Friday, March 10, 2023

A Systems Approach to Diagnosis in Healthcare Emergency Departments

JAMA logo

A recent op-ed* in JAMA advocated greater use of systems thinking to reduce diagnostic errors in emergency departments (EDs).  The authors describe the current situation – diagnostic errors occur at an estimated 5.7% rate – and offer 3 insights why systems thinking may contribute to interventions that reduce this error rate.  We will summarize their observations and then provide our perspective.

First, they point out that diagnostic errors are not limited to the ED, in fact, such errors occur in all specialties and areas of health care.  Diagnosis is often complicated and practitioners are under time pressure to come up with an answer.  The focus of interventions should be on reducing incorrect diagnoses that result in harm to patients.  Fortunately, studies have shown that “just 15 clinical conditions accounted for 68% of diagnostic errors associated with high-severity harms,” which should help narrow the focus for possible interventions.  However, simply doing more of the current approaches, e.g., more “testing,” is not going to be effective.  (We’ll explain why later.)

Second, diagnostic errors are often invisible; if they were visible, they would be recognized and corrected in the moment.  The system needs “practical value-added ways to define and measure diagnostic errors in real time, . . .”

Third, “Because of the perception of personal culpability associated with diagnostic errors, . . . health care professionals have relied on the heroism of individual clinicians . . . to prevent diagnostic errors.”  Because humans are not error-free, the system as it currently exists will inevitably produce some errors.  Possible interventions include checklists, cognitive aids, machine learning, and training modules aimed at the Top 15 problematic clinical conditions. “The paradigm of how we interpret diagnostic errors must shift from trying to “fix” individual clinicians to creating systems-level solutions to reverse system errors.”

Our Perspective

It will come as no surprise that we endorse the authors’ point of view: healthcare needs to utilize more systems thinking to increase the safety and effectiveness of its myriad diagnostic and treatment processes.  Stakeholders must acknowledge that the current system for delivering healthcare services has error rates consistent with its sub-optimal design.  Because of that, tinkering with incremental changes, e.g., the well-publicized effort to reduce infections from catheters, will yield only incremental improvements in safety.  At best, they will only expose the next stratum of issues that are limiting system performance.

Incremental improvements are based on fragmented mental models of the healthcare system.  Proper systems thinking starts with a complete mental model of a healthcare system and how it operates.  We have described a more complete mental model in other posts so we will only summarize it here.  A model has components, e.g., doctors, nurses, support staff, and facilities.  And the model is dynamic, which means components are not fixed entities but ones whose quality and quantity varies over time.  In addition, the inter-relationships between and among the components can also vary over time.  Component behavior is directed by both relatively visible factors – policies, procedures, and practices – and softer control functions such as the level of trust between individuals, different groups, and hierarchical levels, i.e., bosses and workers.  Importantly, component behavior is also influenced by feedback from other components.  These feedback loops can be positive or negative, i.e., they can reinforce certain behaviors or seek to reduce or eliminate them.  For more on mental models, see our May 21, 2021, Nov. 6, 2019, and Oct. 9, 2019 posts.

One key control factor is organizational culture, i.e., the values and assumptions about reality shared by members.  In the healthcare environment, the most important subset of culture is safety culture (SC).  Safety should be a primary consideration in all activities in a healthcare organization.  For example, in a strong SC, the reporting of an adverse event such as an error should be regarded as a routine and ordinary task.  The reluctance of doctors to report errors because of their feelings of personal and professional shame, or fear of malpractice allegations or discipline, must be overcome.  For more on SC, see our May 21, 2021 and July 31, 2020 posts.

Organizational structure is another control factor, one that basically defines the upper limit of organizational performance.  Does the existing structure facilitate communication, learning, and performance improvement or do silos create barriers?  Do professional organizations and unions create focal points the system designer can leverage to improve performance or are they separate power structures whose interests and goals may conflict with those of the larger system?  What is the quality of management’s behavior, especially their decision making processes, and how is management influenced by their goals, policy constraints, environmental pressures (e.g., to advance equity and diversity) and compensation scheme?

As noted earlier, the authors observe that EDs depend on individual doctors to arrive at correct diagnoses in spite of inadequate information or time pressure and doctors who can do this well are regarded as heroes.  We note that doctors who are less effective may be shuffled off to the side or in egregious cases, labeled “bad apples” and tossed out of the organization.  This is an incorrect viewpoint.  Competent, dedicated individuals are necessary, of course, but the system designer should focus on making the system more error tolerant (so any errors cause no or minimal harm) and resilient (so errors are recognized and corrective actions implemented.)          

Bottom line: more systems thinking is needed in healthcare and articles like this help move the needle in the correct direction.

*  J.A. Edlow and P.J. Pronovost, “Misdiagnosis in the Emergency Department: Time for a System Solution,” JAMA (Journal of the American Medical Association), Vol. 329, No. 8 (Feb. 28, 2023), pp. 631-632.