Day Three - Quality Improvement Focus | Working Together to Improve Diagnosis Virtual Conference
This conference, a three half-day virtual conference, will highlight the alarming impact diagnostic error has on patients or residents, care teams and organizations. It will energize teams to identify opportunities for reducing diagnostic error in their own organization by identifying best practices and successes from leading experts. Additionally, it will highlight the importance of communication when a harm event does occur. Participants will have the opportunity to join a new collaborative dedicated to improving the diagnostic process; a year-long group whose focus will be on reduction in patient harm and the subsequent financial burdens, while supporting the implementation of new strategies and shared experiences.
C-Suite, physicians, administrators, patient safety/risk personnel, system engineers, quality leaders and practice leaders from hospitals, clinics, senior living and long-term care organizations
8:45 - 9:45 AM | KEYNOTE: From Principle to Practice: How Communication, Patient Engagement, and Learning Can Prevent and Respond to Diagnostic Errors
Dr. Thomas H. Gallagher, Professor, Department of Medicine, Professor, Department of Bioethics and Humanities, University of Washington, Seattle, WA
Experts on improving diagnosis in medicine have long recognized the important role that effective communication, patient engagement and learning can play in preventing diagnostic errors. Communication and Resolution Programs (CRP) are similarly emphasizing how transparent communication, collaboration with patients and families and accountable learning are critical to responding when care has gone awry. Bringing the Improving Diagnosis and CRP communities together could enhance the effectiveness of both streams of work. Yet both fields also suffer from the challenges of turning these principles into highly reliable practices. This presentation will review how the integration of concepts around improving diagnosis, high reliability and CRP can substantially accelerate the progress of these critical and related areas.
- Describe the common barriers that hinder turning principles of improving diagnosis and CRP into highly reliable practice.
- Recognize how a focus on communication, patient engagement and learning can facilitate the success of efforts both to prevent and respond to diagnostic errors.
- Summarize how learning collaboratives and new tools can accelerate progress in both the improving diagnosis and CRP fields.
10:00 – 11:00 AM | Follow-up System Failures: Stop Dropping the Ball
Laurie C. Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation, Minneapolis, MN; Missy Lindow, Director of Clinic Operations and Access, Lakewood Health System, Staples, MN; Mary Theurer, Lakewood Health System Board, Staples, MN and Andrew Olson, MD, Associate Professor, University of Minnesota Medical School
Follow-up system failures contribute to over half of Constellation’s outpatient diagnostic error malpractice claims. Even when appropriate clinical steps are taken to lead to a correct diagnosis, diagnostic errors due to failures in follow-up and care coordination still persist. This session will provide an overview of Constellation’s malpractice claim data and how Lakewood Health System used co-design to create a new process with community members and patients to minimize the possibility of test result follow-up system failures upon discharge from the emergency department.
- Discuss the causes and contributing factors of breakdowns in diagnostic care processes and follow-up systems that lead to patient injury, malpractice claims and poor business performance.
- Examine Lakewood Health System’s experiences and learned best practices in engaging with a rural community to gather input as they developed new workflow processes for test results communications.
- Identify Lakewood Health System’s operational point of view on co-designing new workflow processes.
11:15 - 12:00 PM | Taking Action to Close the Loop on Diagnostic Error: A Constellation and SIDM Collaborative
Gerry Castro, PhD, MPH, PMP, Quality Improvement Program Manager, Society to Improve Diagnosis Medicine, Evanston, IL
The Collaborative is a joint effort of Constellation and the Society to Improve Diagnosis in Medicine (SIDM) focused on improving the diagnostic process during two of the three key stages of the diagnostic process; tests and results processing and follow-up and coordination. This session will provide information and details for organizations interested in improving the diagnostic process in their community.
- Recognize that almost half of diagnosis-related malpractice claims involve test follow-up system failures and that accurate and timely diagnosis depends nearly as much on the healthcare team and systems as it does on the diagnosticians themselves.
- Identify how to join the Constellation and SIDM Collaborative to work on a diagnostic process quality improvement project via an expert-led virtual community.
Day Three Speakers
Gerry Castro, PhD, MPH, PMP
Gerry Castro director of quality improvement for the Society to Improve Diagnosis in Medicine (SIDM). Prior to joining SIDM he was the project director for patient safety initiatives in the Office of Patient Safety at the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission). Castro was the principal investigator for the Office of the National Coordinator for Health IT project “Investigations of Health IT-related Deaths, Serious Injuries or Unsafe Conditions.” Prior to joining the Joint Commission, he was the health information coordinator for the Village of Oak Park Department of Public Health in Illinois. His professional efforts are focused on improving patient safety through defining and applying evidence-based strategies in healthcare. He received his undergraduate degree from Loyola University in Chicago and his master’s degree in public health from the University of Illinois at Chicago. He received a doctorate in public health sciences from the University of Illinois at Chicago focusing on patient safety and safety event analysis.
Laurie C. Drill-Mellum, MD, MPH
Dr. Laurie C. Drill-Mellum brings more than 30 years as a practicing physician to help guide Constellation’s work of supporting healthcare organizations in order to free physicians and other clinicians to focus on their mission: to help, to heal and to serve. An MD with a master’s degree in public health, she brings a physician’s perspective as well as that of patients and family members in Constellation’s efforts to promote patient safety and mitigate risk. Dr. Drill-Mellum’s passion for, and background in, the studies of culture, behavior, leadership and integrative medicine fuel her commitment and drive in serving the mission of Constellation. She provides insights to health practitioners’ perspectives, challenges and lives and is a fierce advocate for the wellbeing of those practicing medicine on the front lines of care and the critical importance of supporting them when they’ve been involved in a patient-harm event. Preventing these events and mitigating harm once they occur is the core of her dedication to her work.
Thomas H. Gallagher, MD
Dr. Thomas H. Gallagher is a general internist who is Professor in the Department of Medicine at the University of Washington, where he is Associate Chair for Patient Care Quality, Safety, and Value. He is also a Professor in the Department of Bioethics and Humanities. He also is Executive Director of the Collaborative for Accountability and Improvement, an organization dedicated to advancing the spread of Communication and Resolution Programs. Dr. Gallagher’s research addresses the interfaces between healthcare quality, communication, and transparency. Dr. Gallagher received his medical degree from Harvard University, Cambridge, Massachusetts, completed his residency in Internal Medicine at Barnes Hospital, Washington University, St. Louis, and completed a fellowship in the Robert Wood Johnson Clinical Scholars Program, UCSF.
Missy Lindow serves as the director of clinic operations and access at Lakewood Health System in Staples, Minnesota. Passionate about improving access to quality healthcare in rural areas, Lindow has been dedicated to making a difference in the health and wellbeing of rural Minnesota communities for nearly 20 years. Lindow received her bachelor’s degree in healthcare management from St. Catherine University and her certificate in law and leadership in healthcare administration for Michell Hamline School of Law. Lakewood Health System (LHS) is an independent rural healthcare system founded in 1936 with a hospital and clinic in Staples, primary care clinics in Browerville, Eagle Bend, Motley and Pillager and a dermatology clinic and skin and laser center in Sartell. LHS is a recognized leader in providing innovative, patient-based care including women’s specialty services, senior services, surgical and outreach care.
Andrew Olson, MD
Dr. Andrew Olson is an associate professor of medicine and pediatrics at the University of Minnesota Medical School, where he practices hospital medicine and pediatrics. He serves as the Director of Medical Educator Development and Scholarship at the Medical School and is the founding director of the Medical School’s “Becoming a Doctor” course. His areas of interest and study are the development of expertise in decision-making, methods to improve diagnostic reasoning education and competency-based medical education. He is the senior director of Aquifer Diagnostic Excellence project, a national project to develop, implement and evaluate a novel curriculum for medical students about diagnostic reasoning and error. He is also the co-chair of the Education Committee of the Society to Improve Diagnosis in Medicine. Dr. Olson is a leader on a project funded by the Macy Foundation to develop an Interprofessional Curriculum to Improve Diagnosis.
Mary Theurer is an active community member in Staples, MN. She is the Lakewood Health System District Board chair, serves on the Lakewood Health System Board, Patient and Family Advisory Council, Patient Experience, Finance and Governance committees. She is the Trustee Council chair for the Minnesota Hospital Association and acts as a community representative on the Dx-Stop Dropping the Ball grant program. Theurer is fully versed on all aspects of insurance products including negotiating renewals, setting stoploss levels and presenting various renewal options to the self-insured pool. She holds a bachelor’s degree in human biology as well as a doctor of chiropractic degree.
Nursing Contact hours and Certificate of Attendance are not available for the on-demand course.