Revisiting Clinical Protocols: Aligning a Healthy Bottom Line with Clinical Effectiveness

The recent economic downturn gives hospitals a good reason to revisit their protocols and most physicians can appreciate the rationale for looking at changes in the delivery system, even if they do not fully support the identified changes. Likewise, given the financial pressures that physician practices are facing, doctors are likely to appreciate any additional paid work in the form of serving on committees. Finally, serving on a protocol committee provides physicians with input in the process of identifying quality patient care while also balancing economic factors.

Most physicians and hospital staff join protocol committees with the shared goals to:

• Improve every patient's quality of care.
• Improve patient throughput.
• Lower the ALOS by determining a treatment plan in advance so care is coordinated in a more organized manner.
• Reduce readmissions because patients are healthier when they leave or because the protocol dictates that follow-up care take place.
• Increase the nursing staff's role in patient treatment, thus freeing up physicians to see more patients.
• Reduce supply costs by reducing the variation in types of medicines used.
• Improve documentation because any variances from the protocol are documented.
• Prepare for the coming changes in reimbursement.

Developing an effective clinical protocol committee
The concept behind clinical protocol committees is fairly straightforward—stakeholders are tasked with developing the highest quality, most cost-effective treatment pathway for a given illness and making that pathway the standard for how those patients will be treated. (Comparing clinical effectiveness is a more contemporary term that means much of the same.) Here are suggestions for taking the first steps towards developing a committee:

• Offer opportunities for every physician to be involved to some degree and make sure that the most highly respected physicians sign off on the end result.
• Include those physicians who are the most likely to be resistant. In the past, these physicians may have intentionally skipped critical meetings. Some hospitals believe that paying physicians to attend the meetings and to help develop the protocols is allowable under Stark, especially if they have to attend the meetings to receive payment.
• Be inclusive of the staff. Dietary and materials management may not need to attend every meeting, but they should be present when issues affecting their departments are discussed.
• Make it clear that the physician's judgment always trumps the protocol. Give proscriptive examples of when that might occur.
• Make it clear why the hospital is developing protocols. Any good "futurist" consultant can make the argument for why hospitals should be moving in this direction, and a presentation to the board may result in a direct mandate that it be done.
• Start with the small projects that have a reasonable chance of success. Protocols for myopia, hypothyroidism, obstetrics, and normal newborns can be done quickly and establish the legitimacy of the committee. Once the momentum is underway, move into areas such as pneumonia and osteoporosis.
• Know the limits. A little pushing to get your medical staff to work on slightly more complex diseases may be needed, but know when to stop. Until technology and biometrics can provide designer drugs tailored for each patient, intuition will play an important role.

Time is of the essence
In the midst of economic and organizational change, now is the time to re-engage physicians in the process of developing and updating protocols. Waiting until there is a financial crisis is too late and could be seen as an act of desperation by the very physicians whose buy-in is critical.

Physicians today are more aware of how hospitals operate than they were a decade ago when protocols were seen as the tool of managed care companies. They are also less likely to passively resist the measures if they are more reliant upon the hospital for financial help. Done correctly, the development of protocols will be embraced by physicians and help the hospital avoid other painful decisions in the face of economic challenges.