Improving Health Through Medical Physics

Report from the Work Group on the Implementation of TG-100

Brad Schuller, PhD | Denver, CO & Kelly Paradis, Phd | Ann Arbor, MI

AAPM Newsletter — Volume 43 No. 6 — November | December 2018

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The multifaceted settings in which we are treating patients continue to grow in complexity each day. Because of these advancements, prospective approaches to risk management have become increasingly vital in ensuring safe and efficient treatment. As a field, we are moving away from a "check everything" mentality toward a more risk-based approach. The TG-100 implementation session at this year's AAPM Annual Meeting, "Prospective Risk Management in the Wild: Tales from the Clinic," highlighted the application of these techniques in both an academic medical center and a community practice-based center. The following is a brief summary of each presentation in case you missed it! Both are available in the AAPM Virtual Library later this year.

University of Michigan Experience

Dr. Kelly C. Paradis (née Younge), Medical Physicist at the University of Michigan, described two projects conducted at her home institution, sharing tips and tricks regarding the processes, ideas to encourage participation, costs and benefits of the projects, and solutions to possible implementation issues. The first project involved a failure mode and effects analysis (FMEA) of a newly instituted microsphere brachytherapy technology 1. The second was the implementation of a pre-treatment chart review by radiation therapists, driven by incident learning system data 2.

Strategic Timing: FMEA on Microsphere Treatments

A primary advantage of the microsphere FMEA project was the timing of the work. Dr. Paradis explained that FMEA is often ideal for a new program or a major change to an existing program because it allows the team to start from scratch on QA methods, is easier to generate momentum within the team, and helps with the identification of any newly created error pathways and areas where efficiency could be improved. The major cost of this FMEA project was the amount of time involved to complete the project, similar to what has been reported in the literature for other FMEA ventures. Because of the significant upfront investment, it was important to be strategic about splitting up the project elements into group-based and individual work. Sharing the benefits of such efforts, such as improved patient safety, staff safety, efficiency, and role awareness, can help motivate ongoing participation in such long-term projects.

Improved Efficiency for Therapy Chart Checks

For the second project, quantitative data from incident learning system reports were used to strategically design downstream QA performed by treatment therapists. In contrast to the first project, the implementation of the therapist pre-treatment chart review constituted a major workflow change in a large department, and thus the primary hurdle was staff acceptance of the change. Keeping the entire team well-informed on behind-the-scenes efforts (how errors were being addressed upstream with automation and additional workflow changes) and giving the treatment team ownership of the new QA strategies were key to achieving acceptance. Benefits of this prospective risk management approach included significantly reduced treatment unit delays for patients and improved workflow efficiency.

In both cases, Dr. Paradis noted that support from departmental leadership was crucial to achieving the initial goals set out by the project teams.

McKee Medical Center Experience

Dr. Brad Schuller, Medical Physicist at McKee Medical Center in Loveland, CO, presented a complete implementation of failure mode and effects analysis (FMEA) for stereotactic radiosurgery (SRS) in a community practice setting. Rather than focusing on how to perform FMEA, he discussed the subtleties and nuances his team found working through FMEA for the first time as a small community practice, with the aim of helping other interested groups complete their own prospective risk management projects 3.

Buy-In from the Clinical Team

His presentation started by highlighting the central problem for small clinics; since clinical process is equally complicated across various practice sizes, small clinics may have difficulty performing prospective risk management given the time and effort required to complete it. The McKee group anticipated that prioritizing the FMEA project would be a substantial first hurdle. As a result, they dedicated considerable time toward buy-in, which included department education, team recruitment, and thorough training on how to perform FMEA. The net effect was a team consensus that prospective risk management should be made a priority.

Strategic Scheduling for FMEA Meetings

The remainder of Dr. Schuller's presentation focused on solutions to roadblocks his team found working through FMEA for the first time. Meetings were difficult to schedule since the multidisciplinary team composed a large percentage of the available clinical staff. This impacted both process mapping and FMEA scoring meetings. Their solution was to schedule voluntary meetings for staff to attend as their schedules permitted, with the facilitator being present for every meeting. This allowed the team to make progress without requiring attendance to every meeting. The level of detail contained in the process map directly impacts the amount of time required to complete the FMEA. The McKee group chose to provide enough detail such that another radiation oncology team could execute their SRS procedures. This minimized the risk of missing important failure modes due to lack of sufficient detail in their process map. Finally, it was shown that simple mitigation steps were implemented to reduce patient risk following the FMEA. For their ten highest scoring failure modes, simple checklist additions or procedural changes had a large impact on risk reduction.

Communication is Key

A few unforeseen benefits were identified to show the value of prospective risk management beyond generating an FMEA dataset. Creating a process map resulted in a much more comprehensive understanding of the complexity of SRS for every involved team member. This resulted in better communication and more efficient clinical workflows. Spending time together as a multidisciplinary team in a different clinical context enabled discussions between disciplines that do not ordinarily interact in the normal work day. Broad understanding of each discipline's perspective on patient risk had universal positive impact on their program.

  • 1 K. C. Younge et al.: Failure mode and effects analysis in a dual-product microsphere brachytherapy environment. Practical Radiation Oncology 6(6):299-306 (2016).
  • 2 K. C. Younge et al.: Improving patient safety and workflow efficiency with standardized pre-treatment radiation therapist chart reviews. Practical Radiation Oncology 7(5):339-345 (2017).
  • 3 B.W. Schuller et al.: Failure mode and effects analysis: A community practice perspective. J Appl Clin Med Phys 18(6): 258-267 (2017).

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