Diagnostic errors pose a significant threat to patient safety and can erode trust in providers, which may damage organizational reputations and hurt revenue. Medical practices and healthcare systems can prevent a leading cause of diagnostic errors — follow-up system failures — by adopting a team approach to the diagnostic process and optimizing workflows.
Diagnostic errors — inaccurate diagnoses or diagnoses that healthcare teams do not communicate to patients or fail to convey in a timely or coherent manner — are a pervasive problem in health care, regardless of venue. When Constellation, a Minneapolis-based collective of medical professional liability insurers and health service partners, analyzed malpractice claims from a variety of healthcare settings, it found diagnostic errors were the third-most-common reason for claims, accounting for more total incurred costs than any other cause. A breakdown of where diagnostic errors occurred reveals they were especially common beyond hospital walls:
- 57 percent of diagnosis-related malpractice claims arose from outpatient care settings
- 26 percent originated in emergency departments
- 17 percent stemmed from inpatient environments
“Diagnostic errors are widespread in outpatient care because there are a variety of systems that involve many different individuals in those settings,” says Traci Poore, JD, CPHRM, Senior Risk and Patient Safety Consultant at medical professional liability insurance provider MMIC, which is part of the Constellation family. “Often, these errors do not arise from clinical steps or judgment, but from failure to obtain or communicate results. Essentially, the systems break down.”
Those are follow-up systems — the processes healthcare organizations theoretically follow to ensure timely communication of diagnostic information to patients and coordinate care. In practice, however, those systems often fail. In the Constellation analysis, 52 percent of diagnosis-related malpractice claims from outpatient settings featured a follow-up system failure.
What does a follow-up system failure look like? Kassie Remo, MHA, PMP, FACMPE, CPHQ, Director of Health Care at CliftonLarsonAllen LLP, a national healthcare professional services firm that collaborates with Constellation, offers the example of a female patient who visits her OB-GYN’s office for a wellness exam that includes a pap smear.
“The results of the pap smear are abnormal, which warrants performing another within a certain time period,” Remo says. “If no system is in place to ensure an additional test is obtained, it could be a year before the patient returns to the clinic, and then a provider looking up the patient’s record may recognize a test is missing and wonders whether it took place. Often, in cases like this one, patients don’t follow through with additional tests because they don’t understand what steps they need to take.”
“When determining how to appropriately delegate work within a team, it’s important to conduct a time study to establish the volume of work and how much time is devoted to various functions, such as prescription refills, medical triage and rooming patients. That’s the starting point of allowing physicians to transfer administrative work to other staff so they can focus on direct patient care.”
— Kassie Remo, MHA, PMP, FACMPE, CPHQ, Director of Health Care at CliftonLarsonAllen LLP
The High Price of Follow-Up System Failure
Follow-up system failures often result from two common flaws: an approach that places the burden of communicating diagnostic information to patients at the feet of a small number of providers rather than distributing it throughout the entire team, and inefficient processes that are vulnerable to gaps and deviations. Non-team-based care and poor processes resulting in diagnostic errors can have deep, lasting effects, not just for patients whose health may be at stake, but also for healthcare organizations, which may experience lost revenue and productivity.
“Organizations can lose their accreditation if they don’t manage tests and notify patients properly,” Poore says. “They may also receive poor patient experience scores that can affect reimbursement if patients have to wait an inordinate amount of time to receive test results or don’t receive them at all. Diagnostic errors can lead to hospitalizations and readmissions, and poor communication and coordination between providers — often, primary care physicians and specialists — can result in duplicate lab testing.”
The uneven distribution of diagnosis-related follow-up tasks can lead clinicians to perform work far below their level of training, which may contribute to provider burnout and turnover.
“Physicians may become overburdened and fatigued because they don’t have the cognitive strength to look at absolutely every report or data point every day,” Poore says. “Organizations need to engineer better processes to ensure the work physicians are doing is relevant and necessary, and increase cognitive offloading — taking the burden of certain tasks that could be handled by someone else, such as communicating normal test results to patients, off providers.”
Working Better Together: The Benefits of Team-Based Care
Instituting team-based care — an approach to the diagnostic follow-up process in which every team member takes an appropriate amount of ownership of the process through working to his or her level of credentialing and training — is an effective way to close the loop and prevent follow-up system failures. Every team member is a resource with specific skills, and adopting team-based care to allow every individual to focus on work he or she is credentialed or trained to do optimizes individuals’ value, especially physicians’.
“It’s estimated that every hour physicians spend with patients requires two hours of administrative time, and physicians simply can’t work that many hours each day,” Remo says. “There is a shortage of physicians and other clinicians to provide direct patient care, especially at the primary care level. Organizations need to focus on allowing them to spend as much time as possible with patients by putting a robust team in place to support them.”
The first step of implementing team-based care, Remo says, is to assess a team’s current state — what everyone is doing and what part(s) of the process they are responsible for — and then research each individual’s potential scope of practice, based on what the law and his or her training or certification allow, before attempting to reassign or redistribute responsibilities. As part of this current-state analysis, organizations may find some team members working above their level of credentialing and others operating below theirs. Neither scenario is desirable, according to Remo.
“If team members are working above their level of credentialing, that can be problematic because they’re not the ones who should be making decisions about next steps in patient care, or they may not be able to communicate with patients appropriately,” she says. “When individuals operate below their level of credentialing, they’re not realizing their potential. This often occurs because they or team leaders are concerned about the adequacy of their training or are uncertain about their legal scope of practice.”
Pharmacy technicians, Remo says, are examples of an underutilized resource in many medical practices, where clinicians, especially registered nurses, devote significant time each day to refilling prescriptions. Working within clinician-approved protocols, pharmacy technicians can obtain prior authorizations, assist with medication reconciliation, review criteria for continuing medications and notify patients when tests are needed before medications can be renewed, thereby freeing clinicians to focus on direct patient care.
In addition to creating a culture where everyone works to his or her level of credentialing, organizations can promote team-based care by:
- Allowing nonphysician providers, such as registered nurses, to take on patient triage and front-line disease management tasks, as appropriate, such as obtaining strep tests for suspected upper respiratory infections
- Utilizing technology such as EHR alerts so team members can notify patients of normal test results, overdue results functionality to track whether patients follow through with ordered tests, and patient portals to release test results
- Using team members rather than clinicians for tasks such as ordering previsit lab tests and reminding patients of upcoming appointments
“In team-based care, direct communication of critical test results is still important,” Remo says. “Teams shouldn’t completely rely on technology, especially since many physicians end up getting alert fatigue because they’re notified of so many actions to take in the EHR in a given day. It’s important to pull clinicians aside if there’s a result they need to be made aware of, such as if an abnormal imaging result comes back and a protocol calls for the radiologist to contact an individual within the clinic — either the physician who ordered the test or a designee to ensure the informational loop is closed.”
“An organization that improves its care team’s efficiency may be able to see more patients, and perhaps, add to its line of services,” Poore says. “If, for example, an organization reviews its team members’ training and credentials and finds a clinician is highly trained in wound care, there may be a business opportunity to provide that service.”
— Traci Poore, JD, CPHRM, Senior Risk and Patient Safety Consultant at MMIC
Reshaping Diagnostic Processes with Reliability and Resilience in Mind
Ill-defined, inefficient processes open the door to follow-up system failures and diagnostic errors, but with self-examination, clearly defined roles and plenty of communication, organizations can reengineer their follow-up systems to be more dependable and resilient. As with adopting team-based care, process improvement should begin by taking stock of the current state of workflows.
“If you were to ask people on the same care team to recite your process, you might get five or six different answers,” Poore says. “It’s important to define the process and determine the team’s understanding of it. Then, map it and look for vulnerabilities and gaps — not just human errors, but deviations. Conducting a failure modes and effects analysis is a useful way to identify weaknesses. What happens if someone is sick or equipment breaks down or lab results aren’t immediately obtainable? It’s important to decide how to handle those sorts of deviations from the normal process so the organization doesn’t increase risk for its patients when they happen.”
One way to delineate what is expected of each team member is to make a swim lane flowchart — a graphic representation of who is responsible for what.
“Swim lanes can help organizations identify who may be overworked and who may be underutilized,” Poore says. “If one individual has 10 tasks in her lane and another individual has three tasks in his, there may be an opportunity to reorganize and offload certain responsibilities. Some tasks may be more appropriate for a medical assistant to take on instead of a nurse, or a nurse instead of a physician.”
Communication is the glue that holds processes together and ensures their reliability.
“The most important aspects of any follow-up system are clearly defined roles and expectations for the care team and patients,” Poore says. “Often, a care team may think a patient understands what he’s supposed to do next when he doesn’t, or a patient may wrongly assume the care team knows who her primary care physician is and will communicate test results. Communication between providers, team members and patients is what helps organizations manage expectations and ensure everyone knows his or her role.”
MMIC is a member of Constellation, a growing portfolio of medical professional liability insurance and “beyond insurance” companies formed in response to the ever-changing realities of health care and dedicated to reducing risk and supporting physicians and care teams, thereby improving business results. To learn more about the services MMIC provides to physicians, hospitals and health systems, visit MMICgroup.com.