Advantages to adopting a flexible protocol document

When MD Anderson Cancer Center expanded breast imaging services from its downtown campus to 15 sites in the greater Houston area, the company determined that standardized yet flexible protocol guidelines would ensure workflow efficiency, reproducibility and patient safety—especially with new radiologists and technologists hired because of the expansion.

When they discovered some protocols were ill-suited for the community centers, the open and collaborative nature of the protocol document allowed swift and democratic changes. Their experiences with feedback-driven protocols were documented in an article in the Journal of the American College of Radiology.

“We put these protocols together before we had even walked into one of these community facilities,” said Megan J. Kalambo, MD, assistant professor of diagnostic radiology at the University of Texas MD Anderson Cancer Center. “It was based on the assumption that what we do here at the academic center would translate into the community—but the patient population is very different.”

At MD Anderson, Kalambo is mostly treating women who’ve already been diagnosed with breast cancer. This requires a very different evaluation and workup compared to someone coming in for standard screening.

“What we realized once we got into the community setting was that a lot of the protocols implemented at our main campus were overkill,” said Kalambo. “The way we implemented ultrasound protocols had to change drastically to be efficient because of the much higher patient volume in the community.”

With their original protocol, an abnormal mammogram dictated an ultrasound examination of the entire breast and all the nodal basins. The likelihood of additional cancer among their academic center patient population was high.

However, in certain subsets of the community patients—women with no personal history of breast cancer, for example—they didn’t need to evaluate the entire breast. Instead, examining just a quadrant of the breast can save time on exams and detect cancer just as effectively as if the entire breast had been imaged, while cutting down on exam time.

Updates such as these are discussed at monthly section meetings, and proposed changes are disseminated to all faculty members for review before they are voted on. Implementing the protocols requires significant buy-in from everyone involved, from administration to radiologists to technologists. Feedback on the protocols is solicited at every level of care, in addition to workshop courses and monthly didactic conferences.

However, Kalambo cautions imaging centers against designing protocols that are overly rigid, as highly trained physicians may not respond well to “enforcing standardization.”

“We have found that there is a delicate balance between evidenced-based standardization and restricting physician flexibility,” wrote Kalambo. “It must leave some wiggle room for physician preference.”

Expansion or not, a living, breathing protocol document can generate improvements in several key areas of care, according to Kalambo.

“You’re creating a document that’s a brand for your practice. It ensures continuity of care, puts all technologists on the same page, and physicians understand our ‘brand’ of how we work up patients,” she said.