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NQF Issues Report on Diagnostic Quality, Safety

NEW YORK (360Dx) – Building off an earlier study on diagnostic errors, the National Quality Forum released a report on Tuesday to guide healthcare providers in thinking about diagnostic errors, and ways they can address and prevent them.

The report, called "Improving Diagnostic Quality and Safety Final Report," covers a wide swath of topics covering issues around how patients are diagnosed and issues around that process. It builds on a 2015 study by the National Academies of Sciences, Engineering, and Medicine — formerly known as the Institute of Medicine — that found that at least 5 percent of American adults seeking outpatient care experience a diagnostic error, contributing to almost 10 percent of deaths each year, and up to 17 percent of adverse hospital events.

NASEM found that despite those numbers, "stakeholders in quality measurement and patient safety have largely neglected" the issue of diagnostic errors, NQF said. Furthermore, NASEM said that a contributing factor to this has been a lack of "effective measurement related to the diagnostic process and diagnostic outcomes."

In its report, the NQF report mostly stayed away from making direct recommendations on how healthcare providers and institutions can reduce diagnostic errors. Instead, it suggested a conceptual framework for measuring diagnostic quality and safety, as well as priorities for developing measures to address them.

A committee of multiple stakeholders formed by NQF devised their framework, comprising three main "domains" and 11 "subdomains" for measuring diagnostic safety and quality. The three main domains are patients, families, and caregivers; the diagnostic process; and organizational and policy opportunities.

The subdomains within them provide more specific subject areas for diagnostic stakeholders to consider as they develop measures. They include, among other topics, patient experience and engagement; information gathering and documentation; information integration and interpretation; and diagnostic quality and workforce issues.

For example, the report said that patients and their families are a key part of the diagnostic process and added that measures could be developed to ensure that information such as laboratory results, consultation notes, and confidence in the diagnosis is being communicated to patients.

In the area of diagnostic information, the NQF committee acknowledged shortcomings in electronic health record technology. It noted that diagnosis is "an evolving process and often involves a degree of uncertainty" as attempts are made to confirm or explain a diagnosis, and said that while it is crucial that providers can establish and document a differential diagnosis, many EHRs "do not allow differential diagnoses to be recorded in structured fields, and as a result, such information is never documented, diminishing providers' ability to carry out a high-quality diagnostic process."

Members of the committee also said that processes need to be in place to identify and reconcile "discordant" patient health findings and interpretations. They can then be tracked and the information can be fed back into the organization's system, so that the results can be reconciled and the organization can learn from them.

Among the most important issues with diagnostic quality and safety is follow-up, and the NQF committee identified the timely and accurate communication of test results as a major issue in diagnostic errors. Such communication is "'low hanging fruit" that could feasibly addressed by an organization, resulting in immediate benefits, the report said.

It added that follow-up on actionable or abnormal test results is of special importance, and steps to tackle the issue include assessing whether an organization has procedures in place to monitor communication of such results, and identifying the clinician responsible for the test follow-up.

The report also addressed overuse of diagnostic tests and suggested that there may be a need to limit some tests in order to mitigate "potentially high-risk situations. … Committee members also suggested that linking test ordering patterns with use of appropriate interventions may help identify and avoid undertreatment or overtreatment and associated complications."

"As the field of healthcare continues to realize the need for diagnostic quality and safety, a measurement framework is a key component in assessing improvements," the NQF said, adding the committee who created the report "hopes that this provides guidance to the field for both short-term improvements and aspirational initiatives."