar Monte and Anna Rick of California Rural Legal Assistance, who both have extensive first-hand experience in caring for and assisting these populations, lead participants in understanding aspects of the life and health care experiences of their transgender patients and clients.
Webinar participants will also learn methods for asking appropriate, sensitive questions about gender identity concerns, and strategies for providing sensitive, inclusive care based on cultural humility.