IHP 430 Module 4 Final Project Milestone Two example

Milestone Two: A Nurse-Run Registry, a Phone Call and Staged Reminders to Close the Loop on Incidental Lung Nodules

[Student Name]

Southern New Hampshire University

IHP 430: Healthcare Quality Management

Module Four Final Project Milestone Two

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[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 Two: A Nurse-Run Registry, a Phone Call and Staged Reminders to Close the Loop on Incidental Lung Nodules

From Baseline to Proposal

Milestone One showed that at Stoneridge Regional Medical Center, a composite community hospital, only 29.0 percent of emergency department patients with an incidental lung nodule completed the recommended follow-up scan within 60 days of the due date, and only 8.8 percent did when no primary care clinician was on file. The audit also found that the process has six handoffs and no owner. This proposal answers the four questions Milestone One left open: who owns each nodule, how patients are told, what happens to patients with no clinician, and how success will be measured.

Aim Statement

For patients seen in the Stoneridge emergency department whose chest CT report recommends nodule follow-up, increase the proportion who complete follow-up imaging, or whose finding is formally closed by a clinician, within 60 days of the due date from 29.0 percent to 65 percent for recommendations issued between July 1, 2025 and June 30, 2026. The aim counts documented closure as success because a patient who enters hospice or has the nodule followed elsewhere is not a failure of the system. A secondary aim raises completion for patients without a primary care clinician from 8.8 percent to 50 percent in the same period.

The Proposed Change and Its Evidence

The initiative has four parts, and each answers one failure found in the audit.

First, a standard report entry. Radiologists will use a structured nodule statement that records size, type and the Fleischner category and places the recommendation in a discrete field rather than free text (MacMahon et al., 2017). The field makes the recommendation searchable, which the next step depends on. Radiologists already dictate this information, so the added work is a template, not a task.

Second, a registry with an owner. A nurse navigator in the hospital's lung health program will review a daily list of emergency chest CT reports with a follow-up recommendation and enter each patient in a registry. Language processing tools can already find these reports reliably; one open pipeline identified recommended follow-up on emergency chest CTs with an F1 score of 0.85 (Moore et al., 2025), so even reports dictated without the template can be caught. Community programs built on a navigator and a database have shown the model is workable; one Tennessee program grew to 745 referred patients in its second year and saw the share of its lung cancers diagnosed at stage I or II rise from 23 percent before the program to 38 percent (LeMense et al., 2020).

Third, direct notification by telephone. Within 14 days of the emergency visit, the navigator will call the patient, explain the finding in plain language and schedule the scan, followed by a letter. The choice of telephone is deliberate. In a randomized trial of 2,548 patients, early notification by phone produced the highest follow-up completion at 60.4 percent against 53.2 percent for tracking alone, while notification by portal message produced the lowest at 36.4 percent (Loftus et al., 2024).

Fourth, staged reminders and a safety net. If the scan is not complete by the due date, the navigator contacts the patient again and notifies the ordering or primary clinician; at 30 days past due, the case goes to the lung health physician for a decision. A multistage tracking system of this kind raised completion of recommended imaging from 43.1 percent to 70.5 percent at one health system, and the resulting examinations produced revenue about 4.1 times the labor cost (Wandtke & Gallagher, 2017). Patients with no primary care clinician will be booked directly into the lung health clinic, which closes the gap the audit found largest.

Measures and Targets

Table 1 lists the measures, following the structure, process and outcome logic used in Milestone One and the measure set the American College of Radiology developed for this problem (Kadom et al., 2022).

Table 1

Measure Set for the Nodule Follow-Up Initiative

Note. Baselines are composite figures for illustration; targets apply to recommendations issued July 1, 2025 to June 30, 2026.

Roles and Resources

The chief medical officer will sponsor the initiative and chair a monthly review, because the process crosses the emergency department, radiology and primary care and needs a leader above all three. The nurse navigator owns the registry and every patient in it until closure. The radiology group's quality lead owns template adoption, the emergency department medical director owns discharge language that tells patients a finding exists, and a quality analyst owns the monthly data.

First-year costs are modest. One full-time nurse navigator at a fully loaded cost of about 104,000 dollars, 0.2 of an analyst at about 18,000 dollars and an estimated 120 hours of information technology work to build the report field and daily list are the main items, for roughly 136,000 dollars. On the revenue side, if completion rises from 29 to 65 percent, about 400 additional follow-up CT scans a year would be performed at Stoneridge, and some would lead to earlier treatment of cancers that would otherwise have been found late. The business case therefore rests on both revenue and avoided harm, and the proposal presents it that way rather than as a pure return on investment.

Testing the Change

The initiative will not launch all at once. Using the Model for Improvement, each component gets its own small-scale test through plan-do-study-act cycles, and nothing spreads until it has passed one (Langley et al., 2009). Cycle one tests the daily report list and registry entry for two weeks on day-shift reports only. The second tests the telephone script with 20 patients and measures how many are reached on the first or second attempt. The third tests the structured report field with four volunteer radiologists. Only parts that work in testing will spread, and Milestone Three will describe the implementation plan for those that do.

Risks

Three risks are named now so they can be managed. Radiologists may resist the template if it slows reading, which is why turnaround time is a balancing measure. The navigator role could become a single point of failure during leave or turnover, so a backup nurse will be trained from the start. Finally, better tracking may prompt scans for nodules that guidelines say need none, adding radiation and cost, so the navigator will apply the Fleischner criteria before scheduling rather than scheduling every mention of a nodule.

References

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

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

LeMense, G. P., Waller, E. A., Campbell, C., & Bowen, T. (2020). Development and outcomes of a comprehensive multidisciplinary incidental lung nodule and lung cancer screening program. BMC Pulmonary Medicine, 20, Article 115. https://doi.org/10.1186/s12890-020-1129-7

Loftus, J. R., Kadom, N., Baran, T. M., Hans, K., Waldman, D., & Wandtke, B. (2024). Impact of early direct patient notification on follow-up completion for nonurgent actionable incidental radiologic findings. Journal of the American College of Radiology, 21(4), 558-566. https://doi.org/10.1016/j.jacr.2023.07.026

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