January 23, 2023
HOMERuN Collaborative: Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT) Focus Groups
The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.
Moderators: Andrew Auerbach, Jeff Schnipper, Marisha Burden, Katie Raffel, Angela Keniston
Background: We are embarking on a four-year journey in pursuit of diagnostic improvement — Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT). A large and unique part of this effort is considering how we identify and codify resilience in our diagnostic systems of care (Safety II analysis). We convened focus groups to discuss how to identify teams/workflows that are doing the work differently than it's typically imagined to achieve diagnostic accuracy. How can we learn from them and build systems that standardize these unique structures and processes?
What does diagnostic excellence look like?
Much like quality of care in other aspects of our system—timely, efficient, evidence-based, patient-centered, equitable. Themes that may be more unique to diagnosis:
  • Process is iterative
  • Contingency plans are integrated
  • Team-based and structured process utilized
  • Uncertainty and self-awareness are accepted
"A critical skill as a diagnostician is to glean the right information from a patient and caregivers, which requires you to connect with a patient and have the ability to form a therapeutic relationship."
What makes a diagnostic journey seem like it went well?
Two themes rose to the top of the focus group discussions:
  • A course with an expected trajectory, prognosis and/or robust contingency planning with timely recognition of clinical change
  • Effective communication and collaboration with patient/caregiver and within the interprofessional team
Chart Review: It may be possible to detect diagnostic discrepancy based on critical care management after escalation or to detect time from deterioration to diagnostic response.
Clinician/team perspective: We discussed capturing what often cannot be detected from the EHR.
  • Degree of surprise with course or outcome
  • Uncertainty
  • Cognitive load and clinical reasoning
  • Nature of communication and teamwork between patients, consultants, interprofessional collaborators, and primary team
"One of the things about Safety II findings is that they are not just a gradation of work as usual, but instead that the work was done in a way that is not normally imagined and that led to diagnostic efficiency or success."
What sort of things help you make better diagnoses when under difficult situations?
  • Practicing in a psychologically safe environment with sufficient time and the right team members — this allows for opportunities for re-evaluation/reconsideration and discussion with colleagues, consultants, interprofessional teams
  • Access to robust EHR with readily accessible information
  • Effective clinical decision-support
"We have a new team looking at patients and how they progress through their hospitalization. If they aren't following anticipated trajectory, we are going to have other eyes on that case, which may be a potential opportunity to evaluate what is going on with the patient diagnostically."
Key Takeaways:
  1. In addition to previously defined aspects of quality and excellence (IHI pillars), an iterative approach to diagnosis with recognition of uncertainty is critical
  2. Degree of surprise with prognosis, course, or outcome may reveal diagnostic journeys that went well versus not
  3. Evaluation of diagnosis in the intensive care unit may provide insights into diagnostic process that preceded escalation 
  4. Team-based, interprofessional care, and structured process allow for diagnosis in difficult situations 
HOMERuN-Affiliated Study Seeking Partners
Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE) Study
Purpose of RELIANCE:
Both roflumilast and azithromycin have been shown to reduce the risk of COPD exacerbations compared to placebo. However, there has not been a head-to-head comparison of these two FDA-approved medications. RELIANCE is intended to support hospital efforts to reduce the risk of all-cause hospitalization and premature deaths in individuals with COPD. 

RELIANCE is Seeking Community-Based Hospitalists:
Hospitalists are critical in the development of post-discharge care plans and medications used by people with COPD. We found from preliminary work that identification of people with COPD while they are hospitalized is an efficient recruitment method for RELIANCE.

Benefits and Compensation:
  • $500/year honorarium for being a community partner (paid after registration) plus $2,000 per patient enrolled.
  • Option to participate in clinical roundtables with COPD thought leaders.
  • Contribute topic ideas for future grant proposals or publications related to hospitalist care.
  • Community Partners will not be investigators / authors, but will be acknowledged in the RELIANCE publication. 

Please reach out to Tiffany.Lee@ucsf.edu if you are interested in participating and would like more information about RELIANCE.
Our next meeting will be on February 10, 2023.
Image Attributions: Vector images from vecteezy.com
Check out the HOMERuN website for more information.
If you would like to join the HOMERuN Collaborative calls, please reach out to Tiffany.Lee@ucsf.edu.