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Diagnostic Improvement is a Journey

 

Northwell Health Uses Teach-Back Method to Confirm Patient Understanding of Diagnosis

What follows is an interview conversation with Mark P. Jarrett, MD, MBA, MS, Chief Quality Officer, Senior Vice President & Associate Chief Medical Officer at Northwell Health and Ankita Sagar, MD, MPH, Attending Physician in the Department of Internal Medicine at Northwell Health. We spoke to them about the steps they took to improve diagnostic quality within their organization. If you are interested in speaking to Dr. Jarrett or Dr. Sagar to learn more, please email Coalition@ImproveDiagnosis.org.

What diagnostic barrier has your organization chosen to tackle or focus on?

“The process of tackling diagnostic barriers has been—and will continue to be—a journey for Northwell Health,” said Mark P. Jarrett, MD, MBA, MS.

About two years ago, Northwell began examining that when patients weren’t active participants in diagnostic discussions with their providers, it could lead to important information being left out when providing their medical history and significant gaps in understanding.

“We chose to focus on improving conversations between providers, patients and their families in an effort to mitigate misunderstandings and ensure that all relevant information gets shared,” said Dr. Jarrett.

Rather than simply explaining the diagnosis to the patient and asking if he or she understood it, Northwell instituted a teach-back method and instructed providers to go a step further by asking patients to explain the diagnosis back to them.

The result—by asking patients to explain the diagnosis, patients often asked another question, clarified information, or remembered a piece of medical history that they hadn’t before.

Are you working with specific conditions to improve the diagnostic process?

Northwell has another project underway where, through education and training, they are teaching physicians how to identify and care for patients who may be at risk of long-term cardiovascular disease.

“We knew we needed to develop a measurable project that would move the needle,” said Ankita Sagar, MD, MPH. “So the next project will aim to improve the diagnostic accuracy of cardiovascular disease in patients who are cancer survivors.”

According to the National Institutes of Health, radiation treatment can cause cardiovascular disease, and symptoms can occur during treatment or years afterward. Plus, according to the Centers for Disease Control and Prevention, heart disease is the leading cause of death for women in the United States. Dr. Sagar provided an example of why the new project is important:

“Let’s say a primary care doctor has a 40-year-old patient complaining of chest pain,” said Dr. Sagar. “She’s otherwise healthy, but had lymphoma when she was younger, which required radiation. Depending on the information that the physician has in front of him or her, or that the patient is able to remember about the radiation, the physician may erroneously consider her to be at low risk for cardiovascular disease, when actually she may be at higher risk for cardiovascular disease given the history of cancer and radiation therapy.”

Have you developed tools or clinician decision support materials to help your staff engage in either of these interventions?

“We developed a script for the teach-back project and trained clinicians how to use it,” said Dr. Jarrett. “We had to demonstrate that it only took a minute and a half; it wasn’t going to lengthen the visit by 20 minutes.”

Dr. Sagar and her team are aiming to develop clinician decision tools for the new project. “We’re looking to use data to develop a registry or a risk calculator, and to leverage that technology as a secondary test when patients come to their primary care physician, or go to the ER, or are admitted to the hospital.”

What were some of the barriers you needed to overcome to advance this work, and what were some of the surprises that you encountered along the way? How did you address them?

“Going into it, we thought our biggest barrier would be getting physicians on board with taking the extra step to do the teach-back method,” said Dr. Jarrett. “But to our surprise, most of our physicians were receptive to it.”

The key to that positive reaction was the education that Dr. Jarrett provided beforehand. “Asking people to do something just because you say things will be better doesn’t work. We made sure to explain why we were asking them to do this, and what we hoped to gain from it. We also asked them to think from the patient’s viewpoint why this would helpful.”

What best practices would you share and what advice might you give to health system Coalition members or other stakeholders when it comes to implementing interventions to reduce misdiagnosis?

“Start small with a pilot, and keep doing it in an iterative process,” said Dr. Jarrett. “Whatever you think is going to work in the beginning probably won’t, and you’re going to have to change things based on feedback and what you’re learning.”

“It’s also important to be thoughtful about who you want to involve in the project at both the grassroots and leadership levels,” said Dr. Sagar. “The folks at the grassroots level are the ones doing the work, but you also need people who can get buy-in from leadership or from their community.”

How will you define success?

“The success of teach-back was in changing the culture so that our physicians and other providers recognized that there was a problem with cognitive error,” said Dr. Jarrett. “It’s a soft metric, but demonstrating that even the smartest clinicians aren’t right all the time, and that there are mechanisms that help you improve, was Northwell’s first step toward improving diagnostic accuracy.”

The Northwell team is still developing metrics for the cardiovascular disease diagnosis project, but they believe it will be easier to measure diagnostic improvement. “By setting more quantifiable outcome measures, we’ll be able to either develop the project further or implement it in different ways,” said Dr. Sagar. “And we’ll be able to see if we’ve actually reduced the risk of diagnostic error for our patients.”

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