Children's Hospital of Philadelphia

Communication of Diagnostic Uncertainty Across Teams and with Families at Admission

Project Lead:  Ursula Nawab, MD

Project AIM(s): Our goal was to improve recognition and communication of diagnostic uncertainty (DU) in general pediatric patients admitted from the emergency department at out quaternary pediatric center. Specifically, our Aim was to demonstrate a 20% Improvement in communication of DU to the admitting team and to families over 9 months.

Narrative Description

Given the diverse needs of our patient families (including racial minorities, those with language barriers, different levels of health literacy, and varying medical complexity), improving communication about DU requires equitable collaboration with diverse families and awareness of the ways communication contributes to health disparities.  To address gaps in communication of DU the following interventions were implemented.

Milestones Intervention
Recognizing and accepting DU 
Accurately communicating DU
Effectively communicating DU to patients/families

ED Education

  • Completed education series with associated action items for discussion and teaching communication
    best practices
  • Planning for implementation of “DU Champions” in the ED and inpatient floor, responsible for probing DU discussions
  • IPASSU cards and rounding
Hardwire adopted changes from PDSA cycles  EPIC Documentation
  • Completed usability testing and implementation of EPIC documentation of diagnostic discussion and reasoning pre-admission
  • Collected representative examples of ways staff are using as intended vs. unintended to inform on edits and next steps
Develop a system for continuous measurement
and feedback
Handoff Optimization
  • Ongoing pilot of standardized diagnostic questions during handoff with the ED
  • Currently collecting data and feedback on the usefulness and specificity of standardized handoff questions
  • Use of EPIC tools to remind and drive discussion
  • Involvement of EPIC Clinical Champion Group

Develop communication plan

Spread within existing QI/Patient Safety

Monitor adoption and performance


Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)
  • Communicate the explanation to the patient

Root causes/causative factors addressed by the intervention

  • Patient-clinician interaction (includes patient and family engagement)
  • Workflow (includes testing, follow-up, and referrals)
  • Health information sharing and accessibility via health IT
  • Knowledge gaps/inexperience

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)