PROJECT NAME: Maintenance of Rates of Patient-Specific
Quality Assurance in Radiation Therapy
Institution: UT MD Anderson Cancer Center
Primary Author: Jennifer Lynn Johnson
Secondary Author: Prajnan Das, Lei Dong, James Kanke, Michael Kantor,
Beverly Riley, Tatiana Hmar-Lagroun
Project Category: Sustained CS&E Projects
Overview: All health care facilities must monitor and review its patient safety
processes, including a large academic division of radiation oncology that treats more
than 7,000 patients in a fiscal year at both its main center and its outreach facilities. Of
those, almost thirty percent (29%) of new patients were treated with a complex delivery
technique called intensity modulated radiation therapy (IMRT.) For any radiation
therapy, many steps and many individuals are involved in the planning and delivery
process which creates the potential for errors that may cause patients toxicity, injury, or
death. For IMRT in particular, the human-machine interfaces, complicated software and
sophisticated machinery are used in the computer-controlled treatment delivery which
escalates the risk in patient outcomes even more. Patient-specific IMRT quality
assurance (QA) is a critical and essential step that verifies thousands of plan
parameters and thus allows detection of errors and enhances safety in patients
undergoing IMRT.
The baseline rate of conducting IMRT QA prior to the first treatment was 55% in
September 2009 – January 2010. A multi-disciplinary team of faculty and staff from
radiation oncology, radiation physics, dosimetry and radiation therapy worked together
on a project with the goal to improve and sustain the rate of patient-specific IMRT QA.
The project was in alignment with organizational goals of promoting patient safety and
improving patient care.
Aim Statement (max points 150): To increase the rate of patient-specific IMRT QA
prior to the first treatment to 100% in patients undergoing IMRT, by July 2011 and
maintain thereafter.
Measures of Success: We measured the rate of conducting patient-specific IMRT QA
prior to the first treatment in patients undergoing IMRT.
Use of Quality Tools (max points 250):
A run chart was created from baseline data to determine the initial rate. Three key yet
simple quality improvement tools were used to identify and solve the poor completion
rate of IMRT QA prior to the first treatment. The team created a process map (detailed
flowchart) of the treatment planning and patient-specific IMRT QA delivery to study and
understand the process. A fishbone diagram was used to identify the possible causes
for not completing IMRT QA prior to the first treatment. A Pareto chart was used to
analyze the data for the frequency of causes for not completing IMRT QA and
determine which are the most significant. A run chart was then used to continuously
monitor progress during and after the interventions.
Interventions (max points 150 includes points for innovation):
The team identified key requirements and interventions that would help with the IMRT
QA compliance but required buy-in from the multi-disciplinary members of the division.
While leadership was supportive, the success was dependent upon members seeing
the measurement results and wanting to make a change to achieve the aim. Therefore,
the importance of patient-specific IMRT QA was communicated between January 2010
– March 2011 at various disciplinary team meetings, with team members developing
support from faculty and staff. Some sections made their own policy announcements in
January 2010, February 2011, and March 2011, as demonstrated in the second phase
of the run chart. Finally, a radiation oncology division-wide guideline was implemented
April 1, 2011 eliminating late approvals for IMRT plans, eliminating early patient start
times for IMRT treatments, and requiring review of patient-specific IMRT QA to be
completed prior to the patient’s first treatment. This was regularly and consistently
communicated to all members of the division through an official email announcement as
well as disciplinary-specific meetings leading up to the effective date.
Results (max points 250):
A run chart was created from baseline data to determine the initial rate.
Avg. Compliance Rate = 71.4%
Avg. Compliance Rate = 54.6%
Three key yet simple quality improvement tools were used to identify and solve the poor
completion rate of IMRT QA prior to the first treatment. The team created a process
map (detailed flowchart) of the treatment planning and patient-specific IMRT QA
delivery to study and understand the process.
A fishbone diagram was used to identify the possible causes for not completing IMRT
QA prior to the first treatment.
A Pareto chart was used to analyze the data for the frequency of causes for not
completing IMRT QA and determine which are the most significant.
Pareto Diagram of Physics Review IMRT QA "After Tx" Causes
Sep 2010 - Feb 2011
80
100.0%
90.0%
70
70.0%
50
60.0%
40
50.0%
40.0%
30
30.0%
20
Cumulative Percent
Number of Causes
80.0%
60
20.0%
10
10.0%
0
0.0%
LSDA
ES
PH
BST
Physics Review IMRT QA "After Tx" Causes
The results indicated that late or same day approvals of the patient’s plans were the
most common cause by not allowing sufficient time to complete the measurements.
Early morning patient treatment start times were the second most common and also did
not allow sufficient time to review the results prior to treatment. Physics-specific causes
were due to requests for repeated measurements or causing a false-failure in the proxy
measure. Boost IMRT treatments (for patients whose treatment is already underway)
were not found to be initially significant as a contributing factor.
A run chart was then used to continuously monitor progress during and after the
interventions.
Avg.
Compliance
Rate = 99.3%
100
1
2
3
Avg. Compliance
Rate = 98.8%
90
80
Avg. Compliance
Rate = 75.3%
70
60
50
Avg. Compliance
Rate = 54.6%
40
30-Sep-09
30-Oct-09
29-Nov-09
30-Dec-09
29-Jan-10
1-Mar-10
31-Mar-10
1-May-10
31-May-10
1-Jul-10
31-Jul-10
30-Aug-10
30-Sep-10
30-Oct-10
30-Nov-10
30-Dec-10
30-Jan-11
1-Mar-11
1-Apr-11
1-May-11
1-Jun-11
1-Jul-11
31-Jul-11
31-Aug-11
30-Sep-11
31-Oct-11
30-Nov-11
31-Dec-11
30-Jan-12
1-Mar-12
31-Mar-12
30-Apr-12
31-May-12
30-Jun-12
31-Jul-12
IMRT QA Physics Review Completed Before Tx
% Compliance
IMRT QA Physics Review Completed BEFORE First Treatment
30 Sep 2009 - 30 Jun 2012
Goal: 100%
Month
Revenue Enhancement /Cost Avoidance / Generalizability (max points 200):
Since the project was for quality and patient safety of rare events of error, a return on
investment was not determined. However, the project’s early results were presented as
a successful practice quality improvement example at the 54th Annual Meeting of the
American Association of Physicists in Medicine and updated results will be presented at
American Society of Radiation Oncology’s 54th Annual Meeting.
Conclusions and Next Steps:
First and foremost, for any project to be successful, it is very much dependent upon the
champions of the project in order to assist by directing any identified interventions
necessary. Without leadership on board, the project would not have been successful.
Second, the item of interest needs to be measurable, and the data needs to be
accurate. While the project’s aim is to measure the compliance of IMRT QA prior to the
first fraction, the time stamp on the document is not easily ascertained, requiring a proxy
to be used. The proxy measure indicates 98.8% compliance average, when the actual
compliance rate is closer to 99.9% when failures are investigated (i.e., the IMRT QA has
been completed prior to the first treatment but the proxy was not.) One area of
improvement would be to measure the data more directly, but currently is not an option.
Third, although the tools are simple they are effective and applicable to many project
initiatives. For true failures that were investigated, causes were not due to the initial two
identified by the Pareto chart, meaning that the interventions to eliminate late approval
or same day approval and to eliminate early patient start times were very effective.
Physics-related causes and other causes were related back to the involved members
for feedback.
Due to the greatly improved compliance rates, the increased practice of safety is
relevant to patient care and is in alignment with The University of Texas M.D. Anderson
Cancer Center’s commitment to patients. The quality control of anticipated IMRT
delivery is increased and the likelihood of toxicity, injury or death for a patient is
decreased, thus ensures expected patient outcomes.
In the future, the team hopes to switch from a run chart to a p-chart due to the increased
quantity of collected data as well as the decreased deviation in the data. This will help
identify any outliers that may be investigated to improve the process further by
repeating the same steps with quality tools available.
Page 4 of 4