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Implementing Standardized Protocols During Geographic Radiology Expansion

2016; Elsevier BV; Volume: 14; Issue: 1 Linguagem: Inglês

10.1016/j.jacr.2016.07.015

1558-349X

Megan Kalambo, Jay R. Parikh,

Global Cancer Incidence and Screening

The breast radiology section at The University of Texas MD Anderson Cancer Center has undergone unprecedented growth in the past year. After operating at a single academic site for more than 25 years, the department recently expanded its reach outside the Texas Medical Center to an additional 15 community breast centers in the greater Houston area, where our current radiologist staffing has more than doubled. This was executed as part of a strategic plan to increase patient access, market share, and visibility [1Natesan R. Yang W.T. Tannir H. Parikh J. Strategic expansion models in academic radiology.J Am Coll Radiol. 2016; 13: 329-334Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 2Parikh JR, Brown K, Yang WT, Tannir H. Network collaboration of an academic institution and a community health organization. J Am Coll Radiol. In press.Google Scholar]. The change in academic outreach has required adaptation in ways that were not originally anticipated. Clinical standardization has emerged as a vital component in both creating and sustaining quality in any health care organization [3James B.C. Whatis turp? Controlling variation in the performance of clinical processes.in: Blumenthal D. Improving clinical practice: total quality management and the physician. Jossey-Bass, San Francisco, California1995Google Scholar]. Among its many benefits, it helps ensure workflow efficiency, patient safety, reproducibility, and the maximization of cost savings [4Clark D.D. Savitz L.A. Pingree S.B. Cost cutting in health systems without compromising quality care.Front Health Serv Manage. 2010; 27: 19-30PubMed Google Scholar, 5Kruskal J.B. Reedy A. Pascal L. Rosen M.P. Boiselle P.M. Quality initiatives: Lean approach to improving performance and efficiency in a radiology department.Radiographics. 2012; 32: 573-587Crossref PubMed Scopus (118) Google Scholar]. Despite these advantages, the implementation of clinical standardization can be fraught with many inherent challenges as an organization grows. Many of these challenges are driven by the number of involved stakeholders who can range in diversity from the practicing physicians and referring clinicians to the imaging technologists, patients, and hospital administrators [6Leonard M. Graham S. Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care.Qual Safety Health Care. 2004; 13: i85-i90Crossref PubMed Scopus (1390) Google Scholar, 7Meyer G.S. Nelson E.C. Pryor D.B. et al.More quality measures versus measuring what matters: a call for balance and parsimony.BMJ Qual Safety. 2012; 21: 964-968Crossref PubMed Scopus (97) Google Scholar]. As initial discussions about community expansion began, we determined that standardized practice guidelines should be formally defined and established to reduce practice variability and maintain brand recognition. This became more imperative as we began to recruit radiologists from other institutions and communicate with the community-based imaging technologists from the new institutional partnership. In this article, we describe a systematic process that was created to help implement standardized imaging protocols across the enterprise. This process can be followed and adapted by other radiology sections, departments, and health care institutions considering expansion. In preparation for community expansion, we sought to formally define guidelines for the most commonly encountered services in our breast imaging care line. This includes a diverse range of services spanning from screening mammography to specialized procedures such as diagnostic mammography, breast ultrasound, breast MRI, ductography, image-guided biopsies, and preoperative localizations. The guidelines would be presented in a simplified and consistent format to enable ease of interpretation and implementation by both radiologists and technologists across the enterprise. To this end, an official institutional standardization committee was formed composed of breast imaging radiologists with varied interests and tenure at our institution. The committee included newly recruited physicians from community practice, seasoned academic radiologists from the main campus, leadership, and other passionate stakeholders with a keen interest in standardization (see Table 1) [8Collins J. Effective committees.J Am Coll Radiol. 2012; 9: 181-184Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 9Lightfoote J.B. Fielding J.R. Deville C. et al.Improving diversity, inclusion, and representation in radiology and radiation oncology part 1: why these matter.J Am Coll Radiol. 2014; 11: 673-680Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar]. During the initial phase of our committee meetings, we created an outline identifying the most commonly encountered breast imaging care line services. Each modality was then assigned to a committee member who was responsible for drafting the preliminary outline for the protocol subsection.Table 1Committee diversityGenderBackgroundEthnicityAgeYears of Experience1FemaleAcademic practiceWhite44152MalePrivate practiceAsian50203FemalePrivate practiceAsian47134FemaleAcademic practiceWhite39115FemaleAcademic and private practiceAsian4566FemaleAcademic practiceBlack334 Open table in a new tab Given the nature of our interdisciplinary breast center culture, each section was drafted using the current ACR parameters and National Cancer Center Network Clinical Practice guidelines as a loose framework [10Mainiero M.B. Lourenco A. Mahoney M.C. et al.ACR Appropriateness Criteria breast cancer screening.J Am Coll Radiol. 2013; 10: 11-14Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 11Bevers T.B. Anderson B.O. Bonaccio E. et al.NCCN clinical practice guidelines in oncology: breast cancer screening and diagnosis.J Natl Compr Cancer Netw. 2009; 7: 1060-1096Crossref PubMed Scopus (268) Google Scholar]. We also sought input from other interdisciplinary organization position statements for reference (eg, the American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography) [12Saslow D. Boetes C. Burke W. et al.American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography.CA Cancer J Clin. 2007; 57: 75-89Crossref PubMed Scopus (2024) Google Scholar]. Each subsection was then formatted to include a list of approved indications, the procedural imaging protocol with detailed information on images required for interpretation, along with technologist information to be included at case presentation. Once a comprehensive working draft of the document was completed, the protocol was presented to the entire faculty section for input and endorsement. Once reviewed and approved, the protocol was distributed to all practicing sites for implementation. Shortly after implementation of the new guidelines, we discovered that some of the existing protocols driven by our academic main campus environment required tailoring to adapt to community practice [13Mukundan G. Seidenwurm D. Nagy P. Performance quality improvement in community practice.J Am Coll Radiol. 2015; 12: 607-609Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 14Rosenkrantz A.B. Lawson K. Ally R. et al.Focused process improvement events: sustainability of impact on process and performance in an academic radiology department.J Am Coll Radiol. 2015; 12: 75-81Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar]. For example, whole-breast sonography is considered our standard practice for all diagnostic ultrasound examinations at the main campus (tertiary care) facility. Whole-breast ultrasound also includes documentation of the local regional nodal basins [15Lane D.L. Adeyefa M.M. Yang W.T. Role of sonography for the locoregional staging of breast cancer.AJR Am J Roentgenol. 2014; 203: 1132-1141Crossref PubMed Scopus (11) Google Scholar]. We found this process to be of very low diagnostic yield in community practice, where the majority of ultrasound cases are benign and do not require biopsy. For this patient population, targeted or whole-breast ultrasound, without a full nodal basin assessment, can suffice. Our complete nodal basin scanning protocol is now reserved for patients with suspicious breast findings that warrant biopsy and for patients with histories of breast cancer. Our protocol document is considered living and breathing, open to adaptation as our practice and patient needs change. Updates on protocol changes are regularly discussed at monthly sectionwide meetings, and proposed changes are presented to all faculty members for formal review. In an effort to maintain transparency, a quarterly section meeting is also dedicated to protocol review to encourage early open dialogue and input [8Collins J. Effective committees.J Am Coll Radiol. 2012; 9: 181-184Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. Successful implementation of standardization requires buy-in from all involved parties, from administration to the divisional heads, technologists, radiologists, and operational team [3James B.C. Whatis turp? Controlling variation in the performance of clinical processes.in: Blumenthal D. Improving clinical practice: total quality management and the physician. Jossey-Bass, San Francisco, California1995Google Scholar, 16Donnelly L.F. Gessner K.E. Dickerson J.M. et al.Quality initiatives: department scorecard: a tool to help drive imaging care delivery performance.Radiographics. 2010; 30: 2029-2038Crossref PubMed Scopus (36) Google Scholar]. As a vibrant multidisciplinary breast center, we also require endorsement from key stakeholders in other disciplines, such as surgery, medical oncology, and pathology, as well as our primary care physicians. Furthermore, buy-in from other disciplines also adds credibility and visibility to our imaging protocols [16Donnelly L.F. Gessner K.E. Dickerson J.M. et al.Quality initiatives: department scorecard: a tool to help drive imaging care delivery performance.Radiographics. 2010; 30: 2029-2038Crossref PubMed Scopus (36) Google Scholar]. Our protocols are made available for review at all levels of the institutional chain to ensure the continued success of our multidisciplinary model. When dealing with highly trained physicians in the current era, a hierarchical leadership model does not work well at "enforcing" maintenance of standardization. We have found that there is a delicate balance between evidence-based standardization and restricting physician flexibility. Our goal of establishing standardization should not be at the expense of limiting physician flexibility, and it must leave some "wiggle room" for physician preference [3James B.C. Whatis turp? Controlling variation in the performance of clinical processes.in: Blumenthal D. Improving clinical practice: total quality management and the physician. Jossey-Bass, San Francisco, California1995Google Scholar, 17Emiliani B. Better thinking, better results: case study and analysis of an enterprise-wide lean transformation.2nd ed. Center for Lean Business Management, Kensington, Connecticut2007Google Scholar]. We believe that the success of our imaging protocol document as a process improvement tool lies in our ability to maintain a culture that is open to adaptation and feedback, encourages innovation, and prioritizes the maintenance of quality standards [18Pawar M. Creating & sustaining a blame-free culture: a foundation for process improvement.Phys Exec. 2007; 33 (16-9): 12-14PubMed Google Scholar]. In an effort to create this culture, our on-site radiologists provide constructive feedback to technologists on a case-by-case basis and also meet collectively with technologists at each respective facility on a bimonthly basis to discuss any outstanding questions or concerns that may arise. We also provide hands-on workshop courses and monthly didactic conferences to encourage continuing education. With technical staff members and radiologists having input from the clinical trenches, the entire team has pride and ownership of the imaging protocols. This model has allowed us to optimize opportunities for success in implementation and also maintain quality of care in the face of a rapidly evolving health care environment.