A Stakeholder-Driven Workflow Management System for the Continuous Improvement of the College of American...

The College of American Pathologists (CAP) Cancer Protocols are standardized pathology reporting tools that support accurate, complete, and interoperable cancer diagnoses. Available in electronic, downloadable, and mobile formats, they are used by more than 9500 licensed users. CAP has developed a quality management system specifically for the cancer protocols with a focus on stakeholder feedback. It also maintains alignment with multiple international regulatory standards, enabling compliance with accreditation requirements.

To describe the process for tracking, triaging, and resolving inquiries to increase transparency of the creation and maintenance of the CAP protocols. This process ensures that stakeholder feedback is fully considered and systematically incorporated into protocol updates.

Inquiries submitted in 2023-2024 were logged into 2 databases for triage within a customized task management system. For each inquiry, data were captured on volume, source, submission platform, protocol group, issue type, and resolution time.

Of 507 inquiries, 156 (31%) resulted in protocol updates. Despite 278 inquiries (55%) requiring committee input, 446 (88%) were resolved within 7 days. Most inquiries involved content (283; 56%), and technical issues were minimal (61; 12%). Submission via the preferred route (cancerprotocols@cap.org) was used for 395 inquiries (78%). Breast, gastrointestinal, genitourinary, and gynecologic protocols generated the most inquiries.

Stakeholder input is used in a quality management system to create and maintain the CAP Cancer Protocols. Use of this system ensures the ongoing accuracy, usability, and interoperability of the CAP Cancer Protocols, supporting precision oncology and excellence in patient care.