IHP 430 Module 6 Final Project Milestone Three example

Milestone Three: Implementing a Nodule Registry and Navigator Program in a Regional Emergency Department

[Student Name]

Southern New Hampshire University

IHP 430: Healthcare Quality Management

Module Six Final Project Milestone Three

[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 Three: Implementing a Nodule Registry and Navigator Program in a Regional Emergency Department

Implementation Approach

Stoneridge Regional Medical Center, the composite hospital profiled in Milestone One, approved the Milestone Two proposal in May 2025: a registry of incidental lung nodules found on emergency chest CT, owned by a nurse navigator, with telephone notification and staged reminders. Implementation follows a phased approach rather than a single launch date. Each component is tested in small cycles, adjusted, and only then spread across all shifts and all radiologists, consistent with the Model for Improvement (Langley et al., 2009). The chief medical officer sponsors the work, and a steering group of the emergency department medical director, the radiology quality lead, the lung health program director, the navigator and a quality analyst meets every two weeks during the first three months and monthly afterward.

Table 1 shows the phases, dates and owners.

Table 1

Implementation Timeline for the Nodule Follow-Up Initiative

Note. CMO = chief medical officer; ED = emergency department; IT = information technology.

Training and Communication by Audience

Each group needs a different message, so communication is planned by audience. Radiologists receive a 15-minute presentation at their monthly meeting showing the audit results and the new structured nodule field, followed by a one-page tip sheet and a demonstration built into the dictation system. The message to them is that the template replaces text they already dictate and that the registry, not the radiologist, will now carry the follow-up. Emergency physicians and nurses are briefed at staff meetings and through a short email from their medical director explaining the new discharge sentence, which tells the patient a finding was seen and that a nurse will call. The navigator and backup nurse complete two days of training covering the Fleischner criteria, the telephone script, registry documentation and when to escalate to a physician. Primary care practices receive a letter from the chief medical officer describing what the navigator will send them and asking each office to name one contact person.

Communication does not stop at launch. A one-page dashboard showing monthly completion and the number of patients reached goes to the steering group and is posted in the radiology reading room and the emergency department break room. Staff are more likely to keep using a new process when they can see that it is working and that their part in it matters.

Data Collection and Monitoring

Data come from three sources: the daily report list, the registry and the scheduling system. The navigator records each patient's entry date, the date of the first successful call, the scheduled and completed scan dates, and any closure reason. The analyst pulls the registry monthly and calculates each measure from Milestone Two. The primary outcome, follow-up completed or formally closed within 60 days of the due date, is plotted on a p-chart, which suits a proportion with a changing monthly denominator. Improvement is claimed only when the chart shows special cause variation, such as a month beyond a control limit or eight consecutive months falling below or above the mean, rather than one good month (Benneyan et al., 2003). Because follow-up intervals range from 3 to 12 months, outcome data lag behind the change; the process measures, entry within 3 business days and patient reached within 14 days, are therefore tracked weekly during testing because they show early whether the system is working.

Anticipated Barriers

The Consolidated Framework for Implementation Research groups the factors that decide whether an innovation takes hold into the innovation itself, the outer setting, the inner setting, the individuals involved and the process (Damschroder et al., 2009). Using those domains keeps the barrier list from being a set of worries. For the innovation, the report template may be seen as slowing reading, so the radiology lead will review turnaround weekly and adjust the template if it rises. In the outer setting, independent primary care offices may not respond to the navigator, which is why patients are booked into the lung health clinic when no office replies in 10 days. In the inner setting, the emergency department is short-staffed, so the discharge sentence is added to the template automatically rather than typed. Among individuals, some radiologists doubt that a registry will make a difference, and the dashboard is the answer to that doubt. For process, the navigator is a single point of failure, which the trained backup covers.

Resources and Budget Check

The Milestone Two budget of about 136,000 dollars holds, with one change. The navigator was hired at a slightly higher rate than planned, and the analyst's time was reduced because the daily list proved easier to automate than expected, so the total remains within 3 percent of the approved figure. The lung health program has agreed to absorb the navigator position into its operating budget from July 2026 if the initiative meets its targets, which gives the steering group a clear deadline.

Results of the First Test Cycles

Two cycles are complete. In the first, the daily list and registry were tested on day-shift reports for two weeks. The navigator entered 21 of 23 eligible patients within three business days; the two misses were reports dictated without the word nodule, which led the team to add the terms opacity and density to the search. In the second, the telephone script was tested with 20 patients. The navigator reached 12 on the first attempt and 5 more on the second, and 3 could not be reached after three calls. Patients asked most often whether the finding was cancer, so the script now opens by explaining that most nodules are harmless and that the scan is how doctors make sure. These results support calling rather than using the portal, consistent with trial evidence that phone notification outperforms portal messages for follow-up completion (Loftus et al., 2024). The third cycle, testing the report template with four radiologists, begins in August.

References

Benneyan, J. C., Lloyd, R. C., & Plsek, P. E. (2003). Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care, 12(6), 458-464. https://doi.org/10.1136/qhc.12.6.458

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

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.

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