Working Together to Improve Diagnosis

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 improving diagnostic processes in their own organization by sharing best practices and successes from industry 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.


Constellation® is a growing portfolio of medical professional liability (MPL) insurance and partner companies working Together for the common good®. Formed in response to the ever-changing realities of health care, Constellation and its MPL companies MMIC, UMIA and Arkansas Mutual, is dedicated to reducing risk and supporting physicians and care teams, thereby improving business results.

Iowa Healthcare Collaborative (IHC)

The Iowa Healthcare Collaborative (IHC) is a provider-led, patient focused, nonprofit organization dedicated to sustainable healthcare transformation. Nationally recognized for achieving demonstrable and sustainable improvements across healthcare settings and disciplines, IHC placed those that deliver care in a leadership position to drive improvements and accelerate change. This mission is possible because of IHC’s unified approach to healthcare delivery and strong vision for change.

Society to Improve Diagnosis in Medicine (SIDM)

The Society to Improve Diagnosis in Medicine catalyzes and leads change to improve diagnosis and eliminate harm from diagnostic error. We work in partnership with patients, their families, the healthcare community and every interested stakeholder. SIDM is the only organization focused solely on the problem of diagnostic error and improving the accuracy and timeliness of diagnosis. In 2015, SIDM established the Coalition to Improve Diagnosis to increase awareness and actions that improve diagnosis. Members of the Coalition represent hundreds of thousands of healthcare providers and patients – and the leading health organizations and government agencies involved in patient care. Together, we work to find solutions that enhance diagnostic safety and quality, reduce harm, and ultimately, ensure better health outcomes for patients. Visit to learn more.

Target Audience

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

Course summary
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Tuesday, May 25, 2021 – System Focus

8:30 – 9:45 AM  |  KEYNOTE: Defining the Landscape and Setting the Agenda for Diagnostic Errors: What will it Take to Achieve Diagnostic Excellence

David Newman-Toker, MD, PhD, Director, Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins Medicine, Baltimore, MD 

Diagnostic errors are almost certainly the most common, most costly and most catastrophic of medical errors. Despite this, they were largely ignored for the first two decades of the patient safety movement era. Over the past five years since the publication of the National Academy of Medicine report on Improving Diagnosis in Healthcare, this has finally begun to change. In this session, the speaker will review the scope of the problem, the complexity of causes and the need for multi-faceted solutions at provider, organizational and system levels.

  • Summarize the public health burden and financial impact of diagnostic error and misdiagnosis-related harms.
  • List common causes and prioritize targets for diagnostic error reduction and quality-improvement initiatives.
  • Discuss solutions at provider, organizational and system levels that can contribute to diagnostic excellence.

10:00 – 11:00 AM  |  Exploring Solutions to Address Diagnostic Error

Dana Siegal, RN, CPHRM, CPPS, Director, Patient Safety Services, CRICO Strategies, Boston, MA

Diagnostic errors are typically driven by two primary causes: cognitive failures and system failures. In this session, Dana Siegal will share national Medical Professional Liability (MPL) claims data illustrating the prevalence of these challenges in diagnostic error cases, and present solutions to both sources of error, including raising awareness regarding cognitive biases and highlighting decision support tools to aid in this process. She will also present systems-based solutions for closing loops in referral and test result management processes. 

  • Identify primary cognitive- and systems-based drivers of diagnostic error.
  • Discuss the burden of those drivers on providers and care teams through the lens of medical professional liability claims.
  • Identify specific solutions to address cognitive- and system-based drivers of diagnostic error.

11:15 AM – 12:00 PM  |  The Emotional and Organizational Cost of Harm

Julia Prentice, PhD, Research Director, Betsy Lehman Center for Patient Safety, Boston, MA 

Medical error can have significant emotional, financial, physical and socio-behavioral impacts, including reduced healthcare trust and avoidance. The Massachusetts Betsy Lehman Center for Patient Safety fielded a statewide survey to increase their understanding of how patients and families experience medical error. This session will review the data examining the long-term impact of medical error, discuss the relationship between open communication and long-term impacts and identify current tools for communication and resolution best practices.

  • Identify long-term risks of medical error including emotional harm and 
  • healthcare aversion.
  • Assess the impact of transparent communication about the medical error on long-term risks.
  • Identify available communication and disclosure tools. 


Wednesday, May 26, 2021 – Patient Focus

8:30 – 9:45 AM  |  KEYNOTE: The Power of Partnership:  How Patients Can – and Do – Partner to Improve Diagnosis in Medicine

Suzanne Schrandt, Senior Engagement Advisor, Society to Improve Diagnosis in Medicine, Evanston, IL

This session will describe current practices in patient engagement to improve diagnosis in medicine. Patients, particularly those who have been affected by a diagnostic error, have a critical role to play in eliminating diagnostic error through research, policy, patient education and quality improvement. Drawing from their lived experience, patient partners can provide insights that no one else in the healthcare ecosystem can. Appropriately involving and facilitating the involvement of patient partners can yield important gains in this critical work.

  • Describe the concept of patient engagement and how patients are/have been involved as partners in various facets of the healthcare ecosystem.
  • Give tangible examples of the impact patient partners have had on changing the diagnostic error landscape in research, policy and care delivery.
  • Identify tips and tools available, including those that SIDM offers, for learners to use as they work to engineer patient engagement solutions in their work.

10:00 – 11:00 AM  |  CANDOR: Normalizing Compassionate Honesty after Unexpected Harm

Timothy McDonald, MD, JD, Chief Patient Safety and Risk Officer, RLDatix, Chicago, IL Professor of Law, Loyola University and Bruce Lambert, PhD, Professor, Department of Communication Studies, Director, Center for Communication and Health, Northwestern University, Evanston, IL

Candor is a powerful tool that works to maintain open and honest communication with patients and families after an unintended harm event occurs. During this highly experiential session, attendees will learn about the evolution of approaches to the response to patient harm. Empathic and honest communication including the disclosure of mistakes or errors if they have occurred will be discussed. Attendees will also gain a clearer understanding of issues surrounding the emotional angst for members of the care team. 

  • Outline ways to coach a healthcare team through the critical phases of the open communication process.
  • Discuss how to provide initial emotional first aid to clinicians following an adverse medical event.
  • Develop a comprehensive approach to patient harm that includes care for the caregiver.
  • Describe the approach to determining appropriateness of care following patient harm events.
  • Describe the comprehensive, principled and systematic approach to harm from event through resolution.

11:15 AM – 12:00 PM  |  Panel Discussion: Evolution of Approaches to Patient Harm HEAL/CANDOR

Moderator: Tom Evans, MD, FAAFP, President and CEO, Iowa Healthcare Collaborative, Des Moines, IA

Panelists: Timothy McDonald, MD, JD, Chief Patient Safety and Risk Officer, RLDatix, Chicago, IL, Professor of Law, Loyola University, Chicago, IL; Bruce Lambert, PhD, Professor, Department of Communication Studies, Director, Center for Communication and Health, Northwestern University, Evanston, IL; Shelly Davis, JD, BSN, Director of Early Intervention, Constellation, Minneapolis, MN and Laurie Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation, Minneapolis, MN

This panel discussion will focus on the evolution of approaches to the response to patient harm. Honest communication including the disclosure of mistakes or errors if they have occurred and the support that clinicians and patients need after a diagnostic error leads to a harm event will be discussed. Panel members will bring patient and clinician perspectives after a diagnostic error leads to a harm event. They will also share what brought them to the work on CRP programs and consider ways to move forward after a harm event. 

  • Discuss what brought the panel members to work on CRP programs.
  • Describe how this work is making a difference for patients, residents, their families, care teams and organizations.


Thursday, May 27, 2021 – Quality Improvement Focus

8:45 – 9:45 AM  |  KEYNOTE: From Principle to Practice: How Communication, Patient Engagement, and Learning Can Prevent and Respond to Diagnostic Errors

Thomas H. Gallagher, MD, Professor, Department of Medicine, Professor, Department of Bioethics and Humanities, University of Washington, Seattle, W

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 AM – 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.

Speaker Biographies

Gerry Castro, PhD, MPH, PMP

Gerry Castro is 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.

Shelly Davis, JD, BSN

Shelly Davis is director of early intervention at Constellation. In this role, she works with insureds when unexpected outcomes occur. Early intervention facilitates trust and good will between providers and their patients. Before obtaining her law degree from William Mitchell College of Law, Davis worked as a registered nurse throughout Chicago and within the Mayo Clinic system. Her past practice as a medical malpractice lawyer and nurse gives her a unique perspective when handling claims and lawsuits. She appreciates the risks inherent in providing health care. She has represented healthcare providers and facilities in medical negligence claims, during pre-litigation claims and during investigations of unexpected outcomes in health care. She is a frequent lecturer on the topics of medical malpractice, medical negligence claims and risks associated with being a healthcare provider.

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.

Tom Evans, MD, FAAFP

Dr. Tom Evans is president and CEO of the Iowa Healthcare Collaborative. He practiced family medicine for 13 years and served as chief medical officer for UnityPoint Health. Dr. Evans has served on the board for the National Patient Safety Foundation and on the delegations for both the American Medical Association and the American Academy of Family Physicians. He served as president of both the Iowa Medical Society and the Iowa Academy of Family Physicians. Dr. Evans is a faculty member with the Institute for Healthcare Improvement, the College of Medicine at Des Moines University and the College of Public Health at the University of Iowa.

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.

Bruce Lambert, PhD

Bruce Lambert received his doctorate in speech communication from the University of Illinois at Urbana-Champaign. He is a professor in the Department of Communication Studies and director of the Center for Communication and Health at Northwestern University. His research focuses on health communication, patient safety and medical liability reform. Lambert is the principal investigator on a five-year grant, funded by the Agency for Healthcare Research and Quality, to study techniques for preventing wrong-drug and wrong-patient errors. He is president of BLL Consulting and Pharm IR, firms that solve problems involving health, communication and technology. He blogs about communication at

Missy Lindow

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.

Timothy McDonald, MD, JD

Dr. Timothy McDonald is chief patient safety and risk officer at RLDatix and professor of law at Loyola University Chicago. Dr. McDonald is a physician-attorney whose research has focused on the principled approach to patient harm with an emphasis on reporting of patient safety events, the use of simulation and human factors analysis and providing open and honest communication following harm events. His federally funded research has focused on these domains and their impact on improving the quality of care while mitigating medical liability and other legal-related issues.

David E. Newman-Toker, MD, PhD

Dr. David E. Newman-Toker is a Professor of Neurology, Ophthalmology and Otolaryngology at the Johns Hopkins University School of Medicine. He also holds joint appointments in Emergency Medicine and Health Sciences Informatics at the School of Medicine, as well as in Epidemiology and Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. Dr. Newman-Toker also serves as the President of the Society to Improve Diagnosis in Medicine. Dr. Newman-Toker’s academic mission is to eliminate harms from diagnostic errors and maximize the accuracy and efficiency of diagnostic testing in clinical practice. He is as a core faculty member of the Armstrong Institute for Patient Safety and Quality, where he serves as Director of the Johns Hopkins Armstrong Institute Center for Diagnostic Excellence, focused on enhancing diagnostic safety, quality and value. Dr. Newman-Toker’s research focuses on preventing missed strokes in the emergency department and primary care, especially among patients presenting with acute, severe vertigo or dizziness.

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. Dr. Olson's 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 also the co-chair of the Education Committee of the Society to Improve Diagnosis in Medicine. 

Julia Prentice, PhD

Julia Prentice leads the research portfolio at the Betsy Lehman Center. Her projects focus on measuring the prevalence of adverse events, understanding the public perception regarding the long-term impacts of medical error and the health system response, and evaluating the effectiveness of key quality improvement initiatives. Her previous work in the Department of Veterans Affairs (VA) focused on advancing the ability of healthcare systems to enact evidence-based policy and clinical practice. She was the first to find a consistent relationship between longer appointment wait times for VA healthcare services and poorer patient-level satisfaction and health outcomes. In 2013, this work provided the evidence base for a change in access metrics used by the VA and helped to address the access crisis in 2014. Prentice received her doctorate in public health from UCLA, where she also earned her master’s degree in public health. As an undergraduate she studied biology and sociology at Grinnell College.

Suzanne Schrandt

Suzanne Schrandt is a patient and patient engagement advocate with a health and disability law and policy background. She serves as the senior patient engagement advisor to the Society to Improve Diagnosis in Medicine (SIDM), where she helps incorporate patient insights and voices to fuel improvements in the diagnostic process. Schrandt previously served as the director of patient engagement at the Arthritis Foundation, where she led the Foundation’s Patient Engagement strategy and as the deputy director of patient engagement for the Patient-Centered Outcomes Research Institute. Schrandt’s background includes work in bioethics, genetic discrimination and chronic disease self-management, as well as a long history in patient-led clinical training aimed at increasing early diagnosis and appropriate, patient centered management of chronic disease. Schrandt’s passion for patient engagement began in large part from her own experience, having been diagnosed with polyarticular juvenile idiopathic arthritis as a teenager. Schrandt received her law degree from the University of Kansas School of Law.

Dana Siegal, RN, CPHRM, CPPS

Dana Siegal is the director of patient safety for CRICO Strategies, where she provides analytical and educational services to leading academic medical centers, community hospitals and physician practices on the issues of medical liability and patient safety. She evaluates the risk profiles of healthcare organizations throughout the country, assessing where current vulnerabilities exist and making recommendations for prioritizing action plans. Additionally, she provides detailed analysis of medical malpractice claims, with a specific focus on Diagnostic, OB, EHR and Emergency Medicine. Siegal has 30 years’ experience in healthcare quality and risk management, ranging from front line clinical care as an emergency room nurse, to front line risk management where she was involved in all aspects of incident reporting, sentinel event management, root cause analysis and credentialing. She has worked closely with clinicians and administrators in development and implementation of incident reporting systems and has extensive experience in the analysis of hospital and provider performance data and development of patient safety initiatives in a variety of clinical practice settings. Siegal is a Registered Nurse and is a Certified Professional in Healthcare Risk Management and a Certified Professional in Patient Safety.

Mary Theurer

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.

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