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Quality Update - Health care quality issues for Minnesota's health care leaders

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Diagnostic Error in Medicine

Opportunity to Improve Value-Based Care

Attention to diagnostic error has been raised across the country, including in Minnesota, by the Institute of Medicine (IOM) September 2015 report, "Improving Diagnosis in Health Care." As the report clearly and urgently states:

 

The occurrence of diagnostic errors has been largely unappreciated in efforts to improve the quality and safety of health care. The result of this inattention is significant: Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Urgent change is warranted to address this challenge.

 

Improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers.

Rising to the IOM report’s call to action, the Minnesota Alliance for Patient Safety (MAPS), MMIC, and Stratis Health began convening a community dialogue to assess the level of interest and commitment among Minnesota health care leaders in addressing misdiagnosis in medicine through collaborative efforts. Convened four times in 2016, this group of Minnesota leaders developed a shared understanding of the complexity of diagnostic error, reviewed data and studies, and prioritized actions to be undertaken in our community.

Doctor and nurse looking at scans

As part of this effort, MMIC conducted an in-depth analysis of its data, which truly represents only the tip of the iceberg of diagnostic error, as its data is limited to malpractice claims. MMIC analyzed 442 diagnosis-related major and other allegations in medical professional liability claims and cases asserted against their policyholders during the five-year period 2010 and 2014. In this study, 19 different factors were identified as contributors to follow-up system failures of the diagnostic process that led to the clinical event and/ or the assertion of the case. These system failure factors were present in 40 percent of the cases studied, accounting for $31 million in total incurred costs over the five-year period.

Notably, factors involving clinical judgment—such as patient assessment issues and narrow diagnostic focus—played Health care quality issues for Minnesota’s health care leaders Fall 2016 significantly less of a role in system failure cases. Communication factors, failures and delays within clinical systems, and other administrative factors played a significantly higher role.

In addition, improving diagnosis in medicine was a theme at this year’s MAPS conference in October. The patient stories shared about missed and mis-diagnosis were compelling and motivating.

One of the key actions being undertaken by Minnesota leaders to decrease diagnostic error is a community collaborative project focused on follow-up to testing and communication of test results.

Stratis Health is pleased to be working with partners to lead the way in improving diagnosis in medicine in Minnesota. Improving diagnosis clearly links safety and costs, making it a critical component of improving value in health care.

We are taking seriously the IOM’s call for urgent change and invite you to join us.

Jennifer Lundblad

 

Jennifer P. Lundblad, PhD, MBA

President and CEO, Stratis Health

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