Diagnostic Errors in Medicine

1. Diagnostic Errors in Medicine November 12, 2012 William Strull, MD Medical Director Quality and Patient Safety The Permanente Federation, LLC Prepared by: Bettygene Egan, MBA

2. Kaiser Permanente Regions

3. Coded Closed Claims Claims Distributions Payout Distributions Diagnosis Diagnosis

4. High-Level Categories • Cognition • Visual diagnosis • Closing the loop/Follow-up

5. Staff Engagement and Learning • Communication down to the front line level • Diagnostic Reliability and Improvement Initiative • Team and Committees (DRII) • Risk Managers Operations Team • Sentinel Event Risk Care Integration Team

6. Analyze, Share, Prevent, Inter-REgionally,

7. Specimen Handling & Tracking • Anatomical Specimen Handling • Inter-Regional Specimen Tracking

8. Specimen Handling Anatomical Pathology Specimen Handling Project Colorado Region

9. CD Bio National Strategy Background Strategic Alignment • Lack of a uniform specimen tracking mechanism throughout Kaiser Permanente has lead to lost or misplaced specimens during transit or while being processed at hospital or regional laboratories. • Existing Specimen Tracking capabilities do not support all specimen tracking needs for Kaiser Permanente’s multi-site intra-regional laboratories. • Some of the identified specimen tracking pain points during specimen transport includes: specimens lost, misplaced, misrouted, relabeled and stored at the incorrect temperature resulting in unusable specimens . Then they must be recollected when possible resulting in missed or delayed diagnosis, and even litigation risks when high value specimens are lost or mishandled. • The consequence of a loss depends on the type of specimen, varying from the irreparable impact of a lost diagnostic specimen that can’t be recollected to the inconvenience a member experiences being recalled for a repeat blood collection. • Ultimately, these lost specimens results in decreased member and provider satisfaction, increased costs due to repeated procedures or even worse, litigation. • Strategic KP Imperatives • Transform Care Delivery • Solving for Affordability Benefits Realization • Continuous Improvement • Productivity Gains • Compliance Requirements • Cost of Doing Business • Member Satisfaction 9

10. Identify and Manage Outpatient Safety Nets that proactively identify and manage patients with an outpatient safety risks

11. Categories of Gaps • Necessary Follow-up Care • Tracking/follow-up of abnormal results • Medication Management • Appropriate monitoring for long-term medications • Diagnosis Detection • Identify potentially undiagnosed cases • Potentially Harmful Interactions • Pharmacist recommends alternative drug therapy

12. Patient Safety Measurement Portfolio • % of breast cancer diagnosed at stage 1 or 2 • % of cervical cancer diagnosed at stage 1 or 2 • % of colorectal cancer diagnosed at stage 1 or 2 • Testing for HIV among HIV uninfected members • diagnosed with sexually transmitted infection

13. KP HealthConnect • The After Visit Summary • Improves patient follow through with the completion of diagnostic tests • Engages the patient as “partner” • Is the #1 member satisfier • Overdue Results Notification • Provides a safety net to ensure that tests are completed • “Tickler” Reminder Messaging • Allows clinicians to send themselves a reminder to make sure an urgent or important diagnostic test, referral or “hand off” has been completed • In Basket Monitoring • Ensures that all in basket messages, with abnormal results, have been addressed in a timely manner

14. Engagement • Patient Family Centered Care • SMART Partners

15. Diagnosis and Engagement

16. Diagnosis and Engagement

17. Questions