From frameworks to the frontline: Hospitalist perspectives on diagnostic excellence programs

BACKGROUND: The National Academies' Improving Diagnosis in Health Care report outlined eight goals for improving the diagnostic process and building a culture of diagnostic excellence. Despite a decade passing since these recommendations, development of programs remains inconsistent. OBJECTIVES: To explore diagnostic excellence improvement efforts across hospital medicine divisions in largely academic settings to identify opportunities. METHODS: This study used rapid qualitative methods to analyze focus groups with hospitalist clinicians recruited from sites participating in an AHRQ-funded study. After creating focus group summaries and an analytical matrix, thematic analysis was conducted using a mixed inductive and deductive method at the semantic level. RESULTS: Seven focus groups were conducted with 30 participants across 14 hospitals. Participants described more than 80 interventions, programs, and tools to improve diagnostic processes. Five themes were identified: (1) current diagnostic excellence efforts were weighted toward reactive rather than proactive interventions; (2) successful diagnostic excellence programs need to focus on both systems issues and clinician performance; (3) clinicians desired greater support in the diagnostic process, especially when cognitive load impairs clinical reasoning; (4) clinicians desired a supportive culture for feedback; and (5) for new ideas to succeed, context of care and resource constraints will need to be considered. DISCUSSION: Our findings highlight limited scope in diagnostic safety efforts, which remain largely centered on retrospective case reviews and conferences. Clinicians desire system-level redesign encompassing improved team dynamics, reduced cognitive load, psychologically safe feedback, and optimization of the electronic health record. This shift is hindered by cultural, leadership, and resource-related barriers.