Stop Dropping the Ball: Improving Diagnosis Across Transitions of Care in Rural Communities

Background and Significance Diagnostic error is one of the most important safety problems in health care today There is a clear need for process improvement and meaningful patient engagement surrounding diagnostic test management. This process begins with ordering a test and ends with communicating the result and necessary next steps to the patient. Diagnostic test management is critical to accurate and timely diagnosis, but effective follow-up systems are flawed and often riddled with work-arounds, particularly across transitions of care.

Background and Significance Research Question: What is the effectiveness of community-engaged strategies to improve appropriate diagnostic test follow-up after discharge from a rural emergency department? This project aims to decrease diagnostic error risk by: Partnering with community members and providers to redesign the test reporting workflow, and Implementing improvement ideas that have the highest potential to prevent follow-up system failures (FUSFs), and thereby, diagnostic errors. 

Project Partners & Funding Minnesota Alliance for Patient Safety (MAPS) Overall project management Patient engagement expertise and focus Lakewood Health System Emergency Department, project management, physician champion leadership PFAC, Medical Home Advisory Board, other community groups, and individual patient interviews University of Minnesota, Department of Medicine Medical researcher - Dr. Andrew Olson RPAP students Stratis Health Process mapping expertise, Reid Haase Building Healthier Communities grant funding for patient engagement portion of project MMIC/Constellation Overall project funding Data and expertise in diagnostic errors

This research project is centered on co-designing a new process with community members and patients to minimize the possibility of test result follow-up system failures (FUSFs). The patient and family perspective is critical in creating a new process that is reliable, safe, and efficient. The project will run through 2020.

Stage 1 Project Stages Goals: Develop and validate a practical measurement strategy Understand patients’ current experiences Identify ED workflow process failures and best practices Projected Timing: June-December 2019 Develop measurement strategy for appropriate test result follow-up upon ED discharge Below are specific tests and 12-month period averages for Lakewood Health System ED Blood Cultures: 59 ordered/month Urine cultures: 60/month Creatinine: 270/mo (include only BMP, CMP and renal panels) Chest CT: 12.25/mo Chest x-ray: 86/mo Gather pre-intervention data and analyze Map current state workflows that depict current diagnostic test result follow-up Goals: 1. Develop and validate a practical measurement strategy; understand patients’ current experiences, workflow process failures, and best practices. 2. Re-design the process through a community-engaged approach. 3. Implement newly co-designed process and use the measure designed from Stage 1 to determine its effect on the rate of appropriate follow-up; decrease follow up system failures (FUSF)  by 10%.

Project Stages Stage 2 Convene the community to present current state processes, and gather input and perspective that will inform new workflows that are anticipated to decrease follow-up system failure Co-design new workflows and processes together; Create the "Future State“ with a team that includes patients/family, staff, clinicians, leadership, and researchers Goal: Re-design the process through a community engaged approach Projected Timing: Sept/Oct-Dec 2019 Goals: 1. Develop and validate a practical measurement strategy; understand patients’ current experiences, workflow process failures, and best practices. 2. Re-design the process through a community-engaged approach. 3. Implement newly co-designed process and use the measure designed from Stage 1 to determine its effect on the rate of appropriate follow-up; decrease follow up system failures (FUSF)  by 10%.

Project Stages Stage 3 Create necessary materials for education of newly-designed processes Implement new processes Use measurement strategy from Stage 1 and newly-designed process from Stage 2 to determine the effect on appropriateness of diagnostic test follow-up (6 mos) as compared to prior to the intervention; leverage patient insight during the data analysis process Goal: Implement newly co-designed process and use the measure designed from Stage 1 to determine its effect on the rate of appropriate follow-up Decrease FUSFs by 10% Projected Timing: January-December 2020 Goals: 1. Develop and validate a practical measurement strategy; understand patients’ current experiences, workflow process failures, and best practices. 2. Re-design the process through a community-engaged approach. 3. Implement newly co-designed process and use the measure designed from Stage 1 to determine its effect on the rate of appropriate follow-up; decrease follow up system failures (FUSF)  by 10%.

Next Steps Initial meeting with PFAC July 18 Data collection is underway Planning for additional site visits is underway Current and future state mapping to be scheduled for September or October