Five Main Operational Categories for Radiation Therapy
- Patient evaluation
- RT Preparation
- RT Delivery
- RT Treatment Management
- Follow-up evaluation and care
What are SOP’s?
Standard Operating Procedures
* Describe treatment approach and provide consistent protocols for staff
- Essential component of any practice
- Clinical variation from an SOP should be documented
- Collaboration between clinical staff help determine how treatment options outside of an SOP might be tailored to a particular patient’s situation
Roles of RO within RT Department
Supervise delivery of RT (e.g., set dose, volume, approve plan and treatment images)
Coordination with the MDT
Ongoing patient education
Manage patient toxicity
Roles of Physicist with RT Department
Assure the safe and effective delivery of radiation as prescribed
Assess safety of treatment processes (e.g., failure mode analysis, fault trees)R
Roles of RT within RT department
Perform treatment planning
Provide safe and effective delivery of radiation as prescribed
Perform daily equipment and new patient treatment QA]
Assessment of 2D-3D images to make decisions concerning patient alignment
Adapting to changing modalities for IGRT and treatment
Role of Nurses within the RT Department
Assist with patient care/education
Manage patient toxicity
Assist in MDT coordination
Standardisation: Tool to facilitate safety and a safety culture
Widely recognised as a means to reduce errors
Too many diverse approaches may lead to confusion
Rotating between different physical locations and/or equipment may exacerbate misunderstandings
Lean Method: Tool to facilitate safety and safety culture
Used to streamline clinical workflow and alter the work environment
Method can be beneficial in the implementation of rapid improvement projects
Relevant staff create process maps for particular tasks
Value added steps are identified
Non-essential steps and unnecessary stressors are eliminated → more streamlined, unambiguous, standardised process which increases available time for critical tasks
AAPM TG 100 - FMEA: Tool to facilitate safety and safe culture
Failure Modes and effects Analysis (FMEA)
- Clinical Team develop a process map
- Individual steps of the process map are analysed for ways in which the desired outcome of a step may not be achieved –> known as potential failure modes
- For each potential failure mode, three components are assessed and assigned a numerical value from zero to ten:
- Severity (possible outcome on a patient)
- Occurrence (how likely it is that the failure pathway occurs)
- Detectability (how likely is it that the failure pathway, once initiated, will not be intercepted)
- Numerical values of the three parameters are multiplied together to calculate the risk priority number
- By ranking potential failure modes according to risk priority numbers, FMEA’s enable the clinical team to understand where safety and quality issues could arise and their relative priority.
Use of FTA with an FMEA
FTA = Fault Tree Analysis
- used to graphically describe how a possible cause or contributing factor could lead to a particular failure mode (i.e., failure pathway)
- Series of FTA’s can identify systemic issues within a clinical process and provide a basis for discussion on where in the pathway to place QA and QC interventions
- AAPM TG 100 combines process maps, FMEA and FTA to evaluate and change workflow safety and efficiency
What is Peer-Review?
Refer to somewhat more subjective items within the RT process such as target definition and dose selection
Includes review processes for the entire clinical practice and its procedures, for individual clinical care, and qualitative decisions made throughout the process of care (e.g., treatment plan quality, patient set up) for the purposes of quality control and improvement
Can take many shapes and forms, including:
* Intradisciplinary (RO to RO)
* Interdisciplinary (amongst physicians of varying disciplines)
* Multidisciplinary (with other specialties)
Each practice must have a well-developed strategy for peer-review
Benefit of Prospective Peer Review
Prospective:
- Establishing pre-planning and treatment meetings facilitates a healthy interdisciplinary dialogue that can make the subsequent planning and treatment processes smoother
- Supports safety culture
Retrospective
- Can be utilised as a learning tool
Physician: Peer Review vs Quality Assurance
Peer Review:
* Target Delineation
* Dose Selection
* Technique selection
QA
* Verify documentation
* Verify dose constraints are withing policy
* Review portal films
Physicist: Peer Review vs QA
Peer Review
* Independent check of treatment machines output
* Audit plan reviews
QA:
* Verify the correct transfer of data from the TPS to the TMS
Dosimetrist: Peer Review vs QA
Peer Review:
* Assess selection of beam orientation and weighting
* Plan optimisation and evaluation
QA:
* Verify that the prescription matches the treatment plan
RT: Peer Review vs QA
Peer Review:
* Double check patient setup accuracy
QA:
* Ensure patient-specific procedure time-out
Safety Rounds: Definition
Brief, open discussions between key members of the leadership team and frontline staff at the worksite
May include asking staff about near misses or unsafe conditions that could cause potential or real harm to patients or employees
Importance of Incident Learning
Staff should be encouraged to report all safety events (incidents, near-misses, unsafe conditions and operational improvements)
Reporting of all safety events should be met positively, in a supporting environment, and without fear of punitive action
Emphasis is placed on studying events and learning from them, in reducing the severity of events
Importance of collaboration between staff and vendors
To address safety concerns, a partnership with the vendors of these products must mature.
An open exchange is needed where users and manufacturers work synergistically for the healthy evolution of safe and useful products to maximise the likelihood of optimal resources
Case-oriented peer review
Structured review process where individual cases are evaluated by peers
Usually involves a small group of peers, reviewing one case in detail
Chart rounds
MDT meetings where RO, RT’s, physicist’s and nurses discuss each patient’s treatment plan and progress
Ensures treatment plans are accurate, consistent
Evaluates imaging, plan dosimetry and side effect management
MM rounds
Broader interdisciplinary focus, covering various modalities beyond radiation therapy alone and often including members from other disciplines
Involves reviewing patient cases
Ensures all clinical options and perspectives are considered to provide holistic care
