This is the third article in a three-part ACR Bulletin series showcasing the work of the ACR Learning Network quality improvement (QI) collaboratives. This article focuses on lung cancer screening rates and follow-up recommendations. The second article, In It for the Long Haul, highlighted the importance of technologists and patient positioning in mammography. The first article, Collaborating on Quality, focused on improving prostate MRI for clinically significant cancer detection and localization.
The Learning Network was launched in 2022 to improve diagnostic imaging care through a learning health systems approach — defined by fostering strong leadership, maximizing the use of data in clinical settings, and building a workplace culture committed to continuous learning and improvement. Participating Learning Network sites have laid important foundational work that will support current and future QI cohorts by defining and refining QI measures and developing enhanced internal imaging procedures and protocols.
Each collaborative supports teams at the facilities of four to six sites working to solve similar problems, enabling them to grow experience and fresh perspectives as they share insights and advance QI goals. Every improvement collaborative has the support of a radiologist, an administrative lead and dedicated staff — including a learning facilitator, an administrative support specialist and a data support specialist. The program is funded through a grant from the Gordon and Betty Moore Foundation.
Healthcare professionals and patients for years have grappled with barriers to early lung cancer detection to improve and guide patient care and outcomes. When coupled with subpar exam rates from lung screening follow-up recommendations, slow uptake remains a daunting challenge for radiology groups determined to disrupt a systemic and potentially life-threatening pattern.
Lung cancer continues to be the leading cause of cancer deaths in the U.S. Despite the disturbing mortality rate for the disease — which surpassed breast cancer deaths more than three decades ago — up to 90% of eligible patients are not screened. The five-year survival rate, 18.6%, is significantly lower than outcomes from other cancers, and most patients have advanced-stage lung disease at the time of their diagnoses. With earlier screening and diagnosis, however, the survival rate jumps dramatically to more than 75% for Stage I lung cancer.
The path to saving more lives does not end with early detection. Up to 10% of radiology reports contain follow-up recommendations — with concerns about lung nodules representing about 50% of those. Approximately half of the recommended follow-up exams are never performed, resulting in increased downstream costs and putting patients at risk of delayed diagnoses and poorer outcomes.
The ACR tackled this issue in early 2023 in the first cohort of The Learning Network. Two of the four collaboratives focused on lung health access and follow-up exams, with the other two addressing prostate MRI and patient positioning in mammography. Collaborative members have shared what is working and what has been more challenging to implement — and some are planning to participate in future cohorts to apply lessons learned from teambuilding and new approaches to improved workflow and outreach.
“Participating in the collaborative really opened my eyes to how complex the processes around lung cancer screening (or any program) are and how many people and departments across the hospital are involved,” says Margaret Lin, MD, thoracic and cardiovascular radiologist with Stanford Health Care and physician leader for the Learning Network’s Lung Cancer Screening Improvement Collaborative.
“A process may be deceptively simple on the surface until you start looking more closely,” Lin says. “For meaningful change, it is important to look beyond your own silo to engage all stakeholders. You can’t work in a vacuum and expect success.”
The Lung Cancer Screening Improvement Collaborative
It can be intimidating to drive change within a complex environment, but it is also inspiring to see how many people are working toward a common goal, Lin says. “I served as a liaison to physicians and providers within primary care and population health groups,” she says. “I reached out to our ordering providers for feedback on barriers to screening and grew their support for our outreach interventions throughout the collaborative program.”
We saw a chance to jump in and put some rocket fuel into our lung health improvement efforts through the focused structure and the resources ACR was providing.
The overlying collaborative goal was simple: to increase the number of patients receiving lung cancer screening, and thereby decrease lung cancer deaths. “My secondary goal was to understand the process of lung cancer screening at Stanford, because prior to the program, I had a very limited understanding that was mostly restricted to interpreting scans,” Lin says.
“We didn’t quite reach our goal, which was fairly ambitious, but we did have a sustained increase in our screening volumes, which continue to rise,” Lin says. Because of the collaborative’s structured timeframe for meeting specified goals, Lin’s group has continued its work on several initiatives since the first lung screening cohort completed the program. “Participation in the collaborative allowed us to create a strong team that continues to improve our lung cancer screening program and strengthen relationships with partners in other departments,” she says.
Lessons learned through the work of her collaborative team at Stanford allowed them to share newly gained knowledge and serve as a resource for Stanford’s Cancer Center in creating a centralized screening program. “Through participating in the collaborative, I gained a detailed understanding of our lung screening program,” Lin says. “Equally important, I got to know the people who were involved in all stages of the process across our hospital. Participation also helped us learn what institutions across the country are doing — the innovations they have implemented in dealing with some of our common problems.”
Building on Existing Lung Health Programs
Some participating collaborative sites had longstanding lung health programs in place prior to the Learning Network project. It became clear, however, after taking a deeper dive into common lung cancer screening challenges at other sites, that there is always room for quality improvement.
“We have always tried to learn as we go since our program started back in 2011,” says Leslie Whalen, MHA, BSN, RN, lung health program manager at University Hospitals of Cleveland and team leader for the Lung Cancer Screening Improvement Collaborative.
“It was daunting when we first started working within the collaborative,” Whalen says. “But when you start to settle in, it’s impressive to interact with so many smart people. You take away things from those conversations you may not have thought of — the work of other collaborative participants challenges you to do better. The Learning Network project was not just about people talking at you, but rather people offering real solutions to help you navigate an issue or problem. It is an extremely supportive program overall.
“Through the collaborative we were focusing on how to reach new eligible patients who aren't currently enrolled in our lung health program,” Whalen says. “We knew that our outreach efforts were helping get patients in for follow-up, but we also realized that education of staff and providers was key.”
Sometimes outreach to patients can spill over to providers when they learn what you are trying to do, Whalen says. “We had one provider message us to ask for a list of all patients in our lung cancer screening program so that he could follow up with them. How musical is that to hear?” Her team is planning more physician outreach efforts. “We are determined to get back to in-person office visits to educate our clinicians,” she says.
When recruiting new patients, talking to them and listening to their concerns is critical. “Some patients were calling us, feeling frustrated and alienated,” Whalen says. “They didn’t understand the process or were afraid of what screening results might show. We got some lung screening information out into the lobbies, worked to reduce hold times and changed how we were scheduling patients.
“The collaborative kept lung cancer screening top-of-mind for us,” Whalen says. “It has helped us focus and not get caught up in a ‘woe is me’ state of mind. Instead, we now look at a barrier and figure out how we can work around it.”
The collaborative encouraged the Cleveland team to look at open orders that were not getting scheduled. “As a manager, it spurred me to talk to one of my navigators — asking her to call patients with open orders,” Whalen says. “Five out of the eight ended up scheduling after the calls because they talked to a real human being who could answer questions and allay worries.” Whalen says they have also added another navigator and brought in an intake coordinator.
“The collaborative’s approach took us down a path of not complaining about problems in a vacuum or making assumptions about things that were happening within our own program,” Whalen says. “We were compelled to sit down, brainstorm, write things down, put it in a fishbone diagram, and so on.”
Screening on Saturdays helped the team get more patients in the door. “We ramped up efforts to get the word out in our communities that there is no need to be afraid of the scanner,” Whalen says. “We go to luncheons and even line-dancing venues to get conversations going and to educate — and we’re always met with a lot of questions.”
When you rip the Band-Aid off and take a close, hard look, sites quickly realize that there is still work to do. “But it is good work, and if you stay focused it will help patients and maybe save someone’s life,” Whalen says. “Everybody should participate in a Learning Network collaborative if they get the chance.”
Guiding Education and QI Applications
“Lung health is something I’m passionate about, so when I heard about the Learning Network lung cancer screening collaborative, I thought it would be a great chance to grow our program,” says Melinda Willis, MPH, lung screening program manager at Illinois-based Duly Health and Care.
“We currently have 11 outpatient centers doing lung cancer screening. When we joined the collaborative, our goal was to increase screening utilization by 50%, which helps to enhance the early detection of lung cancer in the population we serve,” Willis says. “We were just about there when we graduated from the program and actually hit that goal about three weeks later. We have gone above that since then and maintained it.”
One of the biggest challenges Willis faced was obtaining and properly documenting patient smoking histories. To improve documentation, Duly implemented an idea that was shared by a fellow cohort organization. The X-ray team was trained to obtain and add smoking history to the patient’s chart. This intervention has proved to be very successful, leading to the identification of greater numbers of screening-eligible patients.
To provide education and diminish concerns around screening, the team got physician leadership involved. “We were able to get our physician leaders to speak at provider meetings to review guidelines, shared-decision documentation requirements and annual screening recommendations,” Willis says. “It was also a great way to obtain feedback on how we could make the ordering process easier.”
Anyone who has a chance to participate in one of these collaboratives should get involved, Willis says. “It is a lot of work, and you need to provide time and resources to meet your goals,” she notes. “Still, the results you will likely see make it worth it.
“One of the most interesting things I took away from the collaborative experience is that there is no perfect model of lung cancer screening that works for every organization. You will need to tailor it to your needs,” Willis says. “I also realized you can take what you learn through your own work and the successes of other participating sites and apply those things within other areas. For example, if you want to get your patient wait times down, the collaborative’s principles easily apply to any such quality improvement project.”
The Recommendations Follow-Up Collaborative
The Recommendations Follow-Up (RFU) Improvement Collaborative set out with the goal of improving early detection of lung cancer for incidentally detected lung nodules. Participating quality improvement sites worked mainly toward honing and implementing more efficient and effective follow-up processes.
“The Recommendations Follow-Up Improvement Collaborative is different than the Lung Cancer Screening Collaborative. They both address early detection of lung cancer, but the follow-up challenges and problems are very different than building a lung cancer screening program,” says Ben C. Wandtke, MD, MS, vice chair of quality and safety in imaging sciences at the University of Rochester (UR) Medical Center, chief of radiology at F.F. Thompson Hospital and director of the UR Medicine CT lung screening program. Wandtke was the physician leader for the RFU collaborative and a sponsor of the Lung Cancer Screening Collaborative.
The RFU collaborative’s challenge was to identify the most worrisome lung nodules and standardize follow-up care, essentially creating programs of opportunistic screening. Measuring and improving compliance with follow-up recommendations was also an important consideration.
“When you are working in a collaborative like this, your impact can go even further than mentoring and helping a small number of cohort members,” Wandtke says. “We wanted to identify ways to standardize recommendations to ensure that all nodules of significant size have a recommendation for follow-up. We are trying to set best practices for the nation as a whole, and this is one way to change healthcare in this country and in the field of radiology.”
With that in mind, everyone’s role matters in the work of the collaboratives. “Some interactions happen mostly among non-physician team leaders who communicate the progress of the different sites,” Wandtke says. “As the physician lead for the RFU project, I interacted with other physician leaders, particularly around areas such as metrics development. During those conversations, it takes more clinical understanding of a problem.”
Wandtke says they were able to gather collaborative assistance from other departments — in particular, the primary care network. “We knew it was critical to get them onboard, and the structure of the collaborative gave us a great avenue to reach out to those provider partners,” he says.
“We had been working on promoting lung cancer screening within our community for about six months when the Learning Network went live and we saw that two of the collaboratives could help us with the difficult tasks surrounding what is possibly the biggest population health crisis in the country,” Wandtke says. “We saw a chance to jump in and put some rocket fuel into our lung health improvement efforts through the focused structure and resources the ACR was providing.”
The variability in the collaborative sites was surprising, Wandtke says. “There were participants from private practices and large and small academic centers. There were groups that were very mature that have been working on a problem for years with dedicated teams, and then there were groups just getting started,” he says.
“I thought, going into the project, that it was going to be easier for groups just starting out to learn more and improve,” Wandtke says. “What I found were opportunities for everyone, including sites that were mature. I thought our program was very mature coming into the collaborative, but to see everyone else working on the same problems really helped us to think about potential solutions we would not have thought about otherwise.”
Gaining New Process and Patient Perspectives
“We are always looking for ways to improve upon what we have in place. We started our own recommendations follow-up program back in 2010 but found that it had become a bit stagnant — we were reporting the same data over and over again,” says Amy Warburton, BSHA, RT (R), QI coach for the RFU collaborative and Imaging Quality & Business Operations Manager at Riverside Medical Center in Illinois. “We wanted to see what the ACR had to offer through this collaborative program to help us dig a little deeper into things we might not be doing that could make a stronger positive impact.”
A big part of her team’s work involved getting patients back in for follow-up scans. “Before we got involved in the collaborative, we were happy just to see patients come back — we didn’t have a set timeframe or window during which they needed to come back,” Warburton says. “The need for more timely follow-up visits was an eye-opener for us. One follow-up exam drives the next, and everything can quickly get off schedule. This wreaks havoc on recommendations outcomes, and we wanted to make sure our process was standardized and learn when to close the loop.”
The team needed feedback from patient-facing staff to determine why patients weren’t coming back for recommended follow-up care. “We went on rather long Gemba Walks with different departments and discovered things we could do for our scheduling team or authorization team, for instance, that may make their lives easier,” Warburton says. “Something we learned through the ACR and the collaborative is that you need to go to where the work is being done. You go there, you observe, you listen and learn what they are doing. Map out all the steps they are taking and then try to get them where they need to be.”
Many programs that are focused on follow-up recommendations are new and not well-established, Warburton says. Having guidance and feedback through the collaborative gives fledgling efforts extra support and encourages participants to network with other organizations that have already found success. “That has helped some of my peers get their feet off the ground and come up with a playbook for recommendations follow-up,” she says.
When you are working on anything in the QI arena, you are collecting data, according to Warburton. “We have a small team with two navigators. I asked them to look at what follow-up data we should be pulling initially so we wouldn’t need to go back multiple times to access more,” she says. “The collaborative drove us to look at the big picture — to avoid going back over the same ground by asking the right questions from the beginning.”
In addition to regular check-ins with participating collaborative sites, Warburton met weekly with the navigators to discuss their progress, what type of data was being collected and what next steps should be. “We shared takeaways from these discussions with our physicians to keep them apprised of our work and to get their feedback,” Warburton says.
It is a significant time commitment, Warburton says, but the value is not only in what you can apply to your own program, but what QI techniques you can apply elsewhere in the health system you are working in. “You don't know what you don't know. You might think you're doing fantastic until you see other numbers from other sites. If you don’t start measuring certain pieces the same way others are doing it, you won’t know if your numbers are good or bad — you are just internally benchmarking.”
Keeping the big picture in mind is key — not only for your program and your facility, but for radiology and for healthcare in general, Wandtke says. “For any type of performance improvement process, what should drive us is making healthcare outcomes better for a large number of people — to have more impact than being a single radiologist reading a stack of cases in a day,” he says. “As long as you are willing to make changes to your current practices and to invest the time to make a difference, these improvement collaboratives will maximize the benefits of your work.
“Everyone I know who has participated in the Learning Network collaboratives has walked away more knowledgeable, better able to solve complex problems and to work in teams,” Wandtke says. “The benefits go beyond the gains you get from your specific improvement collaborative — you end up with more high-performing people within your organization.”
Benefits of Participation in the ACR Learning Network
- Rigorous training in proven quality improvement (QI) strategies and processes through the ImPower Program and quality coach training that sites can use for future QI work.
- Guidance from national leaders to get the most out of participation and achieve sustained diagnostic excellence.
- The opportunity to become a regional and/or national leader in one of the collaboratives’ focus areas and continue participation in the Learning Network community.
- Continuing education credits for ImPower program participation and completing a QI initiative
Learn how to apply at the ACR Learning Network web page.
Lung Cancer Screening Videos – These ACR patient-friendly videos were created by radiologist experts to help patients participate in shared decision-making about their own health.
In Focus on Lung Cancer Screening – A collection of content hosted by the ACR showcasing stories, tips and viewpoints on lung health.
Lung Cancer Screening Locator Tool – Refer patients to this list to find out where they can receive screening.
Lung Cancer Screening Day
The ACR has partnered with the American Cancer Society National Lung Cancer Roundtable (ACS NLCRT), GO2 for Lung Cancer (GO2) and the Radiology Health Equity Coalition (RHEC) for the second annual National Lung Cancer Screening Day on Saturday, Nov. 11, 2023. Find out how to participate .