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

2. 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.

3. 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. 

4. 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

5. 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.

6. 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%.

7. 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%.

8. 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%.

9. 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