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Li J, Wang D, Chan M. Predictive quality assurance for linear accelerator target failure using statistical process control. Biomed Phys Eng Express 2023; 9:055018. [PMID: 37437550 DOI: 10.1088/2057-1976/ace6a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/12/2023] [Indexed: 07/14/2023]
Abstract
The performance of a linear accelerator (Linac) depends on the integrity of its x-ray target. The sudden failure of its target not only breaks down the Linac but also could contribute significant disruptions to patient care. This work is to develop a predicative quality assurance (QA) method using Statistical Process Control (SPC) and AutoRegressive Integrated Moving Average (ARIMA) modeling to identify the risk of target failure before it occurs. In the past years, we observed two incidents of target failure among our Linacs. Retrospectively, we collected past daily QA data (from both open fields and enhanced dynamic wedge (EDW) measurements) and analyzed its historical trend using methods of SPC and ARIMA. SPC is a technique that monitors process performance based on statistical analysis. ARIMA is a time-series forecasting algorithm that can be used to estimate future values based on its past pattern. Both have been evaluated for predictive QA in radiotherapy. Application of SPC on open beam QA data would not yield an early warning signal to the pending target failures. However, when the same SPC methodology applies to EDW measurements, the control limits were breached a couple of weeks before the target failed. EDW mechanism introduces nonuniform magnification factors over its wedge-directed beam profiles and is responsible for the sensitivity of its profile to changing beam properties induced by a degrading target. Further extension of the warning period may be possible by using ARIMA modeling. Predicative QA for EDW daily data using SPC and ARIMA methods may provide an early QA warning to incoming Linac target failure.
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Affiliation(s)
- Jingdong Li
- Memorial Sloan-Kettering Cancer Center at Basking Ridge, NJ, United States of America
| | - Dongxu Wang
- Memorial Sloan-Kettering Cancer Center at Basking Ridge, NJ, United States of America
| | - Maria Chan
- Memorial Sloan-Kettering Cancer Center at Basking Ridge, NJ, United States of America
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Damyanovich AZ, Tadic T, Foltz WD, Jelveh S, Bissonnette JP. Time-course assessment of 3D-image distortion on the 1.5 T Marlin/Elekta Unity MR-LINAC. Phys Med 2022; 100:90-98. [PMID: 35777256 DOI: 10.1016/j.ejmp.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/04/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The efficacy of MR-guided radiotherapy on a MR-LINAC (MR-L) is dependent on the geometric accuracy of its MR images over clinically relevant Fields-of-View (FOVs). Our objectives were to: evaluate gradient non-linearity (GNL) on the Elekta Unity MR-L across time via 76 weekly measurements of 3D-distortion over concentrically larger diameter spherical volumes (DSVs); quantify distortion measurement error; and assess the temporal stability of spatial distortion using statistical process control (SPC). METHODS MR-image distortion was assessed using a large-FOV 3D-phantom containing 1932 markers embedded in seven parallel plates, spaced 25 mm × 25 mm in- and 55 mm through-plane. Automatically analyzed T1 images yielded distortions in 200, 300, 400 and 500 mm concentric DSVs. Distortion measurement error was evaluated using median absolute difference analysis of imaging repeatability tests. RESULTS Over the measurement period absolute time-averaged distortion varied between: dr = 0.30 - 0.49 mm, 0.53 - 0.80 mm, 1.0 - 1.4 mm and 2.28 - 2.37 mm, for DSVs 200, 300, 400 and 500 mm at the 98th percentile level. Repeatability tests showed that imaging/repositioning introduces negligible error: mean ≤ 0.02 mm (max ≤ 0.3 mm). SPC analysis showed image distortion was stable across all DSVs; however, noticeable changes in GNL were observed following servicing at the one-year mark. CONCLUSIONS Image distortion on the MR-L is in the sub-millimeter range for DSVs ≤ 300 mm and stable across time, with SPC analysis indicating all measurements remain within control for each DSV.
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Affiliation(s)
- Andrei Z Damyanovich
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada.
| | - Tony Tadic
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada
| | - Warren D Foltz
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada
| | - Salomeh Jelveh
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Jean-Pierre Bissonnette
- Department of Medical Physics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Techna Institute, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
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Mullins BT, Mazur L, Dance M, McGurk R, Schreiber E, Marks LB, Shen CJ, Lawrence MV, Chera BS. Common Error Pathways in CyberKnife™ Radiation Therapy. Front Oncol 2020; 10:1077. [PMID: 32733802 PMCID: PMC7360810 DOI: 10.3389/fonc.2020.01077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/29/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose/Objectives: Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) may be considered “high risk” due to the high doses per fraction. We analyzed CyberKnife™ (CK) SRS and SBRT-related incidents that were prospectively reported to our in-house incident learning system (ILS) in order to identify severity, contributing factors, and common error pathways. Material and Methods: From 2012 to 2019, 221 reported incidents related to the 4,569 CK fractions delivered (5.8%) were prospectively analyzed by our multi-professional Quality and Safety Committee with regard to severity, contributing factors, as well as the location where the incident occurred (tripped), where it was discovered (caught), and the safety barriers that were traversed (crossed) on the CK process map. Based on the particular step in the process map that incidents tripped, we categorized incidents into general error pathways. Results: There were 205 severity grade 1–2 (did not reach patient or no clinical impact), 11 grade 3 (clinical impact unlikely), 5 grade 4 (altered the intended treatment), and 0 grade 5–6 (life-threatening or death) incidents, with human performance being the most common contributing factor (79% of incidents). Incidents most commonly tripped near the time when the practitioner requested CK simulation (e.g., pre-CK simulation fiducial marker placement) and most commonly caught during the physics pre-treatment checklist. The four general error pathways included pre-authorization, billing, and scheduling issues (n= 119); plan quality (n= 30); administration of IV contrast during simulation or pre-medications during treatment (n= 22); and image guidance (n= 12). Conclusion: Most CK incidents led to little or no patient harm and most were related to billing and scheduling issues. Suboptimal human performance appeared to be the most common contributing factor to CK incidents. Additional study is warranted to develop and share best practices to reduce incidents to further improve patient safety.
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Affiliation(s)
- Brandon T Mullins
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Lukasz Mazur
- Division of Healthcare Engineering, Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.,Carolina Health Informatics Program, School of Information and Library Science, University of North Carolina, Chapel Hill, NC, United States
| | - Michael Dance
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Ross McGurk
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Eric Schreiber
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Michael V Lawrence
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Bhishamjit S Chera
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
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Niñerola A, Sánchez-Rebull MV, Hernández-Lara AB. Quality improvement in healthcare: Six Sigma systematic review. Health Policy 2020; 124:438-445. [DOI: 10.1016/j.healthpol.2020.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 12/19/2019] [Accepted: 01/02/2020] [Indexed: 12/26/2022]
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Pal B, Pal A, Das S, Palit S, Sarkar P, Mondal S, Mallik S, Goswami J, Das S, Sen A, Mondol M. Retrospective study on performance of constancy check device in Linac beam monitoring using Statistical Process Control. Rep Pract Oncol Radiother 2020; 25:91-99. [PMID: 32617079 PMCID: PMC7315042 DOI: 10.1016/j.rpor.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/24/2019] [Accepted: 12/02/2019] [Indexed: 11/21/2022] Open
Abstract
AIM To examine the application of Statistical Process Control (SPC) and Ishikawa diagrams for retrospective evaluation of machine Quality Assurance (QA) performance in radiotherapy. BACKGROUND SPC is a popular method for supplementing the performance of QA techniques in healthcare. This work investigates the applicability of SPC techniques and Ishikawa charts in machine QA. MATERIALS AND METHODS SPC has been applied to recommend QA limits on the particular beam parameters using the QUICKCHECK webline QA portable constancy check device for 6 MV and 10 MV flattened photon beams from the Elekta Versa HD linear accelerator (Linac). Four machine QA parameters - beam flatness, beam symmetry along gun target direction and left-right direction, and beam quality factor (BQF) - were selected for retrospective analysis. Shewhart charts, Exponentially Weighted Moving Average (EWMA) charts and Cumulative Sum (CUSUM) charts were obtained for each parameter. The root causes for a failure in machine QA were broken down into an Ishikawa diagram enabling the user to identify the root cause of error and rectify the problem subsequently. RESULTS Shewhart charts and EWMA charts applied could detect loss in control in one variable in the 6 MV beams and in all four variables in 10 MV beams. CUSUM charts detected offsets in the readings. The Ishikawa chart exhaustively included the possible errors that lead to loss of control. CONCLUSION SPC is proven to be effective for detection of loss in control in machine QA. The Ishikawa chart provides the set of probable root causes of machine error useful while troubleshooting.
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Affiliation(s)
- Bipasha Pal
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Angshuman Pal
- Department of Mechanical Engineering, Jadavpur University, 188 Raja SC Mallick Road, Kolkata 700032, West Bengal, India
| | - Suresh Das
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Soura Palit
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Papai Sarkar
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Subhayan Mondal
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Suman Mallik
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Jyotirup Goswami
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Sayan Das
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Arijit Sen
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
| | - Monidipa Mondol
- Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah 711103, West Bengal, India
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Pawlicki T, Mundt AJ. Continued emphasis on quality and safety jeopardizes clinical medical physics careers in radiation oncology: What can be done about it? J Appl Clin Med Phys 2019; 20:4-6. [PMID: 30680931 PMCID: PMC6370986 DOI: 10.1002/acm2.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Todd Pawlicki
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA
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Ezezika J, Easton L, Chung H, Barbera L, Ravi A, Hill-Mugford D, Vesprini D, D'Alimonte L. Going Lean to Improve the Patient Experience in a High-Throughput Brachytherapy Program. J Med Imaging Radiat Sci 2018; 49:130-135. [PMID: 32074030 DOI: 10.1016/j.jmir.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/13/2018] [Accepted: 03/13/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE This article describes how a targeted application of Lean methodology in a high-volume brachytherapy department can result in significant and sustained change that benefits patients and staff. METHODS AND MATERIALS In November 2013, staff and physicians carried out a 3-day Kaizen (rapid improvement) Event with three identified goals: to reduce same-day patient wait times, to reduce staff-hours spent scheduling patients, and to increase the utilization of the brachytherapy operating room (OR). RESULTS At the Lean Event, staff drew up a future state that included a standard booking process (standard booking times for procedures, a booking guideline, and OR schedule reviews) and shortly after the event, time checks, or procedure checkpoints, were introduced to make teams aware of how each case proceeds through key milestones. The implementation of these changes led to a reduction in the average same-day wait times for patients by 37 minutes and 2 seconds and eliminated the need for a team of seven to eight staff to meet weekly to create a feasible OR schedule. Instead, a team of two to three reviews the schedule with the goal of optimizing the utilization of the OR on anesthesia-staffed days and, as a result, OR utilization has gone from 59% to 97%. CONCLUSIONS By using Lean methodology and by emphasizing the Lean concepts of measurement, standardization, simplification, and staff participation, the Brachytherapy Leadership team was able to address barriers to change and improve the department's quality metrics. If an institution has to choose between starting on a small-scale project with Lean or not at all, organizations are encouraged to start with a targeted application of Lean and then expand by conducting research on quality and/or striking a quality improvement committee.
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Affiliation(s)
- Jacqueline Ezezika
- Department of Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Linda Easton
- Department of Radiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hans Chung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Barbera
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ananth Ravi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Diane Hill-Mugford
- Department of Nursing, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danny Vesprini
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Laura D'Alimonte
- Department of Radiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Nguyen CM, Baydush AH, Ververs JD, Isom S, Able CM, Munley MT. Operational consistency of medical linear accelerators manufactured and commissioned in series. Tech Innov Patient Support Radiat Oncol 2018; 7:6-10. [PMID: 32095575 PMCID: PMC7033762 DOI: 10.1016/j.tipsro.2018.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022] Open
Abstract
The purpose of this study was to determine if medical linear accelerators (linac) produced by the same manufacturer exhibit operational consistency within their subsystems and components. Two linacs that were commissioned together and installed at the same facility were monitored. Each machine delivered a daily robust quality assurance (QA) irradiation. Linacs and their components operate consistently, but have different operational parameter levels even when produced by the same manufacturer and commissioned in series. These findings have implications on the feasibility of true clinical beam matching.
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Affiliation(s)
- Callistus M Nguyen
- Biomedical Engineering, Virginia Tech - Wake Forest School of Biomedical Engineering and Sciences, 575 N. Patterson Ave, Winston-Salem, NC 27101, United States.,Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - Alan H Baydush
- Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - James D Ververs
- Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - Scott Isom
- Biostatistical Sciences, Wake Forest School of Medicine, 525 Vine Street, Winston-Salem, NC 27101, United States
| | - Charles M Able
- Radiation Oncology, Florida Cancer Specialists and Research Institute, 8763 River Crossing Boulevard, New Port Richey, FL 34655, United States
| | - Michael T Munley
- Biomedical Engineering, Virginia Tech - Wake Forest School of Biomedical Engineering and Sciences, 575 N. Patterson Ave, Winston-Salem, NC 27101, United States.,Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States
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Shiraishi S, Grams MP, Fong de los Santos LE. Image-guided radiotherapy quality control: Statistical process control using image similarity metrics. Med Phys 2018. [DOI: 10.1002/mp.12859] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Satomi Shiraishi
- Department of Radiation Oncology; Mayo Clinic; 200 First St SW Rochester MN 55905 USA
| | - Michael P. Grams
- Department of Radiation Oncology; Mayo Clinic; 200 First St SW Rochester MN 55905 USA
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Damyanovich AZ, Rieker M, Zhang B, Bissonnette JP, Jaffray DA. Design and implementation of a 3D-MR/CT geometric image distortion phantom/analysis system for stereotactic radiosurgery. ACTA ACUST UNITED AC 2018; 63:075010. [DOI: 10.1088/1361-6560/aab33e] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Data-driven management using quantitative metric and automatic auditing program (QMAP) improves consistency of radiation oncology processes. Pract Radiat Oncol 2016; 7:e215-e222. [PMID: 28110939 DOI: 10.1016/j.prro.2016.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 10/12/2016] [Accepted: 10/19/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE Process consistency in planning and delivery of radiation therapy is essential to maintain patient safety and treatment quality and efficiency. Ensuring the timely completion of each critical clinical task is one aspect of process consistency. The purpose of this work is to report our experience in implementing a quantitative metric and automatic auditing program (QMAP) with a goal of improving the timely completion of critical clinical tasks. METHODS AND MATERIALS Based on our clinical electronic medical records system, we developed a software program to automatically capture the completion timestamp of each critical clinical task while providing frequent alerts of potential delinquency. These alerts were directed to designated triage teams within a time window that would offer an opportunity to mitigate the potential for late completion. Since July 2011, 18 metrics were introduced in our clinical workflow. We compared the delinquency rates for 4 selected metrics before the implementation of the metric with the delinquency rate of 2016. One-tailed Student t test was used for statistical analysis RESULTS: With an average of 150 daily patients on treatment at our main campus, the late treatment plan completion rate and late weekly physics check were reduced from 18.2% and 8.9% in 2011 to 4.2% and 0.1% in 2016, respectively (P < .01). The late weekly on-treatment physician visit rate was reduced from 7.2% in 2012 to <1.6% in 2016. The yearly late cone beam computed tomography review rate was reduced from 1.6% in 2011 to <0.1% in 2016. CONCLUSIONS QMAP is effective in reducing late completions of critical tasks, which can positively impact treatment quality and patient safety by reducing the potential for errors resulting from distractions, interruptions, and rush in completion of critical tasks.
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Potters L, Ford E, Evans S, Pawlicki T, Mutic S. A Systems Approach Using Big Data to Improve Safety and Quality in Radiation Oncology. Int J Radiat Oncol Biol Phys 2015; 95:885-889. [PMID: 27302504 DOI: 10.1016/j.ijrobp.2015.10.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/06/2015] [Accepted: 10/12/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Louis Potters
- Department of Radiation Medicine, Northwell Health and Hofstra Northwell School of Medicine, Lake Success, New York.
| | - Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Suzanne Evans
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Todd Pawlicki
- Department of Radiation Oncology, University of California San Diego, San Diego, California
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
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Crema M, Verbano C. Investigating the connections between health lean management and clinical risk management. Int J Health Care Qual Assur 2015; 28:791-811. [DOI: 10.1108/ijhcqa-03-2015-0029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to investigate connections and overlaps between health lean management (HLM) and clinical risk management (CRM) understanding whether and how these two approaches can be combined together to pursue efficiency and patient safety improvements simultaneously.
Design/methodology/approach
– A systematic literature review has been carried out. Searching in academic databases, papers that focus not only on HLM, but also on clinical errors and risk reduction, were included. The general characteristics of the selected papers were analysed and a content analysis was conducted.
Findings
– In most of the papers, pursing objectives of HLM and CRM and adopting tools and practices of both approaches, results of quality and, particularly, of safety improvements were obtained. A two-way arrow between HLM and CRM emerged but so far, none of the studies has been focused on the relationship between HLM and CRM.
Originality/value
– Results highlight an emerging research stream, with many useful theoretical and practical implications and opportunities for further research.
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Mazur L, Chera B, Mosaly P, Taylor K, Tracton G, Johnson K, Comitz E, Adams R, Pooya P, Ivy J, Rockwell J, Marks LB. The association between event learning and continuous quality improvement programs and culture of patient safety. Pract Radiat Oncol 2015; 5:286-294. [DOI: 10.1016/j.prro.2015.04.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/27/2015] [Accepted: 04/30/2015] [Indexed: 11/28/2022]
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Analysis of an inter-centre, web-based radiation oncology peer-review case conference. JOURNAL OF RADIOTHERAPY IN PRACTICE 2015. [DOI: 10.1017/s1460396915000102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurposePeer-review programmes in radiation oncology are used to facilitate the process and evaluation of clinical decision-making. However, web-based peer-review methods are still uncommon. This study analysed an inter-centre, web-based peer-review case conference as a method of facilitating the decision-making process in radiation oncology.MethodologyA benchmark form was designed based on the American Society for Radiation Oncology targets for radiation oncology peer review. This was used for evaluating the contents of the peer-review case presentations on 40 cases, selected from three participating radiation oncology centres. A scoring system was used for comparison of data, and a survey was conducted to analyse the experiences of radiation oncology professionals who attended the web-based peer-review meetings in order to identify priorities for improvement.ResultsThe mean scores for the evaluations were 82·7, 84·5, 86·3 and 87·3% for cervical, prostate, breast and head and neck presentations, respectively. The survey showed that radiation oncology professionals were confident about the role of web-based peer-reviews in facilitating sharing of good practice, stimulating professionalism and promoting professional growth. The participants were satisfied with the quality of the audio and visual aspects of the web-based meeting.ConclusionThe results of this study suggest that simple inter-centre web-based peer-review case conferences are a feasible technique for peer review in radiation oncology. Limitations such as data security and confidentiality can be overcome by the use of appropriate structure and technology. To drive the issues of quality and safety a step further, small radiotherapy departments may need to consider web-based peer-review case conference as part of their routine quality assurance practices.
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Pawlicki T, Potters L. Research on Quality and Safety: What Are We Missing? Int J Radiat Oncol Biol Phys 2015; 91:17-9. [DOI: 10.1016/j.ijrobp.2014.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/06/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
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Gagneur JD, Ezzell GA. An improvement in IMRT QA results and beam matching in linacs using statistical process control. J Appl Clin Med Phys 2014; 15:4927. [PMID: 25207579 PMCID: PMC5711098 DOI: 10.1120/jacmp.v15i5.4927] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 06/12/2014] [Accepted: 06/02/2014] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study is to apply the principles of statistical process control (SPC) in the context of patient specific intensity‐modulated radiation therapy (IMRT) QA to set clinic‐specific action limits and evaluate the impact of changes to the multileaf collimator (MLC) calibrations on IMRT QA results. Ten months of IMRT QA data with 247 patient QAs collected on three beam‐matched linacs were retrospectively analyzed with a focus on the gamma pass rate (GPR) and the average ratio between the measured and planned doses. Initial control charts and action limits were calculated. Based on this data, changes were made to the leaf gap parameter for the MLCs to improve the consistency between linacs. This leaf gap parameter is tested monthly using a MLC sweep test. A follow‐up dataset with 424 unique QAs were used to evaluate the impact of the leaf gap parameter change. The initial data average GPR was 98.6% with an SPC action limit of 93.7%. The average ratio of doses was 1.003, with an upper action limit of 1.017 and a lower action limit of 0.989. The sweep test results for the linacs were ‐1.8%,0%, and +1.2% from nominal. After the adjustment of the leaf gap parameter, all sweep test results were within 0.4% of nominal. Subsequently, the average GPR was 99.4% with an SPC action limit of 97.3%. The average ratio of doses was 0.997 with an upper action limit of 1.011 and a lower action limit of 0.981. Applying the principles of SPC to IMRT QA allowed small differences between closely matched linacs to be identified and reduced. Ongoing analysis will monitor the process and be used to refine the clinical action limits for IMRT QA. PACS number: 87.55.Qr
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Hoisak JDP, Pawlicki T, Kim GY, Fletcher R, Moore KL. Improving linear accelerator service response with a real- time electronic event reporting system. J Appl Clin Med Phys 2014; 15:4807. [PMID: 25207564 PMCID: PMC5711091 DOI: 10.1120/jacmp.v15i5.4807] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 05/08/2014] [Accepted: 04/24/2014] [Indexed: 11/23/2022] Open
Abstract
To track linear accelerator performance issues, an online event recording system was developed in-house for use by therapists and physicists to log the details of technical problems arising on our institution's four linear accelerators. In use since October 2010, the system was designed so that all clinical physicists would receive email notification when an event was logged. Starting in October 2012, we initiated a pilot project in collaboration with our linear accelerator vendor to explore a new model of service and support, in which event notifications were also sent electronically directly to dedicated engineers at the vendor's technical help desk, who then initiated a response to technical issues. Previously, technical issues were reported by telephone to the vendor's call center, which then disseminated information and coordinated a response with the Technical Support help desk and local service engineers. The purpose of this work was to investigate the improvements to clinical operations resulting from this new service model. The new and old service models were quantitatively compared by reviewing event logs and the oncology information system database in the nine months prior to and after initiation of the project. Here, we focus on events that resulted in an inoperative linear accelerator ("down" machine). Machine downtime, vendor response time, treatment cancellations, and event resolution were evaluated and compared over two equivalent time periods. In 389 clinical days, there were 119 machine-down events: 59 events before and 60 after introduction of the new model. In the new model, median time to service response decreased from 45 to 8 min, service engineer dispatch time decreased 44%, downtime per event decreased from 45 to 20 min, and treatment cancellations decreased 68%. The decreased vendor response time and reduced number of on-site visits by a service engineer resulted in decreased downtime and decreased patient treatment cancellations.
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Radiation therapist peer review: raising the bar on quality and safety in radiation oncology. JOURNAL OF RADIOTHERAPY IN PRACTICE 2014. [DOI: 10.1017/s1460396914000132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurposeAn emerging developmental tool to help radiation therapists achieve better outcomes is ‘peer review’. This review of the current literature summarises the challenges and benefits of peer review in both individual and departmental practice.DiscussionThere is compelling evidence supporting peer review implementation at both individual and department level in many professions. Implementing peer review requires that radiation therapists and other radiation oncology professionals embrace a culture that supports safety. Peer review can identify trends and barriers associated with quality radiotherapy and share best practice or recommend changes accordingly. Support for peer review must come from pre-registration educational systems as well as clinical managers. Continuing professional development in the workplace is nurtured by peer review of radiotherapy practice and an aptitude for this should be viewed as important to the profession as technical and clinical skills.ConclusionIt is clear that peer review has the potential to facilitate reflective practice, improve staff motivation and help foster a culture of quality and safety in radiation oncology. To drive the issues of quality and safety a step further radiation therapists need to accept the challenge of adopting peer review methods in day-to-day practice.
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Crema M, Verbano C. Guidelines for overcoming hospital managerial challenges: a systematic literature review. Ther Clin Risk Manag 2013; 9:427-41. [PMID: 24307833 PMCID: PMC3845536 DOI: 10.2147/tcrm.s54178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The need to respond to accreditation institutes' and patients' requirements and to align health care results with increased medical knowledge is focusing greater attention on quality in health care. Different tools and techniques have been adopted to measure and manage quality, but clinical errors are still too numerous, suggesting that traditional quality improvement systems are unable to deal appropriately with hospital challenges. The purpose of this paper is to grasp the current tools, practices, and guidelines adopted in health care to improve quality and patient safety and create a base for future research on this young subject. METHODS A systematic literature review was carried out. A search of academic databases, including papers that focus not only on lean management, but also on clinical errors and risk reduction, yielded 47 papers. The general characteristics of the selected papers were analyzed, and a content analysis was conducted. RESULTS A variety of managerial techniques, tools, and practices are being adopted in health care, and traditional methodologies have to be integrated with the latest ones in order to reduce errors and ensure high quality and patient safety. As it has been demonstrated, these tools are useful not only for achieving efficiency objectives, but also for providing higher quality and patient safety. Critical indications and guidelines for successful implementation of new health managerial methodologies are provided and synthesized in an operative scheme useful for extending and deepening knowledge of these issues with further studies. CONCLUSION This research contributes to introducing a new theme in health care literature regarding the development of successful projects with both clinical risk management and health lean management objectives, and should address solutions for improving health care even in the current context of decreasing resources.
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Affiliation(s)
- Maria Crema
- Department of Management and Engineering, University of Padova, Vicenza, Italy
| | - Chiara Verbano
- Department of Management and Engineering, University of Padova, Vicenza, Italy
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Cheung FWK, Law MYY. A novel conformity index for intensity modulated radiation therapy plan evaluation. Med Phys 2012; 39:5740-56. [PMID: 22957639 DOI: 10.1118/1.4742848] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Intensity modulated radiation therapy (IMRT) has gained popularity in the treatment of cancers. Manual evaluation of IMRT plans for head-and-neck cancers has been especially challenging necessitating efficient and objective assessment tools. In this work, the authors address this issue by developing a personalized conformity index (CI) for comparison of IMRT plans for head-and-neck cancers and evaluating its plan quality discerning power in comparison with other widely used CIs. METHODS A two-dimensional CI with dose and distance incorporated (CI(DD)) was developed using the MATLAB program language, to quantify the planning target volume (PTV) coverage. Valuable information contained in the digital imaging and communication in medicine (DICOM) RT objects were harvested for computation of each of the CI(DD) components. Apart from the dose penalty factor, a distance-based exponential function was employed by varying the penalty weight associated with the location of cold spots within the PTV. With the goal of deriving a customized penalty factor, the distances between individual pixel and its nearest PTV boundary was found. Using the exponential function, the impact of distance penalty was substantially larger for cold spots closer to the PTV centroid but petered out quickly wherever they were situated in the vicinity of PTV border. In order to evaluate the CI(DD) scoring system, three CT image data sets of nasopharyngeal carcinoma (NPC) patients were collected. Ten IMRT plans with degrading qualities were generated from each dataset and were ranked based on CI(DD) and other existing indices. The coefficient of variance was calculated for each dataset to compare the degree of variation. RESULTS The CI(DD) scoring system that considered spatial importance of each voxel within the PTV was successfully developed. The results demonstrated that the CI(DD) including four discrete factors could provide accurate rankings of plan quality by examining the relative importance of each cold spot within the PTVs. Apart from the dose penalty factor, a distance-based exponential function was employed taking the specific tumor geometry into account. Compared with other commonly used CIs, the CI(DD) resulted in the largest coefficient of variance among the ten IMRT plans for each dataset, indicating that its discerning power was the best among the CIs being compared. CONCLUSIONS The CI(DD) scoring system was successfully developed to incorporate patient-specific spatial dose information and provide a geometry-based physical index for comparison of IMRT plans for head-and-neck cancers. By taking individual tumor geometry into account, the superiority of CI(DD) in plan discerning power was demonstrated. The use of CI(DD) could provide an effective means of benchmarking performance, reducing treatment plan variability, and advancing the quality of current IMRT planning.
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Affiliation(s)
- Fion W K Cheung
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong.
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Harrison AS, Yu Y, Dicker AP, Doyle LA. Using Qualitative Measures to Improve Quality in Radiation Oncology. Am J Med Qual 2012; 28:345-51. [DOI: 10.1177/1062860612461826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Amy S Harrison
- Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA 19107, USA.
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Abstract
Despite many studies over the last 3 decades that have attempted to explicitly quantify the decision-making process for radiotherapy treatment plan evaluation, judgments of an individual plan's degree of quality are still largely subjective and can show inter- and intra-practitioner variability even if the clinical treatment goals are the same. Several factors conspire to confound the full quantification of treatment plan quality, including uncertainties in dose response of cancerous and normal tissue, the rapid pace of new technology adoption, and the human component of treatment planning. However, new developments in clinical informatics and automation are lowering the bar for developing and implementing quantitative metrics into the treatment planning process. This review discusses general strategies for using quantitative metrics in the treatment planning process and presents a case study in intensity-modulated radiation therapy planning whereby control was established on a variable system via such techniques.
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Affiliation(s)
- Kevin L Moore
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO 63110, USA.
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Bujold A, Craig T, Jaffray D, Dawson LA. Image-guided radiotherapy: has it influenced patient outcomes? Semin Radiat Oncol 2012; 22:50-61. [PMID: 22177878 DOI: 10.1016/j.semradonc.2011.09.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cancer control and toxicity outcomes are the mainstay of evidence-based medicine in radiation oncology. However, radiotherapy is an intricate therapy involving numerous processes that need to be executed appropriately in order for the therapy to be delivered successfully. The use of image-guided radiation therapy (IGRT), referring to imaging occurring in the radiation therapy room with per-patient adjustments, can increase the agreement between the planned and the actual dose delivered. However, the absence of direct evidence regarding the clinical benefit of IGRT has been a criticism. Here, we dissect the role of IGRT in the radiotherapy (RT) process and emphasize its role in improving the quality of the intervention. The literature is reviewed to collect evidence that supports that higher-quality dose delivery enabled by IGRT results in higher clinical control rates, reduced toxicity, and new treatment options for patients that previously were without viable options.
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Affiliation(s)
- Alexis Bujold
- Département de Radio-Oncologie Clinique-Enseignement-Recherche, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Canada.
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Jagsi R, Bekelman JE, Brawley OW, Deasy JO, Le QT, Michalski JM, Movsas B, Thomas CR, Lawton CA, Lawrence TS, Hahn SM. A research agenda for radiation oncology: results of the radiation oncology institute's comprehensive research needs assessment. Int J Radiat Oncol Biol Phys 2012; 84:318-22. [PMID: 22436790 DOI: 10.1016/j.ijrobp.2011.11.076] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 11/22/2011] [Accepted: 11/22/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE To promote the rational use of scarce research funding, scholars have developed methods for the systematic identification and prioritization of health research needs. The Radiation Oncology Institute commissioned an independent, comprehensive assessment of research needs for the advancement of radiation oncology care. METHODS AND MATERIALS The research needs assessment used a mixed-method, qualitative and quantitative social scientific approach, including structured interviews with diverse stakeholders, focus groups, surveys of American Society for Radiation Oncology (ASTRO) members, and a prioritization exercise using a modified Delphi technique. RESULTS Six co-equal priorities were identified: (1) Identify and develop communication strategies to help patients and others better understand radiation therapy; (2) Establish a set of quality indicators for major radiation oncology procedures and evaluate their use in radiation oncology delivery; (3) Identify best practices for the management of radiation toxicity and issues in cancer survivorship; (4) Conduct comparative effectiveness studies related to radiation therapy that consider clinical benefit, toxicity (including quality of life), and other outcomes; (5) Assess the value of radiation therapy; and (6) Develop a radiation oncology registry. CONCLUSIONS To our knowledge, this prioritization exercise is the only comprehensive and methodologically rigorous assessment of research needs in the field of radiation oncology. Broad dissemination of these findings is critical to maximally leverage the impact of this work, particularly because grant funding decisions are often made by committees on which highly specialized disciplines such as radiation oncology are not well represented.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA.
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Our Pledge to Achieve Safety. Int J Radiat Oncol Biol Phys 2012; 82:1310-1. [DOI: 10.1016/j.ijrobp.2011.10.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 10/01/2011] [Accepted: 10/20/2011] [Indexed: 11/16/2022]
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de la Vega JM, Martínez-Luna RJ, Guirado D, Vilches M, Lallena AM. Statistical control of the spectral quality index in electron beams. Radiother Oncol 2012; 102:406-11. [DOI: 10.1016/j.radonc.2011.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 08/02/2011] [Accepted: 08/10/2011] [Indexed: 10/17/2022]
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Herruzo I, Romero J, Palacios A, Mañas A, Samper P, Bayo E, Guedea F. The white book of radiation oncology in Spain. Clin Transl Oncol 2011; 13:385-95. [PMID: 21680299 DOI: 10.1007/s12094-011-0672-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The White Book of Radiation Oncology provides a comprehensive overview of the current state of the speciality of radiation oncology in Spain and is intended to be used as a reference for physicians, health care administrators and hospital managers. The present paper summarises the most relevant aspects of the book's 13 chapters in order to bring the message to a wider audience. Among the topics discussed are the epidemiology of cancer in Spain, the role of the radiation oncologist in cancer care, human and material resource needs, new technologies, training of specialists, clinical and cost management, clinical practice, quality control, radiological protection, ethics, relevant legislation, research & development, the history of radiation oncology in Spain and the origins of the Spanish Society of Radiation Oncology (SEOR).
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Kapur A, Potters L. Six sigma tools for a patient safety-oriented, quality-checklist driven radiation medicine department. Pract Radiat Oncol 2011; 2:86-96. [PMID: 24674084 DOI: 10.1016/j.prro.2011.06.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 06/03/2011] [Accepted: 06/13/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The purpose of this work was to develop and implement six sigma practices toward the enhancement of patient safety in an electronic, quality checklist-driven, multicenter, paperless radiation medicine department. METHODS AND MATERIALS A quality checklist process map (QPM), stratified into consultation through treatment-completion stages was incorporated into an oncology information systems platform. A cross-functional quality management team conducted quality-function-deployment and define-measure-analyze-improve-control (DMAIC) six sigma exercises with a focus on patient safety. QPM procedures were Pareto-sorted in order of decreasing patient safety risk with failure mode and effects analysis (FMEA). Quantitative metrics for a grouped set of highest risk procedures were established. These included procedural delays, associated standard deviations and six sigma Z scores. Baseline performance of the QPM was established over the previous year of usage. Data-driven analysis led to simplification, standardization, and refinement of the QPM with standard deviation, slip-day reduction, and Z-score enhancement goals. A no-fly policy (NFP) for patient safety was introduced at the improve-control DMAIC phase, with a process map interlock imposed on treatment initiation in the event of FMEA-identified high-risk tasks being delayed or not completed. The NFP was introduced in a pilot phase with specific stopping rules and the same metrics used for performance assessments. A custom root-cause analysis database was deployed to monitor patient safety events. RESULTS Relative to the baseline period, average slip days and standard deviations for the risk-enhanced QPM procedures improved by over threefold factors in the NFP period. The Z scores improved by approximately 20%. A trend for proactive delays instead of reactive hard stops was observed with no adverse effects of the NFP. The number of computed potential no-fly delays per month dropped from 60 to 20 over a total of 520 cases. The fraction of computed potential no-fly cases that were delayed in NFP compliance rose from 28% to 45%. Proactive delays rose to 80% of all delayed cases. For potential no-fly cases, event reporting rose from 18% to 50%, while for actually delayed cases, event reporting rose from 65% to 100%. CONCLUSIONS With complex technologies, resource-compromised staff, and pressures to hasten treatment initiation, the use of the six sigma driven process interlocks may mitigate potential patient safety risks as demonstrated in this study.
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Affiliation(s)
- Ajay Kapur
- Department of Radiation Medicine, North Shore-Long Island Jewish Health System, New Hyde Park, New York.
| | - Louis Potters
- Department of Radiation Medicine, North Shore-Long Island Jewish Health System, New Hyde Park, New York
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Chung JB, Kim JS, Ha SW, Ye SJ. Statistical analysis of IMRT dosimetry quality assurance measurements for local delivery guideline. Radiat Oncol 2011; 6:27. [PMID: 21439096 PMCID: PMC3073875 DOI: 10.1186/1748-717x-6-27] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 03/28/2011] [Indexed: 11/25/2022] Open
Abstract
Purpose To establish our institutional guideline for IMRT delivery, we statistically evaluated the results of dosimetry quality assurance (DQA) measurements and derived local confidence limits using the concept confidence limit of |mean|+1.96σ. Materials and methods From June 2006 to March 2009, 206 patients with head and neck cancer, prostate cancer, liver cancer, or brain tumor were treated using LINAC-based IMRT technique. In order to determine site specific DQA tolerances at a later stage, a hybrid plan with the same fluence maps as in the treatment plan was generated on CT images of a cylindrical phantom of acryl. Points of measurement using a 0.125 cm3 ion-chamber were typically located in the region of high and uniform doses. The planar dose distributions perpendicular to the central axis were measured by using a diode array in solid water with all fields delivered, and assessed using gamma criteria of 3%/3 mm. The mean values and standard deviations were used to develop the local confidence and tolerance limits. The dose differences and gamma pass rates for the different treatment sites were also evaluated in terms of total monitor uints (MU), MU/cGy, and the number of PTV's pieces. Results The mean values and standard deviations of ion-chamber dosimetry differences between calculated and measured doses were -1.6 ± 1.2% for H&N cancer, -0.4 ± 1.2% for prostate and abdominal cancer, and -0.6 ± 1.5% for brain tumor. Most of measured doses (92.2%) agreed with the calculated doses within a tolerance limit of ±3% recommended in the literature. However, we found some systematic under-dosage for all treatment sites. The percentage of points passing the gamma criteria, averaged over all treatment sites was 97.3 ± 3.7%. The gamma pass rate and the agreement of ion-chamber dosimetry generally decreased with increasing the number of PTV's pieces, the degree of modulation (MU/cGy), and the total MU beyond 700. Our local confidence limits were comparable to those of AAPM TG 119 and ESTRO guidelines that were provided as a practical baseline for center-to-center commissioning comparison. Thus, our institutional confidence and action limits for IMRT delivery were set into the same levels of those guidelines. Discussion and Conclusions The systematic under-dosage were corrected by tuning up the MLC-related factors (dosimetric gap and transmission) in treatment planning system (TPS) and further by incorporating the tongue-and groove effect into TPS. Institutions that have performed IMRT DQA measurements over a certain period of time need to analyze their accrued DQA data. We confirmed the overall integrity of our IMRT system and established the IMRT delivery guideline during this procedure. Dosimetric corrections for the treatment plans outside of the action level can be suggested only with such rigorous DQA and statistical analysis.
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Affiliation(s)
- Jin Beom Chung
- Department of Radiation Oncology, Seoul National University Bundang Hospital Seongnam, Gyeonggi-Do, Korea 463-707
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Experience-based quality control of clinical intensity-modulated radiotherapy planning. Int J Radiat Oncol Biol Phys 2011; 81:545-51. [PMID: 21277097 DOI: 10.1016/j.ijrobp.2010.11.030] [Citation(s) in RCA: 241] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 10/12/2010] [Accepted: 11/16/2010] [Indexed: 12/22/2022]
Abstract
PURPOSE To incorporate a quality control tool, according to previous planning experience and patient-specific anatomic information, into the intensity-modulated radiotherapy (IMRT) plan generation process and to determine whether the tool improved treatment plan quality. METHODS AND MATERIALS A retrospective study of 42 IMRT plans demonstrated a correlation between the fraction of organs at risk (OARs) overlapping the planning target volume and the mean dose. This yielded a model, predicted dose = prescription dose (0.2 + 0.8 [1 - exp(-3 overlapping planning target volume/volume of OAR)]), that predicted the achievable mean doses according to the planning target volume overlap/volume of OAR and the prescription dose. The model was incorporated into the planning process by way of a user-executable script that reported the predicted dose for any OAR. The script was introduced to clinicians engaged in IMRT planning and deployed thereafter. The script's effect was evaluated by tracking δ = (mean dose-predicted dose)/predicted dose, the fraction by which the mean dose exceeded the model. RESULTS All OARs under investigation (rectum and bladder in prostate cancer; parotid glands, esophagus, and larynx in head-and-neck cancer) exhibited both smaller δ and reduced variability after script implementation. These effects were substantial for the parotid glands, for which the previous δ = 0.28 ± 0.24 was reduced to δ = 0.13 ± 0.10. The clinical relevance was most evident in the subset of cases in which the parotid glands were potentially salvageable (predicted dose <30 Gy). Before script implementation, an average of 30.1 Gy was delivered to the salvageable cases, with an average predicted dose of 20.3 Gy. After implementation, an average of 18.7 Gy was delivered to salvageable cases, with an average predicted dose of 17.2 Gy. In the prostate cases, the rectum model excess was reduced from δ = 0.28 ± 0.20 to δ = 0.07 ± 0.15. On surveying dosimetrists at the end of the study, most reported that the script both improved their IMRT planning (8 of 10) and increased their efficiency (6 of 10). CONCLUSIONS This tool proved successful in increasing normal tissue sparing and reducing interclinician variability, providing effective quality control of the IMRT plan development process.
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The challenge of maximizing safety in radiation oncology. Pract Radiat Oncol 2011; 1:2-14. [DOI: 10.1016/j.prro.2010.10.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 10/04/2010] [Indexed: 11/18/2022]
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Mutic S, Brame RS, Oddiraju S, Parikh P, Westfall MA, Hopkins ML, Medina AD, Danieley JC, Michalski JM, El Naqa IM, Low DA, Wu B. Event (error and near-miss) reporting and learning system for process improvement in radiation oncology. Med Phys 2010; 37:5027-36. [PMID: 20964222 DOI: 10.1118/1.3471377] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The value of near-miss and error reporting processes in many industries is well appreciated and typically can be supported with data that have been collected over time. While it is generally accepted that such processes are important in the radiation therapy (RT) setting, studies analyzing the effects of organized reporting and process improvement systems on operation and patient safety in individual clinics remain scarce. The purpose of this work is to report on the design and long-term use of an electronic reporting system in a RT department and compare it to the paper-based reporting system it replaced. METHODS A specifically designed web-based system was designed for reporting of individual events in RT and clinically implemented in 2007. An event was defined as any occurrence that could have, or had, resulted in a deviation in the delivery of patient care. The aim of the system was to support process improvement in patient care and safety. The reporting tool was designed so individual events could be quickly and easily reported without disrupting clinical work. This was very important because the system use was voluntary. The spectrum of reported deviations extended from minor workflow issues (e.g., scheduling) to errors in treatment delivery. Reports were categorized based on functional area, type, and severity of an event. The events were processed and analyzed by a formal process improvement group that used the data and the statistics collected through the web-based tool for guidance in reengineering clinical processes. The reporting trends for the first 24 months with the electronic system were compared to the events that were reported in the same clinic with a paper-based system over a seven-year period. RESULTS The reporting system and the process improvement structure resulted in increased event reporting, improved event communication, and improved identification of clinical areas which needed process and safety improvements. The reported data were also useful for the evaluation of corrective measures and recognition of ineffective measures and efforts. The electronic system was relatively well accepted by personnel and resulted in minimal disruption of clinical work. Event reporting in the quarters with the fewest number of reported events, though voluntary, was almost four times greater than the most events reported in any one quarter with the paper-based system and remained consistent from the inception of the process through the date of this report. However, the acceptance was not universal, validating the need for improved education regarding reporting processes and systematic approaches to reporting culture development. CONCLUSIONS Specially designed electronic event reporting systems in a radiotherapy setting can provide valuable data for process and patient safety improvement and are more effective reporting mechanisms than paper-based systems. Additional work is needed to develop methods that can more effectively utilize reported data for process improvement, including the development of standardized event taxonomy and a classification system for RT.
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Affiliation(s)
- Sasa Mutic
- Department of Radiation Oncology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 4921 Parkview Place, St. Louis, Missouri 63110, USA.
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Chan AJ, Islam MK, Rosewall T, Jaffray DA, Easty AC, Cafazzo JA. The use of human factors methods to identify and mitigate safety issues in radiation therapy. Radiother Oncol 2010; 97:596-600. [PMID: 21044802 DOI: 10.1016/j.radonc.2010.09.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 09/22/2010] [Accepted: 09/26/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE New radiation therapy technologies can enhance the quality of treatment and reduce error. However, the treatment process has become more complex, and radiation dose is not always delivered as intended. Using human factors methods, a radiotherapy treatment delivery process was evaluated, and a redesign was undertaken to determine the effect on system safety. MATERIAL AND METHODS An ethnographic field study and workflow analysis was conducted to identify human factors issues of the treatment delivery process. To address specific issues, components of the user interface were redesigned through a user-centered approach. Sixteen radiation therapy students were then used to experimentally evaluate the redesigned system through a usability test to determine the effectiveness in mitigating use errors. RESULTS According to findings from the usability test, the redesigned system successfully reduced the error rates of two common errors (p<.04 and p<.01). It also improved the mean task completion time by 5.5% (p<.02) and achieved a higher level of user satisfaction. CONCLUSIONS These findings demonstrated the importance and benefits of applying human factors methods in the design of radiation therapy systems. Many other opportunities still exist to improve patient safety in this area using human factors methods.
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Affiliation(s)
- Alvita J Chan
- Healthcare Human Factors, University Health Network, Ontario, Canada.
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Zhang B, MacFadden D, Damyanovich AZ, Rieker M, Stainsby J, Bernstein M, Jaffray DA, Mikulis D, Ménard C. Development of a geometrically accurate imaging protocol at 3 Tesla MRI for stereotactic radiosurgery treatment planning. Phys Med Biol 2010; 55:6601-15. [PMID: 20962365 DOI: 10.1088/0031-9155/55/22/002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The purpose of this study is to develop a geometrically accurate imaging protocol at 3 T magnetic resonance imaging (MRI) for stereotactic radiosurgery (SRS) treatment planning. In order to achieve this purpose, a methodology is developed to investigate the geometric accuracy and stability of 3 T MRI for SRS in phantom and patient evaluations. Forty patients were enrolled on a prospective clinical trial. After frame placement prior to SRS, each patient underwent 3 T MRI after 1.5 T MRI and CT. MR imaging protocols included a T1-weighted gradient echo sequence and a T2-weighted spin echo sequence. Phantom imaging was performed on 3 T prior to patient imaging using the same set-up and imaging protocols. Geometric accuracy in patients and phantoms yielded comparable results for external fiducial reference deviations and internal landmarks between 3 T and 1.5 T MRI (mean ≤ 0.6 mm; standard deviation ≤ 0.3 mm). Mean stereotactic reference deviations between phantoms and patients correlated well (T1: R = 0.79; T2: R = 0.84). Statistical process control analysis on phantom QA data demonstrated the stability of our SRS imaging protocols, where the geometric accuracy of the 3 T SRS imaging protocol is operating within the appropriate tolerance. Our data provide evidence supporting the spatial validity of 3 T MRI for targeting SRS under imaging conditions investigated. We have developed a systematic approach to achieve confidence on the geometric integrity of a given imaging system/technique for clinical integration in SRS application.
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Affiliation(s)
- B Zhang
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.
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Breen SL, Moseley DJ, Zhang B, Sharpe MB. Statistical process control for IMRT dosimetric verification. Med Phys 2008; 35:4417-25. [DOI: 10.1118/1.2975144] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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