Leapfrog Group Releases Updated Diagnosis Recommendations for Hospitals

By Jay Kumar

The Leapfrog Group last week released a new report that updates its recommended practices to prevent diagnostic errors in hospitals.

Diagnostic errors account for an estimated 40,000 to 80,000 deaths annually, according to the group. The report, Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals, aims to build a national consensus with practices that hospitals can adopt to improve patient outcomes. A multi-stakeholder group identified 22 evidence-based actions for hospitals to implement.

Diagnostic error “is an enormous problem in healthcare,” says Jean-Luc Tilly, Program Manager of Health Care Ratings at the Leapfrog Group. “Just about everyone should expect that they’ll experience at least one diagnostic error in their lifetimes, and sometimes with devastating consequences.”

In July 2022, Leapfrog published the first edition of the Recognizing Excellence in Diagnosis report, highlighting 29 recommended practices. Since then, Leapfrog conducted a pilot survey of nearly 100 hospitals, asking them to report their progress in implementing the 29 practices and offer feedback on them.

“Our goal at first was to really put a baseline out there. It was 29 different practices and we had collected a lot of literature to support it,” Tilly says. “We weren’t sure what implementation was like so the goal of the first report was to give us a sense of where to start and how to direct a survey that we did of what ended up being 95 hospitals across the country.”

Leapfrog used the results of the pilot survey and public comments and feedback from hospitals to create the 2024 update. The new report takes 22 recommendations and puts them into three categories to make them easier for organizations to digest and implement:

Building on Progress (well-aligned with existing quality and safety initiatives)

1. Openly communicate diagnostic errors to patients
2. Make it easy for hospital staff to report diagnostic errors and concerns
3. Provide clinicians with resources to update knowledge and support decision-making
4. Communicate clear instructions to patients discharged with an uncertain diagnosis
5. Ensure critical results from tests pending at discharge are reviewed
6. Manage diagnostic uncertainty at handoffs
7. Establish for patient engagement, communication, and teamwork
8. Help patients and their family caregivers communicate complete and accurate instructions

Focused innovation (Practices where implementation will require a specific focus on diagnosis, as opposed to relying on an extension of an existing patient safety initiative)

9. Measure and monitor diagnostic safety outcomes
10. Dedicate time for analysis and learning
11. Promote teamwork
12. Jointly review differences between imaging and pathology results
13. Provide access to appropriate subspecialty expertise for pediatric patients and patients with a possible stroke in the emergency department
14. Implement “closed loop” communication
15. Convene a multidisciplinary team to promote diagnostic safety and quality
16. Demonstrate commitment to diagnostic excellence through executive leadership
17. Conduct a risk assessment

Aspirational (Practices for improving diagnostic safety and quality where implementation is quite rare nationwide, and where universal implementation may take longer for many hospitals)

18. Implement and monitor adherence to diagnostic guidelines
19. Optimize the electronic health record to support accurate and timely diagnosis
20. Communicate progress of diagnosis safety programs
21. Train clinicians to recognize and minimize cognitive errors
22. Provide feedback to clinicians

Most diagnoses are made in an outpatient setting such as a doctor’s office, Tilly says. “So when we’re thinking about hospitals specifically, the problem is more limited but based on the research, every year, 250,000 people will experience diagnostic error involving a hospital inpatient.”

There are two different types of diagnostic errors, he says. One is a missed opportunity, where something like cancer was missed by the clinician. “But the other kind of diagnostic error is you did correctly make the diagnosis…but it wasn’t effectively communicated to the patient or to that patient’s ordering physician.”

Other communication lapses could occur if a lab result comes back but the family physician doesn’t receive the email, or if a patient changes physicians and the test result isn’t passed along, Tilly says. Or if a patient goes to the emergency department and has a test done, but doesn’t receive the result and may have a serious condition that isn’t diagnosed.

Sometimes the person making the diagnosis may not have the correct expertise, he adds. “For example, strokes are quite rare in young people, but they do happen, right? So it can take a particular kind of expert in diagnosing strokes to identify strokes that are happening,” adds Tilly.

Leapfrog added questions to its annual survey of hospitals in the hopes of setting a standard to grade hospitals on how well they’re implementing these diagnostic practices. “We won’t be able to do that this first year and just because we’re still evaluating what hospital responses are like, we may not even be able to do it next year necessarily,” Tilly says.

Asked what would constitute a victory for this initiative, Tilly says it’s to see hospitals begin following the recommendations in the report. “The way we’ll monitor improvement over time is hospitals’ implementation of those structures,” he adds. “That said, you know there’s a lot of research that’s being done and every few years, I’m hoping that we’ll see in the clinical research a lower incidence of diagnostic error. But for our part, we’re looking really at the implementation of these structures.”