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The three-year Victorian Managed Insurance Authority (VMIA) Research and Innovation Program with BehaviourWorks Australia and The Shannon Company exploring how simple, scalable interventions can reduce avoidable risks in delivering hospital care.

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Hover and click to view trials Trial 1: Improving diagnosis Trial 2: Communicating test results Trial 3: Supporting informed consent Trial 4: Enhancing patient voice Trial 5: Escalation of patient care Trial 6: Hospital collaboration Trial 7: Communication in the boardroom About the program arrow

Trial 1

Improving Medical Diagnosis

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Trial 1

Improving Medical Diagnosis

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When a patient arrives at the emergency department the correct diagnosis is critical to ensuring the appropriate treatment.

Trial 1

Improving Medical Diagnosis

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Misdiagnosis can happen

Hospital emergency departments are busy, chaotic environments and there is an increased risk that cognitive biases -the mental shortcuts we all use every day- will influence clinicians’ decision making, leading to misdiagnosis and poor patient outcomes, and in some instances death.

The aim of this behaviour change trial was to test the effectiveness of a structured conversation between two clinicians, to discuss their independent medical diagnoses.

Click here to learn more about this trial.

Trial 1

Improving Medical Diagnosis

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The Rapid Diagnosis Discussion tool (RaDD)

Patients presenting to the emergency department with abdominal pain were first examined by one clinician then independently reviewed by another clinician. The two clinicians then had a prompted, short discussion about their working diagnoses before proceeding with patient management.

    Question prompts included:

  • • ‘Are there any symptoms or signs that don’t fit? Any red flags?’
  • • ‘Are any additional tests/investigations needed or do you already have sufficient confidence in the diagnosis to proceed without them?’
  • • ‘Do we have all the relevant information about the patient?’

The trial involved three hospital emergency departments. One hospital used the RaDD tool and two didn’t (the control groups).

Trial 1

Improving Medical Diagnosis

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Aided discussion can reduce misdiagnosis

We found that two heads are better than one, and the Rapid Diagnostic Discussion tool was found to be effective for reducing cognitive bias and improving communication between clinicians.

Of the 155 patients enrolled in RaDD, the original working diagnosis of the first doctor was changed in almost a quarter (24.7%) of cases. Clinician confidence in diagnosis increased and the use of RaDD led to fewer patients being inappropriately discharged.

Click here to learn more about this trial.

Trial 1

Improving Medical Diagnosis

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Aided discussion can reduce misdiagnosis

There were some cases in the RaDD trial where the final diagnosis was a more serious condition than the initial one, avoiding potentially catastrophic outcomes. The tool can not only help to improve patient outcomes but also help to reduce costs across the health system.
“Misdiagnosis is a direct cause to a contributing factor of 30% of our medical indemnity claims. Using behavioural science, this trial developed a tool for doctors to navigate and mitigate some of the common challenges behind misdiagnosis. Initial results from the trial are promising, but further work needs to happen to assess its use in the future.”
“Clinicians got an enormous amount of relief and confidence by having someone else also assess the patient and have a structured conversation about what their thoughts were.”

Dr Paul Buntine, Emergency Doctor, Box Hill Emergency Department

This trial shows that a second opinion and brief peer discussions can alter a doctor’s working diagnosis by reducing cognitive bias. More research is needed to see if this works on other types of patients and in other settings, such as smaller emergency departments, wards or non-hospital environments. Studies are also needed to examine whether the savings of identifying misdiagnoses outweigh the costs.

Trial 2

Communicating Test Results

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Trial 2

Communicating Test Results

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Patient test results need to be clearly communicated between clinicians in a timely manner to inform and improve diagnosis and the appropriate treatment.

Trial 2

Communicating Test Results

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Errors can lead to serious consequences

Delays and errors in communicating diagnostic information between clinicians can -and often do- result in serious negative consequences.

The challenge of communicating diagnostic information is magnified in the emergency department. This is due to time pressures, distractions, information inaccessibility, unfamiliarity with patients and the likelihood of patients leaving the hospital before results are returned.

The aim of this trial was to test the effectiveness of a mobile application myBeeper (‘app’) for improving for the communication of urgent and critical diagnostic information.

Click here to learn more about this trial.

Trial 2

Communicating Test Results

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A secure communication tool

We tested the usability and effectiveness of a secure mobile application designed for the Australian healthcare system.

The myBeepr app allows users to send secure messages, transmit clinical photos and access other customised features on-the-go while maintaining the privacy and security of patient health information.

myBeepr was used by radiologists and emergency department consultants at Monash Health to send secure messages for all adult computed tomography scans requested by the department.

Click here to learn more about the app.

Trial 2

Communicating Test Results

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An app-based tool could improve communication

myBeepr showed potential for communicating critical diagnostic information securely and quickly, with a median read time of 59 seconds from the time the message was sent.

Radiologists viewed myBeepr as potentially timesaving, efficient and an extremely useful way to improve communication.

In contrast, emergency department consultants did not view the app as useful for communication. This may be explained by the trial set up, which required the clinicians to carry an additional phone.

Click here to learn more about this trial.

Trial 2

Communicating Test Results

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An app-based tool could improve communication

Patients may be able to receive their test results faster, reducing the risk that they will leave the emergency department before knowing their results and are therefore lost in follow-up procedures. The timely communication of test results can have a positive impact on patient safety.
“Communication failures such as missed results are a key indicator in claims and serious incidents and continue to be a common problem across the health system. This trial offered an opportunity to test how technology can improve communication between radiology and emergency departments. Although the trial showed mixed results, there are still many opportunities for this product to be rolled out in a wider hospital system rather than in silos (such as between departments), which could benefit many health organisations.”
“myBeepr has been proven to close the communication loop faster and protect patient health information, which is likely to improve patient care. In a hospital setting, thousands of communications occur daily within and between care teams. myBeepr ensures that healthcare staff can collaborate in a secure manner and on-the-go, streamlining care coordination and helping to reduce miscommunication.”

Vikram Balakrishnan, Co-founder & CEO, myBeepr

An important part of this project was the ‘closed loop’ nature of the communication. Radiology could see when the emergency department had viewed their message, thereby removing worry that the department didn’t know the results were ready. This reduces the need for phone calls and follow up in some cases.
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Trial 3

Supporting informed consent

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Trial 3

Supporting informed consent

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Before consenting to treatment, the patient should have a conversation with their clinician to fully understand their treatment options, including the risks and benefits.

Trial 3

Supporting informed consent

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Failure to gain informed consent can happen

True informed consent is a conversation between the clinician and the patient. It involves full disclosure of diagnosis, treatment options, risks and benefits as well as any likely outcomes of doing nothing.

Unfortunately, failure to obtain true informed consent can occur and contribute to regret, which can have negative impacts on quality of life, health outcomes and experiences within the healthcare system.

The aim of this trial was to explore the effect of a behavioural self-reflective exercise for clinicians after their informed consent conversations with patients.

Click here to learn more about this trial.

Trial 3

Supporting informed consent

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Using a reflective tool

Our intention was to test the use of a ‘diary tool’ to encourage clinicians to reflect on their conversations with patients.

    Reflective questions include;

  • • ‘What did you do well during this consultation to ensure that the patient could make an informed decision about their treatment’
  • • ‘How could you improve this in future consultations?’
  • • ‘What aspect of the consultation could have been improved to ensure that the patient could make an informed decision about their treatment?’

Trial 3

Supporting informed consent

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Trial postponed

Due to the impact of the coronavirus pandemic on the health services industry, we’re postponing this trial until further notice.

Click here to learn more about this trial.

Trial 3

Supporting informed consent

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Trial postponed

“The reflection tool encourages active listening, exploration with the patient and a shared understanding of what matters to the patient with reflection on the effectiveness of the practitioner providing vital information.”

Maureen Williams, Patient Advocate

“Miscommunication and perceived lack of disclosure around treatment options and risks are common features of malpractice claims. We know that ensuring effective communication between clinicians and patients about life-changing decisions is critically important. This trial aimed to test a product which assists clinicians to reflect on the complex discussions they have with patients when they’re recommending them for surgery. The ability to analyse their communication techniques against an ideal model helps clinicians learn and refine their skills and ensure better patient understanding.”
The behavioural reflection tool is simple and designed to facilitate scaling. Reflection is an essential part of ongoing learning for clinicians and self-reflective activities can become habits, in this case, potentially helping to increase patient understanding of risks, benefits and alternative options. If patients can make a fully-informed decision about their care, there is potential to reduce medical malpractice claims.
Although the trial wasn’t able to go into field, the trial development resulted in an evidence-based, feasible intervention that is ready for testing.

Trial 4

Enhancing patient voice

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Trial 4

Enhancing patient voice

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While in hospital the patient should be engaged with their healthcare team and feel empowered to speak up and ask questions.

Trial 4

Enhancing patient voice

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Patients can feel overlooked and too afraid to speak up

While patients may have intentions to engage with healthcare professionals and/or ask questions, they can be hesitant to speak up due to perceptions of constraints around clinicians’ time. Patients may also forget questions they want to ask during ward rounds or perceive that it is unacceptable.

The aim of this behaviour change trial was to explore the effectiveness of a tool that allows patients to keep a record of their questions and concerns.

Click here to learn more about this trial.

Trial 4

Enhancing patient voice

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Empowering patients to speak up

We wanted to increase ‘patient power’ by testing the effectiveness and impact of providing a bedside notepad to encourage patients to ask questions in the post-operative setting.

The ‘patient power notepads’ were specifically designed to include question prompts that would encourage patients to remember to ask questions and provide an easy way for them to record their questions when no one was around. Clinicians regularly checked the notepads to ensure questions were answered.

Trial 4

Enhancing patient voice

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A notepad can enhance patient voice

Overall, the notepad was perceived to be a very useful way of encouraging patients to ask more questions and for clinicians and patients to have better and more constructive conversations.

It is a simple and scalable intervention -a notepad and pen- but an effective way to enhance patient voice.

Click here to learn more about this trial.

Trial 4

Enhancing patient voice

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A notepad can enhance patient voice

“It was a pleasure to have the chance to use it...having the notepad opened up lines of communication. The notepad was useful in prompting me to think [of] and ask questions about my operation”.

Patient feedback, Peninsula Health

“Bypassing patients’ and their families’ concerns are commonly reflected as a contributing factor in medical indemnity claims. Making patients central to their care journey gives them the opportunity to feel included in their health decisions. The Patient Power notepad gives patients the ability to ask important questions about their care that would otherwise be forgotten in the usual clinician consultation setup. The simplicity of this product means that it is easily scalable, while being an effective and economical solution for hospitals to adopt.”
“I think every patient should have one, as it encourages patients to ask questions about their care which can result in better patient outcomes. It's also good evidence for a couple of the national standards. As far as communicating for safety and partnering with consumers, it really does tick our boxes there, ensuring that we’re fulfilling our requirements”.

Justin Aylward, Nurse Unit Manager, Peninsula Health

A pressure-free communication channel opened up between patients, families and their healthcare team. The notepad acted as a prompt for patients to ask questions and helped them overcome some of the identified barriers in speaking up. They could ask questions at any time and didn’t have to remember them during the ward rounds. The notepad did not disrupt workflows and could potentially save time in the long run by smoothing communication channels between patients and staff.
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Trial 5

Escalation of patient care

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Trial 5

Escalation of patient care

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Early identification of patient deterioration is critical to patient safety and treatment.

Trial 5

Escalation of patient care

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Patient deterioration can go undetected

Early identification of patient deterioration in hospital settings can assist in providing timely escalation of care and improve patient outcomes. However, escalation of care conversations between clinicians in the early stages of deterioration can be difficult to initiate due to behavioural barriers, such as fear of hierarchy, and cultural beliefs.

The aim of this behaviour change trial was to explore the effectiveness of a training video to help clinicians navigate some of the key challenges in escalation of care conversations.

Click here to learn more about this trial.

Trial 5

Escalation of patient care

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An interactive training video

We created a choose-your-own-adventure training video to help clinicians gain experience navigating situations where there may be challenges or pushback.

The training video walked clinicians through typical scenarios depicting escalation of care conversations between clinicians in the early stages of patient deterioration. At the end of each scenario, the clinician was asked to select the appropriate response.

Trial 5

Escalation of patient care

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Clinicians became more confident with early identification

After viewing the interactive training video, participating clinicians were slightly less reluctant, and more confident about escalating care. Participants also reported having fewer escalation of care conversations and fewer challenges experienced, however these findings did not reach statistical significance.

The average number of Medical Emergency Team calls made per day for the recruited wards at one site was significantly lower following training, which could be due to earlier recognition of deterioration. Clinicians reported that the interactive training video was useful for learning when and how to escalate care and for taking the perspectives of other clinicians on board.

Click here to learn more about this trial.

Trial 5

Escalation of patient care

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Clinicians became more confident with early identification

If clinicians can escalate patient care more confidently, and at earlier stages of deterioration, the appropriate care can be provided in a timely manner. This can prevent patients becoming very sick and needing higher levels of care such as intensive care admission.
“One of the problems in healthcare is the ability for clinicians to escalate patient deterioration in a timely manner. Junior staff find this challenging because of perceived negative responses due to hierarchy. These types of issues are commonly found in medical malpractice claims managed by VMIA. This trial shows the importance of finding a product that teaches clinical staff to recognise the deteriorating patient, while also empowering them to escalate in a timely manner in a protected environment.”
“Communication is a common theme in incidents related to recognising and responding to acute deterioration. Involvement in this trial gave our health service the opportunity to test a different way of engaging and training staff in the non-technical skills required for escalating care for deteriorating patients. Feedback from staff about the interactive video was very positive.”

Andrea Doric, Clinical Risk Manager for Clinical Deterioration, Eastern Health

We identified that an innovative and immersive choose-your-own-adventure training video could be an effective intervention to help clinicians gain experience in navigating some of the key challenges around escalation of care conversations during the early stages of deterioration.

Trial 6

Improving hospital collaboration

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Trial 6

Improving hospital collaboration

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Providing the most effective care for the patient involves teamwork and collaboration between the whole healthcare system.

Trial 6

Improving hospital collaboration

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Non-critical hospital transfers are not always easy

In many areas of Victoria, clinical care for patients with complex health issues is not available in small hospitals as they are not designed to cater for all conditions (for example, they do not have specialised equipment available in larger hospitals). Inter-hospital transfers therefore play an important part in the healthcare system, ensuring that patients can access appropriate care in a timely manner.

The aim of this trial was to foster an empathetic and collaborative mindset among clinicians who receive non-critical patient transfer requests from another hospital.

Click here to learn more about this trial.

Trial 6

Improving hospital collaboration

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Highlighting the need for collaboration and teamwork

We tested the effectiveness of a video that reminded clinicians, who receive transfer requests, of the shared goals across hospitals and the healthcare system. For instance, the video contained a message to remind clinicians that they all want to help their patients get better.

We compared outcomes before and after exposure to the video in 21 emergency department clinicians within Victorian public hospitals, using audio vignettes to simulate transfer request phone calls from smaller hospitals for non-critical patients.

Trial 6

Improving hospital collaboration

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Clinicians are more likely to take action when they understand the situation

Emergency department clinicians’ feedback about the video was largely positive.

After viewing the video, emergency department clinicians reported a stronger intention to accept a non-critical patient. They perceived the medical case as more severe and urgent and were more accepting of the calling clinician’s claims about their capability or resources to treat the patient

Click here to learn more about this trial.

Trial 6

Improving hospital collaboration

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Clinicians are more likely to take action when they understand the situation

If doctors collaborate during an inter-hospital transfer request, the transfer process can be more efficient, and delays can be reduced. This has important implications for patients' safety, since delays in transfer can negatively impact patient care and patient outcomes.
“Inter-hospital transfers are a key part of how health services have to operate to manage capacity and capability requirements. This is a stressful process for health services and patients involved, with poor management sometimes leading to patient harm. The inter-hospital transfer trial helped larger units further develop empathy and better understand their smaller counterparts, with the aim of enabling smoother transitions between health services.”
"Improving engagement between rural and metropolitan clinicians by creating a shared understanding and purpose can improve the efficiency of inter-hospital transport. Rural junior staff will be more comfortable asking advice when the metropolitan clinicians take a collaborative rather than combative approach."

Tim Baker, Rural Emergency Physician

We identified that a persuasive message could be developed and delivered in video format to target key attitudinal barriers that can inhibit productive communication between sending and receiving doctors during non-critical inter-hospital transfer requests.
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Trial 7

Communication in the boardroom

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Watch the video
Watch the video

Trial 7

Communication in the boardroom

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Health service boards play a critical role in ensuring patient safety, and effective communication among board members is important.

Trial 7

Communication in the boardroom

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A lack of communication at board level can be detrimental

Health service boards oversee the operation of hospitals to ensure that healthcare is safe and effective.

When health boards don’t function well, negative patient outcomes, including avoidable deaths, can occur. Therefore it is critical that board members have the communication skills required to navigate difficult conversations.

Those new to a boardroom setting may not have these skills required and there are few opportunities for them to learn and practise in a controlled environment.

Click here to learn more about this trial.

Trial 7

Communication in the boardroom

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Encouraged and guided conversations

We explored the effectiveness of a two-hour workshop for health service board members. Twelve health service boards across Victoria were randomly selected and asked to attend the workshop or act as a control group.

During the workshop, each board member practised various conversational strategies with a professional actor under the guidance of a trained facilitator.

Trial 7

Communication in the boardroom

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Facilitated conversations help improve communication

Three months after attending the workshop, board members reported significant improvements in their skills and confidence in communicating effectively during health board meetings and in-meeting processes, compared to the control group.

Click here to learn more about this trial.

Trial 7

Communication in the boardroom

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Facilitated conversations help improve communication

If more board members have the skills to ask difficult questions in health service boardrooms, this can reduce the likelihood of tragic outcomes, including avoidable deaths.
“There is research to suggest a well-functioning board that prioritise patient care and safety will have better outcomes. Simulation training allows participants to build and practice communications skills in a protected environment. This trial allowed simulation training at a board level for the first time and the results were positive -board members felt empowered to ask the hard questions and expand discussions with their executives to deliver improved patient care.”
“Often when you read the transcripts from court cases where things have gone horribly wrong, the directors of companies will often say ‘I did wonder about that’ but for whatever reason they don’t ask the question … those questions that we learned [as part of of the training] will be really helpful in terms of having the confidence and having the ability to actually ask the difficult questions”

Marie Aitken, Chair of a Victorian Health Service Board that participated in the workshop

This is the first known randomised controlled trial of simulation training for health boards in the world. The positive results reinforce that key communication skills are best developed through real-time practice in a safe environment.

About the Research and Innovation Program

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As the Victorian Government’s insurer and risk adviser, the Victorian Managed Insurance Authority (VMIA) supports Victorian public health services and hospitals by identifying avoidable risks that may lead to medical indemnity claims.

In 2017, VMIA joined forces with BehaviourWorks Australia, a research enterprise within the Monash Sustainable Development Institute, and The Shannon Company to develop and deliver a three-year Research and Innovation Program.

Through a rigorous prioritisation process involving a wide range of stakeholders, including the Department of Health and Human Services, the BehaviourWorks research team and VMIA identified seven priority healthcare challenges. These challenges led to the development of trials conducted in Victorian hospitals between 2018 and 2020.

Each trial has a key role as part of the patient journey through the Victorian public healthcare system.

Learn more

Interview with representatives from VMIA, BehaviourWorks Australia and The Shannon Company (June 2020).

Interview with representatives from VMIA, BehaviourWorks Australia and The Shannon Company (June 2020).

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