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

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.

To explore diagnostic excellence improvement efforts across hospital medicine divisions in largely academic settings to identify opportunities.

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.

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.

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.