Practice Guidelines: A Recipe for Success

Practice guidelines are translational research writ large: tools that gain value as they enable evidence-based care. When more patients get better quicker because standardized procedures produce more precise and useful test results, everybody wins.

Elizabeth H. Hammond, MD, FCAP, a consultant pathologist at Intermountain Healthcare as well as professor of pathology and adjunct professor of internal medicine (cardiology) at the University of Utah School of Medicine, has a mantra. Reality-based, systems-driven guidelines free up the physician's bandwidth for intentional focus on patient-centered routes to outcomes improvement, she says. To construct guidelines, collaborate with clinicians, examine the evidence, educate everybody, measure the outcomes, and communicate effectively. Apply. Tweak. Repeat.

A former member of the CAP's Board of Governors and former chair of both the CAP's Education Committee and Cancer Committee, Dr. Hammond has served her specialty during times of accelerated innovation. In 2013, the CAP selected her as the first recipient of the CAP Pathology Advancement Award, citing her work to develop the CAP Pathology and Laboratory Quality Center. The Center, which fosters multidisciplinary, evidence-based guideline development, has published eight sets of guidelines to date and eight more are in the pipeline.

"In the guidelines created through the Center, we've tried to include other organizations as partners who could speak for the clinical concerns," Dr. Hammond says. "You can't figure out the right answer by yourself. It's impossible. You'll come up with an answer, but it won't be reality tested. If what you say only makes sense to you and not to them, then it's not going to modify patient care."

Dr. Hammond learned some of this while serving on the Cancer Committee, which manages the CAP Cancer Protocols, an integral part of pathology reporting for many institutions. "You can't design a cancer protocol unless you talk to the surgeons who are removing the tumor and the doctors who are then going to treat the patient afterward," Dr. Hammond says. "You ask the questions: 'What kind of information do you need? How should we provide that information to you so you will understand it?' The only way you can give clinicians informed advice is to speak their language and understand their concerns."

Dr. Hammond's work in cardiac transplant pathology also formed these observations; she has been director of the Utah Cardiac Transplant Program since 1986. "Most of my personal research has been on antibody-mediated rejection," she says. "Why did I worry about that? Because it's the kind of rejection that kills patients—and I learned that from dealing with clinicians, not from talking with other pathologists!"

Dr. Hammond has collaborated with clinicians, too, on expert panels for both the International Society of Heart Lung Transplantation and the National Cancer Institute (NCI). It was on an NCI panel that she first worked with surgeons and oncologists to design improved proficiency testing (PT) methods for HER2, a predictive marker in invasive breast cancer. And that experience, Dr. Hammond says, had another important benefit. "It enabled the other clinicians on the panel to realize that the CAP was a powerful organization to modify behavior because we had the ability to provide PT and also to inspect laboratories."

Dr. Hammond is a former member of the Intermountain Healthcare Board of Trustees who chaired the LDS Hospital Department of Pathology for 11 years and also did a stint as medical staff president. Her observations about the team-oriented, patient-centered culture there come from experience. She describes an innovation-friendly environment where a novel approach will get a fair trial because everyone wants it to work. And when it does, it catches on.

For example, clinic patients at Intermountain can have immediate access to a mental health team if their physician sees the need. And Dr. Hammond makes herself available to patients referred by their physicians with questions about laboratory test reports or other health concerns, something that she enjoys and recommends. "If a patient has a question that needs to be answered, you want someone who can describe it in a user-friendly way," she says. "You want someone who understands the tests and the medical implications of the findings. You're being a resource to the doctor, which is the way pathologists have always worked."

If managed electronically, patient advocacy of this kind need not require a great deal of time, Dr. Hammond points out, and there are benefits all around. Comforted patients become loyal patients, overburdened clinicians appreciate the support, and administrators will draw their own conclusions about the talents that pathologists bring to the table.

If this model were more broadly employed, Dr. Hammond says, "People would realize that pathologists know a lot about a lot of different things, that we can put two and two together in a way other people can’t. That’s teamwork."

Summary

Properly constructed guidelines can enable pathologists to identify and document those laboratory findings most useful to their clinical partners. Intentional communication within medical teams will further free up physicians' collective bandwidth by creating a continuous feedback loop that informs and educates all parties about how best to share what they know and what they need to know. Patients benefit, efficiencies multiply, economies emerge. People start thinking about doing things differently. And from there, as the saying goes, the sky's the limit.