By Doriann Geller, ASTRO Communications
ASTRO’s APEx – Accreditation Program for Excellence® counts nearly 200 radiation oncology practices among those having earned the distinguished APEx badge since the program's inception in 2016. APEx recently granted its first reaccreditation in December 2020 to Lutheran Medical Center, located at the foothills of the Rocky Mountains in Wheat Ridge, Colorado. Lutheran Medical earned the distinction of being the first facility to become reaccredited after their first four-year cycle. Tyler Kemmis, MD, medical director of radiation oncology at Lutheran Medical, took time out of his day to talk about “Why APEx.”
“I know we were first in Colorado, only maybe sixth in the country for initial accreditation,” he said glowingly on a recent afternoon. “So, I guess it’s pretty neat that we’re first for reaccreditation.”
Lutheran Medical’s mottos include “Excellence: setting and surpassing high standards.” APEx accreditation, which demonstrates safe, high-quality care, validated their commitment to this value, Dr. Kemmis said. The accreditation process, which focuses on the entire radiation oncology team, allowed them to review and modify policies and procedures and to improve documentation. “I think what accreditation does, specifically ASTRO’s APEx, is it forces you to do a self-audit. It helped us modify some of our policies and procedures, update them, define them ― easily identifiable areas we were able to benefit.”
Dr. Kemmis mentioned that the team identified some deficiencies during the Self-Assessment, which is designed for success. “We did not realize some deficiencies until we were sitting down and going through [the Self-Assessment],” he said. “We improved on them, even though they were potentially going to be disclosed at the site visit.” If they were called out, the Lutheran Medical team was prepared with a proactive response. “We could say, ‘Yes, we noticed that, and we've done this to improve it.’”
Lutheran Medical Center’s website describes their facility as a place where “Our patients and families are the center of every thought, communication and action that takes place in this healing space.” The APEx accreditation program evaluates the standard of care that addresses communication, not only among staff but specifically with patients. “Here at Lutheran, we really make sure that we, as radiation oncologists, are there for the entire spectrum of care, and communication is really central to that.”
The APEx accreditation process, while achievable, is known to be rigorous. Asked if that is a fair assessment, Dr. Kemmis concurred. “Yes, I think it’s fair. I won’t lie. It is no walk in the park by any means. Of course, when you go through that much work, there is a greater sense of accomplishment when you get there. Whether it’s an initial accreditation or specifically reaccreditation, the majority of the work is done on the front end and leading up to the site interview. It involves a lot of people putting a lot of work into it, [which] makes it more fulfilling when you do receive your accreditation or reaccreditation,” Dr. Kemmis observed.
“There were additional things that we never thought of, even during the review, [that] forced us to think critically. So, at that point in time you say, ‘Yes this maybe is something that we need to work on.’ Each part of the reaccreditation you can use as a learning experience,” he remarked.
Among the changes Lutheran Medical implemented as a result of the accreditation process was improvement in new staff onboarding. The radiation oncology department enjoys low staff turnover, a point of pride. However, the surveyor noticed that documentation of onboarding processes needed some attention. “We're fortunate that we really don't have a lot of staff turnover, and we didn't really have the opportunity to review some of our training processes and procedures for onboarding new staff,” Dr. Kemmis said. As a result, they have revamped some of those policies and procedures.
The four-year accreditation cycle provides generous time for facilities to continue to improve. During the first four-year cycle, Lutheran Medical used ASTRO accreditation as a framework for future improvements in developing new documentation for their system of radiation oncology departments, expanding the benefits of accreditation system-wide.
Dr. Kemmis stated that Lutheran Medical’s radiation oncology department considered other accrediting bodies, but they chose APEx. “I think it was the fact that, as a radiation oncologist, I felt more aligned with ASTRO. And when it was offered as a new accreditation, I think there was that allure that this was a new accreditation, that [it] would be exciting to be involved with.” The four-year reaccreditation, as opposed to three, was also a factor, he said. “It was all those factors put together.”
Would Dr. Kemmis recommend APEx accreditation to his radiation oncology colleagues? “Yes absolutely,” he responded. “I haven't gone through any accreditation other than ASTRO, but I've had a good experience with it so far, so I would.”
If you would like information on how your facility can become accredited by APEx, we invite you to contact an ASTRO team member at APExSupport@astro.org to schedule an online discussion. By this time next year, your facility could join Lutheran Medical in the family of APEx accredited facilities.