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Objectives & Outline

Objective

  • To provide a cadre of individuals qualified to train others in risk-analysis-based generation of quality management.

Course Directors and Speakers

Saiful Huq, UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine

Frank Rath, University of Wisconsin, Madison

Bruce Thomadsen, University of Wisconsin, Madison

Program Outline

Large Conference Room, AAPM HQ, 1631 Prince Street, Alexandria, VA
Wednesday, October 23
8:15 – 9:15AM SESSION 1
A. Learning Objectives
Rath, Thomadsen, Huq
  a. How to lead a TG-100 tools workshop – teach participants how to use process mapping, Failure Mode and Effects Analysis (FMEA) and fault-tree analysis (FTA) to improve Radiotherapy (RT) treatment safety and quality
b. How to “sell” a TG-100 program to clinic administrators and to clinic staff
c. How to get started
B. TG-100 Motivation and Objectives


a. Goals and objectives – reduced staff work load, improved treatment quality, improved patient safety and improved safety culture in clinic
b. How to address a need for TG100 – what does the evidence show?
c. Should there be a standard methodology for TG-100 training?
9:15 – 10:15AM SESSION 2
C. Quality Improvement
  a. Processes, quality controls and quality improvement
b. Identifying the process to improve – suggestions and limitations
c. Managing change
d. PDCA
e. SPC Six Sigma, Lean and The Team
Rath, Thomadsen
10:15 – 10:45AM COFFEE BREAK
10:45 – 11:45AM SESSION 3
D. The Team
  a. Composition with examples
b. Organization
  • i. Secretariat
  • ii. Face-to-face and electronic collaboratives
c. Managing the team
Rath, Thomadsen
E. The TG-100 Tools
  a. Process Mapping
  • i. Choosing the "right"process
    • 1. Selecting an integer, limited process
    • 2. When each type of process map is most useful
    • 3. Level of detail needs to be useful
    • 4. Level of detail and complexity
  • ii. Teaching with the examples: keeping them on task, watching logic
  • iii. Organizational order
  • iv. Mapping transfers
  • v. Mapping information flow
  • vi. Including controls
  • vii. Beginning and end – what comes in and what goes out
  • viii. Example
  • ix. Video
  • x. Slide set
  • xi. Tools
Noon – 1:00PM LUNCH
1:00 – 3:00PM SESSION 4
  b. Risk Assessment
  • i. Potential failure modes (PFM) definition and discussion
  • ii. Inclusion or exclusion of controls
  • iii. FMEA
    • 1. What it does and does not do
    • 2. What are the types
    • 3. Single-source failures and what that means for applications compared with actual events
    • 4. Taking PFM from the process steps, and color coding
    • 5. The OSD scale
      • a. Not important
      • b. Logarithmic often most useful
      • c. Consistent for the three facets
      • d. D is specifically before failure reaches patient
      • e. S may be for more than just patient
      • f. Values only to educate the analysts on hazards
    • 6. Sorts by PRN and by S to annotate process map and fault tree – and why
    • 7. Determining D based on control and by process
    • 8. Roughly about 3 or 4 PFM per action
    • 9. Roughly can determine about 20 PFM per hour and score about 20 rows per hour based on Excel, a little longer using the AAPM tool.
    • 10. Difference with HFMEA
  • iv. In person vs virtual
Thomadsen, Rath, Huq
3:00 – 3:30PM COFFEE BREAK
3:30 – 5:00PM SESSION 5
 
  • v. Example
  • vi. Video
  • vii. Slide set
5:30PM DINNER ON YOUR OWN
Thursday, October 24
8:15 – 10:15AM SESSION 6  
 
  • viii. Tools
  • ix. Step-by-step instructional slides
    • 1. KISS, standard methodology to apply the tools (avoid confusion, lengthy discussions, frustration, etc.)
    • 2. Excel guidebook to applying TG100 – a standard FMEA worksheet also providing step by step instructions how to perform an FMEA
    • 3. Glossary of terms
    • 4. Common mistakes, misunderstandings
    • 5. Obstacles and barriers
    • 6. Spreading successful results to adjacent processes
    • 7. Workshop
Thomadsen, Rath, Huq
10:15 – 10:45AM COFFEE BREAK
10:45 – 11:15AM SESSION 7  
 
  • x. What does a “bad” FMEA look like
    • 1. Any FMEA resulting from a post mortem analysis of an “incident”
    • 2. Workshop
    • 3. Examples of FMEA errors and potential resulting problems
Thomadsen, Rath, Huq
11:15AM – Noon SESSION 8  
  c. Fault tree analysis
  • i. Start using the PFMs from the FMEA along a branch of the process tree
  • ii. Examples of the universe
  • iii. Drawing by hand is as good as using software
  • iv. Usually made by one member of the team and edited by the rest of the team
Noon – 1:00PM LUNCH
1:00 – 2:00PM SESSION 9  
 
  • v. Consistent terminology for the failures is essential
  • vi. Looking for common causes
    • 1. Can be exact same box that propagates along several branches
    • 2. Can be same category, e.g., training
  • xii. About 4 hours with software, 2 hours by hand
Thomadsen, Rath, Huq
2:00 – 3:00PM SESSION 10  
F. Creation of Quality Management Program
Thomadsen, Rath, Huq
  a. All paths in fault tree must be addressed
b. Actions can be
  • i. Addressing Technical and environmental first
  • ii. Key Core Components
  • iii. Redesign and reevaluation
  • iv. QM (and discussion of QM)
    • 1. ISMP hierarchy of effectiveness
    • 2. Compare with guidelines and previous controls
  • v. Highlighting what been addressed
c. Example
d. Video
e. Slide set
f. Tools
G. Questions and Discussion
3:00PM RIDE SHARE TO THE AIRPORT

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