Organizers and Facilitators: Andrew Auerbach, Jeff Schnipper, Katie Raffel, Angela Keniston, Sara Westergaard, Gopi Astik, Marisha Burden

Background: While much of what HOMERuN has focused on in safety has been related to faults — in readmissions, interhospital transfers, and diagnostic errors — our July 12 session focused on the things that go well day-to-day, which is called "Safety II" thinking.

Safety II practices are how we adapt to complexity and a range of usual challenges and lead to resilient physicians. 

On our July 12 session, we thought about the day-to-day work we do, and the Safety II practices that help hospitalists make a timely and accurate diagnosis and communicate it to the patient.

Breakout groups considered tasks, habits, or processes that help make diagnosis go smoothly and accurately; common problems and challenges which introduce complexities; and the ways these complexities force hospitalists to adapt or improvise in our diagnostic journeys.

Themes and Strategies

1. Structured Approaches to Patient Review: Consistency is key. Develop a systematic approach to chart reviews and documentation.

"I try to approach my chart review the same for all patients, like checking vital signs and labs, imaging data."

"I use my note as my thinking about my thought process, recording it and then changing it as I go."

2. Effective Triage and Prioritization: Prioritize patients based on acuity and complexity to manage time effectively.

"I'm also triaging diagnostic complexity and patient acuity at that same time."

"Go through those three Ds: the dead, dying, discharging."

3. Collaborative Diagnostic Processes: Encourage open communication with team members to refine diagnoses and improve patient care.

"The conversation with another team member is crucial; it does alter diagnostic processes."

"I encourage the residents to talk to patients or families and nurses, and other specialties who are on the patient."

4. Managing Interruptions: Implement strategies to minimize disruptions that can lead to errors.

"Managing up front. I'm actually sending secure chats to all the nurses, please only reach out for emergency."

5. Maintaining Diagnostic Flexibility: Stay curious and develop ways to avoid anchoring bias to improve diagnostic accuracy.

"Always ask them what doesn't fit the picture. If you're so confident about your diagnosis, please tell me in their story what doesn't fit."

"If you think you're sure of the diagnosis, force yourself to come up with at least one other thing in the differential."

Key Takeaways for Practicing Hospitalists

1. Time Management: Develop a routine for chart reviews and rounds to reduce cognitive load, maximize communication between team members, and minimize interruptions.

2. Technology Utilization: Leverage EHRs and communication tools, particularly documentation practices, to provide the spaces where you can revisit your diagnostic thinking.

3. Interdisciplinary Communication: Actively participate in interdisciplinary discussions and rounds, being physically present whenever possible.

4. Continuous Learning: Regularly reflect on past cases to improve future diagnostic accuracy.

5. Adaptive Strategies: Be comfortable with improvisation on challenging days.

6. Patient-Centered Care: Prioritize direct patient interactions as a way to refine your diagnostic skills and bring meaningfulness back into the challenges of everyday work.

We encourage you to reflect on these insights from your colleagues and consider how you might incorporate them into your daily practice. Your experiences and strategies are valuable — please share them with colleagues to foster a culture of continuous improvement.

Stay curious, stay compassionate, and keep up the excellent work!

New Publications

Health Equity, Anti-racism, and Social Justice (HEARS) Work Group:

Violence in healthcare settings is an escalating, serious, and nuanced concern. HOMERuN's HEARS group had the opportunity to collaborate with the Society of Hospital Medicine and others to inform guidance on how violence in healthcare may be mitigated while acknowledging and addressing the ethical conflicts and threats to equitable care that are currently inherently intertwined with the issue. This resource is now available for review here.

Workforce Planning Work Group:

The Workforce Planning Group manuscript on administrative harm was recently published in JAMA Internal Medicine!

Administrative harm (AH) refers to the negative consequences of administrative decisions in healthcare that affect work structures, processes, and programs. Despite its prevalence, AH remains poorly understood and inadequately described. Through a mixed-methods study involving 41 participants from 32 organizations, we found that AH is widespread with significant impacts, yet organizations often lack mechanisms to identify it. Organizational pressures emerged as key contributors to AH. The work was also featured by STATnews and other media.

Burden M, Asik G, Auerbach AD, Bowling G, Kangelaris KN, Keniston A, Kochar A, Leykum LK, Linker AS, Sakumoto M, Rogers K, Schwatka N, Westergaard S. Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. JAMA Intern Med. 24 June 2024.

More information about what the HOMERuN Work Groups are working on is available on our Collaborative Work Groups Page.

Our next meeting will be on September 13, 2024.