Closing the Loop: Redesigning Test Result Notifications to Improve Patient Safety and Trust

This project at the Birmingham VA focused on improving the efficiency and compliance of provider-to-patient test result notifications per VHA Directive 1088. Initial challenges included inconsistent escalation protocols, lack of surrogate training, and no standardized documentation. Baseline compliance was 76.19%, with 578,000 open alerts and zero health factor usage. Interventions included policy updates, surrogate training, contact verification improvements, and a new health factor tracking system. By FY25Q1, compliance improved to 94.44%, open alerts reduced to 158,000, and health factor usage reached 3,120. The initiative yielded a 20,134% ROI, with over $2.5 million in cost avoidance. Sustained improvements are ensured through monthly audits, a dashboard, and formal process owner handoff. The project demonstrates how structured quality improvement can enhance patient safety, communication, and operational efficiency.

Identify common barriers to timely provider-to-patient test result communication in complex healthcare systems.

Describe a scalable, data-driven approach to improving compliance with VHA Directive 1088 using Lean tools and methodologies.

Apply lessons learned from Birmingham VA’s project to enhance closed-loop communication and reduce diagnostic delays in their own settings.