IHP 430 Module 2 Final Project Milestone One example

Milestone One: Incidental Lung Nodules That Leave the Emergency Department Without a Plan at a Composite Regional Medical Center

[Student Name]

Southern New Hampshire University

IHP 430: Healthcare Quality Management

Module Two Final Project Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: Incidental Lung Nodules That Leave the Emergency Department Without a Plan at a Composite Regional Medical Center

The Organization

Stoneridge Regional Medical Center, a composite nonprofit community hospital with 280 beds, serves a small New England city and the rural towns around it. It is the only hospital within 35 miles, it holds Joint Commission accreditation, and it belongs to a three-hospital system whose quality department reports to a system board committee. The emergency department recorded 51,800 visits in fiscal year 2024 and ordered 9,640 chest computed tomography scans, most of them CT pulmonary angiograms for suspected blood clots and trauma scans after car crashes. Radiology is provided by a contracted group of 14 radiologists who read remotely overnight. About 27 percent of emergency patients list no primary care clinician, a figure that has risen since a local practice closed in 2022.

Authority matters for any quality project, so it is worth stating plainly. The emergency department reports to the chief medical officer, the radiology group reports to its own partners and to the system through a contract, and the primary care practices that receive most follow-up work are a mix of system-employed and independent offices. No single leader owns a patient's journey from an emergency scan to a clinic appointment months later.

The Quality Problem

Chest CT scans ordered for one reason often show something else. A small pulmonary nodule is the most common of these incidental findings, and although most are benign, some are early lung cancers that are curable when found small. The Fleischner Society guidelines set follow-up intervals by nodule size, number, appearance and patient risk, from no follow-up for tiny nodules in low-risk patients to repeat CT at 3 to 12 months for larger ones (MacMahon et al., 2017). The quality problem at Stoneridge is that these recommendations are written in the radiology report and then, in most cases, acted on by no one.

A chart audit made the problem measurable. The quality department reviewed every emergency department chest CT from January through June 2024 and a random sample of 200 patients whose report recommended nodule follow-up with a due date that had passed by March 2025. The results are shown in Table 1.

Table 1

Baseline Audit of Incidental Nodule Follow-Up After Emergency Department Chest CT

Note. Composite audit data for illustration. ED = emergency department.

The Findings Match the Literature

Stoneridge is not an outlier. In a review of 1,000 CT pulmonary angiograms ordered in an emergency department, Blagev et al. (2014) found that about one in ten showed a nodule needing follow-up and that only 29 percent of those patients received it; even when the report explicitly recommended follow-up, the rate stayed at 29 percent. A more recent study of 26,545 emergency chest CTs across three departments found that 12.4 percent carried a follow-up recommendation (Moore et al., 2025), close to Stoneridge's 11.6 percent. A systematic review of ambulatory test results found radiology results not followed up in as many as 35.7 percent of cases in some studies and noted that responsibility for notification was rarely defined (Callen et al., 2012). The published record and the local audit agree: a clear report is necessary, but it is not a follow-up system.

Why It Matters

The first stake is patients. At Stoneridge's volume, about 1,100 emergency patients a year are told, somewhere in a report they will probably never read, that they need another scan. If 71 percent do not get it, roughly 790 patients a year have an unresolved finding, and even a small cancer rate among them means lives affected by a stage shift that was avoidable. The second stake is legal. Delay in diagnosis is a preventable error commonly identified in malpractice claims involving radiologists and office-based clinicians (Wandtke & Gallagher, 2017), and a documented recommendation that nobody acted on is difficult to defend. The third is financial and reputational. The American College of Radiology has developed a measure set for closing the loop on follow-up recommendations for incidental findings, with pulmonary nodules as a named use case (Kadom et al., 2022), which signals that this gap is moving from an internal concern to a measured and reported one.

Stakeholders

Emergency physicians want the problem solved but see follow-up as outside their role; they discharge patients within hours and rarely see them again. Radiologists already write recommendations and worry that a tracking program will add unpaid work. Primary care clinicians receive many results they did not order and fear inheriting findings for patients they have never met. Patients are the most affected and the least informed, particularly the 28.5 percent without a primary care clinician. Hospital leaders care about harm, liability and the system's reputation, and the quality department needs an owner, a data source and a budget line. Any initiative that adds work for one group without relief will stall, so the proposal will have to show each group what it gains.

Where the Current Process Breaks

Tracing one patient through the current process shows six handoffs, each with no one accountable for the next step. The radiologist writes the recommendation in the report. The emergency physician may or may not read the impression before discharge. The discharge instructions, generated from a template, have no field for incidental findings. The visit summary goes to a primary care clinician only if one is listed. That clinician must notice the recommendation among other results, and finally the patient must schedule and attend a scan months later. Read through the structure, process and outcome framework (Donabedian, 1988), the structure lacks a registry and an owner, the process depends on memory at every step, and the outcome, completed follow-up, is not measured anywhere except in this audit.

Culture and Readiness for Change

Stoneridge has some assets for this work. Its safety culture survey from 2024 showed that 71 percent of emergency staff agreed that mistakes had led to positive changes, and the hospital already runs a critical results callback process that radiologists trust, which proves the organization can close a loop when it decides a result matters. The weaknesses are equally clear. Incidental findings sit in a gray zone that no policy covers, the radiology contract says nothing about follow-up, and the quality department has one analyst for three hospitals. Readiness is therefore moderate: staff accept the problem once they see the audit, but no one will change practice until leaders assign ownership and fund the work that ownership requires.

Questions for Milestone Two

The audit leaves four questions the initiative proposal must answer. Who will own each nodule from the moment it is reported until follow-up is complete or closed? How will patients be told directly, in plain language and in a way they will act on? What happens to patients with no primary care clinician? And which measures, with what targets, will show whether the change worked without adding burden to radiologists and emergency physicians? Milestone Two will propose a change that answers each one.

References

Blagev, D. P., Lloyd, J. F., Conner, K., Dickerson, J., Adams, D., Stevens, S. M., Woller, S. C., Evans, R. S., & Elliott, C. G. (2014). Follow-up of incidental pulmonary nodules and the radiology report. Journal of the American College of Radiology, 11(4), 378-383. https://doi.org/10.1016/j.jacr.2013.08.003

Callen, J. L., Westbrook, J. I., Georgiou, A., & Li, J. (2012). Failure to follow-up test results for ambulatory patients: A systematic review. Journal of General Internal Medicine, 27(10), 1334-1348. https://doi.org/10.1007/s11606-011-1949-5

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Kadom, N., Venkatesh, A. K., Shugarman, S. A., Burleson, J. H., Moore, C. L., & Seidenwurm, D. (2022). Novel quality measure set: Closing the completion loop on radiology follow-up recommendations for noncritical actionable incidental findings. Journal of the American College of Radiology, 19(7), 881-890. https://doi.org/10.1016/j.jacr.2022.03.017

MacMahon, H., Naidich, D. P., Goo, J. M., Lee, K. S., Leung, A. N. C., Mayo, J. R., Mehta, A. C., Ohno, Y., Powell, C. A., Prokop, M., Rubin, G. D., Schaefer-Prokop, C. M., Travis, W. D., Van Schil, P. E., & Bankier, A. A. (2017). Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society 2017. Radiology, 284(1), 228-243. https://doi.org/10.1148/radiol.2017161659

Moore, C. L., Socrates, V., Hesami, M., Denkewicz, R. P., Cavallo, J. J., Venkatesh, A. K., & Taylor, R. A. (2025). Using natural language processing to identify emergency department patients with incidental lung nodules requiring follow-up. Academic Emergency Medicine, 32(3), 274-283. https://doi.org/10.1111/acem.15080

Wandtke, B., & Gallagher, S. (2017). Reducing delay in diagnosis: Multistage recommendation tracking. American Journal of Roentgenology, 209(5), 970-975. https://doi.org/10.2214/AJR.17.18332