IHP 430 Module 8 Final Project Performance Improvement Plan example

Closing the Loop on Incidental Lung Nodules: A Performance Improvement Plan for Emergency Department Imaging at a Regional Medical Center

[Student Name]

Southern New Hampshire University

IHP 430: Healthcare Quality Management

Module Eight Final Project

[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.

Closing the Loop on Incidental Lung Nodules: A Performance Improvement Plan for Emergency Department Imaging at a Regional Medical Center

Executive Summary

Before this initiative, fewer than one in three emergency department patients at Stoneridge Regional Medical Center, a composite 280-bed community hospital, received the follow-up scan recommended for an incidental lung nodule. A nurse-owned registry, direct telephone notification and staged reminders lifted the share of patients whose scan was done, or whose finding was formally closed, no later than 60 days past due, taking it from 29.0 percent at baseline to 66.4 percent for scans falling due from January to June 2026, meeting the 65 percent target. Completion among patients with no primary care clinician rose from 8.8 percent to 41.2 percent, short of the 50 percent target. Seven lung cancers were diagnosed among registry patients, five at stage I. The program cost about 139,000 dollars in its first year and will move into the lung health program's permanent budget. This plan recommends sustaining the program, fixing the gap for patients without a clinician and extending the registry to other actionable findings.

The Problem and Its Root Causes

Emergency physicians order chest CT scans to rule out blood clots, injuries and infections, and about one in nine of those scans at Stoneridge shows a lung nodule that the Fleischner Society guidelines say should be rechecked (MacMahon et al., 2017). A baseline audit of 200 such patients found that 58 completed the recommended scan within 60 days of its due date. The published record shows the same pattern elsewhere; in one emergency department study, follow-up occurred in 29 percent of cases even when the radiology report explicitly recommended it (Blagev et al., 2014).

A root cause analysis with radiologists, emergency physicians, primary care representatives and two patients grouped the causes into five categories, shown in Table 1. No single cause explained the failure; the defect was that each step assumed someone else would take the next one.

Table 1

Root Causes of Missed Nodule Follow-Up, by Category

Note. Categories adapted from a cause-and-effect diagram completed by the project team.

The Initiative

The change had four components, each matched to a root cause. Radiologists adopted a structured nodule statement with a searchable recommendation field. A nurse navigator took ownership of every flagged patient through a registry fed by a daily report search. The navigator called each patient within 14 days, a choice based on a randomized trial in which telephone notification produced higher follow-up completion than portal messages or tracking alone (Loftus et al., 2024). Reminders escalated at the due date and at 30 days past due, following a multistage tracking model that had raised completion from 43.1 to 70.5 percent elsewhere (Wandtke & Gallagher, 2017). Each component was tested in small plan-do-study-act cycles before spreading (Langley et al., 2009).

Results

Between July 2025 and June 2026, 1,087 patients entered the registry. Table 2 reports each measure against its target. Because follow-up intervals vary, outcome figures are reported by the month each scan fell due.

Table 2

Twelve-Month Results Against Targets

Note. Composite results for illustration. Outcome results are for recommendations due January to June 2026.

The monthly completion rate was plotted on a p-chart with limits calculated from the six-month baseline. Beginning in December 2025, every point sat above the baseline center line, and March 2026 exceeded the upper control limit, which together meet the rules for special cause variation and support the conclusion that the change, not chance, produced the improvement (Benneyan et al., 2003). The process measures moved first, as expected: registry entry within three business days reached 96 percent by the second month, and the share of patients reached by phone within 14 days reached 82 percent by the fourth.

The missed target deserves direct attention. Patients with no primary care clinician improved almost fivefold, but many could not be reached by phone, and those who were often lacked transportation for a daytime scan. The navigator's call logs show that 31 percent of these patients had a disconnected or incorrect number, a registration problem rather than a follow-up problem.

Balancing Measures

Two balancing measures guarded against unintended harm. The concern that tracking would lead to scans for nodules too small to need them did not materialize; such scans fell from 3.1 to 2.4 percent, because the navigator applied the guidelines before scheduling. Median report turnaround rose by one minute, which radiologists judged acceptable. A third, informal check came from patients: the navigator logged 14 calls in which patients described anxiety about the finding, and the script was revised twice to address it.

Financial Implications

First-year costs were about 139,000 dollars: the navigator and a trained backup at 109,000 dollars, analyst time at 14,000 dollars and information technology work at 16,000 dollars. Against those costs, the registry generated about 400 additional follow-up CT scans at Stoneridge, and the seven cancers diagnosed led to surgery, bronchoscopy and treatment at the hospital rather than elsewhere. The finance department estimates net revenue from follow-up imaging alone at roughly 150,000 dollars, so the program approximately pays for itself before any value is placed on cancers found early or on the malpractice exposure it reduces. The more important return is not financial. Five patients had stage I lung cancer found while it could still be removed.

Sustaining the Gains

The largest risk now is that the program depends on attention that will move elsewhere. Four steps make it part of normal operations. The navigator position and backup move permanently into the lung health program's budget in July 2026. A hospital policy, approved by the medical executive committee, assigns responsibility for incidental nodules to the registry and requires the structured field in chest CT reports. The completion rate and the two balancing measures join the quality committee's quarterly dashboard indefinitely. Finally, a trigger is set: two consecutive months below 55 percent completion prompt a review by the chief medical officer rather than waiting for the annual report.

Recommendations for Spread

Three recommendations follow. First, fix the missed subgroup at its source by having emergency registration confirm a working phone number at every visit and by offering evening and weekend scan times through the lung health clinic. Second, extend the registry to inpatient and outpatient chest CT, which the navigator estimates would add about 600 patients a year and require a second nurse. Third, adapt the model to other actionable incidental findings named in the American College of Radiology measure set, such as abdominal aortic aneurysms (Kadom et al., 2022), using the same ownership, notification and staged reminder design.

Conclusion

The failure at Stoneridge was not that clinicians did not care about incidental nodules but that no one owned them. Assigning an owner, telling patients directly and building a system that reminds people rather than relying on memory more than doubled follow-up in a year, at a price Stoneridge can carry. The unmet target for patients without a primary care clinician is the next project, and the method that produced this result is the one that will address it.

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

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

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.

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

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