Elsevier

Practical Radiation Oncology

Volume 10, Issue 3, May–June 2020, Pages 151-157
Practical Radiation Oncology

Basic Original Report
Improvements in Physician Clinical Workflow Measures After Implementation of a Dashboard Program

https://doi.org/10.1016/j.prro.2019.11.014Get rights and content

Abstract

Purpose

To determine whether a combination of data-driven, personalized feedback and implementation of a graduated, sequential intervention model improved key measures of physician workflow and quality in radiation treatment planning.

Methods and Materials

All radiation oncologists across 3 facilities at a single academic institution were prospectively evaluated on 5 predefined metrics of timeliness and accuracy in the treatment-planning process using a web-based institutional data repository and an institutional incident learning system. The study period encompassed 10 quarters from 2014 to 2016, with 2013 serving as a retrospective baseline. Physicians received quarterly individualized reports of their compliance metrics (a practice labeled the Physician Dashboard), and administrative interventions were initiated if >20% noncompliance with any metric was exceeded within a quarter. Consecutive quarters of noncompliance resulted in escalating interventions, including progress meetings with department leadership, and culminated in financial penalties. Rates of noncompliance were compared before and after implementation of this model.

Results

Three thousand six hundred sixty pre-Dashboard and 9497 post-Dashboard simulations were analyzed. After Dashboard implementation, significant reductions were observed in the rates of simulation orders requiring signature by a covering physician (14.1% vs 7.4%, P < .001), and the submission of plan contours ≥1 day (43.1% vs 23.1%, P < .001) or ≥2 days (30.8% vs 18.3%, P = .002) after the due date. There was some decrease in rates of inaccurate or incomplete plan submissions (6.2% vs 3.9%, P = .08). Seven of the 12 physicians received at least 1 intervention, with only 2 receiving all levels of intervention.

Conclusions

Regular assessment and targeted feedback using the Physician Dashboard significantly improved radiation oncologist compliance with clinically meaningful treatment planning responsibilities at a high-volume academic center.

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.

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