MPLA Case 1: Implementing Cone‐Beam CT in a Community Hospital

Abstract This fictional case describes a managerial situation of implementing cone‐beam computed tomography faced by a solo medical physicist in a rural community hospital. The intended use of the case study, in either a facilitated learning session or self‐study, is to inspire the readers to discuss the situation, analyze the institutional and personal factors, apply relevant leadership skills, and propose action plans. This case study falls under the scope of, and is supported by, the Medical Physics Leadership Academy (MPLA). A sample facilitator’s guide or self‐study guide is included in the manuscript for reference by users of this case study.

Dr. Garner was eager to implement the cone-beam computed tomography (CBCT) on the Varian 21EX Linear Accelerator (linac).
The Varian 21EX was a staple in radiation therapy treatment in the hospital's cancer clinic. She knew the standard of care of three-dimensional image guided radiation therapy (IGRT) with CBCT could easily be delivered by the Varian 21EX equipped with the on-board imager. In her office Dr. Garner sat down in the comfortable nylon chair the hospital had purchased for her. She used a disinfectant wipe to clear off the thin layer of dust that had collected along the top of the computer monitor and on its stand. She had just finished the CBCT acquisition of a phantom on the linac. Everything worked fine so far. Now she was ready to load the CBCT in MOSAIQ on an office workstation. She clicked on the "Review" button, and there was no response. She waited, knowing the computer was significantly slower than the GPU-equipped one she had used at her previous employer, a high-ranking research hospital in San Francisco. At Concord Hospital, she was a little disappointed that the computer workstation assigned to her had low specifications. She was told it met the hospital's IT specifications, and everybody else had the same computer.
Five minutes passed and the CBCT she had acquired finally showed up in MOSAIQ. However, she couldn't scroll the image slices, move, or zoom. The image on the screen froze. She gave up and pressed "Ctrl+Alt+Dlt." At Dr. Garner's previous position, CBCT had been common and was the standard method for image-guided radiation therapy. She was puzzled that this hospital, which had the foresight to hire a fulltime medical physicist, used computers with such poor performance.
Not utilizing CBCT due to computer performance had to be a mistake. She decided to check with Mark Robinson, the on-site medical dosimetrist, who had worked here through many generations of technologies.
Dr. Garner found Mark upstairs in his small office, patiently waiting for a plan optimization to finish. Not wanting to startle him, Dr.
Garner rapped her knuckles along the doorframe to announce her arrival. After they exchanged greetings, Dr. Garner asked whether there had been problems with CBCT review in MOSAIQ.
Mark sighed. "It's been like this forever. We've never used it successfully. We tried a few times before, but the computers couldn't handle it." "Isn't there something we can do to fix that? A simple computer update or a new computer for the system? CBCT is commonplace.
It's strange that it's not being used here." Mark nodded, but his facial expression conveyed resignation.
"I've been here for 18 years, and we seem to always have low-end computers for office work." "But this isn't office work. It's high-tech medical work!" "I completely agree!" Mark said. "Maybe you can change this. If you'd like, we can put in a request for new equipment, but the clinical supervisor is wary of any additional investments in computers, and the IT department has specific requirements about which programs we're allowed to run. With those restrictions, I'm not sure if we'll be able to do much. But maybe you'll make the difference.
They hired you to do the high-tech work in the first place." Dr. Garner couldn't help noticing that his tone of voice didn't sound hopeful.
Concord Hospital's junior radiation oncologist, Dr. Aaron Mitchell, had joined the practice a year before Dr. Garner. He finished his residency in the same research hospital as Dr. Garner and felt lucky to be given the opportunity to practice only a few hundred miles from where he grew up, where job opportunities for radiation oncologists were sparse. In the past year, he had not only convinced the hospital to hire a full-time medical physicist but was also able to recruit Dr. Garner, his residency physics mentor in San Francisco.
However, Dr. Mitchell was beginning to wonder if he had settled for the easiest option. The equipment he worked with felt clunky in comparison to the first-rate machines at his previous hospital. He had turned down an offer at his resident hospital, wanting to slow things down a bit to return to his family. After a year in Concord, Dr. Mitchell was disappointed and found himself in frequent disagreement with his senior practicing partner, Dr. David Bell.
"Shouldn't we let the deep-pocketed treatment centers figure this out before we plunge ahead and spend dollars we don't have?" "I don't think the costs are going to be prohibitive for us, and we could be saving lives that would be lost otherwise," said Dr. Garner. "It might be just two or three a year, but in a community this size, that makes a big difference." No one said anything for a while.
"I don't want to seem cold hearted," said Dr. Bell. "But won't our therapists and dosimetrist have to be trained on the new equipment? That's going to be a significant cost for the hospital. I've seen it many times before. The implementation of new technology is much harder and more expensive than the vendor says it will be."  Garner returns to her hometown for a clinical medical physicist position at a community hospital. She enjoys the slower pace of the small town and feels that it is a great place to raise her kids. Shortly upon arrival, Dr. Garner realizes that the hospital is not using conebeam computed tomography (CBCT) on their linear accelerator, which is the standard of care for three-dimensional image guided radiation therapy (IGRT). She learns that the department's computers are not powerful enough to process CBCT images.
Dr. Garner and her colleague Dr. Mitchell, a junior radiation oncologist, confront the senior practicing physician, Dr. Bell. Dr. Bell explains that as a small clinic with limited budget, the costs of upgrading the computers and training personnel is prohibitive. He asks his young colleagues of any evidence of better clinical outcomes to support the need for CBCT, to which they cannot answer.
Dr. Bell warns them of the hurdles they will face with IT and administration if they decide to move forward. This case is a Decision Scenario: the case presents a "need to make a critical decision and potentially persuade" others to accept it 1 .

LEARNING OBJE CTIVES
1. Recognize the impact that culture has on clinical practice.

2.
Prepare an action plan to sell a new idea to members of the clinic with different personalities and incentives.
3. Understand that cost-benefit analysis or return-on-investment are often the key metrics to convince hospital administration to adopt new technology, which may bring in high-quality care as well as new revenues.

PEDAGOGY
• Audience: medical physics and radiation oncology students, residents, and faculty    a Dr. Garner should ensure that the dosimetry staff is consulted and trained on the additional plan preparation needed to support using CBCT for image guidance.
Ongoing education: a Dr. Garner should anticipate that there will be growing pains associated with the introduction of new technology. Appropriate policies, procedures and protocols should be put into place and resources for refresher education for the new technology should be budgeted into any project plan. 8. A great resource for learning and understanding radiation therapy billing is AAPM's Professional Economic Committee. ASTRO also publishes annual coding guide and billing refresher. To come up with an accurate financial projection pro forma, collaboration with the hospital billing staff is needed. For learning the subjects of organizational finance and budgeting, a useful resource is Harvard ManageMentor 3 (https://hbr.org/harvardmanagementor/ , paid subscription required).

TEACHIN G PLAN
1. Read the case-15 min.

3.
Teach the 8 step change model and apply it to the case-30 min.

CONCLUSION
The students should leave the discussion with a greater understanding of the differing viewpoints of clinical staff. They should have a better appreciation for hospital budget, leadership structure, and building relationships. Lastly, they should be able to identify the necessary aspects for successful change management.