3037 — A Root Cause Analysis of Diagnostic and Treatment Delays in the VA Outpatient Setting
Davis Giardina T, Houston HSR&D Center of Excellence, Michael E. DeBakey VAMC and Baylor College of Medicine; King B, Ignaczak A, Hoeskma L, Mills P, and Neily J, Department of Veterans Affairs and VA National Center for Patient Safety; Singh H, Houston HSR&D Center of Excellence, Michael E. DeBakey VAMC and Baylor College of Medicine;
Delays in care in the outpatient setting are common and poorly studied. In order to improve this aspect of patient safety, we sought to identify and describe outpatient process breakdowns that lead to delays.
From 5,272 root cause analyses (RCAs) reported to the VA National Center of Patient Safety between fiscal years 2007 and 2010, we selected RCAs categorized as “Outpatient Delay in Treatment and/or Diagnosis” (n = 141). Two study reviewers confirmed the correct category by consensus prior to data extraction, which led to exclusion of 53 cases, including those where documented delay time was <1 day. Of the remaining 88 cases, 58 have thus far been reviewed retrospectively by 3 independent reviewers. Reviewers used a 5-dimensional model of ambulatory care processes as a guiding framework to categorize which dimension was most closely associated with delay. A standardized data collection instrument collected information on the following variables: 1) five dimensions of care processes (patient behavior, provider-patient encounter, referral and/or consult, performance/interpretation of diagnostic tests and consults, and follow-up of patients; 2) types of providers involved; and 3) contributory factors responsible for delays. Reviewers resolved differences in categorization by consensus.
Analysis of 58 RCAs identified a mean of 2.3 process breakdowns/case, occurring in each dimension as follows: referrals/consults (26.1%), follow-up (25.4%), performance and interpretation of tests/consults (23.1%), provider-patient encounter (16.4%), and patient behaviors (9.0%). Generalists were most often involved (91.4%), followed by medical subspecialists (75.9%), clinical/administrative support (56.9%), nursing professionals (50.0%), surgeons (43.1%), other (22.4%), and pharmacists (12.1%). We identified 528 (9.1/case) contributory factors responsible as follows: cognitive (43.6%), communication failure (23.3%), scheduling (13.3%), general system issues (10.0%), and patient issues (9.8%).
Root cause analyses data reveal that delays in diagnosis and treatment in the VA outpatient setting arise from multiple dimensions of ambulatory care processes and involve a large number of contributory factors per case. Cognitive factors contribute most often to these process breakdowns.
Design, implementation and evaluation of interventions to reduce outpatient care delays must account for the multifaceted nature of process breakdowns and contributory factors. Moreover, these interventions should support provider cognition, an important and often unaddressed aspect of patient safety.