Quality Improvement

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Quality Improvement

• Elizabeth Small B.S.R.T.(T)

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Quality Improvement

• Other names-
• CQI- Continuous Quality Improvement
• CI- Continuous Improvement
• TQM- Total Quality Management
• A method that improves on the processes of
  providing health care
• The emphasis is ongoing, always looking to see
  where improvements can be made

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Dr. W. E. Demings 14 Principles of Management

• Introduced after WW II in Japans industry
• Health care early 1980s
• Demings 14 principles of management
• employee input, education, awareness,
  communication, recognition, teamwork
• eliminate dept. barriers, quality- not quantity,
  CI
• define organization mission/goals, do not set
  thresholds, long term costs and appropriateness
  of service

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Health Care Organizations Concerns

• Increased competition
• Escalating costs
• Quality concerns
• Demands increased accountability
• A CQI program has been shown to address these
  concerns- decrease cost, increase customer
  satisfaction, and ensure quality

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JCAHO

• Joint Commission on the Accreditation of Health
  Organizations
• independent and non-profit
• goal is improvement of HC services
• Health care organizations have used quality
  improvement activities to analyze the quality of
  services to meet the requirements for
  accreditation

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What is Involved in Quality Assurance, Control
and Assessment?

• Measurement of performance
• Compare processes with outcomes to quality
  indicators
• Outcomes are the measurable aspect of quality
• Provides standards of measurement
• Systemic collection/review of data
• Control and assessment of performance are stressed

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CQI Plan

• Integration of
• Quality Assurance-the measurable
  outcomes-(mortality rates, wait times)
• Measurable outcomes and quality indicators-less
  is better! lt 15 minute wait time is goal
• Quality Control- A component of QA-mechanical
  checks. Provides standards to compare results to.
• Quality Assessment- collection/review of data-
  (surveys look at the documentation of wait times)

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Quality Improvement in Radiation Oncology

• Three major areas
• Clinical
• Physical
• Technical
• Goal- to deliver quality radiation and patient
  care
• Continuous evaluation of all aspects- output
  machines, brachy, mechanical checks, patient care
  and treatments assessed
• Each member of the team needs to be committed to
  quality in all they do!

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Evolution of QI

• Began with the standardization of a unit for
  measuring radiation
• 1st erythema dose
• Then the Roentgen- R ionization in air
  (exposure)
• Unit of absorbed dose- Gray (Gy)
• Equipment performance standardized- quality
  improvements focus

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Hospital Oversight and Accreditation- History

• Oversight of hospitals began in 1917 when the ACS
  (American College Surgeons) developed the
  Hospital Standardization Program
• 1919 minimum standards were developed

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Hospital Oversight and Accreditation- History

• 1952
• The JCAH- Joint Commission on Accreditation of
  Hospitals was formed to improve hospital based
  medicine, through the efforts of ACR, AMA, AHA,
  ACP, CMA
• 1965- Medicare, reimbursable- only to hospitals
  accredited by JCAHO
• Gave this organization a lot of power!
• 1988-JCAHO- to broaden scope

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JCAHO and Radiation Oncology

• Prior to 1987 Radiation Oncology did not have
  individualized standards-grouped with radiology
• 1987 separate standards were developed
• A dedicated quality improvement plan is required
  for each dept.

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JCAHO and Radiation Oncology

• Emphasis went from only the control processes- tx
  machine output, and delivery of patient care to
• doing the right thing, and doing the right
  thing well
• Deliver effective and appropriate tx, and
  effective, accurate patient care in a timely
  manner, with respect and care for the pt

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Definitions

• Developed by the ISO- International Standards
  Organization
• Quality- the totality of features and
  characteristics of a radiation therapy process
  that speak to its ability to satisfy stated or
  implied needs of the patient.
• For example the quality of treatment at U of M
  is excellent

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Definitions

• Quality Assurance- all those planned or
  systematic actions necessary to provide adequate
  confidence that a product or service will satisfy
  given requirements for quality.
• For example Examining data of treatment
  variances, unsatisfactory patient surveys and
  complaints

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Definitions

• Quality Control- defined as the operational
  techniques and activities used to fulfill
  requirements of quality.
• For example Chart checking, MUT calcs, charting
  processes, machine QA, Chart rounds

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Patient Outcomes

• Measurements now required by JCAHO
• Morbidity
• Mortality
• Recurrence of disease
• Survival rates
• Patient satisfaction
• QOL

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Components of Quality Improvement

• QI Team- all staff that interacts with the
  patient and family
• Behind the scene staff as well
• JCAHO- requires the dept medical director be
  responsible for establishing/maintaining QI
  program
• A committee may be appointed with
• developing/monitoring the program,
  collecting/evaluating data, determining areas for
  improvement, implement changes, evaluate results

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Components of Quality Improvement

• The director is also responsible for ensuring
  that all employees are qualified for their job
• Job descriptions must clearly state the minimum
  qualifications, credentials required, continuing
  education requirements, scope of practice for
  each practice
• Institutional requirements- CPR, fire safety,
  infectious disease education must be adhered to
  and documented, as well as all radiation safety
  standards

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Components of Quality Improvement

• Staff physicians must document active
  participation in dept QI activities for
  recredentialing purposes
• Chart rounds
• Film checking
• Morbidity/mortality conferences
• Development and review of dept. policies
• Pt and family education
• Completion/review of incident reports

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Components of Quality Improvement

• Physicists, dosimetrists, and engineers must all
  adhere to quality controls to meet the needs of
  the department and required national and
  mandated standards
• Weekly and final physics review of treatment
  records

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Components of Quality Improvement

• Radiation Therapists
• Warm-ups for tx and sim
• Quality control tests
• Verify presence of complete/signed
  prescription/consent form
• Initial tx prescription/ tx plan are checked
• Deliver accurate tx
• Accurately record tx given
• Take initial/weekly films/images
• Daily assessment of patient
• Pt and family education
• Provide care and comfort to the pt

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Components of Quality Improvement

• Oncology Nurses
• Nursing assessment that determines overall
  physical and psychological status
• Evaluates the educational needs and determines
  any barriers to education
• Develops an education plan to meet needs
• Evaluates the effectiveness of the education
  provided by entire team
• Monitor the patients health status throughout
  course of tx and as needed
• Monitor blood counts/weights

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Components of Quality Improvement

• Department Support Staff
• Clerks
• Gather pertinent info and put in chart prior to
  consultation
• Contact patient to set up visits
• Give instructions regarding info or diagnostic
  studies to be brought
• Greet/assist pt and family daily
• Indicate pt arrival to dept.
• Answer question, file, set tone for pt encounter

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Development of a Quality Improvement Program

• A QI plan lists the organizations structure,
  responsibilities, processes, procedures, and
  resources for implementation
• Audit mechanism that documents measurement and
  evaluation activities meet institutional/departmen
  tal quality standards
• Mechanism to institute change

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Development of a Quality Improvement Program

• Objectives of the Program
• Important aspects of care are collected on an
  ongoing basis
• Evaluate/assess the info to ensure high standards
  of care
• Implement necessary changes
• Assess effectiveness
• Report QA activities to proper hospital
  committees

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Development of a PlanQuality Indicators

• First-
• Identification of all aspects of department
  activities that affect the patients care
  (patient flow)
• Consult/informed consent
• Treatment planning
• Treatment delivery
• Documentation of treatment delivery
• Patient outcomes

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Development of a Plan

• Activities that can be evaluated within each area
  need to be identified
• Quality indicators can be developed for each
  important aspect of care
• Indicators are tools used to measure performance
• Well-defined and measurable indicators help focus
  attention on opportunities for improved pt care

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First Phase of Process

• Pt is considered for treatment in radiation
  therapy dept
• Radiation Oncologist reviews information-pathologi
  cal diagnosis, clinical extent of dx, physical
  status of pt, pt/family wishes
• Tx recommendations are made to the pt/family
  along w/details regarding tx type recommended,
  alternatives, no tx- what happens, all potential
  side effects, answer ?s
• Then- pt are asked for informed consent

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Informed Consent

• Benefits/risks
• Form that lists all possible side
  effects-acute/long term
• Area to be treated
• Permission to perform blood tests, tattoo, take
  photos, review record for future studies
• Asks female if they might be pregnant
• states no guarantees have been made
• Who signs this form?

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Consult Dictated/Filed in Chart

• After the consultation, a detailed report is made
  that contains
• Patient history
• Results of physical exam
• And the tx recommendations made to the pt
• Report is signed by the radiation
  oncologist/filed in chart

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Consult/Informed Consent Quality Indicators

• Measurable Quality Indicators
• History and physical documentation in chart
• Path in chart
• Staging form in chart
• Consent form signed by patient
• Consent from signed by physician

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QA in tx planning aspects

• Simulator QA tolerances
• Developed by AAPM American Association of
  Physicists in Medicine. Individual institutions
  may be different
• Daily, monthly and annual checks, minimum
  requirements

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Sim QA

• Procedure/tolerance
• Daily lasers- 2 mm
• Distance indicator- 2 mm
• What would you do if these are off by more than
  2mm?

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Sim QA

• Procedure/tolerance
• Monthly
• Field size indicator- 2mm
• gantry/coll angle indicators 1 degree
• Cross hair centering- 2mm diameter
• Focal spot/axis indicator- 2mm
• Fluoro image quality- baseline
• Emergency/collision avoidance- function
• Light/radiation field coincidence 2mm
• Film processor sensitometry baseline

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Sim QA

• Procedure/tolerance
• Annually
• Mechanical checks
• -Coll/gantry, couch rotation iso-2mm
• -Coincidence of collimator, gantry, couch axes,
  and isocenter-2mm
• Table top sag-2 mm
• Vertical travel of couch -2mm

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Sim QA

• Procedure/tolerance
• Annually
• Radiographic Checks
• Exposure rate- baseline
• Table top exposure w/fluoro-baseline
• kvp and ma calibration- baseline
• High and low contrast resolution-baseline

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Treatment Planning and Target Volume Localization

• Simulation performed
• Physician must approve CT images before pt leaves
  sim room
• if films taken signed by physician-staff!
• Target volume is identified-diagnostic info and
  surgical reports
• Radiation Oncologist decides treatment technique
  to use

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Treatment Planning and Target Volume Localization

• All setup parameters are recorded on setup page
• Photos, tattoos, immobilization, bite block,
  denture info, special notes-voiding instructions,
  pace maker alert, etc.
• What will you do if a patient has a pacemaker?
• Sim note is completed by Dr and a pt education
  form is completed by sim therapists

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Treatment Planning and Target Volume Localization

• All physics info is recorded and contour info
  taken
• All dosimetry information is recorded in the
  chart including calcs and dose distributions
• A double checking system is used to verify the
  calcs are accurate before placing in chart
• The plan is signed by radiation oncologist
• Blocks are made if necessary

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Treatment Planning Quality Indicators

• QC program for sim, imaging processing equip,
  immobilization devices, accessory equip
• QC program for tx planning computer systems
• Adherence to dept policies/procedures
• Target volume is indicated on planning
  films/DRRs
• Tx parameters are accurately recorded
• F.S., gantry, collimator or pedestal angles, mus
• Setup info, diagrams, photos are in chart
• Calc and plans are double checked

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Treatment Delivery

• Quality Indicators (tools to measure performance
• QA tests on tx units, film processor,
  immobilization devices, accessory equip, safety
  equipment
• Verify Written/signed script
• Review all data prior to initial tx (boosts,
  changes) to be familiar with tx plan
• Verify correct transcription on all parameters
  chart, R/V system and the plan
• Port film- initial and weekly
• What are verifying on films?
• What films are you taking weekly?
• Exceptions?
• Dr reviews and signs films/images

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QI Treatment Delivery

• Results of QA tests performed- daily, monthly,
  annually
• Written/signed Rx
• Approved/signed tx plan
• Initial port films compared with sim films/DRRs
• Weekly port films are taken
• Initial and weekly port films are approved by Dr

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Documentation of Treatment

• Each tx is documented/dated
• Missed days are recorded in side note
• Accurate and legible
• Includes beam modifying devices
• Compensators, wedges, blocks, bolus
• Document films taken
• Changes in f.s., pt position or dose is recorded.
  Any change!

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Documentation of Treatment

• R/V systems are replacing paper charts- have a
  backup system in case computer fails
• Variances are reported to Dr/dosimetry
• Written up, note in chart- see variance
• Variances just state the facts
• Weekly/final physics chart check- signs
• Verify math, adherence to Rx
• Charts/Films are reviewed weekly
• Adherence to standards/dept policy and procedure
• Compares films to sim films/images
• Checks chart for completeness of info
• Checklist used
• Dr signs the reviewed chart

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Documentation of Treatment Delivery Quality
Indicators

• Adherence to prescription
• Documentation of weekly/final physics review
• Adherence to department/professional standards
• Completeness of treatment record
• Incident/unusual occurrence reports-Variance
  Reports

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Patient Evaluation

• Therapist assesses the medical condition of each
  pt daily before tx
• Any unusual reactions are reported- some may hold
  tx!
• What are these likely to be?
• Weekly Dr visit
• Response to tx, tolerance
• Changes in tx may be made based on visit
• Upon completion-Dr writes a summary note
• A summary of tx- filed in chart
• F/U visits are documented
• Copy sent to referring Dr/PCP

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QOL Assessment

• QOL- (survey completed by pt)
• Relief of pain/sx
• Normal lifestyle
• Intensity of tx reactions
• Self-image
• Alopecia

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Patient Satisfaction Tools

• Pt surveys- are pt expectations met?
• Treatment experience
• Provided education
• Time spent waiting
• Parking problems
• Responses can show where improvements are needed

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Patient Outcomes and Quality Indicators

• Completion of notes/treatment summary filed in
  chart
• Follow/up notes filed in chart
• Documentation of tx outcomes, including
• Morbidity
• Mortality
• Recurrence
• Survival
• Patient satisfaction
• Quality of survival

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Assessing the Data

• Examine the data collected
• Charts, graphs
• Distribute to dept
• Changes may need to involve other dept as well
• Strategic planning
• Performance mgmt
• Budgetary
• Management info