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2023 HSR&D/QUERI National Conference Abstract

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1153 — Reducing Missed Test Results Through a Virtual Breakthrough Series Collaborative

Lead/Presenter: Andrew Zimolzak,  COIN - Houston
All Authors: Zubkoff L (Birmingham VAMC, University of Alabama Birmingham), Zimolzak AJ (Center for Innovations in Quality, Effectiveness and Safety at Houston VAMC; Baylor College of Medicine) Shahid U (Center for Innovations in Quality, Effectiveness and Safety at Houston VAMC; Baylor College of Medicine) Giardina TD (Center for Innovations in Quality, Effectiveness and Safety at Houston VAMC; Baylor College of Medicine) Memon SA (Center for Innovations in Quality, Effectiveness and Safety at Houston VAMC; Baylor College of Medicine) Meyer AND (Center for Innovations in Quality, Effectiveness and Safety at Houston VAMC; Baylor College of Medicine) Murphy DR (Center for Innovations in Quality, Effectiveness and Safety at Houston VAMC; Baylor College of Medicine) Singh H (Center for Innovations in Quality, Effectiveness and Safety at Houston VAMC; Baylor College of Medicine)

Objectives:
Implementing patient safety interventions is challenging, especially when extrinsic motivators (e.g., incentives, accountability measures, mandates, public reporting) for health care organizations are absent. Such motivators are lacking when addressing failures in timely follow-up of test results (“missed test results”), even though they lead to significant patient harm from diagnosis and treatment delays. We evaluated implementation of a multifaceted approach (“SAFER TRACKS”) to reduce missed test results in multiple VA facilities. The approach involved use of a change package (menu of appropriate interventions) delivered using a Virtual Breakthrough Series (VBTS) collaborative and supplemented with automated surveillance data on missed test results.

Methods:
A stepped-wedge cluster-randomized controlled trial (NCT04166240) was conducted at 11 VA facilities to reduce missed test results. The VBTS was adapted from the Institute for Healthcare Improvement’s model and included 3 phases: pre-work, action, and continuous improvement. In the 3-month pre-work phase, teams prepared by gathering baseline data and reviewing the change package. In the 6-month action phase, teams participated in educational calls, conducted plan-do-study-act cycles, received coaching, extracted local EHR data about missed test results, and submitted monthly reports about accomplishments to the study team. To quantify the number and type of interventions implemented (new or modified existing interventions), we coded each intervention reported in the final reports submitted by each team. Consistent with the change package, interventions were grouped by domains: enhancing patient engagement with test results (3 interventions), improving situational awareness among all providers and care teams (4 interventions), and implementing processes to close the loop on test results reporting and follow-up (4 interventions). We also coded interventions reported that did not appear in the change package. To determine outcomes, we are currently applying an established EHR-based trigger algorithm to evaluate rates of missed abnormal test results suspicious for lung and colon cancer (chest imaging, FIT, and suspected iron deficiency anemia).

Results:
Forty-seven unique interventions were implemented by the 11 site teams. The average number of interventions implemented per team was 4.28 (range 3-8, mode of 3). The most frequently implemented changes were increasing access to test results (91%, N = 10), reducing provider result notification fatigue (55%, N = 6), and monitoring for breakdowns in test results review and communication (45%, N = 5). Interventions not identified in the change package included: revised policies and procedures (n = 2), provider education (n = 1), demonstrated use of QI tools (e.g., process mapping, PDSA) (n = 2), procedures to better label abnormals (n = 2), pay for performance (n = 1), and transportation support to reduce no-shows (n = 1). Trigger algorithm application outcomes are pending.

Implications:
A multifaceted approach including VBTS successfully engaged teams in implementing interventions to prevent missed test results. All sites met a prespecified goal of implementing at least one intervention from each of the three major domains. We observed a wide variance in the adoption of interventions. Whether these interventions reduce missed test results is now being determined.

Impacts:
A multifaceted VBTS-based approach could be a useful strategy to implement interventions to improve safety. This approach could be particularly useful to engage sites to work on safety problems that do not currently have any external incentives and motivators for change.