Plenary 2 - New Resources to Promote Diagnostic Excellence in Clinicians and Health Care Organizations

Monday, October 17

This session will highlight several diagnostic safety resources recently developed through collaboration and support from AHRQ. The resources provide hands-on guidance to health care organizations, leaders, quality and safety professionals and clinicians on how they can improve the diagnostic process and reduce harm from diagnostic errors. Panelists will discuss how these newly developed tools can be implemented and used to advance diagnostic excellence as part of continuous improvement and learning.

Learning Objectives

  • Describe recently developed tools, innovations and strategies for diagnostic safety measurement and improvement in practice;
  • Explore how AHRQ resources can be used for achieving diagnostic excellence in your practice or at your organization;
  • Adopt ideas from pioneering organizations that are aiming to advance diagnostic excellence. 


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    Hardeep Singh, MD, MPH

    Chief, Health Policy, Quality & Informatics Program
    Michael E. DeBakey VA Medical Center
    Houston, TX

    Hardeep Singh, MD, MPH, Co-Chief, Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston  Hardeep Singh, MD MPH is a Professor of Medicine at the Center for Innovations in Quality, Effectiveness and Safety (IQuESt) based at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston. He leads a portfolio of multidisciplinary patient safety research related to measurement and reduction of diagnostic errors in health care and improving the use health information technology. His research has informed several national and international patient safety initiatives and policy reports, including those by the National Academies, CDC, NQF, AMA, ACP, AHRQ, OECD and the WHO. He serves as a nominated member of National Academies' Board of Health Care Services and is an elected Fellow of the American College of Medical Informatics for significant and sustained contributions to the field of biomedical informatics. His contributions include co-developing the "ONC SAFER Guides" which are CMS required guides that provide national recommendations for safe electronic health record use, co-chairing or participating on several national panels and workgroups on measuring or improving safety, and developing pragmatic resources to promote patient safety and diagnostic excellence in clinical practice. He has received several prestigious awards for his pioneering work, including the AcademyHealth Alice S. Hersh New Investigator Award in 2012, the Presidential Early Career Award for Scientists and Engineers (PECASE) from President Obama in 2014, the VA Health System Impact Award in 2016 and the 2021 John M. Eisenberg Patient Safety and Quality Award for Individual Lifetime Achievement.

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    Christine Goeschel

    Christine Goeschel, ScD, MPA, MPS, RN, FAAN

    Assistant Vice President
    Medstar Institute for Quality and Safety
    Columbia, MD

    Dr. Christine (Chris) Goeschel is a health care consultant, teacher, mentor, and implementation scientist who recently retired from her role as a system leader at MedStar Health and professor of Medicine at Georgetown University School of Medicine. During her tenure as Assistant Vice President in the MedStar Institute for Quality and Safety (MIQS) and inaugural Director of the Center for Improving Healthcare Diagnosis, Chris focused her research on clinical and administrative leadership to improve the science of health care delivery and on improving diagnostic processes.

    Her experience includes diverse health care roles: as a critical care nurse, a hospital executive, as founder and first executive for the Michigan Health & Hospital Association Keystone Center for Patient Safety and Quality, and as an implementation scientist/quality and patient safety researcher. Dr. Goeschel was Michigan PI on groundbreaking research to reduce bloodstream infections in intensive care units from 2003-2005, ("Keystone ICU"). From 2006 until 2013 she was an assistant professor in the schools of Medicine, Public Health and Nursing at Johns Hopkins and an advisor to the World Health Organization Patient Safety Program, where she contributed to large scale improvement projects in Spain, England, and Peru and the Middle East. She was a member of the 2013-2015 "NAM" Committee that produced "Improving Health Care Diagnosis" as part of the IOM Crossing the Quality Chasm series.

    Dr. Goeschel served on The U.S. Department of Health and Human Services to the National Advisory Council for Quality and Safety Research (NAC), and for five years on the SIDM National Advisory Committee for the Coalition to Improve Diagnosis. Chris was PI on three unique multi-year awards focused on building diagnostic capacity and improving diagnostic processes to achieve diagnostic excellence. In addition to peer reviewed publications and 12+AHRQ issue briefs (developed by national leaders addressing diverse aspects of diagnostic safety), resources developed during the awards include publicly available tools focused on diagnostic calibration, measurement, patient and family engagement and teamwork.Dr Goeschel continues to teach a required healthcare leadership course at Johns Hopkins and serves on the Board of a multi-hospital system in Michigan.

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    Helen Haskell, MA

    Helen Haskell, MA

    Patient Advocate
    Mothers Against Medical Error
    Columbia, SC

    Helen Haskell is president of the nonprofit patient organizations Mothers Against Medical Error and Consumers Advancing Patient Safety. She is an Institute for Healthcare Improvement senior fellow, a board member of the Patient Safety Action Network and the International Society for Rapid Response. She is a recently retired board member of the Institute for Healthcare Improvement and the Accreditation Council for Graduate Medical Education and a previous chair of the Patient Engagement Committee of the Society to Improve Diagnosis in Medicine and of the WHO Patients for Patient Safety Advisory Group. She continues to work with the World Health Organization on patient safety and patient engagement and with SIDM and AHRQ on diagnostic issues.   Helen’s goal since the medical error death of her young son Lewis has been to enhance the patient contribution to safety and quality in healthcare. She has written or co-authored dozens of articles, book chapters, and educational materials on patient engagement in safety, quality, and diagnosis, including a co-edited textbook of case studies from the patient perspective. Her son Lewis’s story has been featured in educational programs and videos including Transparent Health’s full-length Lewis Blackman Story. Helen holds a bachelor's degree in Classical Studies from Duke University and a master’s degree in Anthropology from Rice University in the United States.

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    Margie Shofer, BSN, MBA

    Margie Shofer, BSN, MBA

    Health Scientist Administrator
    Agency for Healthcare Research and Quality
    Rockville, MD

    Margie Shofer, the Director of the General Patient Safety Program within the Center for Quality Improvement and Patient Safety (CQuIPS) at the Agency for Healthcare Research and Quality (AHRQ), manages the Agency’s activities related to general patient safety issues including funding of grants and contracts, and development and dissemination of evidence-based patient safety tools and resources. She has a particular interest in engaging patients and families to improve patient safety and oversaw the work to develop three different AHRQ resources to engage patients and families in their care in ways that improve patient safety.  More recently she has led the Agency's work to improve diagnostic safety and quality. Before working in CQuIPS she worked in AHRQ's Office of Communication where she oversaw several different AHRQ learning networks, including the Medicaid Medical Directors Learning Network and the High Reliability Organizations Learning Network. Prior to working at AHRQ, Ms. Shofer was a senior policy analyst with the American Association of Health Plans, assistant staff to the Health Committee at the National Conference of State Legislatures, and committee staff for the House Environmental Matters Committee of the Maryland General Assembly.  Ms. Shofer began her health care career working as an RN at the Hospital of the University of Pennsylvania in Philadelphia.   She graduated from the University of Pennsylvania with a Bachelor of Science in Nursing and from Boston University’s MBA program where she concentrated in health care management.

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    Andrea Bradford, PhD

    Assistant Professor
    Baylor College of Medicine
    Houston, TX

    Dr. Andrea Bradford is an Associate Professor in the Department of Medicine at Baylor College of Medicine, where she divides her effort between clinical and research missions. Her clinical practice focuses on behavioral interventions for adults with chronic medical conditions, whereas most of her research focuses on understanding how clinicians and systems can improve the safety of the diagnostic process. Dr. Bradford is also involved in teaching medical students and psychology trainees. She is the Editor-in-Chief of the Journal of Clinical Psychology in Medical Settings and has served on the boards of the Society for Health Psychology and the Association of Psychologists in Academic Health Centers.