Redesign of process map to increase efficiency: Reducing procedure time in cervical cancer brachytherapy

Identifying opportunities to optimize mass drug administration for soil-transmitted helminths: A visualization and descriptive analysis using process mapping

BACKGROUND

The control of soil-transmitted helminths (STH) is achieved through mass drug administration (MDA) with deworming medications targeting children and other high-risk groups. Recent evidence suggests that it may be possible to interrupt STH transmission by deworming individuals of all ages via community-wide MDA (cMDA). However, a change in delivery platforms will require altering implementation processes.

METHODS

We used process mapping, an operational research methodology, to describe the activities required for effective implementation of school-based and cMDA in 18 heterogenous areas and over three years in Benin, India, and Malawi. Planned activities were identified during workshops prior to initiation of a large cMDA trial (the DeWorm3 trial). The process maps were updated annually post-implementation, including adding or removing activities (e.g., adaptations) and determining whether activities occurred according to plan. Descriptive analyses were performed to quantify differences and similarities at baseline and over three implementation years. Comparative analyses were also conducted between study sites and areas implementing school-based vs. cMDA. Digitized process maps were developed to provide a visualization of MDA processes and inspected to identify implementation bottlenecks and inefficient activity flows.

RESULTS

Across three years and all clusters, implementation of cMDA required an average of 13 additional distinct activities and was adapted more often (5.2 adaptations per year) than school-based MDA. An average of 41% of activities across both MDA platforms did not occur according to planned timelines; however, deviations were often purposeful to improve implementation efficiency or effectiveness. Visualized process maps demonstrated that receipt of drugs at the local level may be an implementation bottleneck. Many activities rely on the effective setting of MDA dates and estimating quantity of drugs, suggesting that the timing of these activities is important to meet planned programmatic outcomes.

CONCLUSION

Implementation processes were heterogenous across settings, suggesting that MDA is highly context and resource dependent and that there are many viable ways to implement MDA. Process mapping could be deployed to support a transition from a school-based control program to community-wide STH transmission interruption program and potentially to enable integration with other community-based campaigns.

TRIAL REGISTRATION

NCT03014167.

Reducing first appointment delays for electron radiotherapy patients by improving the treatment planning pathway: a quality improvement project

Clatterbridge Cancer Centre (CCC) is a specialist hospital trust in England with three sites.Delay to the start of an appointment for radiotherapy, especially the first appointment (a 'New Start') is poor, both for operational efficiency and patient experience, causing stress for both patients and staff. Our aim is for the New Start to begin within 30 min of the allotted appointment time. To this end, we established another aim: for 'Final Checks' to the radiotherapy plan to be completed at least 30 min prior to the New Start appointment time.Prior to this quality improvement (QI) project, only 33% of electron-treatment New Start appointments started within the target 30 min (the average delay was 52.4 min) and only 48% of the corresponding Final Checks had been completed by their 30 min prior target.The treatment pathway for these patients was redesigned, with the aim of 90% of New Start appointments starting within 30 min of the allotted appointment time.By the end of this QI project, 69.2% of New Start appointments started within 30 min of the appointment time (with average delay reduced to 27.2 min), and 92.3% of Final Checks were completed by their 30 min prior target. We also reduced the number of safety (Datix) incidents due to plan not ready from 10 to 0. A year after the project, we have held most of the time improvements and still have had 0 plan-not-ready Datix.The largest improvement was achieved by introducing a proxy (without the patient present) 'day 0' appointment. This takes place in advance of the New Start appointment to enable earlier planning. Subsequent improvements included: automating previously manual planning calculations, making the care path consistent with other external beam radiotherapy care paths at CCC to reduce staff cognitive load and sharing key performance data with staff.

Developing Next-Generation 3-Dimensional Printing for Cervical Cancer Hybrid Brachytherapy: A Guided Interstitial Technique Enabling Improved Flexibility, Dosimetry, and Efficiency

PURPOSE

We developed a 3-dimensionally (3D) printed tandem anchored radially guiding interstitial template (TARGIT) to increase the simplicity of intracavitary/interstitial technique for tandem-and-ovoid (T&O) procedures in cervical cancer brachytherapy. This study compared dosimetry and procedure logistics between T&O implants using the original TARGIT versus the next-generation TARGIT-Flexible-eXtended (TARGIT-FX) 3D-printed template designed for practice-changing ease-of-use with further simplified needle insertion and increased flexibility in needle placement.

METHODS AND MATERIALS

This single-institution retrospective cohort study included patients undergoing T&O brachytherapy as part of definitive cervical cancer treatment. Procedures used the original TARGIT from November 2019 through February 2022 and the TARGIT-FX from March 2022 through November 2022. The FX design features full extension to the vaginal introitus with 9 needle channels and allows for needle additions or depth adjustments intraprocedure and after computed tomography/magnetic resonance imaging.

RESULTS

A total of 148 implants were performed, 68 (46%) with TARGIT and 80 (54%) with TARGIT-FX, across 41 patients. Across implants, the TARGIT-FX achieved higher mean V100% (+2.8%, P = .0019), and across patients, the TARGIT-FX achieved higher D90 (+2.0 Gy, P = .037) and higher D98 (+2.7 Gy, P = .016) compared with the original TARGIT. Doses to organs at risk were overall similar between templates. Procedure times for TARGIT-FX implants were 30% shorter on average than for those using the original TARGIT (P < .0001), and 28% shorter on average for the subset of implants with high-risk clinical target volume ≥30 cc (P = .013). All residents (100%, N = 6) surveyed regarding the TARGIT-FX indicated ease-of-use for needle insertion and interest in applying the technique in future practice.

CONCLUSIONS

The TARGIT-FX achieved shorter procedure times with increased tumor coverage and similar normal tissue sparing compared with the previously applied TARGIT and illustrates the potential of 3D printing to enhance efficiency and shorten the learning curve for intracavitary/interstitial procedure technique in cervical cancer brachytherapy.

Risk and Quality in Brachytherapy From a Technical Perspective

AIMS

To provide an overview of the history of incidents in brachytherapy and to describe the pillars in place to ensure that medical physicists deliver high-quality brachytherapy.

MATERIALS AND METHODS

A review of the literature was carried out to identify reported incidents in brachytherapy, together with an evaluation of the structures and processes in place to ensure that medical physicists deliver high-quality brachytherapy. In particular, the role of education and training, the use of process and technical quality assurance and the role of international guidelines are discussed.

RESULTS

There are many human factors in brachytherapy procedures that introduce additional risks into the process. Most of the reported incidents in the literature are related to human factors. Brachytherapy-related education and training initiatives are in place at the societal and departmental level for medical physicists. Additionally, medical physicists have developed process and technical quality assurance procedures, together with international guidelines and protocols. Education and training initiatives, together with quality assurance procedures and international guidelines may reduce the risk of human factors in brachytherapy.

CONCLUSION

Through application of the three pillars (education and training; process control and technical quality assurance; international guidelines), medical physicists will continue to minimise risk and deliver high-quality brachytherapy treatments.

How to improve efficiency in cancer care: dimensions, methods, and areas of evaluation

Efficiency in healthcare is crucial since available resources are scarce, and the opportunity cost of an inefficient allocation is measured in health outcomes foregone. This is particularly relevant for cancer. The aim of this paper was to gain a comprehensive overview of how efficiency in cancer care is defined, and what the indicators, different methods, perspectives, and areas of evaluation are, to provide recommendations on the areas and dimensions where efficiency can be improved. METHODS: A comprehensive scoping literature review was performed searching four databases. Studies published between 2000-2021 were included if they described experiences and cases of efficiency in cancer care or methods to evaluate efficiency. The results of the literature review were then discussed during two rounds of online consultation with a panel of 15 external experts invited to provide their insights and comments to deliberate policy recommendations. RESULTS: 46 papers met the inclusion criteria. Based on the papers retrieved we have identified six areas for achieving efficiency gains throughout the entire care pathway and, for each area of efficiency, we have categorized the methods and outcome used to measure efficiency gain CONCLUSION: This is the first attempt to systematize a scattered body of literature on how to improve efficiency in cancer care and identify key areas to improve it. Based on the findings of the literature review and on the opinion of the experts involved in the consultation, we propose seven recommendations that are intended to improve efficiency in cancer care throughout the care pathway.

Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology

BACKGROUND

Implementing city-wide patient navigation processes that support patients across the continuum of cancer care is impeded by a lack of standardized tools to integrate workflows and reduce gaps in care. The authors present an actionable workflow process mapping protocol for navigation process planning and improvement based on methods developed for the Translating Research Into Practice study.

METHODS

Key stakeholders at each study site were identified through existing community partnerships, and data on each site's navigation processes were collected using mixed methods through a series of team meetings. The authors used Health Quality Ontario's Quality Improvement Guide, service design principles, and key stakeholder input to map the collected data onto a template structured according to the case-management model.

RESULTS

Data collection and process mapping exercises resulted in a 10-step protocol that includes: 1) workflow mapping procedures to guide data collection on the series of activities performed by health care personnel that comprise a patient's navigation experience, 2) a site survey to assess program characteristics, 3) a semistructured interview guide to assess care coordination workflows, 4) a site-level swim lane workflow process mapping template, and 5) a regional high-level process mapping template to aggregate data from multiple site-level process maps.

CONCLUSIONS

This iterative, participatory approach to data collection and process mapping can be used by improvement teams to streamline care coordination, ultimately improving the design and delivery of an evidence-based navigation model that spans multiple treatment modalities and multiple health systems in a metropolitan area. This protocol is presented as an actionable toolkit so the work may be replicated to support other quality-improvement initiatives and efforts to design truly patient-centered breast cancer treatment experiences.

LAY SUMMARY

Evidence-based patient navigation in breast cancer care requires the integration of services through each phase of cancer treatment. The Translating Research Into Practice study aims to implement patient navigation for patients with breast cancer who are at risk for delays and are seeking care across 6 health systems in Boston, Massachusetts. The authors designed a 10-step protocol outlining procedures and tools that support a systematic assessment for health systems that want to implement breast cancer patient navigation services for patients who are at risk for treatment delays.

Analysis of Applicator Insertion Related Acute Side Effects for Cervical Cancer Treated With Brachytherapy

Purpose

To report applicator insertion-related acute side effects during brachytherapy (BT) procedure for cervical cancer patients.

Materials and Methods

Between November 2017 and December 2019, 407 BT fractions were performed in 125 patients with locally advanced cervical cancer. Acute side effects recorded comprised anesthesia-related side effects, mechanical-related side effects and infection, whose frequency and degree were recorded. Pain was assessed using numeric rating scale; vaginal bleeding volume was counted by weighing gauze pieces used in packing. The BT procedure comprised eight stages: anesthesia, applicator insertion, image acquisition, transport, waiting for treatment, dose delivery, applicator removal, and removed which denoted 0.5-12.0 h period after removal, with time of each stage recorded. Factors influencing acute side effects were assessed by Spearman correlation and Mann-Whitney U test.

Results

The most common acute side effect was pain, followed by vaginal bleeding. The mean scores for pain were highest during removal time, 4.9 ± 1.6 points. The mean vaginal bleeding volume was 44.4 ml during removal time. Mean total procedure time was 218.8 (175-336) min, having positive relationship with frequency of acute side effects. The total procedure time with acute side effects was longer than that without acute side effects. The longest procedure time was waiting time, 113.0 (91.0-132.0) min. More needles generated higher pain scores and larger volume of vaginal bleeding.

Conclusion

Pain and vaginal bleeding were the most common acute side effects, especially during removal time, which physicians should focus on. Shortening patients' waiting time helps to reduce the total procedure time, thus, reduce acute side effects. While meeting dose requirement, less needles are helpful to reduce acute side effects.

Quantifying risk using FMEA: An alternate approach to AAPM TG-100 for scoring failures and evaluating clinical workflow

PURPOSE

Renovation of the brachytherapy program at a leading cancer center utilized methods of the AAPM TG-100 report to objectively evaluate current clinical brachytherapy workflows and develop techniques for minimizing the risk of failures, increasing efficiency, and consequently providing opportunities for improved treatment quality. The TG-100 report guides evaluation of clinical workflows with recommendations for identifying potential failure modes (FM) and scoring them from the perspective of their occurrence frequency O, failure severity S, and inability to detect them D. The current study assessed the impact of differing methods to determine the risk priority number (RPN) beyond simple multiplication.

METHODS AND MATERIALS

The clinical workflow for a complex brachytherapy procedure was evaluated by a team of 15 staff members, who identified discrete FM using alternate scoring scales than those presented in the TG-100 report. These scales were expanded over all clinically relevant possibilities with care to emphasize mitigation of natural bias for scoring near the median range as well as to enhance the overall scoring-system sensitivity. Based on staff member perceptions, a more realistic measure of risk was determined using weighted functions of their scores.

RESULTS

This new method expanded the range of RPN possibilities by a factor of 86, improving evaluation and recognition of safe and efficient clinical workflows. Mean RPN values for each FM decreased by 44% when changing from the old to the new clinical workflow, as evaluated using the TG-100 method. This decreased by 66% when evaluated with the new method. As a measure of the total risk associated with an entire clinical workflow, the integral of RPN values increased by 15% and decreased by 31% with the TG-100 and new methods, respectively.

CONCLUSIONS

This appears to be the first application of an alternate approach to the TG-100 method for evaluating the risk of clinical workflows. It exemplifies the risk analysis techniques necessary to rapidly evaluate simple clinical workflows appropriately.

Systems thinking for health emergencies: use of process mapping during outbreak response

Process mapping is a systems thinking approach used to understand, analyse and optimise processes within complex systems. We aim to demonstrate how this methodology can be applied during disease outbreaks to strengthen response and health systems. Process mapping exercises were conducted during three unique emerging disease outbreak contexts with different: mode of transmission, size, and health system infrastructure. System functioning improved considerably in each country. In Sierra Leone, laboratory testing was accelerated from 6 days to within 24 hours. In the Democratic Republic of Congo, time to suspected case notification reduced from 7 to 3 days. In Nigeria, key data reached the national level in 48 hours instead of 5 days. Our research shows that despite the chaos and complexities associated with emerging pathogen outbreaks, the implementation of a process mapping exercise can address immediate response priorities while simultaneously strengthening components of a health system.

Evaluation of an MR-only interstitial gynecologic brachytherapy workflow using MR-line marker for catheter reconstruction

PURPOSE

Magnetic resonance imaging (MRI) offers excellent soft-tissue contrast enabling the contouring of targets and organs at risk (OARs) during gynecological interstitial brachytherapy procedure. Despite its benefit, one of the main challenges toward MRI-only workflows is that the implanted catheters are not reliably visualized on MR images. This study aims to evaluate the feasibility of MR-only workflow using an in-house MR line marker during interstitial gynecological high-dose-rate (HDR) brachytherapy.

METHODS AND MATERIALS

Ten patients diagnosed with locally advanced cervical cancer treated with HDR brachytherapy were included in this study. The hybrid CT/MR-treated plan was used as the study reference plan. Five users manually reconstructed the catheter's path on MR images (3D T1- and T2-weighted). Subsequently, the dwell positions from the users' plans were superimposed on the reference plans to evaluate the dosimetric impact of the using MR-only for catheter reconstruction in comparison with hybrid CT/MR approach. Variability of dwell positions between users and reconstruction time was also evaluated.

RESULTS

More than 96.90% of catheter reconstruction variations were < 2 mm. No statistical differences were reported between MR-only and hybrid CT/MR in gross tumor volume D₉₈ and high-risk clinical target volume D₉₀, respectively. For the OARs (bladder, sigmoid, rectum, and bowel), no significant changes were observed in any dose metrics between MR-only and hybrid CT/MR. The average reconstruction time was 51 ± 10 minutes across all ten patients.

CONCLUSION

The feasibility of MR-only workflow using MR line marker during interstitial gynecological HDR brachytherapy has been validated in this study. The results show that the MR-only workflow is equivalent to the conventional hybrid CT/MR approach in terms of gross tumor volume and high-risk clinical target volume coverage and respecting of OARs dose limits.

Interstitial High-Dose-Rate Gynecologic Brachytherapy: Clinical Workflow Experience From Three Academic Institutions

An interstitial brachytherapy approach for gynecologic cancers is typically considered for patients with lesions exceeding 5 mm within tissue or that are not easily accessible for intracavitary applications. Recommendations for treating gynecologic malignancies with this approach are available through the American Brachytherapy Society, but vary based on available resources, staffing, and logistics. The intent of this manuscript is to share the collective experience of 3 academic centers that routinely perform interstitial gynecologic brachytherapy. Discussion points include indications for interstitial implants, procedural preparations, applicator selection, anesthetic options, imaging, treatment planning objectives, clinical workflows, timelines, safety, and potential challenges. Interstitial brachytherapy is a complex, high-skill procedure requiring routine practice to optimize patient safety and treatment efficacy. Clinics planning to implement this approach into their brachytherapy practice may benefit from considering the discussion points shared in this manuscript.

Workflow and efficiency in MRI-based high-dose-rate brachytherapy for cervical cancer in a high-volume brachytherapy center

PURPOSE

We report the clinical workflow and time required for MRI-based image-guided brachytherapy (MR-IGBT) of cervical cancer patients in a high-volume brachytherapy center with 10 years of experiences to provide a practical guideline for implementing MR-IGBT into clinical use.

METHODS AND MATERIALS

We recorded the time and workflow of each procedure step within the 40 consecutive ring and tandem applicator fractions of MR-IGBT by our multidisciplinary team. We divided the entire procedure into four sections based on where the procedure was performed: (1) applicator insertion under sedation, (2) MR imaging, (3) planning, and (4) treatment delivery. In addition, we compared the current procedure time to the initial procedure time when first implementing MR-IGBT in 2007-2008 via a retrospective review.

RESULTS

Mean total procedure time was 149.3 min (SD 17.9, ranges 112-178). The multidisciplinary team included an anesthesia team, radiologist, radiation oncologist, nurses, radiation therapists, MRI technicians, dosimetrists, and physicists. The mean procedure time and ranges for each section (min) were as follows: (1) 56.2 (28.0-103.0), (2) 31.0 (19.0-70.0), (3) 44.3 (21.0-104.0), and (4) 17.8 (9.0-34.0). Under current setting, the combined mean procedure time for MR imaging and planning was 63.2 min. In comparison, the same procedure took 137.7 min in 2007-2008 period, which was significantly longer than the current workflow (p < 0.001).

CONCLUSIONS

A skilled and dedicated multidisciplinary team is required for an efficient clinical workflow and delivery of MR-IGBT. Over the years, we have improved efficiency with clinical experience and continuous efforts in staff education.

Automated calculation of point A coordinates for CT-based high-dose-rate brachytherapy of cervical cancer

Purpose

The goal is to develop a stand-alone application, which automatically and consistently computes the coordinates of the dose calculation point recommended by the American Brachytherapy Society (i.e., point A) based solely on the implanted applicator geometry for cervical cancer brachytherapy.

Material and methods

The application calculates point A coordinates from the source dwell geometries in the computed tomography (CT) scans, and outputs the 3D coordinates in the left and right directions. The algorithm was tested on 34 CT scans of 7 patients treated with high-dose-rate (HDR) brachytherapy using tandem and ovoid applicators. A single experienced user retrospectively and manually inserted point A into each CT scan, whose coordinates were used as the “gold standard” for all comparisons. The gold standard was subtracted from the automatically calculated points, a second manual placement by the same experienced user, and the clinically used point coordinates inserted by multiple planners. Coordinate differences and corresponding variances were compared using nonparametric tests.

Results

Automatically calculated, manually placed, and clinically used points agree with the gold standard to < 1 mm, 1 mm, 2 mm, respectively. When compared to the gold standard, the average and standard deviation of the 3D coordinate differences were 0.35 ± 0.14 mm from automatically calculated points, 0.38 ± 0.21 mm from the second manual placement, and 0.71 ± 0.44 mm from the clinically used point coordinates. Both the mean and standard deviations of the 3D coordinate differences were statistically significantly different from the gold standard, when point A was placed by multiple users (p < 0.05) but not when placed repeatedly by a single user or when calculated automatically. There were no statistical differences in doses, which agree to within 1-2% on average for all three groups.

Conclusions

The study demonstrates that the automated algorithm calculates point A coordinates consistently, while reducing inter-user variability. Point placement using the algorithm expedites the planning process and minimizes associated potential human errors.

The value of systematic contouring of the bowel for treatment plan optimization in image-guided cervical cancer high-dose-rate brachytherapy

PURPOSE

To investigate the dose-volume histogram metrics and optimization results of the contoured bowel in cervical cancer brachytherapy.

METHODS AND MATERIALS

Treatment plans of cervical cancer patients treated with image-guided high dose rate were retrospectively analyzed with institutional review board approval. In addition to the clinical target volume, rectum, bladder, and sigmoid, the bowel was contoured at the time of planning (Group 1) or at the time of this analysis (Group 2).

RESULTS

Thirty-two patients treated with 145 insertions were included. Before optimization, mean ± 1 standard deviation overall bowel minimum dose to the most irradiated 2 cm³ volume of an organ (D_2cc) was 67.8 Gy_α/β3 ± 13.7 Gy_α/β3 (Group 1: 72.6 ± 13.2 Gy_α/β3; Group 2: 57.3 ± 8.0 Gy_α/β3). Before optimization, one patient in Group 1 presented a bowel D_2cc metric exceeding 100 Gy_α/β3. After optimization, bowel D_2cc mean ± 1 standard deviation was 59.4 ± 6.7 Gy_α/β3 (Group 1: 61.4 ± 6.0 Gy_α/β3, p < 0.001; Group 2: 55.2 ± 6.5 Gy_α/β3, p = 0.026).

CONCLUSIONS

Given the potentially high doses and the benefit of optimization in reducing dose to the organs at risk, we recommend consideration of systematic contouring of the bowel when bowel is present in the pelvis.

Guidelines by the AAPM and GEC-ESTRO on the use of innovative brachytherapy devices and applications: Report of Task Group 167

Although a multicenter, Phase III, prospective, randomized trial is the gold standard for evidence-based medicine, it is rarely used in the evaluation of innovative devices because of many practical and ethical reasons. It is usually sufficient to compare the dose distributions and dose rates for determining the equivalence of the innovative treatment modality to an existing one. Thus, quantitative evaluation of the dosimetric characteristics of innovative radiotherapy devices or applications is a critical part in which physicists should be actively involved. The physicist's role, along with physician colleagues, in this process is highlighted for innovative brachytherapy devices and applications and includes evaluation of (1) dosimetric considerations for clinical implementation (including calibrations, dose calculations, and radiobiological aspects) to comply with existing societal dosimetric prerequisites for sources in routine clinical use, (2) risks and benefits from a regulatory and safety perspective, and (3) resource assessment and preparedness. Further, it is suggested that any developed calibration methods be traceable to a primary standards dosimetry laboratory (PSDL) such as the National Institute of Standards and Technology in the U.S. or to other PSDLs located elsewhere such as in Europe. Clinical users should follow standards as approved by their country's regulatory agencies that approved such a brachytherapy device. Integration of this system into the medical source calibration infrastructure of secondary standard dosimetry laboratories such as the Accredited Dosimetry Calibration Laboratories in the U.S. is encouraged before a source is introduced into widespread routine clinical use. The American Association of Physicists in Medicine and the Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology (GEC-ESTRO) have developed guidelines for the safe and consistent application of brachytherapy using innovative devices and applications. The current report covers regulatory approvals, calibration, dose calculations, radiobiological issues, and overall safety concerns that should be addressed during the commissioning stage preceding clinical use. These guidelines are based on review of requirements of the U.S. Nuclear Regulatory Commission, U.S. Department of Transportation, International Electrotechnical Commission Medical Electrical Equipment Standard 60601, U.S. Food and Drug Administration, European Commission for CE Marking (Conformité Européenne), and institutional review boards and radiation safety committees.

Improving the efficiency of image guided brachytherapy in cervical cancer

Brachytherapy is an essential component of the treatment of locally advanced cervical cancers. It enables the dose to the tumor to be boosted whilst allowing relative sparing of the normal tissues. Traditionally, cervical brachytherapy was prescribed to point A but since the GEC-ESTRO guidelines were published in 2005, there has been a move towards prescribing the dose to a 3D volume. Image guided brachytherapy has been shown to reduce local recurrence, and improve survival and is optimally predicated on magnetic resonance imaging. Radiological studies, patient workflow, operative parameters, and intensive therapy planning can represent a challenge to clinical resources. This article explores the ways, in which 3D conformal brachytherapy can be implemented and draws findings from recent literature and a well-developed hospital practice in order to suggest ways to improve the efficiency and efficacy of a brachytherapy service. Finally, we discuss relatively underexploited translational research opportunities.

The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for "intensity modulated radiation therapy (IMRT)" as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.

MR-guided brachytherapy for cervical cancer: Quantifying process waste and identifying opportunities for system performance improvement

PURPOSE

The aim of this study was to evaluate the current cervical cancer magnetic resonance-guided brachytherapy (MRgBT) process in the study institution and seek opportunities to improve efficiency and optimize quality of care.

METHODS

Eight procedures were observed where the time, location, and activities performed by health care professionals were recorded using Lean method principles. Wastes, as defined within Lean methodology, were identified during the observation. Workflow was illustrated by process maps. Milestone activities were identified for final time analysis. Finally, the research team developed solutions by eliminating wastes in the workflow.

RESULTS

The mean procedure time ± standard deviation was 8.2 ± 0.41 hours, including 1.9 ± 0.18 hours spent on Lean wastes (84% waiting, 16% transportation). The most inefficient high-level activity was MRI with 1.1 hours spent on waiting and transportation. The parallel processing solution yields a 2.3 hours' time saving in each case. The optimal solution recommends an integrated MRgBT suite and dedicated human resource, yields a 4.1 hours' time saving (50% increase in efficiency) in each case.

CONCLUSION

This was the first study to quantify the performance of an MRgBT process. This study can serve as a template for other brachytherapy process improvements.

Parallelized patient-specific quality assurance for high-dose-rate image-guided brachytherapy in an integrated computed tomography-on-rails brachytherapy suite

PURPOSE

To describe a parallelized patient-specific quality assurance (QA) program designed to ensure safety and quality in image-guided high-dose-rate brachytherapy in an integrated computed tomography (CT)-on-rails brachytherapy suite.

MATERIALS AND METHODS

A patient-specific QA program has been modified for the image-guided brachytherapy (IGBT) program in an integrated CT-on-rails brachytherapy suite. In the modification of the QA procedures of Task Group-59, the additional patient-specific QA procedures are included to improve rapid IGBT workflow with applicator placement, imaging, planning, treatment, and applicator removal taking place in one room.

RESULTS

The IGBT workflow is partitioned into two groups of tasks that can be performed in parallel by two or more staff members. One of the unique components of our implemented workflow is that groups work together to perform QA steps in parallel and in series during treatment planning and contouring. Coordinating efforts in this systematic way enable rapid and safe brachytherapy treatment while incorporating 3-dimensional anatomic variations between treatment days.

CONCLUSIONS

Implementation of these patient-specific QA procedures in an integrated CT-on-rails brachytherapy suite ensures confidence that a rapid workflow IGBT program can be implemented without sacrificing patient safety or quality and deliver highly-conformal dose to target volumes. These patient-specific QA components may be adapted to other IGBT environments that seek to provide rapid workflow while ensuring quality.