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To solve the problems posed by the new challenge of diagnostic safety, leaders cannot rely on physician skill alone. Organizations need infrastructure and processes in place to support the entire diagnostic team as they work with patients and caregivers and as they do the difficult work of understanding and improving current diagnostic practices. Transformational leaders with a growth mindset—a belief that improvement is possible with effort, good strategy, and broad input²¹â€”can help improve diagnostic safety. To that end, leaders must create a sense of collective accountability for diagnostic safety.

Collective accountability involves cultivating a shared sense of responsibility, contribution, and control for diagnostic safety improvement among all formal and informal leaders. The Collective Accountability Framework depicted in Figure 3 was developed by the Armstrong Institute while working with the CMS Hospital Engagement Networks. This practical framework can be used to engage and coach hospital executives on their role in patient safety and quality improvement efforts. The framework is rooted in the organizational sciences and has been field tested in numerous initiatives and organizations over the past decade.

First, all staff in the organization need to understand their responsibility for diagnostic safety. It is a critical part of their job and they are expected to participate fully in diagnosis and diagnostic safety improvement efforts as appropriate. Second, they need to feel that they can meaningfully contribute to those efforts. Their perspective is valued, and they have the skills to meet the demands of diagnostic safety improvement. Third, they have the autonomy or support (control) to make the changes in the workplace needed to address deficient diagnostic processes.⁴

The success of any quality improvement effort relies on leadership support and buy-in.²² Staff need to know that once they identify a problem and develop a solution, leaders will work with them to make the needed changes and communicate them accordingly. Strong collective accountability can lead to robust progress in diagnostic safety without which improvement efforts may struggle. We describe several strategies^5,23 below to cultivate collective accountability for diagnostic safety.

Figure 3. Building Collective Accountability

Using the levers of collective accountability to drive diagnostic safety improvement. Levers are a means to an end and a way to move one’s organization toward its goals. Developing collective accountability for any organizational priority is complex, and, once developed, it is prone to slip away unless mindfully and reliably tended.²⁴ Use of management approaches can ensure the necessary conditions are in place for the emergence of collective accountability and key leadership behaviors can focus and engage staff in diagnostic safety improvement efforts. These management and leadership tactics are the levers of collective accountability.

First, leaders can promote a shared sense of responsibility for diagnostic safety through role clarity, responsibility, and feedback mechanisms. These include setting and communicating diagnostic improvement goals that are meaningful for everyone in the organization. People need to understand the goal, but also what they can do on a daily basis to help reach that goal. In addition, people need feedback on the organization’s progress toward those goals and to understand what will happen if they do or do not meet those goals. Effective leaders maintain and use different approaches to recognize and celebrate successes, and they support staff who may be struggling to meet organizational goals.⁵

Second, leaders use formal and informal learning strategies to build capacity. Improving quality and safety requires a skill set above and beyond that of a frontline clinician. Whether in process improvement methods, evaluation skills, or coaching, team members need opportunities to develop as professionals. By fostering key individual competencies, organizations should improve the likelihood of meeting their diagnostic safety goals. Staff in different areas of the organization should be sharing diagnostic-related experiences and learning from one another. This process rarely happens organically, and leaders need to create the capacity for these interactions.

Third, leaders use transparent and formal processes for allocating resources to priorities. All staff should know that they are positioned for success when they undertake diagnostic safety improvement efforts and that the organization is aligning its resources with its priorities.

Fourth, leaders lead, and they do so with a hands-on and transformational style²⁵ across professional and other organizational boundaries. The aforementioned levers are largely management tactics, which are necessary but not sufficient to improve diagnostic safety. Leaders must engage people intellectually and motivationally in diagnostic safety and do so by building strong relationships in the organization. Table 1 provides mechanisms and strategies to establish collective accountability for safe diagnosis. Table 2 provides questions healthcare leaders should consider when building collective accountability for diagnostic safety.

Table 1. Implementing a Collective Accountability Framework for Safe Diagnosis

Table 2. Considerations for Building Collective Accountability for Diagnostic Safety