Memorial Hermann Health System LDCT Program: “Taking a Breath in the Right Direction”

November 2018 Vol 9, NO 11
Carol Kirton, BSN, RN, OCN, ONN-CG
Memorial Hermann-Texas Medical Center Cancer Center
Houston, TX
Carolyn Allsen, BSN, RN, OCN, ONN-CG
Memorial Hermann – The Woodlands

Background: According to the American Cancer Society Facts & Figures 2018, lung cancer is the leading cause of death in men and women in the United States. Approximately 234,030 new cases of lung cancer will be identified and 154,050 deaths will occur in 2018. Stage I non–small cell lung cancer has a 5-year survival rate between 77% and 92%.1 With early detection in mind, Memorial Hermann established a low-dose computed tomography (LDCT) screening program in 2015. To implement the program, Memorial Hermann modeled the standards established by the Lahey Hospital in Massachusetts because they were the first facility in the United States designated by the American College of Radiology (ACR) as an accredited lung cancer screening center.2 During the implementation year, several barriers to program growth were encountered. These included the ordering process, patient follow-up, education among the multidisciplinary teams, insurance verification, coding, billing, and compliance with the Centers for Medicare & Medicaid Services (CMS) and ACR guidelines.

Objective: Use a multidisciplinary approach to implement a performance improvement project to grow and sustain the LDCT lung screening program at Memorial Hermann.

Methods: Memorial Hermann Health System comprises over 300 care delivery sites and served over 2 million patients in fiscal year 2016.3 A system-wide task force team and approach was required to standardize the process, create awareness/education, and ensure compliance with CMS and ACR guidelines. In the first year, the task force met quarterly. Additionally, the oncology nurse navigation team convened monthly to recognize barriers, challenges, possible improvements for the program, and to share best practices. Flow sheets were designed to help align the process across the whole system. Daily LDCT census reports were created so navigators could follow the patients by Lung-RADS category and navigate where needed. A standardized ordering form was also implemented in 2016 to streamline the process further, and since then an electronic order has been launched.

Results: In 2015, Memorial Hermann performed 316 LDCT screens. This number increased to 594 in 2016, an 88% increase. A further 88% increase occurred from January 2016 to December 2017, yielding 1115 LDCT scans. In the first 6 months of 2018, Memorial Hermann performed 780 LDCT scans, and it is projected that between 1600 and 2000 LDCT scans will be completed by December 2018.

Conclusion: As a result of the quality improvement project, Memorial Hermann increased compliance with CMS and ACR guidelines, eliminated barriers, and increased growth by over 250% from 2015 to 2017. Through our quality improvement and growth, Memorial Hermann identified that there are still limitations, because, at this time, patients do not receive an automated results letter. To eliminate this barrier, Memorial Hermann is committed to installing software to assist with data collection, improve efficiency, and streamline follow-up care. Utilization of this software will further grow our program, as well as improve follow-up imaging rates. We believe that the Memorial Hermann LDCT program is in fact breathing in the right direction!


  1. American Cancer Society. Cancer Facts & Figures 2018. Atlanta, GA: American Cancer Society; 2018.
  2. Lahey Hospital and Medical Center 2018 Lung Cancer Awareness. 2017. Acessed July 2, 2018.
  3. Memorial Hermann Health System. Memorial Hermann Annual Report 2016. Accessed July 2, 2018.
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