Diagnostic quality requires the active engagement of individuals and a responsive healthcare system. Three distinct targets for improvement rely on a safe environment, all grounded in psychological safety and an organizational culture of safety: the individual, the team, and the organization.16
Strategies at the Individual Level
A variety of activities can encourage individual learning and improvement, particularly when they take place in a supportive environment. Clinicians may find informal support in the form of real-time casual “curbside consults” by seeking the opinion of a trusted colleague. Sometimes simply constructing a question can help the busy clinician articulate their reasoning and explain aspects of the case that create doubt or concern. A colleague can validate their reasoning and affirm their conclusion or suggest alternate ideas.17 Outside major practices and healthcare settings, few have the privilege of working side by side with a trusted colleague, so this benefit is limited to select healthcare settings.
When reviewing a case after the fact, or when grappling with concern about a mistake, personal reflection, with or without a peer coach, can help clinicians examine their thinking and imagine how they might respond differently in the future.18,19 Personal reflection may be facilitated by reflective writing to help clinicians better understand their unique susceptibilities and vulnerabilities to cognitive errors.20
Individuals may benefit from standardized tools designed to help them review their performance on cases, such as Calibrate Dx. AHRQ developed this resource to help individuals assess and improve diagnostic decisions.21
Feedback on performance can help calibrate clinical reasoning. Professionals may develop their own system to surveil for error, although consistent and reliable feedback can be engineered into a system and supported by system design.22 Feedback mechanisms help physicians better understand how their clinical practice compares with others and when they are prone to misjudgments.
Physicians value specific programs designed to provide corrective and positive peer feedback, explanations, and suggestions for improvement.23 The American College of Radiology has developed a “peer learning” program that uses interpersonal relationships to assess and enhance performance; this program recognizes mistakes as opportunities to learn and fosters openness and trust between peers.24,25
Outside academic settings and training programs, opportunities for individual learning are less accessible. One approach to address this gap is to develop and participate in “practice inquiry,” a problem-based learning and improvement method organized between clinicians at different primary practice sites to discuss difficult cases.26 The forum allows clinician colleagues to share strategies and ideas outside regulatory or oversight mechanisms, creating open exchange for improvement strategies free of judgment. The program requires active management and personal investment to sustain, and programs may have significant drop-off over time.
Strategies at the Team Level
While medical education focuses on individual achievement, in practice, care delivery requires coordinated activity between individuals in a complex environment. Teamwork principles promote a culture of cooperation, coordination, communication, situation monitoring, and mutual support within the context of psychological safety.
TeamSTEPPS has emerged as a valuable program to enhance team performance. The program includes a diagnosis improvement course that incorporates teamwork principles to engage a team (including patients, families, providers, radiology and lab personnel, other staff, and support services) to support optimal diagnosis.27
While the TeamSTEPPS program does not explicitly discuss psychological safety, the principles of shared accountability and mutual support model psychological safety. The focus on safety huddles and situation awareness promotes shared vision and fosters a team engaged in solutions and innovation.
Within healthcare systems, efforts to help team members and consultants become familiar with each other promote shared understanding for quality improvement. Relationship building improves communication, generates understanding of different perspectives, and fosters collaboration.16 Shared goals over time can avoid conflicts that arise in crisis clinical settings.
Strategies at the Organization Level
Organizational leadership can support and incentivize event reports with well-designed and user-friendly reporting systems. For meaningful use, the system should provide timely investigation and analysis and feed forward corrective actions that are responsive to the reporter.
Optimal systems will build capacity for measuring and monitoring diagnostic quality in support of quality improvement. Measure Dx is a tool that can provide practical guidance for starting a systematic process to gather and analyze data to identify missed opportunities for improvement.28 As organizations develop a robust quality reporting system, they will benefit from a more exhaustive view of broader system factors that impact safety. The Safer Dx framework can guide such assessments and includes technological factors and external forces such as payment systems, legal issues, regulatory requirements, and health policy.29
Forums to discuss diagnostic problems are also key to improvement. For example, mortality and morbidity conferences may involve analysis of events, engage team members, and support a comprehensive assessment from a systems perspective. An open, honest, and nonpunitive environment ensured by a culture of safety will reveal opportunities for improvement.30 However, these forums can fail if they are used to harass or bully junior team members; they can also lose their effectiveness if they become case conferences focused on rare and unusual conditions.
Leadership committed to a culture of safety should invest resources to solve system problems that threaten diagnostic safety and provide educational resources and training for continuous learning for the team. A mature and healthy organization will provide proactive solutions to identified problems that encourage and reward reporting. One method to promote recognition of risk is to reward individuals for detecting and announcing safety risks; an example is the “Good Catch” safety program that promotes active surveillance for problems.31
Organizations can also seek feedback about the quality of diagnosis from patients on patient and family advisory councils (PFACs)32 or via patient experience measures specifically designed to capture diagnostic quality.33
Organizations can drive engagement and promote team vision by identifying and supporting healthcare champions. Highly motivated and influential individuals can play a key role in successfully implementing improvement efforts by modeling desired behaviors and engaging their team to support change.34 Such champions are now considered essential to implement new healthcare informatics technology or integrate new processes, equipment, or workflow solutions.
AHRQ’s voluntary Patient Safety Organization (PSO) program is another significant advancement that promotes reporting by providing legal protections for reporters.35 Participation offers hospitals access to shared learning.
A 2019 report by the Department of Health and Human Services Office of the Inspector General found that 97 percent of hospitals working with a PSO find it valuable; 80 percent found that feedback and analysis of safety events helped prevent future events. Involvement with a PSO provides peer-to-peer learning in confidential “safe tables” where patient safety topics and adverse events are discussed to understand the causes and find solutions, an experience one participant described as “priceless.”36
Each of these mechanisms offers promising strategies, but their successful application relies on a secure environment of psychological safety that supports and encourages frontline clinicians to act as the best defense for reducing harm from diagnostic safety events.
