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Based on policy review, protocol review, "The American College of Radiology (ACR) Appropriateness Criteria" review, medical record review, and staff and physician interviews, outpatient staff failed to notify a patient's primary care physician about the need for an order change for 1 of 1 outpatient records reviewed.

The findings included:

Review on 09/23/2020 of a policy titled "Outpatient Diagnostic & Therapeutic Orders" last revised 04/2020 revealed "...In order to ensure that all patients can receive the correct outpatient services, a complete order from a provider for the services should be obtained...H. If necessary, personnel should seek clarification of the order with the ordering provider prior to rendering any service or treatment to the patient..."

Review on 09/23/2020 of a protocol titled "Breast Imaging Protocols Screening" last revised 09/20/2019 revealed "...New or change in existing Breast Lumps or new Nipple Discharge: Offer to reschedule the patient for a diagnostic mammogram. Assist patient in calling the physician's office for order and getting the diagnostic exam scheduled. All diagnostic facilities should try to offer same day diagnostic appointment if a physician's order can be obtained..."

Review on 09/23/2020 of the "ACR Appropriateness Criteria for Breast Pain" last revised 2018 revealed "...Variant 4: Female with clinical significant breast pain. Age greater than or equal to 40. Initial Imaging...Mammography diagnostic Usually Appropriate...US (Ultrasound) breast Usually Appropriate..."

Closed medical record review on 09/22/2020 revealed Patient #12 was a 54-year-old female who arrived to the outpatient imaging center on 03/24/2020. Review revealed an order from Patient #12's primary care physician (PCP) written on 03/20/2020 for a left breast ultrasound "STAT." Review of the exam reason revealed "contusion left breast with hematoma." Review revealed Patient #12 was scheduled for an ultrasound of her left breast on 03/24/2020 at 1530. Review of the appointment notes revealed Patient #12 was called by the scheduler on 03/20/2020 and stated "...-callback number (phone number) -last mammo (mammogram) (Name of Healthcare System A) - Pt (Patient) was asked about coronavirus - has not been outside of the US (United States) - and is not having any symptoms..." Review revealed Patient #12 stated she had her last mammography at Healthcare System A, which was the same healthcare system as the imaging center. Review revealed Patient #12 checked-in for her ultrasound appointment on 03/24/2020 at 1410. Review revealed the check-in was canceled at 1504. Review of the cancel reason revealed "Department [needs priors per radiologist]." Review revealed the Radiologist needed Patient #12's prior breast imaging before an ultrasound could be completed. Review of a note written by the Patient Access Specialist revealed "...3/26/20 (Hospital B Name) faxed back to (Imaging Center) that patn (sic) (patient) has no priors..." Review revealed no documentation of notifying Patient #12's primary care physician about Patient #12's canceled ultrasound.

Closed medical record review revealed Patient #12 returned to the imaging center on 04/07/2020. Review revealed an order from Patient #12's PCP written on 04/07/2020 at 0938 for a left breast ultrasound "STAT." Review of the associated diagnosis revealed "Hematoma of left breast Chest trauma..." Review revealed Patient #12 had an appointment scheduled for an ultrasound of her left breast on 04/07/2020 at 1330. Review revealed Patient #12 checked-in to the imaging center on 04/07/2020 at 1318. Review revealed the check-in was canceled at 1415. Review of the cancel reason revealed "Provider [EXAM CX (canceled) WILL BE RESCHEDULED ONCE DIAG (Diagnostic) MAMMO ORDER IN (sic) ENTERED BY PATIENT DR.]." Review revealed on 04/08/2020 at 1603 Patient #12's PCP placed an order for a diagnostic mammogram and ultrasound if needed. Review of scheduling notes revealed a note dated 04/13/2020 at 0907 (5 days after the order was placed) revealed "Spoke w/pt (with patient) did not want to schedule would like me to defer order out until end of May."

Interview on 09/23/2020 at 1040 with the Patient Access Specialist (PAS) revealed she would help to get patients' prior imaging that was needed by the Radiologist before their procedure. Interview revealed if a patient stated they had previous breast imaging Healthcare System A, which was the case for Patient #12 on 03/20/2020, the PAS stated, she did not have to do anything because the Radiologist would be able to pull up the images in the electronic medical record. Interview revealed on 03/26/2020, the PAS called (Hospital Name B) to see if Patient #12 had any previous breast imaging completed there. Interview revealed (Hospital Name B) stated they did not have any imaging for Patient #12.

Interview on 09/23/2020 at 0935 with the Mammography Technician from Patient #12's 04/07/2020 visit revealed she did not recall Patient #12. Interview revealed she did review Patient #12's record and the reason why the ultrasound was canceled was because the patient would need a diagnostic mammogram before she could get an ultrasound. Interview revealed normally she would call or fax the ordering provider to let them know a diagnostic mammogram needed to be ordered. Interview revealed calling the ordering provider about getting an order change was not always documented.

Interview on 09/23/2020 at 1215 with the Regional Mammography Manager, Supervisor of the Breast Center, Senior Director of Hospital Operations, and the Director of Women Imaging revealed normally providers enter orders in the electronic medical record system for imaging. Interview revealed when the scheduler called the patient to make an appointment the patient was asked if they had any previous breast imaging and where they had that completed. Interview revealed Patient #12 was called on 03/20/2020 and she stated her previous breast imaging was done at the same hospital system the imaging center belonged to. Interview revealed because of that, the images would already be in the electronic medical record system for the Radiologist to access. Interview revealed when Patient #12 arrived for her ultrasound appointment on 03/24/2020 she would have been asked again if she had any prior breast imaging completed because there were none in her electronic medical record system. Interview revealed Patient #12 must have said (Hospital Name B) which was why the PAS called (Hospital Name) on 03/26/2020. Interview revealed once the prior images were obtained the patient would be rescheduled. Interview revealed if a patient did not have any prior images then a diagnostic mammogram would have to be ordered and completed prior to an ultrasound being completed. Interview revealed the practice of the imaging center per the Radiologist and ACR Appropriateness Criteria was to get a diagnostic mammogram prior to doing a breast ultrasound. Interview revealed the physician who ordered the ultrasound for Patient #12 should be notified that a diagnostic mammogram needed to be ordered and completed prior to Patient #12 getting a breast ultrasound. Interview revealed breast mammography and ultrasounds were only done at the imaging center not at the hospital. Interview revealed normally the Mammography Technician would call the ordering physician to notify them of the need to get an order for a diagnostic mammogram since the patient did not have any prior breast imaging. Interview confirmed there was no documentation of a phone call to Patient #12's primary care doctor on 03/24/2020.

Interview on 09/23/2020 at 1330 with MD #7 (Medical Doctor), Patient #12's PCP revealed she recalled Patient #12 and ordering multiple breast ultrasounds for the patient. Interview revealed Patient #12 presented to MD #7's clinic due to a trauma, Patient #12 was moving a dresser and had injured her left breast causing a hematoma. Interview revealed MD #7, ordered an ultrasound of the breast to make sure that Patient #12's injury was a hematoma. Interview revealed MD #7 was notified by the imaging center on 04/07/2020 that Patient #12 needed a diagnostic mammogram prior to getting an ultrasound of her left breast. Interview revealed MD #7, placed an order for a diagnostic mammogram and ultrasound of the left breast on 04/08/2020. Interview revealed normally the imaging center would call MD #7's office to notify them of the need for a new order or different order. Interview revealed MD #7 did not recall being notified after the 3/24/2020 visit of Patient #12's left breast ultrasound. Interview revealed when MD #7 put in a STAT imaging order, she expected it to be completed in a couple days.

Interview on 09/23/2020 at 1630 with MD #8, a Radiologist who worked at the imaging center revealed once the provider placed an order for an imaging test the facility would have a scheduler call the patient to make an appointment. Interview revealed in Patient #12's case, the 03/20/2020 order for a breast ultrasound, the scheduler should have checked the patient's age and the reason for the exam. Interview revealed because Patient #12 was 54 years old and was coming in due to pain in her breast, a diagnostic mammogram should have been ordered. Interview revealed the ordering provider should be notified of the need for the order change. Interview revealed if a patient came in with no prior imaging and only had an ultrasound ordered, a diagnostic mammogram would have to be ordered and done first based on the ACR appropriateness criteria. Interview revealed based on Patient #12's age and symptoms a mammogram should be completed first and then an ultrasound on the first visit on 03/24/2020. Interview revealed the ordering provider should have been made aware of that by the imaging facility.

Interview on 09/23/2020 at 1509 with the Radiology Scheduling Supervisor revealed when a provider orders an imaging test the order populates to a work cue for the schedulers to call the patient. Interview revealed orders were sorted by order priority such as STAT or routine. Interview revealed the "Autodialer" (automated phonecall system) would call patients who had orders, starting with patients who had not been called yet and who were ready to be scheduled. The "Autodialer" then called patients who had been called one time already and then patients who had been called two times already. Interview revealed the Autodialer asked the patient if they would like to make an appointment and if so puts them through to a live scheduler. Interview revealed the Autodialer also gave patients the option to put their phone number in for a live scheduler to call them back. Interview reveled when STAT orders were put in the system, the live schedulers normally called the patient not the "Autodialer." Interview revealed the schedulers tried to schedule STAT orders within 24 hours but it depended on the procedure that was ordered. Interview revealed when COVID-19 started, it put the scheduling of patients behind some and a backlog started. Interview revealed the Scheduling Supervisor did see that the imaging center called Patient #12's PCP to get an order for a diagnostic mammogram after her 04/07/2020 ultrasound cancellation. Interview revealed the Scheduling Supervisor did not see any notes about Patient #12's PCP being notified of Patient #12's 03/24/2020 ultrasound being canceled and the need for a diagnostic mammogram to be ordered.

NC00165128, NC00169565