Lean method live update- real-time librarian support for evidence-based practice in radiotherapy clinical protocols

A new method for updating radiotherapy (RT) clinical protocols to the latest evidence in a time efficient way.

During which period did you implement your innovation?

We started this in October 2014 and it has now reached the second cycle for some protocols.

What was the driver for your innovation?

As Clinical Librarian (CL) for a new cancer team the radiotherapy department was keen to utilise my expertise to provide evidence for processes and treatments. Radiotherapy clinical protocols had been implemented when the department opened but not updated with recent evidence. With the formation of new teams there was sometimes a delay in the latest evidence reaching practice for logistical reasons such as resources and time. The radiotherapy researcher in partnership with the CL developed a lean process to undertake the real-time live update of clinical RT protocols to enable a streamlined approach to the latest evidence reaching practice. 

What did you do?

We looked at the existing protocols and reviewed options as how best to bring the knowledge of busy professionals together to ensure these were efficiently updated to reflect the latest evidence.
A multistep development process was deployed, including the principles of Quality Function Deployment (QFP) The consecutive steps involved developing a process comparable to a systematic review (Fig. 1).

Once a date had been agreed for the live update the Multi-Professional Team (MPT) (Radiation Therapists, Oncologists, Physicists, service leads and CL) provided the CL with search terms. From references provided full papers were then selected and circulated to the MPT providing new evidence for the live update. The MPT convened for 3 hours for the live update. The previous protocol was displayed on a screen and updated systematically with the new evidence with the CL ensuring in-text referencing and conducting ad hoc follow up searches. The session concluded with a clinical protocol approved for radiotherapy practice that was uploaded to the in-house document management system, Q-Pulse®.

The CL retrospectively added the search strategy and resources list along with the complete reference list. This ensured consistency for future updates.

Diagram of processes to make innovation live. Under 'pre-live update' is 'search terms sent to clinical librarians' which has an arrow pointing to 'clinical librarians perform evidence search with results sent to MPT' which has an arrow pointing to 'MPT request relevant full text from list of results'. This then moves to the post live section. There is a direct line down the middle with the appropriate actions as time moves on. The first is 'Q pulse- clinical protocol checked out for editing' halfway along the arrow to the next point on the central line is an interjected text box saying 'thinking lean! RTT applies new template and duplications removed'. The next text box on the central line is 'Live update of clinical protocol'. This has two external boex pointing to it 'further evidence search undertaken as requested' and 'MPT read clinical protocols verbatim and editing according to EBP'. The next text box on the central line is 'Q pulse - clinical protocol checked-in ready for approval'. This points to the final box on the central line 'MPT present approved clinical protocol'.
Fig 1.

What methods were used to evaluate your innovation?

Initial evaluation focussed on the percentage difference made to content within the clinical protocol in the following areas: dose/fractionation, outlining, planning, image guidance and treatment delivery compared to the previous 2 years. Since 2014 twelve clinical RT protocols have been through the live update process, with one having been through a second time. The live update resulted in 80% of differences to the clinical protocol compared to the previous two years before the process

 Satisfaction of the live update was scored on a 5 point Likert  scale among the MPT (1 Very dissatisfied; 5 Very satisfied). Questions included: how satisfied were you with the process/ end result? Among 10 respondents, a mode of 5 was scored for how satisfied the MPT were with the process and end result. (Fig 2)

Two graphs both showing ten responses. The first is titled
Fig 2.

What were the outcomes and key learning points?

The novel approach of the live update has been successful in providing a lean process ensuring that the latest evidence reaches clinical RT practice in a timely manner. An innovative collaboration incorporates Clinical Librarians with the RT MPT for ensuring an efficient, methodical approach and improved team working. The lean process of the real-time live update resulted in a small investment of time from the MPT, ensuring up to date clinical practice based on the latest evidence contributing to improved patient outcomes. 

Learning Points:

  • Innovative collaboration between the Radiotherapy Researcher  and the CL.
  • CL explored new service development methods such as lean methodology.
  • CL recognised as a key member of the MPT, such that the live updates would not convene without them.
  • Proved the value of CL in that evidence was identified via searches even when the other members of the MPT thought there was no new recent practice-changing research/guidelines.
  • Including the search strategy and list of resources searched means the process can be replicated by other Librarians.
  • Building knowledge of a diverse range of information resources.
  • Value your skills and expertise as a professional.

Please provide a short quote from a member of staff who has benefitted from the innovation

Simon Goldsworthy, Lead Radiotherapy Researcher

“Your provision of evidence has changed some of the radiotherapy doses and fractionation we deliver. This means that our patients will directly benefit from this change in practice, and their outcomes improved.

This impact suggests that it is always worth doing these live updates even if we think we will not change much. We are always proven wrong and find that the evidence inevitably improves patient’s outcomes”. 

Anon from evaluation:

“Having the Clinical Librarian involved is  impressive and ensures evidence based practice”

Submitted by Carol-Ann Regan, Library and Knowledge Services Manager, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust,