Equity-Driven Diagnostic Excellence framework: An upstream approach to minimize risk of diagnostic inequity

Introduction

Diagnostic errors represent the leading cause of harm to patient safety and one of the most economically burdensome errors in healthcare [1], [2], [3]. According to the National Academy of Medicine (NAM), they are likely to affect us at least once in our lifetime [4]. They are not only frequent but also severe – up to one-half of diagnostic errors can result in serious harm, such as permanent disability to premature death [2], 5], 6]. These figures are likely underestimates for racialized groups, lower-income communities, and individuals with intersecting structural vulnerabilities who disproportionately face diagnostic errors [7], [8], [9], [10], [11], [12]. This underscores the need for a more robust, evidence-based approach to diagnostic practice that directly addresses these inequities.

In the 2015 seminal report, Improving Diagnosis in Health Care, the NAM lists enhancing healthcare professional training and education as one of eight goals to improve diagnosis and reduce diagnostic error [4]. NAM scholars additionally identified five themes to improve diagnostic process, the first of which is “there is no diagnostic excellence without equity” [13]. As the field of health equity training and diagnostic equity is relatively nascent, it is essential to develop strategies that equip the healthcare workforce to practice the inseparability of diagnostic excellence and diagnostic equity.

In this context, the Equity-Driven Diagnostic Excellence (DxEqEx) competency framework provides a comprehensive approach to tackling the persistent disparities in diagnostic outcomes. Grounded in diagnostic error reduction strategies, diagnostic excellence literature, and health equity frameworks like Structural Competency, Social Determinants of Health, and Human Rights-Based Approach, this framework equips healthcare professionals to identify how upstream decisions and structural conditions shape patient symptom presentation, prognosis, and treatment – beyond individual identity markers [14], [15], [16], [17], [18], [19].

The DxEqEx framework is supported by four conceptualizations:

1. Diagnostic excellence and diagnostic equity are inseparable.

2. Diagnostic errors disproportionately impact historically marginalized communities.

3. Uncertainty and bias are inherent in diagnostic reasoning, particularly when navigating complex cases.

4. Most diagnostic errors are preventable, and there are actionable strategies to mitigate these risks throughout the diagnostic process.

DxEqEx can be defined as practices that ensure socially, economically, demographically, and geographically disadvantaged populations receive a fair and just opportunity to access accurate, timely, resource-efficient, patient-centered, and uncertainty-managed diagnostic processes [7], 12], 20]. By positioning equity as an essential driving force to diagnostic excellence, the term “Equity-Driven Diagnostic Excellence” underscores that equitable practices are integral – rather than peripheral – to achieving a high-quality diagnostic process, thereby reinforcing that diagnostic excellence and diagnostic equity cannot be separated. The development and implementation of the DxEqEx framework represents and adopts an upstream approach by proactively aiming to address inequities before they arise [21].

The primary objective of this study is to develop, refine, and validate the DxEqEx competency framework through a consensus-building process, ensuring it is both theoretically robust and grounded in clinical settings by evaluating its importance, feasibility, level of skill acquisition, and disciplinary relevance.

Methods

Results

The analysis from rounds 2 and 3 revealed a Cronbach’s alpha exceeding 0.9, indicating strong internal consistency in the responses across the evaluated competencies. As shown in Figure 1, the boxplots illustrate the distribution of ratings for each measure.

Figure 1:

Boxplots of ratings for six measures: Importance, Feasibility, Level of Skill Acquisition, Granularity, Representativeness, and Disciplinary Relevance. Each boxplot shows the distribution of ratings, including the mean, median, and standard deviation for each measure.

Round 3 results

In the third round (R3), participants gave consistently high ratings for both Granularity and Representativeness of the competencies (Supplementary Material, Appendix E). The mean score for granularity was 8.36 (SD 0.22), and for representativeness, it was 8.27 (SD 0.23). Lower scores were accompanied by feedback, which informed minor adjustments that were incorporated into the final version of the competency framework.

Sixteen essential competencies have been identified, categorized into three domains, as outlined in Table 1 and illustrated in Figure 2. The three domains are organized in a progressively macro manner as follows: Intrapersonal, Team-based, and Structural to guide an individual’s integration of these competencies [23], 24]. Among the competencies’, 55 sub-behaviours were identified and included in Supplementary Material, Appendix F.

Table 1:

Overview of the 16 DxEqEx competencies organized within three key domains.

Domain 1: Intrapersonal Competencies are centered on transdisciplinary, patient-centered approach to diagnostic clinical reasoning that acknowledges uncertainty and bias, promotes equitable and adaptive practices, integrates structural competency and leverages health information management tools.
I-1	Adopts transdisciplinarya collaboration, and a patient-centered approach to diagnostic clinical reasoning. aTransdisciplinary encompasses collaborative efforts including institutional disciplines, community, patients, and caregivers.
I-2	Acknowledges that uncertainty and bias are inherent in diagnostic reasoning. Recognizes clinical cues that indicate when a more deliberate approach is necessary and attempts to mitigate explicit and implicit social biases that may negatively influence clinical reasoning and diagnostic hypotheses.
I-3	Implements a pragmatic, and adaptive approach to diagnostic reasoning, balancing complexity, urgency, patient-specific needs, systemic barriers and resource constraints.
I-4	Gathers and synthesizes clinical information, including biomedical, psycho-social, structural, to develop and refine diagnostic hypotheses and differential diagnoses centered around the patient’s social determinants of health.
I-5	Practices structural competency in developing accurate problem representation of patients with multiple intersecting identities and overlapping structural vulnerabilities.
I-6	Recognizes prototypical symptom presentations and expands understanding of atypical manifestations during differential diagnosis formulation, while utilizing relevant diagnostic testing when appropriate.
I-7	Uses available health information management tools and clinical decision support tools to facilitate diagnostic team communication and ensure access of clinical notes and diagnostic test results, reliable follow-up, assessment of patient course, and differential diagnosis accuracy.
Domain 2: Team-based Competencies are centered on building trusting relationships, fostering patient empowerment and engagement, promoting inclusive and empathetic communication while exercising cultural humility, upholding ethical principles, and practices interprofessional collaboration.
T-1	Establishes a supportive relationship and promotes capacity-building to empower patients, families and caregivers, and encourages collaboration and engagement in co-producing and monitoring diagnosis.
T-2	Fosters belongingness that results in individuals feeling valued for their authenticity, intersectionality, and expression without fear of retribution.
T-3	Promotes inclusive and collaborative written and spoken communication that help patients, families, and caregivers understand and actively integrate health care information as equal members of the diagnostic team.
T-4	Provides relevant, accurate and complete diagnostic information with transparency, integrity, and compassion through upholding legal and ethical principles.
T-5	Recognizes that achieving accurate and timely diagnosis is a “team sport”. Practices interprofessionala collaboration by seeking information, evidence and decision support, including and equally valuing diverse sources. aInterprofessional: collaborative efforts among professionals from multiple disciplines.
T-6	Adopts the attitude that a diverse and well-functioning diagnostic team will outperform an individual diagnostician or monolithic/homogeneous diagnostic team. Acknowledges that communication failures between health care professionals are recognized as a leading cause of patient harm, error, and associated inequity.
Domain 3: Structural Competencies are centered on acknowledging and addressing the intersectional impacts of structural violence and social determinants of health on patient outcomes, advocating for historically marginalized patients, integrating socio-economic and political factors into healthcare, exercising structural humility, and continually reassessing practices.
S-1	Acquires working knowledge of how structural violence and social determinants of health intersectionally manifest in the patient’s health state at the time of them engaging with the healthcare system and seeking diagnosis for their health problem and recognizes the importance of upstream intervention to address the social drivers of health and illness.
S-2	Seeks to integrate social, economic, and political factors that may trigger or exacerbate the patient’s health problem(s) into differential diagnosis, patient engagement and effective treatment plan.
S-3	Recognizes the fallibility of existing knowledge and systems. Engages in critical review of normative system practices and guidelines, acknowledging that well-intentioned interventions can lead to unintended consequences.

Figure 2:

Diagram of the Equity-Driven Diagnostic Excellence (DxEqEx) framework, illustrating three core domains: Intrapersonal (blue), Team-based (red), and Structural (yellow). The framework identifies a total of 16 core competencies distributed across the domains, with seven in the Intrapersonal domain, six in the Team-Based domain, and three in the Structural domain.

Discussion

The study’s results indicate that the DxEqEx framework is perceived as critical for improving the diagnostic process, as evidenced by the notably high ratings of its importance. However, the qualitative feedback on feasibility suggests that, while the competencies are theoretically achievable, their practical implementation may be hindered by systemic barriers embedded within healthcare environments, such as incentive systems.

According to the Dreyfus Model of Skill Acquisition, participants ranked the competencies as most appropriately introduced at stage four, or the “proficiency” skill level. This suggests that the framework is most suitable during clinical training stages, when learners are developing experience-based, intuitive decision-making skills [22].

The granularity ratings confirmed that the language used in the framework was appropriately specific, neither overly detailed nor insufficiently so. The representativeness ratings indicated that the framework effectively encompassed the essential knowledge, skills, and attitudes necessary for practicing DxEqEx.

Several limitations warrant consideration in this study. The use of snowball sampling may have introduced selection bias, as participants were likely drawn from similar networks. Additionally, the reliance on small sample sizes and independent samples influenced the decision to prioritize descriptive statistics over non-parametric statistical significance tests. By focusing on measures such as central tendency, we aimed to provide a more meaningful and contextually relevant representation of the data.

This framework is designed to support diagnostic practices and should be implemented by practitioners according to available resources, context, and limitations of their clinical environment. Modifications may be required depending on the tools, institutional guidelines, and the specific needs of the patient population. A thorough evaluation of the framework’s relevance and applicability across diverse healthcare settings and patient populations is essential, allowing for adaptations that address the distinct needs of historically marginalized communities facing especially high diagnostic risks. Examples include the “Big Three” (cancer, infection, and vascular events), dermatological conditions on melanated skin, heart conditions in women, “psych-out” errors in mental health diagnoses among others.

While our primary aim was to develop, refine and validate the DxEqEx framework for clinical practice, exploration on implementing the framework into health and medical professional training and education is needed. The competencies are intended to complement, rather than substitute, existing standards. Organizations dedicated to health equity, diagnostic improvement, patient safety, quality improvement, and patient-centeredness, along with key players such as program directors, educators, and health system leaders, can adapt this framework to their respective contexts. In this regard, we envision multiple avenues for practical application: from bundling the framework with patient-reported outcomes and patient-reported experience measures, professional standards and guidelines, incorporating tailored content into existing health and medical profession learner programs to exploring more innovative modalities, such as AI-enabled patient simulations and interactive online learning platforms. These simulations, for example, may facilitate resource-efficient practice scenarios that adapt to learners’ needs, offering real-time feedback. We acknowledge, however, that detailed implementation planning for in-depth curricular design lie beyond the scope of this study. Representing current health profession learner(s), health system leader(s), instructor(s) and patient advocate(s), the authors find that future investigations should focus on participatory implementation strategies and resource-efficient solutions that are conscious of feasibility barriers.

Conclusions

Developed, refined, and validated through a comprehensive literature review, patient experiences, and transdisciplinary consensus-building, the DxEqEx framework both aligns with and advances current discourse on diagnostic excellence and diagnostic equity. DxEqEx goes a step further by explicitly tying equity to every facet of the diagnostic process – from initial clinical encounter to eventual outcomes. This dual focus on excellence and equity differentiates it from frameworks that treat disparities as an adjunct or secondary consideration. Rather than positioning health equity as a separate initiative, DxEqEx weaves it into the very definition of diagnostic quality. By adopting this upstream, prevention-focused approach, the DxEqEx framework proactively addresses the needs of historically marginalized patients throughout the diagnostic process and seeks to reduce their risk to diagnostic errors, particularly those that result in severe harm. Future research should focus on participatory, resource-efficient implementation strategies, intended to complement existing training and education standards.