Basic Original ReportImprovements in Physician Clinical Workflow Measures After Implementation of a Dashboard Program
Introduction
Radiation treatment planning (TP) requires physician input at multiple critical steps. Accurate and timely submission of simulation orders, radiation prescriptions, and planning contours is essential to avoid unnecessary patient delays, frustration among the multidisciplinary care team, and potentially dangerous treatment errors. As the complexity of radiation therapy continues to increase, so too does the need for an efficient TP workflow.
Numerous methods have been proposed to change physician efficiency and practice patterns across specialties.1, 2, 3 Among these, active interventions including targeted feedback to physicians, meetings with role models or opinion leaders (also known as “academic detailing”), and prospective reminders have proven particularly useful in effecting change in behavior,4, 5, 6, 7 whereas passive interventions such as didactics and continuing medical education are comparatively weak.8,9 Behavioral interventions comprising multiple methods appear to have the greatest effectiveness.10,11
Quality improvement initiatives have a long history in radiation oncology, dating to at least 1973 with the American College of Radiology Patterns of Care Study.12 Whereas the majority of interventions have focused on clinical tasks such as contouring and plan evaluation, fewer have addressed the TP process, despite studies implicating workflow deficiencies as a patient safety issue.13,14 Chera et al reported the successful implementation of initiatives to reduce simulation delays and rates of replanning among other markers of operational efficiency.15 Kovalchuk and colleagues demonstrated that use of Visual Care Path modules in ARIA 11 increased compliance with TP tasks and was well-received by users.16
Given the seeming importance of treatment planning in reducing patient errors and the improved efficacy of active physician-directed approaches, we hypothesized that an active, multifaceted intervention would result in a measurable increase in radiation oncologist compliance with key responsibilities during the TP process at a high-volume academic center. Our approach incorporated regular, personalized feedback delivered to each physician and a system of graduated, sequential administrative involvement modeled after the Disruptive Behavior Pyramid first proposed by Hickson and colleagues.17 The aim of the study was to provide a novel, generalizable framework for workflow improvement in the radiation oncology clinic.
Section snippets
Study design
Five specific metrics of physician noncompliance with radiation TP workflow were identified as high priority by a multidisciplinary operations team consisting of leadership from therapy, physics, and dosimetry, in addition to the clinical director. Metrics identified for intervention were (1) late (signed after 7 AM on the day of simulation) or inaccurate simulation orders; (2) simulation orders requiring completion or signature by a physician other than the treating physician (representing
Treatment planning compliance pre- and post-Dashboard implementation
Our study population comprised a total of 12 academic radiation oncologists working at 3 individual clinics affiliated with a single institution. All physicians practicing at the clinics were required to participate. The study took place prospectively between the first quarter (Q1) of 2014 and the second quarter of 2016, with comparative retrospective analysis encompassing all of 2013. Eleven of the 12 physicians were actively engaged in clinical practice for the entirety of the retrospective
Discussion
Targeted interventions to change physician behavior have been validated in various inpatient and outpatient settings as a means to improve clinical workflow and decrease potentially dangerous errors. Given the paucity of studies evaluating such interventions for radiation therapy treatment planning, an important step for both clinical efficiency and patient safety, we conducted a prospective study of physician adherence to key TP metrics using a personalized reporting system of physician
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Sources of support: This work was supported by The John and Pembroke France Noble Oncology Research Fund.
Disclosures: none.