- Email: [email protected]
Standardized Implementation of Clinical Practices
Journal of Medical Imaging and Radiation Sciences
Journal of Medical Imaging and Radiation Sciences 48 (2017) 326-327
Journal de l’imagerie médicale et des sciences de la radiation
www.elsevier.com/locate/jmir
Commentary
Standardized Implementation of Clinical Practices James Loudon, MHS, MRT(T), PMP* The Bahen Chant Radiation Treatment Centre, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada
Radiation therapy is a continuously changing profession. New evidence-based practices, technology advances, and pressures to increase organizational performance all motivate change initiatives [1]. Image-Guided Radiation Therapy (IGRT), in particular, has been an area of significant change in radiation therapy. Pretreatment IGRT requires critical decision-making immediately before radiation treatment delivery [2]. In addition to standardizing the IGRT decision-making, a standard approach to the continuous implementation of IGRT evidence ensures that changes are implemented in a consistent way. It influences change so that there is a higher chance of it being implemented successfully and delivering the intended result. The change management processes described in this article represent change control. Change control is considered a best practice in the project management profession and involves the application of standard processes for the consistent management of change [3]. However, the concepts are broadly applicable and benefits include balancing resources, reducing risks and influencing factors so that approved changes are beneficial [3–5]. Documenting changes to IGRT clinical practices is an important first step for the impacts of the change to be quickly understood and evaluated [3, 5, 6]. For instance, information tracked can include the change, version, date, and any approvals the practice has already undergone. Standard documentation templates also help to ensure that the correct version is implemented into clinical practice [3, 5, 6]. A simple way to track changes is to include a summary table at the end of clinical protocols, which describes the changes made and their rationale. Diagrams, such as flowcharts, are also useful tools for documenting and explaining proposed changes. Flowcharts graphically illustrate processes and decision-making, which allow the impacts of the change to be visualized within the framework of a given clinical practice [4]. * Corresponding author: James Loudon, MHS, MRT(T), PMP, The Bahen Chant Radiation Treatment Centre, Stronach Regional Cancer Centre, Southlake Regional Health Centre, 596 Davis Drive, Newmarket, Ontario L3Y 2P9, Canada. E-mail address: [email protected]
Assessing a change often involves analyzing the costs and benefits [7]. The extent that a change is adopted may be modified to better balance resources with the intended benefits [2, 7]. For example, a new IGRT technique could require increased time on the treatment unit [2]. The scope of the new practice, such as imaging frequency or settings for image acquisition, could be modified so it can be performed within current time constraints. The change could also be accommodated by no longer performing previous techniques, such as discontinuing the need to acquire electronic portal images of treatment fields with the implementation of cone beam computed tomography [2]. Balancing resources is not always straightforward however, and although a practice change may require increased time, it may be justified by its respective increase in the quality of the procedure [2]. Approval of the proposed change is an important step to be completed before its implementation [3, 7, 8]. Formal approval of proposed changes frequently includes a committee that is responsible for reviewing proposed changes and determining whether or not they should be accepted [3, 5, 7]. For IGRT, an interprofessional committee of Radiation Therapists, Physicists, and Radiation Oncologists can act as a resource for image-guidance and focuses on the development and implementation of related processes. This also provides a transparent process for protocol review, approval, and communication before clinical implementation. Depending on the scope of the change, final approval to implement clinically could also be contingent on staff training and coaching [4, 8]. Applying a standard implementation process ensures that proposed changes are supported with a solid rationale and sufficient evidence [7]. Reviewing evidence to justify clinical practice changes is an essential component of healthcare [9]. However, evidence may be adapted to the specific clinical practice environment and the resulting documentation should be an accurate representation of the actual practice that will be used clinically [9, 10]. Once written and approved, the protocol does not become a static document, but is intended to be refined and change as new evidence becomes available. Using a structured framework to review proposed changes and their justification ensures that clinical practice changes are supported with sufficient evidence. Changes that are not supported would instead be queried for further information.
1939-8654/$ - see front matter Ó 2017 Canadian Association of Medical Radiation Technologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jmir.2017.09.001
This process assists in the prevention of unauthorized change, such as ad hoc decision-making, which could lead to a higher chance of unanticipated consequences. For example, the adoption of a new clinical practice, when the specific decision-making for its use has not been clearly established, could increase the risk of improper use. Standardized implementation practices also act as a supportive process for innovation to take place [11]. The process of clearly documenting a practice facilitates an understanding of how it will be affected by proposed changes and identifies areas to be further developed [11]. For instance, opportunities to introduce new techniques or technologies become apparent where they fit into the outlined process and can then be strategically integrated to improve the clinical practice. Potential aspects of an IGRT practice that would benefit from new image registration tools could become evident when the decision-making process is clearly defined. As standardization increases the quality of processes, it creates additional opportunities for innovation and enhancing clinical practice. As the pace of change in healthcare continues, establishing effective implementation processes is essential. Documenting and tracking all changes allow impacts to be assessed within current clinical practices. Any necessary trade-offs can then be considered before determining whether the change should be approved. Standardized implementation processes enable a systematic approach to furthering evidence-based clinical practices and supports innovation. As IGRT decisionmaking becomes increasingly complex, and the rate of change continues, these processes facilitate a disciplined approach to continuously improving IGRT clinical practices. Footnotes Competing interests: The author has completed the ICMJE uniform disclosure form at http://www.icmje.org/
coi_disclosure.pdf and declares: no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Ethical approval: Not required.
References [1] Lega, F., & Calciolari, S. (2012). Coevolution of patients and hospitals: how changing epidemiology and technological advances create challenges and drive organizational innovation. J Healthc Manag 57(1), 17–33. [2] Bujold, A., Craig, T., Jaffray, D., & Dawson, L. (2012). Image-guided radiotherapy: has it influenced patient outcomes? Semin Radiat Oncol 22(1), 50–61. [3] Project Management Institute (2008). A guide to the project management body of knowledge (PMBOKÒ Guide), (4th ed.). (pp. 93–95). Newtown Square, PA: Project Management Institute. [4] Griffith-Cooper, B., & King, K. (2007). The partnership between project management and organizational change: integrating change management with change leadership. Perform Improvement 46(1), 14–20. [5] Schwalbe, K. (2010). Information technology project management, (6th ed.). (pp. 162–164). Boston, MA: Course Technology, Cengage Learning. [6] Koteska, B., & Mishev, A. (2014). Change management and version control of scientific applications. IJCSIT 6(2), 153–161. [7] Stare, A. (2010). Comprehensive management of project changes. Econ Business Rev 12(3), 195–210. [8] Sparger, K., Selgas, M., Collins, P. M., Lindgren, C. L., Massieu, M., & Castillo, A. S. (2012). Nurs Manag 14–20. [9] Cullen, L., & Adams, S. L. (2012). Planning for implementation of evidence-based practice. JONA 42(4), 222–230. [10] Berwick, D. M. (2003). Disseminating innovations in health care. JAMA 289(15), 1969–1975. [11] American Society for Quality (2010). Fresh thinking on innovation and quality: an ASQ white paper. From ASQ website. www.asq.org. Accessed July 27, 2017.
J. Loudon/Journal of Medical Imaging and Radiation Sciences 48 (2017) 326-327
327
Journal of Medical Imaging and Radiation Sciences 48 (2017) 326-327
Journal de l’imagerie médicale et des sciences de la radiation
www.elsevier.com/locate/jmir
Commentary
Standardized Implementation of Clinical Practices James Loudon, MHS, MRT(T), PMP* The Bahen Chant Radiation Treatment Centre, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada
Radiation therapy is a continuously changing profession. New evidence-based practices, technology advances, and pressures to increase organizational performance all motivate change initiatives [1]. Image-Guided Radiation Therapy (IGRT), in particular, has been an area of significant change in radiation therapy. Pretreatment IGRT requires critical decision-making immediately before radiation treatment delivery [2]. In addition to standardizing the IGRT decision-making, a standard approach to the continuous implementation of IGRT evidence ensures that changes are implemented in a consistent way. It influences change so that there is a higher chance of it being implemented successfully and delivering the intended result. The change management processes described in this article represent change control. Change control is considered a best practice in the project management profession and involves the application of standard processes for the consistent management of change [3]. However, the concepts are broadly applicable and benefits include balancing resources, reducing risks and influencing factors so that approved changes are beneficial [3–5]. Documenting changes to IGRT clinical practices is an important first step for the impacts of the change to be quickly understood and evaluated [3, 5, 6]. For instance, information tracked can include the change, version, date, and any approvals the practice has already undergone. Standard documentation templates also help to ensure that the correct version is implemented into clinical practice [3, 5, 6]. A simple way to track changes is to include a summary table at the end of clinical protocols, which describes the changes made and their rationale. Diagrams, such as flowcharts, are also useful tools for documenting and explaining proposed changes. Flowcharts graphically illustrate processes and decision-making, which allow the impacts of the change to be visualized within the framework of a given clinical practice [4]. * Corresponding author: James Loudon, MHS, MRT(T), PMP, The Bahen Chant Radiation Treatment Centre, Stronach Regional Cancer Centre, Southlake Regional Health Centre, 596 Davis Drive, Newmarket, Ontario L3Y 2P9, Canada. E-mail address: [email protected]
Assessing a change often involves analyzing the costs and benefits [7]. The extent that a change is adopted may be modified to better balance resources with the intended benefits [2, 7]. For example, a new IGRT technique could require increased time on the treatment unit [2]. The scope of the new practice, such as imaging frequency or settings for image acquisition, could be modified so it can be performed within current time constraints. The change could also be accommodated by no longer performing previous techniques, such as discontinuing the need to acquire electronic portal images of treatment fields with the implementation of cone beam computed tomography [2]. Balancing resources is not always straightforward however, and although a practice change may require increased time, it may be justified by its respective increase in the quality of the procedure [2]. Approval of the proposed change is an important step to be completed before its implementation [3, 7, 8]. Formal approval of proposed changes frequently includes a committee that is responsible for reviewing proposed changes and determining whether or not they should be accepted [3, 5, 7]. For IGRT, an interprofessional committee of Radiation Therapists, Physicists, and Radiation Oncologists can act as a resource for image-guidance and focuses on the development and implementation of related processes. This also provides a transparent process for protocol review, approval, and communication before clinical implementation. Depending on the scope of the change, final approval to implement clinically could also be contingent on staff training and coaching [4, 8]. Applying a standard implementation process ensures that proposed changes are supported with a solid rationale and sufficient evidence [7]. Reviewing evidence to justify clinical practice changes is an essential component of healthcare [9]. However, evidence may be adapted to the specific clinical practice environment and the resulting documentation should be an accurate representation of the actual practice that will be used clinically [9, 10]. Once written and approved, the protocol does not become a static document, but is intended to be refined and change as new evidence becomes available. Using a structured framework to review proposed changes and their justification ensures that clinical practice changes are supported with sufficient evidence. Changes that are not supported would instead be queried for further information.
1939-8654/$ - see front matter Ó 2017 Canadian Association of Medical Radiation Technologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jmir.2017.09.001
This process assists in the prevention of unauthorized change, such as ad hoc decision-making, which could lead to a higher chance of unanticipated consequences. For example, the adoption of a new clinical practice, when the specific decision-making for its use has not been clearly established, could increase the risk of improper use. Standardized implementation practices also act as a supportive process for innovation to take place [11]. The process of clearly documenting a practice facilitates an understanding of how it will be affected by proposed changes and identifies areas to be further developed [11]. For instance, opportunities to introduce new techniques or technologies become apparent where they fit into the outlined process and can then be strategically integrated to improve the clinical practice. Potential aspects of an IGRT practice that would benefit from new image registration tools could become evident when the decision-making process is clearly defined. As standardization increases the quality of processes, it creates additional opportunities for innovation and enhancing clinical practice. As the pace of change in healthcare continues, establishing effective implementation processes is essential. Documenting and tracking all changes allow impacts to be assessed within current clinical practices. Any necessary trade-offs can then be considered before determining whether the change should be approved. Standardized implementation processes enable a systematic approach to furthering evidence-based clinical practices and supports innovation. As IGRT decisionmaking becomes increasingly complex, and the rate of change continues, these processes facilitate a disciplined approach to continuously improving IGRT clinical practices. Footnotes Competing interests: The author has completed the ICMJE uniform disclosure form at http://www.icmje.org/
coi_disclosure.pdf and declares: no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Ethical approval: Not required.
References [1] Lega, F., & Calciolari, S. (2012). Coevolution of patients and hospitals: how changing epidemiology and technological advances create challenges and drive organizational innovation. J Healthc Manag 57(1), 17–33. [2] Bujold, A., Craig, T., Jaffray, D., & Dawson, L. (2012). Image-guided radiotherapy: has it influenced patient outcomes? Semin Radiat Oncol 22(1), 50–61. [3] Project Management Institute (2008). A guide to the project management body of knowledge (PMBOKÒ Guide), (4th ed.). (pp. 93–95). Newtown Square, PA: Project Management Institute. [4] Griffith-Cooper, B., & King, K. (2007). The partnership between project management and organizational change: integrating change management with change leadership. Perform Improvement 46(1), 14–20. [5] Schwalbe, K. (2010). Information technology project management, (6th ed.). (pp. 162–164). Boston, MA: Course Technology, Cengage Learning. [6] Koteska, B., & Mishev, A. (2014). Change management and version control of scientific applications. IJCSIT 6(2), 153–161. [7] Stare, A. (2010). Comprehensive management of project changes. Econ Business Rev 12(3), 195–210. [8] Sparger, K., Selgas, M., Collins, P. M., Lindgren, C. L., Massieu, M., & Castillo, A. S. (2012). Nurs Manag 14–20. [9] Cullen, L., & Adams, S. L. (2012). Planning for implementation of evidence-based practice. JONA 42(4), 222–230. [10] Berwick, D. M. (2003). Disseminating innovations in health care. JAMA 289(15), 1969–1975. [11] American Society for Quality (2010). Fresh thinking on innovation and quality: an ASQ white paper. From ASQ website. www.asq.org. Accessed July 27, 2017.
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