Diagnostic Excellence in the Context of Climate Change: A Review.

Climate change is leading to a rise in heat-related illnesses, vector-borne diseases, and numerous negative impacts on patients' physical and mental health outcomes. Concurrently, healthcare contributes about 4.6% of global greenhouse gas emissions. Low-value care, such as overtesting and overdiagnosis, contributes to unnecessary emissions. In this review, we describe diagnostic excellence in the context of climate change and focus on two topics. First, climate change is affecting health, leading to the emergence of certain diseases, some of which are new, while others are increasing in prevalence and/or becoming more widespread. These conditions will require timely and accurate diagnosis by clinicians who may not be used to diagnosing them. Second, diagnostic quality issues, such as overtesting and overdiagnosis, contribute to climate change through unnecessary emissions and waste and should be targeted for interventions. We also highlight implications for clinical practice, research, and policy. Our findings call for efforts to engage healthcare professionals and policymakers in understanding the urgent implications for diagnosis in the context of climate change and reducing global greenhouse gas emissions to enhance both patient and planetary outcomes.

The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation.

INTRODUCTION: One in three patients is affected by diagnosis-related communication failures. Only a few valid and reliable instruments that measure teamwork and communication exist, and none of those focus on improving diagnosis. The authors developed, refined, and psychometrically evaluated the TeamSTEPPSⓇ for Improving Diagnosis Team Assessment Tool (TAT), which assesses diagnostic teamwork and communication in five critical teamwork domains and can be used to identify strengths and opportunities for improvement and monitor performance. METHODS: The TAT was administered as a cross-sectional survey to 360 health professionals across nine diverse US health systems. Content and construct validity were evaluated through pilot implementation and subject matter expert review. Reliability and internal consistency were assessed with Cronbach's alpha. To understand sources of variation in TAT scores and assess the tool's consistency across diverse health care organizations, generalizability theory (G-theory) was used. Best practices in screening for careless responding identified participants with random or nonvarying responses. RESULTS: Analyses indicated strong support for the tool. Content validity findings indicated that the TAT encompassed relevant diagnostic improvement teamwork and communication content. Construct validity, evaluated through pilot implementations, demonstrated the tool's effectiveness in assessing teamwork categories. Reliability analyses confirmed the TAT's internal consistency, with an overall Cronbach's alpha of 0.97. Each dimension of the TAT exhibited good reliability coefficients, ranging from 0.83 to 0.95. G-theory analysis showed that variations in TAT scores were primarily attributed to respondents (28.0%) and scale dimensions (59.6%); both are desirable facets of variation. Further, examination of careless respondents ensured the accuracy and quality of the results, enhancing the TAT's credibility as a valuable diagnostic improvement tool. CONCLUSION: Psychometric evaluation demonstrated that the TAT is a reliable and valid instrument for assessing teamwork and communication among and across diagnostic teams. The TAT adds a novel, evidence-based, psychometrically sound measurement tool to help advance diagnostic teamwork and communication to improve patient care and outcomes.

The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.

OBJECTIVES: No framework currently exists to guide how payers and providers can collaboratively develop and implement incentives to improve diagnostic safety. We conducted a literature review and interviews with subject matter experts to develop a multi-component 'Payer Relationships for Improving Diagnoses (PRIDx)' framework, that could be used to engage payers in diagnostic safety efforts. CONTENT: The PRIDx framework, 1) conceptualizes diagnostic safety links to care provision, 2) illustrates ways to promote payer and provider engagement in the design and adoption of accountability mechanisms, and 3) explicates the use of data analytics. Certain approaches suggested by PRIDx were refined by subject matter expert interviewee perspectives. SUMMARY: The PRIDx framework can catalyze public and private payers to take specific actions to improve diagnostic safety. OUTLOOK: Implementation of the PRIDx framework requires new types of partnerships, including external support from public and private payer organizations, and requires creation of strong provider incentives without undermining providers' sense of professionalism and autonomy. PRIDx could help facilitate collaborative payer-provider approaches to improve diagnostic safety and generate research concepts, policy ideas, and potential innovations for engaging payers in diagnostic safety improvement activities.

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events.

OBJECTIVES: Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs. DESIGN: Longitudinal quasi-experimental study. SETTING: Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. INTERVENTIONS: We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal. MEASUREMENTS AND RESULTS: ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively. CONCLUSIONS: A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.