Tapping into the wisdom in the room: results from participant discussion at the 7th International Conference on Diagnostic Error in Medicine facilitated by a World Café technique

Introduction

The annual International Conference on Diagnostic Error in Medicine brings together experts and interested individuals to present leading ideas and challenges in diagnosis and diagnostic error. In 2014, the 7th International Diagnostic Error in Medicine Conference Merging Policy, Practice and Technology: Paths to Improve Diagnosis met over 3-1/2 days in Atlanta, Georgia and included three keynote speakers and 42 faculty. The conference concluded with a group discussion facilitated by a World Café method. Participants were given the opportunity to interact and engage in conversations to identify concepts they learned and new insights gained. In addition, they were challenged to create a call to action for the conference leaders as well as for themselves. This paper summarizes the major ideas revealed during the session and describes the use of a novel method to capture the collective experiences of conference attendees as well as generate additional insight from shared discussions.

Methods

At the concluding session of the conference participants were seated at tables of eight to 10 participants each. Groups were instructed to avoid sitting with people they knew, and table leaders were encouraged to assemble a group that had representatives from a variety of professional backgrounds.

The session was conducted using a World Café method [1] that is designed around the following core operating principles:

• Create a safe, comfortable space

• Explore questions that matter

• Encourage contribution and participation from all

• Build on the diversity of ideas and people in the group

• Listen to surface insights, patterns and questions that probe further

• Make the knowledge revealed explicit

Prior to the event, consultants (LZ, BB) and the leadership of the Society to Improve Diagnosis in Medicine (SIDM) worked together to determine the questions to anchor the conversation for the World Café. The intent of the session was to create opportunities for individuals in the multidisciplinary audience to be able to contribute equally to the conversation and encourage a broad set of ideas and perspectives.

Participants were given the following questions to discuss: “What actions as a community devoted to change can we/SIDM take to transform diagnostic outcomes in the next 24 months? Synthesis: What did we hear? What did we learn? How does it connect to your conversations?” Small groups assembled at tables met to discuss these questions and record their conversations in note cards or scribbled on paper tablecloths. After 15 min, participants changed tables and exchanged ideas with new groups of people at a different table. Note cards and conclusions of each table were then shared with the larger group. In the second half of the session, questions were given to the larger group and individuals were encouraged to give rapid spontaneous responses (“Popcorn Insight”) [2]. Popcorn questions included: “What inspired you (during the conference)”? “What can the SIDM board do next?,” and “What are YOU going to do next?”

Results

Discussion

The three major themes of partnership, culture, and communication reflect characteristics of environments that nurture and sustain psychological safety. Psychological safety is a social construct that describes a work climate characterized by interpersonal trust and mutual respect [3]. Edgar Schein and Warren Bennis described psychological safety as early as 1965 [4]. Schein is well known for his extensive study of organizational culture and describes psychological safety as a climate where people feel confident in speaking up [5]. This is essential especially to signal when things may be going wrong or when there is a sense of lack of clarity. He also notes that additional outcomes of psychological safety are that people gain a sense of capability to change, increase engagement, and work in a climate of trust and respect. While many of the attributes of psychological safety speak to the work environment, clinicians will easily recognize it is equally vital for patients and families in care relationships – in their comfort in speaking up, questioning, and seeking to understand.

Relationships built on trust and respect are essential to a thriving safety culture. In healthcare, the fear of looking incompetent often silences voices and concerns that need to be heard to assure ongoing creation of safety. In her extensive work on Teaming, Amy Edmondson describes making it safe “to team” and lists the benefits of psychological safety as [3]:

• Encourages speaking up

• Enables clarity of thought – decreases what Schein describes as “learner anxiety”

• Supports constructive conflict rather than avoiding differences

• Mitigates failure – makes it easier to speak up, catch errors, and intervene to avoid harm

• Stimulates innovation by removing fear of speaking up and appearing “dumb”

• Frees up energy pursuing goals rather than self-protection

• Increases accountability through holding ourselves and each other accountable for achieving intended goals

Leadership and courage are necessary to achieve an environment of psychological safety. Members of SIDM and the SIDM Board can actively promote and role model the essential leadership behaviors for psychological safety. The behaviors described by Edmondson for nurturing psychological safety include: [3]

• Be accessible and approachable. The ability of colleagues and patients to ask questions without fear of rebuff or criticism keeps vital sources of information flowing. The ability to ask, “What else might this be?”, can avoid premature closure and cognitive biases from overtaking deliberate and thoughtful decision-making.

• Acknowledge the limits of current knowledge. When leaders share that they do not know something and ask others for help they model humility, enhance team performance, and recognize that it takes a variety of skills to achieve safety as well as a commitment to learning rather than false bravado.

• Be willing to acknowledge failure. Speaking up and learning from our failure is essential for leader credibility rather than maintaining a false facade of infallibility.

• Invite the voices of others. Leaders who ask for, listen, and value the insights and wisdom of others promote psychological safety.

• Use failures as learning opportunities. Leaders can make good use of failure by highlighting opportunities to learn rather than blame.

• Use clear, direct language to stimulate learning; avoid confusing, “code words” that obfuscate the deep learning that comes from looking clearly at what works and does not work in our care.

• Set boundaries. Psychological safety does not mean “I get to do what I like”; leaders are clear on behavioral expectation with clear boundaries between what is and is not acceptable; this clarity provides freedom for all involved once expectations are clear and explicit.

• Be accountable. Individuals are held fairly and consistently accountable for boundary violations.

Conclusions

Diagnosis is considered to be a core skill of the physician, but increasingly we recognize that the diagnostic process, and diagnostic accuracy, are dependent upon more than any single provider’s influence. The patient, their medical team, the healthcare system itself, and broader community and societal factors all play a role in diagnosis. As in other areas of safety, multidisciplinary team approaches have been envisioned as a strategy for improvement, as well as institutional commitment to supporting the difficult work of diagnosis. In addition, expertise from safety experts in domains outside traditional healthcare can provide new perspectives and insight and much remains to fully integrate their lessons. However, bringing these views together to facilitate understanding and further current debate is sometimes difficult with each group often siloed in its own thinking. We sought to facilitate interaction and exchange of a multidisciplinary group to enhance understanding and generate deeper insights.

The Society to Improve Diagnosis in Medicine (SIDM) has been at the forefront of increasing awareness of problems in diagnosis, and striving to define and generate ideas for system level improvements to make diagnosis more “accurate, timely, efficient, and safe” [6]. Their commitment to engage a wide range of stakeholders is demonstrated by their attempts to recruit and encourage perspectives beyond physicians, including patients and their families, nurses, risk managers, librarians, policy makers, laboratorians and laboratory technicians, information technology experts, and researchers. The World Café, a method drawn from the system thinking community, provides one method to capture ideas and perspectives from a multidisciplinary group interested in and committed to improving diagnosis. The World Café process has been used to explore avenues for improvement in other complex challenges such as education reform, climate change, and public health initiates [7]. This is the first report of its application for discussing the complexity and difficulty with diagnostic error. We seek to address this gap and illustrate the value of a collaborative facilitation process to capture the collective wisdom in the room at a multidisciplinary conference to inform organizational and individual action for change in the distinct facet of patient safety: diagnostic error.