Program Implemented to Standardize Diagnostic Bronchoscopy Data Ensures Quality Care

On average, Cleveland Clinic performs thousands of diagnostic bronchoscopies each year. But because there are several reasons why a bronchoscopy might be performed, it can be challenging to communicate and track what has been done, what was found and next steps.

To help overcome this challenge, Francisco Almeida, MD, MS, Quality Director, Bronchoscopy and Interventional Pulmonary in Cleveland Clinic’s Respiratory Institute, and Sonali Sethi, MD, Director of Lung Cancer Diagnosis at the Respiratory Institute, met with database manager, Luke Hayden. The trio decided to focus their attention primarily on tracking endobronchial ultrasound (EBUS) and implemented a new program that extracts data from every single procedure and updates a patient’s medical record and a quality metric database in real-time.

Why standardization is critical

“EBUS procedures are quite common, and they should typically all be performed uniformly so there isn’t much variability,” explains Dr. Almeida. “But there is some subjectivity involved. For example, if a patient has lung cancer — either confirmed or suspected — then staging must be performed to determine the best course of treatment. Staging involves evaluating as many lymph nodes as possible for the specific situation.”

He continues, “But maybe there’s a case where you sampled only until you have identified a malignant lymph node, or you think you obtain the proper information to provide the patient's hilar and mediastinal staging. This subjectivity is problematic and can confuse caregivers, so we wanted to figure out a way to remove this subjectivity and help clinicians better track patient statuses.”

Drs. Almeida and Sethi worked with Hayden to create a templated note that physicians were instructed to fill out with each bronchoscopy. The note documents which lymph node they’re evaluating and sampling. This note is automatically extracted into the patient’s medical record for any procedure, and in addition to being available on the patient's medical record to every provider involved with that patient’s care, this data is automatically analyzed to ensure its high standards.

“When we document a note, it goes into the patient’s EMR — just as it always has,” says Dr. Almeida. “But before this program, there was not a standardized or automated way to analyze how we were documenting and performing. So, now all our documentation can be evaluated, and we can analyze in real-time the performance of each provider.”

“The data is uploaded into the patient’s EMR, and it also goes to our analytics page, known as Tableau,” explains Dr. Sethi. “From Tableau, we can find the aggregate of how any of our doctors are performing a procedure. We can also review specific procedures in a much easier and more streamlined process than going back to the patient’s EMR. It’s helped us to standardize our EBUS procedures as well as track how we’re doing. It’s also streamlined our processes quite a bit. The only manual labor in the process is the initial templated note — everything else is automated.”

Program impact

After the process was implemented in June 2023, the number of instances in which patients were incorrectly documented dropped from on average of about 40% to less than 10%.

Dr. Almeida notes, “With the dashboard, there isn’t much training involved because the data analysis it’s so straightforward. We’ve had the templated notes for about eight or nine years, but unfortunately, many clinicians weren’t filling them out properly. We now check their documentation to make sure it’s being done and being done correctly. We’ve also sent out a short video to the group to help with training. Once the templated notes are filled out correctly, everything else falls into place thanks to the automated extraction.”

Leading the way

“We believe that this system is unique, and we don't think anyone else has such a system for endobronchial ultrasound,” says Dr. Sethi. “We believe we're the first in the country — maybe the world — to have such a robust way of checking how our physicians are doing their procedures. We think we'll get to a quality standard that is going to be unparalleled until other medical institutions catch up to us.”

In July 2023, the World Association for Bronchology and IP (WABIP) released an expert panel consensus statement that proposed quality indicators and recommended standard reporting items and performance of EBUS bronchoscopy. The statement identified three aims: 1) establish a set of quality indicators for EBUS bronchoscopy, 2) establish performance targets for each of these quality indicators and 3) develop a list of standard reporting items for inclusion in the EBUS bronchoscopy report.

Dr. Sethi explains, “The statement from the WABIP lays out what clinicians should be reporting out regarding EBUS. The program that we established is completely in compliance with that statement. The WABIP document lays out what everyone should be doing, so it shows that Cleveland Clinic is ahead of the game in respect to EBUS utilization because we’ve already implemented their suggestions.”

Next steps

Dr. Sethi notes that there have been different registries in the past that have been tried out for reporting data. But because these were mainly dependent on manual labor and the amount of time it took for reporting, these registries haven't been able to be incorporated into institutions. The standardized bronchoscopy notes and automated extraction has helped Cleveland Clinic move towards that registry model.

“We are standardizing all of our EBUS procedures, findings and documentation, terminology, follow-ups — everything,” says Dr. Almeida. “Because all of this has been recommended by WABIP, we expect that other institutions will start doing this too and everything will become quantified and qualified. I think that’s really the long-term goal here is to have everything standardized to a point where we’re all speaking the same language and if I have a patient coming from another institution, I can see what kind of procedures this patient has had along with the findings from the other medical team.”

Eventually, there is hope that the automatic data collection that has been implemented with EBUS can be applied to other procedures within bronchoscopy, such as lung transplantation and lung cancer screening.

Dr. Almeida will be presenting at the Thoracic Oncology Retreat to share how Cleveland Clinic has implemented the EBUS program and the positive impact it has had.