Get your Protocols in a Row

August 28, 2008

If physicians use protocols to treat patients there will be consistent outcomes, mechanisms in place to measure success and quality of life, and a foundation for pay-for-performance initiatives.

For those of you who chafe against “the rules,” consider this:

This past Wednesday, the Associated Press ran a story about a young Egyptian woman who, thanks to fertility drugs, just gave birth to septuplets. The 27-year-old and her 31-year-old husband, a part-time farm laborer, already have three children, but no sons. They live in a mud hut. The article discusses in depth the lack of protocols and pharmaceutical regulation in Egypt’s health industry.

Compare that to the U.S., where protocols, treatment guidelines, regimens -- or some other term that refers to consistency in providing care -- are now a major part of our lives. The implication is this:

If physicians use protocols to treat patients there will be consistent outcomes, mechanisms in place to measure success and quality of life, and a foundation for pay-for-performance initiatives.

Therefore, managers need to understand these approaches.

You’ll find protocols popping up more and more these days. For example, some specialty organizations -- the National Comprehensive Cancer Network or the American Diabetic Association, to name just two -- have developed treatment recommendations for patients with a specific disease, such as cancer or diabetes, respectively.

There are also protocols to follow for participating in a pay-for-performance program, such as CMS’s Physician Quality Reporting Initiative. PQRI has an 80 percent reporting target threshold that physicians must attain in order to cash in on the program’s proffered bonus. This allows for physician and patient variances based upon the specific case of each patient (e.g., you decided that treatment with aspirin was contraindicated in Mrs. Smith because she takes Coumadin).

Although no single set of protocols (to treat a particular condition) will work for every patient -- and such guidelines are not mandated by law -- you’ll find more and more payers requiring you to apprise them of which protocols you use and which you plan to implement. More importantly, you’ll also have to show how you’ll justify your actions when there’s an exception.

And so, practices would do well to adopt the most appropriate set of protocols that fit their style and patient population. Take time to review the vast amount of information available, determine which protocols make the most sense, and treat patients accordingly.

Beyond simply implementing protocols, you should also develop a monitoring and audit system to ensure that your protocol program is working. Let’s assume there are three standards for treating a Type 2 diabetic patient: hemoglobin A1C every three months, an annual foot exam, and an annual eye exam. Pull ten charts now and note the percentage of compliance with these standards. This becomes your base line. Perform the same audit again in three or six months to see if the percentage of compliance has improved. Continuously do this over the next several years, and document the activity. Don’t be afraid to share with outside sources.

Have your practice administrator look into forms, training programs, patient communication, computer adaptability, and clinic functions (e.g., scheduling, staffing, collections), in order to support your decision to follow a set of protocols.

Yes, this all this does add to the workload for administrators, but the rewards in improved patient care, consistency in delivery, patient satisfaction, and (hopefully) recompense from pay-for-performance initiatives will make the effort well worthwhile.

Owen Dahl, FACHE, CHBC, is a nationally recognized medical practice management consultant with over 24 years of experience in consulting for and managing medical practices and author of Think Business! Medical Practice Quality, Efficiency, Profits. He can be reached at or 281 367 3364.