Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis. Studies have found that the average duration of time from first symptom recognition to diagnosis, and finally to the initiation of lung cancer treatment is more than 4 ½ months.³ Research has found that even a four-week delay in cancer treatment is associated with increased mortality.⁴ Failure to recognize an abnormal test result creates missed treatment opportunities and is associated with higher healthcare costs.⁵

There are health disparities in cancer mortality rates and shorter survival times associated with race and socioeconomic status.^6,7,8,9 In radiology, social determinants of health lead to the disparate use of imaging services, which can delay diagnosis and treatment.¹⁰ A study in Michigan found that patients at the greatest risk of late-stage cancer diagnosis and death were patients under 65 who were insured by Medicaid.¹¹

To address these concerns, this Ambulatory Safety Net (ASN) innovation built on the work done by Kaiser Permanente Southern California, which developed the notion of a safety net in ambulatory settings.¹² “Safety net” is defined many ways in healthcare settings, but a literature review on the topic developed a collective definition: “A consultation technique to communicate uncertainty, provide patient information on the red-flag symptoms, and plan for future appointments to ensure timely re-assessment of a patient’s condition.”¹³ Furthermore, safety nets are developed in hospitals mainly through inpatient settings. The Brigham and Women’s Hospital’s (BWH) Patient Safety Collaborative, which included Ambulatory Patient Safety, Radiology Quality and Safety, and the Center for Evidence-Based Imaging (CEBI) teams, identified a gap and need for a safety net in their ambulatory care setting. This collaborative defined an ambulatory care setting as any outpatient setting or any place where a same-day procedure can be conducted, or any medical service that can be performed in a hospital that does not require hospital admission.¹⁴

Starting in 2017, the BWH Patient Safety Collaborative began to brainstorm ideas to prevent missed and delayed cancer diagnoses. Specifically, they investigated radiologist follow-up recommendations and colonoscopy test follow-up after abnormal test results to design a lung cancer safety net and a colon cancer safety net.¹ The ASN was constructed for colon cancer by creating a quality metric to track the percentages of patients over time who were scheduled for or completed a colonoscopy following safety net outreach to the patient.¹ After a test result was flagged, an outreach worker would contact the patient to ensure follow-up tests were scheduled.¹ The quality metric for the lung cancer ASN was the proportion of patients with a scheduled or completed chest computed tomography (CT) scan after appropriate follow-up.¹

The lack of necessary clinical follow-up after a key cancer screening or imaging test can delay diagnosis and treatment. In addition to the failure to follow up, the failure to recognize an abnormal test result creates missed treatment opportunities and is associated with higher healthcare costs.⁵ The impetus for the innovation stemmed from a patient experience of a preventable, serious adverse event at BWH. The event, which BWH researchers believe was in alignment with current national standards of care, was evaluated through a Collaborative Case Review.¹⁵ This review illuminated substantial opportunities within the existing systems of care. This patient case influenced much of the work. The hospital espouses an equity-informed high-reliability organizational framework; therefore, hospital leadership aspired to reduce the risk of similar events in the future. The chain of events leading to patient harm and the resulting commitment has built steady and staunch support for this project in all iterations moving forward.

• Leadership buy-in and support for ambulatory patient safety
• Buy-in from a multidisciplinary stakeholder team
• An equity-informed, highly reliable organizational framework
• Subject matter expertise interpreting imaging exams, such as x-rays or CT scans, and performing colonoscopies
• Workflow redesign
• Information technology registries, tools, and analytic capabilities to track each clinically necessary recommendation to resolution and to evaluate progress, impact, and demonstrate value to sustain the innovation

Currently, this ASN innovation has been adapted and is being implemented across the Mass General Brigham system, which includes two academic medical centers, seven community hospitals, and three specialty care hospitals, as well as numerous ambulatory care and outpatient imaging centers.