Implementation of Best Practices in an Urban Practice

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Implementation of Best Practices in an Urban
Practice

• Elizabeth H Hammond MD
• Pathologist, Intermountain Healthcare Professor
  of Pathology
• University of Utah School of Medicine

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Topics

• What best practices has CAP provided?
• What are steps in implementation?
• What are the barriers to doing it?
• Intermountain as example in each case
• Lessons learned

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Current CAP Best Practices

• CAP Cancer Checklists
• Published in Archives
• Reporting Requirements for Surgical Pathology
• Published in Archives
• ASCO-CAP HER2 guideline
• Published in JCO and Archives

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CAP Cancer Protocols

• Defined by multidisciplinary task force for each
  cancer type
• Format standardized
• Evidence required to support each element
• Checklists provided as report templates

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CAP Cancer Checklists

• Elements required in cancer reports which are
  evidence based and provided as list for inclusion
  in reports
• Required by COC accreditation
• Updated as literature changes
• Provided free to CAP members on website
• Publicized through educational efforts

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Case Example Breast Cancer Reports at LDS
Hospital

• Phone calls about cancer reports were
  interrupting pathologists work
• Tally sheet documented that report problems were
  related to report content and format
• Pareto analysis showed extent of problem
• Flow chart highlighted
  
  areas in need of improvement
• Iterative process led to
  
  synoptic cancer reports in 1992

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Impact of Report IssuesOn Pathologists

• Pathologists are frequently interrupted to
  provide correct or clear information about breast
  cancer reports
• Phone calls lead to disruption of work, rework,
  potential confusion of other cases being done at
  the time

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1990 Report Review (Pareto)
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We Evaluated Potential Solutions to
Correct Poor Reports

• We reviewed the literature
• We selected synoptic reporting
• We brainstormed with our oncologists
• What elements of reports were important for
  patient care?
• How should these elements be reported to create
  clarity and effectiveness?

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We Implemented The Report Format Iteratively

• A teaching discussion with pathologists defined
  how to fill in the required fields in the new
  report and included case examples
• A draft synoptic report was tested for acceptance
  by pathologists for one month
• A follow-up conference was held to modify the
  form based on suggestions of oncologists and
  pathologists
• The form was put in place

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Holding the GainImpact of Change Over Time
Pareto Analysis
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Pathology Practice Implications

• Decreased phone calls about cancer reports
• Satisfied clinicianswe even get fan mail!
• Simplified transcription elimination of 1 FTE
• Less pathologist interruption
• Less pathologist resistance
• More consistent reporting
• More oncologist satisfaction

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Implementation Throughout System Stalled

• No pathology groups outside central region would
  adopt synoptic formats
• I understand what I am doing now why should I
  change?
• My oncologists are not asking for it
• Too much work to change
• I am getting no complaints about my reports
• Change only occurred when there were economic
  drivers
• Oncologist pressure did not result in change

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Intermountain-wide Dissemination

• CAP protocols summarized in checklists (synoptic
  report formats)
• AP IS in Intermountain determined to be non
  regulation compliant in 1998
• New APIS purchased, with opportunity to
  disseminate cancer synoptic reporting thru
  Intermountain
• New APIS modified to simplify reporting and
  enable synoptic cancer reports

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AP IS Implementation Intermountain Healthcare

• Nationally approved items (CAP) were adapted to
  our clinicians defined formats
• Synoptic formats (checklists) implemented as
  WORD macros with a pick list of choices for each
  element to standardize data for retrieval
• WORD macros interfaced with AP computer system
  and all pathologists trained in use

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Example of IHC Breast Macro Data Entry Screen
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Another ExampleSurgical Pathology Reporting
Elements

• Published by CAP in 2008
• Archives Pathology Lab Medicine

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Surgical Pathology Reporting Elements

• Reporting course at CAP 06
• Pathologists wanted definition of required
  elements for all report types
• Ad hoc committee formed and considered elements
  based on evidence and experience
• Elements standardization will make electronic
  interfacing more generic

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Implementation at Intermountain

• We reviewed the list of elements and compared
  them to our list of report fields in APIS
• We were not recording the fixative and fixation
  time
• A team met to
  define intervention

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Implementation Ideas

• Create stamp and have OR, gross room and
  pathologist fill out
• Have pathologist or PA dictate information
• Create macro to be filled out by PA or
  pathologist
• Create EIS solution to
  automatically collect
  elements

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Process Improvement

• We tried stamps in OR and gross room
• Only about 20 of reports actually got adequate
  information
• Only 2/5 institutions participated
• Currently, we are creating information by
  dictation
• Difficult to search and retrieve information
• Burden on pathologist to make sure he/she
  indicates if fixation parameters met (gt6 hours of
  NBF fixation)

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ASCO-CAP HER2 Guideline

• Collaboration Leads to Greater Gains

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ASCO-CAP Guideline

• Reasons for development
• Concern about quality of testing
• Five studies showed significant efficacy of HER2
  targeted therapy
• Panel multidisciplinary and involved all
  stakeholder groups
• Evidence and expert opinion were basis of elements

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HER2 Guideline

• Evidence-based guideline
• Algorithm for HER2 testing
• Definition of positive, equivocal, negative
• Caveats
• Required QA elements
• Required external monitoring
• Proficiency testing
• Accreditation

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Optimal Testing Algorithm IHC
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Optimal Testing Algorithm FISH
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QA and External QA

• Guideline specifies elements that cause
  variation
• Specimen handling
• Appropriate test selection
• Method validation
• Reporting
• Internal quality assurance measures
• Guideline mandates review by
• Mandatory proficiency testing
• Standard laboratory accreditation

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HER2 Testing in Intermountain Healthcare

• We compared our current algorithm and QA
  processes to the guideline elements
• We created equivocal category in report
• We implemented process to record fixation time
• We discussed and are trying to improve our
  validation processes
• Each effort required a dedicated champion who did
  not give up until the process was fixed

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Barriers to Implementing Best Practices
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Inertia and Satisfaction with Status Quo

• Disseminate the evidence basis and the reality of
  local performance
• Doctors desire to do excellent work
• If there is data that current efforts are not
  good or if there is a better way, they will
  change, particularly if they see that others are
  doing it
• Create dissatisfaction with status quo

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Overcoming Inertia

• Use local data to show that current status is not
  optimal
• Contrast current status versus desired result
• Flow chart current process
• Define root causes to be
  addressed
• Devise strategy to deal
  with root
  causes
• Remeasure after
  implementation

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Suspicion of Change

• Evidence must be persuasive that change is needed
• There must be acknowledgement of difficulty and
  disadvantages
• Provide ample time for feedback and discussion
• Recommendations must be clear, concise
• Define how they can be implemented using local
  examples
• Define principles, not rules if possible

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Making New Learning Easier

• Have effective teachers
• Use examples and case scenarios
• Allow practice and feedback
• Provide multiple learning activities if learning
  is complex
• Provide job aids checklists, charts,
  illustrations

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Project Champions

• Champion must be committed
• Champion should be opinion leader or be teamed
  with opinion leader
• Champion must be willing to stick with it to the
  end
• Champion teaches, recruits, trains and encourages
  participation
• Champion must listen to identify barriers and
  remove them

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Summary

• Best practice implementation is not easy
• Overcoming resistance requires...

...Local data ...Clear strategy ...Patience and
persistence ...Luck