Applying an equity lens to hospital safety monitoring: a critical interpretive synthesis protocol.

INTRODUCTION: Hospital safety monitoring systems are foundational to how adverse events are identified and addressed. They are well positioned to bring equity-related safety issues to the forefront for action. However, there is uncertainty about how they have been, and can be, used to achieve this goal. We will undertake a critical interpretive synthesis (CIS) to examine how equity is integrated into hospital safety monitoring systems. METHODS AND ANALYSIS: This review will follow CIS principles. Our initial compass question is: How is equity integrated into safety monitoring systems? We will begin with a structured search strategy of hospital safety monitoring systems in CINAHL, EMBASE, MEDLINE and PsycINFO for up to May 2023 to identify papers on safety monitoring systems generally and those linked to equity (eg, racism, social determinants of health). We will also review reference lists of selected papers, contact experts and draw on team expertise. For subsequent literature searching stages, we will use team expertise and expert contacts to purposively search the social science, humanities and health services research literature to support the development of a theoretical understanding of our topic. Following data extraction, we will use interpretive processes to develop themes and a critique of the literature. The above processes of question formulation, article search and selection, data extraction, and critique and synthesis will be iterative and interactive with the goal to develop a theoretical understanding of equity in hospital monitoring systems that will have practice-based implications. ETHICS AND DISSEMINATION: This review does not require ethical approval because we are reviewing published literature. We aim to publish findings in a peer-reviewed journal and present at conferences.

Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study.

BACKGROUND: Efforts to increase physician engagement in quality and safety are most often approached from an organisational or administrative perspective. Given hospital-based physicians' strong professional identification, physician-led strategies may offer a novel strategic approach to enhancing physician engagement. It remains unclear what role medical leadership can play in leading programmes to enhance physician engagement. In this study, we explore physicians' experience of participating in a Medical Safety Huddle initiative and how participation influences engagement with organisational quality and safety efforts. METHODS: We conducted a qualitative study of the Medical Safety Huddle initiative implemented across six sites. The initiative consisted of short, physician focused and led, weekly meetings aimed at reviewing, anticipating and addressing patient safety issues. We conducted 29 semistructured interviews with leaders and participants. We applied an interpretive thematic analysis to the data using self-determination theory as an analytic lens. RESULTS: The results of the thematic analysis are organised in two themes, (1) relatedness and meaningfulness, and (2) progress and autonomy, representing two forms of intrinsic motivation for engagement that we found were leveraged through participation in the initiative. First, participation enabled a sense of community and a 'safe space' in which professionally relevant safety issues are discussed. Second, participation in the initiative created a growing sense of ability to have input in one's work environment. However, limited collaboration with other professional groups around patient safety and the ability to consistently address reported concerns highlights the need for leadership and organisational support for physician engagement. CONCLUSION: The Medical Safety Huddle initiative supports physician engagement in quality and safety through intrinsic motivation. However, the huddles' implementation must align with the organisation's multipronged patient safety agenda to support multidisciplinary collaborative quality and safety efforts and leaders must ensure mechanisms to consistently address reported safety concerns for sustained physician engagement.

Understanding the Family Context: A Qualitative Descriptive Study of Parent and NICU Clinician Experiences and Perspectives.

Enabling individualized decision-making for patients requires an understanding of the family context (FC) by healthcare providers. The FC is everything that makes the family unique, from their names, preferred pronouns, family structure, cultural or religious beliefs, and family values. While there is an array of approaches for individual clinicians to incorporate the FC into practice, there is a paucity of literature guiding the process of collecting and integrating the FC into clinical care by multidisciplinary interprofessional teams. The purpose of this qualitative study is to explore the experience of families and Neonatal Intensive Care Unit (NICU) clinicians with information sharing around the FC. Our findings illustrate that there are parallel and overlapping experiences of sharing the FC for families and clinicians. Both groups describe the positive impact of sharing the FC on building and sustaining relationships and on personalization of care and personhood. The experience by families of revolving clinicians and the risks of miscommunication about the FC were noted as challenges to sharing the FC. Parents described the desire to control the narrative about their FC, while clinicians described seeking equal access to the FC to support the family in the best way possible related to their clinical role. Our study highlights how the quality of care is positively impacted by clinicians' appreciation of the FC and the complex relationship between a large multidisciplinary interprofessional team and the family in an intensive care unit, while also highlighting the difficulties in its practical application. Knowledge learned can be utilized to inform the development of processes to improve communication between families and clinicians.

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative.

BACKGROUND: The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact. OBJECTIVE: We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada. METHODS: The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents. RESULTS: Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes. CONCLUSION: The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change.

Protocol for a stepped wedge cluster randomized quality improvement project to evaluate the impact of medical safety huddles on patient safety.

Introduction: Physician engagement is crucial for furthering patient safety and quality improvement within healthcare organizations. Medical Safety Huddles, which are physician-specific huddles, is a novel way to engage physicians with patient safety and may reduce adverse events experienced by patients. We plan to conduct a multi-center quality improvement (QI) initiative to implement and evaluate Medical Safety Huddles. The primary objective is to determine the impact of the huddles on adverse events experienced by patients. Secondary objectives include assessing the impact of the huddles on patient safety culture and physician engagement, and a process evaluation to assess the fidelity of implementation. Methods: This stepped wedge cluster randomized study will be conducted at four academic inpatient hospitals over 19 months. Each site will adapt Medical Safety Huddles to its own practice context to best engage physicians. We will review randomly selected patient charts for adverse events. Generalized linear mixed effects regression will be used to estimate the overall intervention effect on adverse events. Process measures such as physician attendance rates and number of safety issues raised per huddle will be tracked to monitor implementation adherence. Conclusion: Medical Safety Huddles may help healthcare organizations and medical leaders to better engage physicians with patient safety. The project results will assess the fidelity of implementation and determine the impact of Medical Safety Huddles on patient safety.

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme.

BACKGROUND: Healthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by HROs. Interventions aiming to foster these principles are common in healthcare; however, there have been few examinations of the perceptions of those who have planned or experienced these efforts. OBJECTIVE: This single-site qualitative study explores how healthcare professionals understand and enact the HRO principles in response to an HRO-inspired hospital-wide safety programme. METHODS: We interviewed 71 participants representing hospital executives, programme leadership, and staff and physicians from three clinical services. We observed and collected data from unit and hospital-wide quality and safety meetings and activities. We used thematic analysis to code and analyse the data. RESULTS: Participants reported enactment of the HRO principles 'preoccupation with failure', 'reluctance to simplify interpretations' and 'sensitivity to operations', and described the programme as adding legitimacy, training, and support. However, the programme was more often targeted at, and taken up by, nurses compared with other groups. Participants were less able to identify interventions that supported the HRO principles 'commitment to resilience' and 'deference to expertise' and reported limited examples of changes in practices related to these principles. Moreover, we identified inconsistent, and even conflicting, understanding of concepts related to the HRO principles, often related to social and professional norms and practices. Finally, an individualised rather than systemic approach hindered collective actions underlying high reliability. CONCLUSION: Our findings demonstrate that the safety programme supported some HRO principles more than others, and was targeted at, and perceived differently across professional groups leading to inconsistent understanding and enactments of the principles across the organisation. Combining HRO-inspired interventions with more targeted attention to each of the HRO principles could produce greater, more consistent high-reliability practices.

A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic.

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.

OBJECTIVE: To characterise the extent to which health professionals perform SBAR (situation, background, assessment, recommendation) as intended (ie, with high fidelity) and the extent to which its use improves communication clarity or other quality measures. DATA SOURCES: Medline, Healthstar, PsycINFO, Embase and CINAHL to October 2020 and handsearching selected journals. STUDY SELECTION AND OUTCOME MEASURES: Eligible studies consisted of controlled trials and time series, including simple before-after design, assessing SBAR implementation fidelity or the effects of SBAR on communication clarity or other quality measures (eg, safety climate, patient outcomes). DATA EXTRACTION AND SYNTHESIS: Two reviewers independently abstracted data according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses on study features, intervention details and study outcomes. We characterised the magnitude of improvement in outcomes as small (<20% relative increase), moderate (20%-40%) or large (>40%). RESULTS: Twenty-eight studies (3 randomised controlled trials, 6 controlled before-after studies, and 19 uncontrolled before-after studies) met inclusion criteria. Of the nine studies assessing fidelity of SBAR use, four occurred in classroom settings and three of these studies reported large improvements. The five studies assessing fidelity in clinical settings reported small to moderate effects. Among eight studies measuring communication clarity, only three reported large improvements and two of these occurred in classroom settings. Among the 17 studies reporting impacts on quality measures beyond communication, over half reported moderate to large improvements. These improvements tended to involve measures of teamwork and culture. Improvements in patient outcomes occurred only with intensive multifaceted interventions (eg, early warning scores and rapid response systems). CONCLUSIONS: High fidelity uptake of SBAR and improvements in communication clarity occurred predominantly in classroom studies. Studies in clinical settings achieving impacts beyond communication typically involved broader, multifaceted interventions. Future efforts to improve communication using SBAR should first confirm high fidelity uptake in clinical settings rather than assuming this has occurred. PROSPERO REGISTRATION NUMBER: CRD42018111377.

Implementation of a central-line bundle: a qualitative study of three clinical units.

BACKGROUND: Evidence for the central line-associated bloodstream infection (CLABSI) bundle effectiveness remains mixed, possibly reflecting implementation challenges and persistent ambiguities in how CLABSIs are counted and bundle adherence measured. In the context of a tertiary pediatric hospital that had reduced CLABSI by 30% as part of an international safety program, we aimed to examine unit-based socio-cultural factors influencing bundle practices and measurement, and how they come to be recognized and attended to by safety leaders over time in an organization-wide bundle implementation effort. METHODS: We used an interpretivist qualitative research approach, based on 74 interviews, approximately 50 h of observations, and documents. Data collection focused on hospital executives and safety leadership, and three clinical units: a medical specialty unit, an intensive care unit, and a surgical unit. We used thematic analysis and constant comparison methods for data analysis. RESULTS: Participants had variable beliefs about the central-line bundle as a quality improvement priority based on their professional roles and experiences and unit setting, which influenced their responses. Nursing leaders were particularly concerned about CLABSI being one of an overwhelming number of QI targets for which they were responsible. Bundle implementation strategies were initially reliant on unit-based nurse education. Over time there was recognition of the need for centralized education and reinforcement tactics. However, these interventions achieved limited impact given the influence of competing unit workflow demands and professional roles, interactions, and routines, which were variably targeted in the safety program. The auditing process, initially a responsibility of units, was performed in different ways based on individuals' approaches to the process. Given concerns about auditing reliability, a centralized approach was implemented, which continued to have its own variability. CONCLUSIONS: Our findings report on a contextualized, dynamic implementation approach that required movement between centralized and unit-based approaches and from a focus on standardization to some recognition of a role for customization. However, some factors related to bundle compliance and measurement remain unaddressed, including harder to change socio-cultural factors likely important to sustainability of the CLABSI reductions and fostering further improvements across a broader safety agenda.

More than words: methods to elicit talk in interviews.

In health services and primary care research, semi-structured interviews are a very common method of generating data. These interviews have a pre-determined set of topics, with questions and prompts written in advance, though there is flexibility to adjust the interview to match the direction set by the participant. Like all methods, semi-structured interviews have limits, some of which can be addressed through adaptation. In the social sciences, some interview methods include prompts beyond verbal questions to participants, called elicitation tools. Visuals (e.g. photos), videos, audio excerpts and texts can be brought into interviews to orient the discussion. Another type of interview­mobile interview­happens in places meaningful to the participants. Depending on the research question, elicitation methods can enrich semi-structured interviews. This methods brief will introduce interviewing with elicitation tools, and outline strengths of such methods.

Understanding decisions to scale up: a qualitative case study of three health service intervention evaluations.

OBJECTIVE: Efforts to scale up evidence-based health care interventions are seen as a key strategy to address complex health system challenges. However, scale-up efforts have shown significant variability. We address the gap between scale-up theory and practice by exploring the socio-cultural factors at play in the evaluation and scale-up of three interventions within the clinical field. METHODS: A qualitative multiple case study was conducted to characterize the evaluation and scale-up efforts of three interventions. We interviewed 18 participants, including clinicians and researchers across the three cases. Using Pierre Bourdieu's concepts of field and capital as a theoretical lens, we conducted a thematic analysis of the data. RESULTS: Despite the espoused goals of ensuring that health service interventions are always based on high-quality evidence within the clinical field, this study demonstrates that the outcomes of the evaluations are not the only factor in the decision to engage in scale-up efforts. Important socio-cultural factors also come into play. Bourdieu uses the term capital to refer to the resources that agents compete for and with their acquisition, accumulate power and/or social standing. The type of evidence valued in the clinical field and the ability to leverage capital in demonstrating that value are also important factors. CONCLUSIONS: Determining if an intervention is effective and should be scaled up is more complex in practice than described in the literature. Efforts are needed to explicitly include the role of social processes in the current frameworks guiding scaling-up efforts.

When all else fails: The (mis)use of qualitative research in the evaluation of complex interventions.

RATIONAL, AIMS, AND OBJECTIVES: Qualitative research has been promoted as an important component of the evaluation of complex interventions to support the scale up and spread of health service interventions, but is currently not being maximized in practice. We aim to identify and explore the sociocultural and structural factors that impact the uses (and misuses) of qualitative research in the evaluation of complex health services interventions. METHODS: We conducted a qualitative analysis of data collected in a multiple case study of the evaluation and scale up and spread of three health service intervention. RESULTS: Our findings demonstrate the challenges of meaningfully integrating qualitative research in evaluation programmes lead by clinicians with limited qualitative expertise and operating within an environment dominated by biomedical research, even with methodological support. CONCLUSIONS: Based on these findings we encourage ongoing engagement of qualitative researchers in evaluation programmes to begin to refine our methodological understanding, while also suggesting changes to medical education and evaluation funding models to create fertile environments for interdisciplinary collaborations.

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals.

BACKGROUND AND OBJECTIVES: Recent years have seen increasing calls for more proactive use of patient complaints to develop effective system-wide changes, analogous to the intended functions of incident reporting and root cause analysis (RCA) to improve patient safety. Given recent questions regarding the impact of RCAs on patient safety, we sought to explore the degree to which current patient complaints processes generate solutions to recurring quality problems. DESIGN/SETTING: Qualitative analysis of semistructured interviews with 21 patient relations personnel (PRP), nursing and physician leaders at three teaching hospitals (Toronto, Canada). RESULTS: Challenges to using the patient complaints process to drive hospital-wide improvement included: (1) Complaints often reflect recalcitrant system-wide issues (eg, wait times) or well-known problems which require intensive efforts to address (eg, poor communication). (2) The use of weak change strategies (eg, one-off educational sessions). (3) The handling of complaints by unit managers so they never reach the patient relations office. PRP identified giving patients a voice as their primary goal. Yet their daily work, which they described as 'putting out fires', focused primarily on placating patients in order to resolve complaints as quickly as possible, which may in effect suppress the patient voice. CONCLUSIONS: Using patient complaints to drive improvement faces many of the challenges affecting incident reporting and RCA. The emphasis on 'putting out fires' may further detract from efforts to improve care for future patients. Systemically incorporating patients' voices in clinical operations, as with co-design and other forms of authentic patient engagement, may hold greater promise for meaningful improvements in the patient experience than do RCA-like analyses of patient complaints.

Faculty-Resident "Co-learning": A Longitudinal Exploration of an Innovative Model for Faculty Development in Quality Improvement.

PURPOSE: To examine the effectiveness of co-learning, wherein faculty and trainees learn together, as a novel approach for building quality improvement (QI) faculty capacity. METHOD: From July 2012 through September 2015, the authors conducted 30 semistructured interviews with 23 faculty participants from the Co-Learning QI Curriculum of the Department of Medicine, Faculty of Medicine, University of Toronto, and collected descriptive data on faculty participation and resident evaluations of teaching effectiveness. Interviewees were from 13 subspecialty residency programs at their institution. RESULTS: Of the 56 faculty participants, the Co-Learning QI Curriculum trained 29 faculty mentors, 14 of whom taught formally. Faculty leads with an academic QI role, many of whom had prior QI training, reinforced their QI knowledge while also developing QI mentorship and teaching skills. Co-learning elements that contributed to QI teaching skills development included seeing first how the QI content is taught, learning through project mentorship, building experience longitudinally over time, a graded transition toward independent teaching, and a supportive program lead. Faculty with limited QI experience reported improved QI knowledge, skills, and project facilitation but were ambivalent about assuming a teacher role. Unplanned outcomes for both groups included QI teaching outside of the curriculum, applying QI principles to other work, networking, and strengthening one's QI professional role. CONCLUSIONS: The Co-Learning QI Curriculum was effective in improving faculty QI knowledge and skills and increased faculty capacity to teach and mentor QI. Findings suggest that a combination of curriculum and contextual factors were critical to realizing the curriculum's full potential.

Ontario's emergency department process improvement program: the experience of implementation.

OBJECTIVES: In recent years, Lean manufacturing principles have been applied to health care quality improvement efforts to improve wait times. In Ontario, an emergency department (ED) process improvement program based on Lean principles was introduced by the Ministry of Health and Long-Term Care as part of a strategy to reduce ED length of stay (LOS) and to improve patient flow. This article aims to describe the hospital-based teams' experiences during the ED process improvement program implementation and the teams' perceptions of the key factors that influenced the program's success or failure. METHODS: A qualitative evaluation was conducted based on semistructured interviews with hospital implementation team members, such as team leads, medical leads, and executive sponsors, at 10 purposively selected hospitals in Ontario, Canada. Sites were selected based, in part, on their changes in median ED LOS following the implementation period. A thematic framework approach as used for interviews, and a standard thematic coding framework was developed. RESULTS: Twenty-four interviews were coded and analyzed. The results are organized according to participants' experience and are grouped into four themes that were identified as significantly affecting the implementation experience: local contextual factors, relationship between improvement team and support players, staff engagement, and success and sustainability. The results demonstrate the importance of the context of implementation, establishing strong relationships and communication strategies, and preparing for implementation and sustainability prior to the start of the project. CONCLUSIONS: Several key factors were identified as important to the success of the program, such as preparing for implementation, ensuring strong executive support, creation of implementation teams based on the tasks and outcomes of the initiative, and using multiple communication strategies throughout the implementation process. Explicit incorporation of these factors into the development and implementation of future similar interventions in health care settings could be useful.

'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds.

OBJECTIVE: This article is an exploration of views and experiences of Patient Safety Walkrounds, a widely recommended strategy for identifying patient safety problems and improving safety culture. DESIGN AND SETTING: Qualitative analysis of semistructured, in-depth interviews with 11 senior leaders and 33 front-line staff at two major teaching hospitals with mature walkrounds programmes, collected as part of a larger mixed-methods evaluation. RESULTS: Despite differences in the structure of the two walkrounds programmes, senior leaders at both institutions reported attitudes and behaviours that contradict the stated goals and principles of walkrounds. Senior leaders tended to regard executive visibility as an end in itself and generally did not engage with staff concerns beyond the walkrounds encounter. Some senior leaders believed they understood patient safety issues better than front-line staff and even characterised staff concerns as 'stupid'. Senior leaders acknowledged that they often controlled the conversations, delimiting what counted as patient safety problems and sometimes even steered the conversations to predetermined topics. Some front-line staff made note of these contradictions in their interviews. DISCUSSION/CONCLUSIONS: Our study found that walkrounds may inadvertently lead to counter-productive attitudes by senior leaders at odds with the recommended principles of walkrounds. The results demonstrate similar attitudes from senior leaders at two hospitals with quite different formats for walkrounds, suggesting that this pattern may exist elsewhere. Better preparation of senior leaders prior to the walkrounds may help to avoid the counter-productive attitudes and dynamics that we identified.

A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: The Focus on System-Related Factors.

BACKGROUND: Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis. METHODS: As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005. The focus groups included questions about the process of diagnosis, specific factors contributing to missed diagnosis, use of guidelines, atypical vs. typical presentations of disease, diagnostic tools, and follow-up, all with regard to delays in the diagnostic process. The interviews were analyzed (1) deductively, with application of the Systems Engineering Initiative for Patient Safety (SEIPS) model, which addresses systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes, and (2) inductively, with identification of novel themes using content analysis. RESULTS: A total of 25 physicians participated in the six focus groups, which yielded 12 hours of discussion. Providers identified multiple barriers to timely and accurate diagnosis, including organizational culture, information availability, and communication factors. CONCLUSIONS: Multiple themes relating to each of the participants in the diagnostic process-health system, provider, and patient-emerged. Concerns about health system structure and providers' interactions with one another and with patients far exceeded discussion of the cognitive factors that might affect the diagnostic process. The results suggest that, at least in physicians' views, improving the diagnostic process requires attention to the organization of the health system in addition to the cognitive aspects of diagnosis.