Background: The Safety I diagnosis framework primarily evaluates underlying causes of adverse events, tacitly assuming that system components either work or do not work.(1) By contrast, the Safety II diagnosis framework evaluates how performance goes as expected, which starts from a “work as imagined” and moves to “work as done”. The aims of this study are to describe hospitalists’ everyday diagnostic processes, thinking and challenges to diagnosis. This was conducted as part of a larger study on achieving diagnostic excellence in Hospital Medicine which was funded by the Agency for Healthcare Research and Quality.(2)
Methods: We conducted seven semi-structured, virtual focus groups via Zoom with a convenience sample of participants from a national Hospital Medicine research network(3) to answer three core questions regarding promoting safety in diagnosis: 1) what are the usual habits and practices that individuals and teams use to make the diagnostic process go well, most of the time? 2) what are the daily complexities and usual challenges that stand in the way of making a diagnosis? 3) How do systems and teams adapt to complexity in making a diagnosis? Rapid qualitative methods using templated summaries and matrix analysis were then used to identify major themes and best approaches.(4)
Results: Thirty-one hospitalists from academic medical centers across the United States participated in seven concurrent focus groups. Qualitative analysis identified three overarching themes shown in Table 1. First, the structural features of the clinical work environment and organizational expectations have deep impacts on the diagnostic process, summarized in greater detail in Table 2. Second, the management of interruptions and the need to navigate varied technology represent critical practical challenges requiring adaptation. Finally, awareness of one’s own internal cognitive processes, such as cognitive biases, reasoning strategies and metacognitive checks plays a vital role in arriving at an accurate diagnosis.
Conclusions: Using the Safety-II diagnostic framework to examine the diagnostic process helps us understand how hospitalists not only work to prevent errors, but also understand what makes things go right in everyday practice. By moving from “work as imagined” to “work as done”, our analysis shows that the diagnostic process is shaped by the broader clinical environment, the realities of the hospitalist workflow and the dynamic adjustments hospitalists make in real time. Taken together, these themes underscore that diagnostic safety is impacted by hospitalists interacting with their environment, technology, and cognitive strategies. Hospital leaders might consider incorporating some of structural features including staffing systems, electronic health record integrations, and communication guidelines suggested in Table 1 to promote an environment where diagnoses can be made accurately and efficiently. A Safety-II lens encourages health systems to support the conditions that allow hospitalists to adapt, collaborate and think effectively, cultivating an environment that fosters diagnostic excellence, a growing area for quality improvement among US hospitals. (5)
