This article was originally published in the American Association for Physicists in Medicine (AAPM) March/April newsletter.
By Eric Ford, PhD, FASTRO, Sue Evans, MD, MPH, and Jean Wright, MD
Patient Safety Awareness Week (PSAW) began in 2002 as annual event intended to encourage a continued focus on health care safety. This year it is observed March 13-19 and serves as a national education campaign for promoting patient safety practices. We know that quality and safety are priorities for medical physicists every day, and this week is an opportunity to increase awareness within your practice.
Patient safety was at the center of most radiation oncology discussions after the 2010 New York Times article, and tremendous progress has been achieved since that time. However, much like quality, safety assessments and improvements are an ongoing exercise. In the wake of the 2010 events, the American Society for Radiation Oncology (ASTRO) and the American Association of Physicists in Medicine (AAPM) collaborated to develop a national radiation oncology incident learning system (ILS), RO-ILS, to facilitate safer and higher quality care in a secure and non-punitive environment. In 2014, using the guidance in Safety is No Accident, ASTRO created its own radiation oncology-specific practice accreditation program. ASTRO’s APEx - Accreditation Program for Excellence® builds on consensus statements, AAPM Task Group reports and technical standards to support safety and quality.
Medical physicist, Eric Ford, PhD, FASTRO, from University of Washington, Seattle, along with radiation oncologists, Sue Evans, MD, Yale School of Medicine, and Jean Wright, MD, Johns Hopkins Medicine, are well known contributors to the topic of quality and safety within radiation oncology. In light of the upcoming PSAW, these leaders recently discussed quality and safety initiatives that resonate with them, including incident learning, accreditation and the importance of safety culture.
Eric: Let’s start off by talking about one of my areas of focus, ILSs. Active engagement in programs such as RO-ILS can directly benefit our patients, and everyone has a role to play.
Sue: Certainly, and there is a central and pivotal role that medical physicists play in supporting quality improvement, especially in incident learning. I believe that if a physicist is not advocating for and engaging with an ILS, it will simply fail. We need the thoughtful analysis from the physics perspective to make our systems stronger and there’s nobody else better suited to speak to all the processes involved in an incident.
Eric: I know I feel that way, but it’s so important to hear those kinds of affirmations from our colleagues.
Sue: I’m reminded how the late Peter Dunscombe used to quibble and call it an incident teaching system, because he would say that the learning is up to you. Those of us in radiation oncology know the same sorts of incidents keep happening and sometimes they fail in new and exciting ways, and sometimes they fail in the same old boring ways. Having data in a national system enables us to explore this further, identify trends and work with community partners, such as vendors, to resolve some of these error pathways. Varian and Sun Nuclear Corporation have been long standing supporters of RO-ILS and hopefully other vendors will join the effort.
Eric: The practice culture underpins everything that happens, and PSAW presents an opportunity to improve it. How does RO-ILS support safety culture?
Sue: One of my favorite ways is creating a safe space to talk about errors. It’s easier to discuss an error that occurred somewhere else, so practices can start with RO-ILS education and then analyze the data in their local RO-ILS system. It is helpful to not feel alone; to know that on the national level, they might be seeing the same thing that happened at your practice. I do think it's a way to normalize errors and to allow people to be more open about it and foster safety culture from that aspect. In 2021, RO-ILS added safety check questions in the educational resources to encourage more active reading, reflection and spark conversations.
Jean: Incident learning is a forward-thinking approach. Rather than focusing on what happened to assign blame, we must investigate the contributing factors and understand why the error occurred. This allows us to appreciate how errors happen and then work to address it, so it doesn’t happen again. I think all the resources that come with RO-ILS really convey that message and make it easy. You can have a discussion and go over the errors as a group.
We [Johns Hopkins Medicine Department of Radiation Oncology] are in the process of transitioning fully to RO-ILS. One of the reasons we wanted to change from our internal program is that the participation at the national level is more impactful and gives us the ability to learn from others and provide more information back to the community in a safe, protected way. But we’ve known that for a long time. To be honest, I'd say the biggest driver for us is the ability to do the analytics in a way that's more ready-made. Once you learn the features of RO-ILS, you realize that it has options to tailor reports.
Eric: Accreditation is another initiative that gives practices an opportunity to review their specific reports, promote safety and should be celebrated for PSAW.
Sue: I think we all understand that the same basic processes happen in each radiation oncology practice, regardless of our vendor equipment and our individual workflows. In our APEx assessment, we found areas that required more standardization and where we could beef up our processes. I know when we went through APEx, it was amazing how many processes that we thought were buttoned up well, but in reality hadn't been revised in three or four years. Also, it showed us where we didn’t have a defined process.
Jean: Another thing I want to highlight about APEx is that there are two phases — this is the crux of the program. It has the self-assessment phase and then the site visit. The self-assessment phase consists of an initial review where practices conduct an internal assessment of their own medical records policies, procedures and other forms of documentation. As a result, you have the opportunity to identify areas that you may want to improve on prior to the site visit like Sue just talked about, where they didn't even know there was a problem. That definitely happens with APEx. The self-assessment helps you realize you don't have something in place.
Eric: Jean, how are the physics elements assessed in APEx?
Jean: The APEx medical record review is fairly equally weighted between physician medical notes and physics documentation that supports quality assurance (QA) for patient safety. Another substantial component of the program is the document review. APEx assesses individual specifications for machines like commissioning documentation, results of annual and monthly testing, and all the different QA checks are done at the machine level. It's really a physics-driven process in a lot of ways.
Sue: The other thing that I'll add to that, Jean, is from my understanding of having friends at other institutions going through this process, they've actually found the accreditation process to be very helpful when they're in discussions with their hospital or funding source because sometimes you'll have an accreditation notation and say the QA process you have for this modality is certainly adequate, but it’s recommended that you look at adding an aspect that requires new equipment acquisition. A lot of organizations that I know have been able to successfully lobby their hospital or parent institution and say APEx told us that we were OK, but if we really want to be excellent, we need to add something. The institution or organization will really listen to that. Accreditation helps advocate for you in terms of really elevating your game.
Eric: I’ve witnessed this as well. Accreditation can be an ally for physicists.
Jean: The APEx Standards are very clearly delineated so practices know what is going to be evaluated and there is no mystery. Because of the Self-Assessment, you’ll have a very clear sense of how you will do even before the surveyors arrive.
Eric: I agree. In reviewing the APEx Standards, I think the requirements should not come as a surprise to any medical physicists. These are well documented, well accepted standards that are published and align with AAPM Task Group reports and other professional recommendations. Practice accreditation is doing what we all know is right and confirming it’s effective.
Sue: I think that's why accreditation can be undervalued. People look at the requirements and say to themselves, well, of course we do that. But one of the things that we discovered when we went through APEx was that while we do a lot of those things, the process of having a deadline, a formal assessment, an outside evaluator meant that we still discovered new things. Everything just got squared away with the accreditation process, and it was extremely informative.
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Patient safety is a key aspect of radiation therapy every day; however, PSAW presents a chance to assess your own practice. Many tools, like RO-ILS and APEx, are used by radiation oncology practices around the country to measure and improve the consistency and effectiveness of daily practice. ASTRO challenges you to take advantage of PSAW to evaluate your own practice and learn how RO-ILS and APEx can help with your patient care.
By Bruce Haffty, MD, FASTRO,1 Chair; Chirag Shah, MD,2 and Pranshu Mohindra, MD,3 Co-chairs, ASTRO Workforce Task Force
Issues around the state and future of the radiation oncology workforce have taken on more urgency in the recent years given the imbalance in residency positions secured during the Match and Supplemental Offer and Acceptance Program (SOAP) process. In an effort to better inform medical students about the specialty, ASTRO updated the medical student section of the website to include a Journals collection, which provides a range of studies and perspectives specific to the specialty, including workforce issues. Additionally, recognizing and respecting diverse viewpoints, ASTRO offers many channels for thoughtful and transparent debates and discussions, including ROhub, the ASTRO Blog and ASTRO’s suite of scientific journals.
The ASTRO Board of Directors has long shared our concerns about the future radiation oncology workforce. In fact, in each of the past three years, the Chair of the ASTRO Board provided updates to members about why addressing workforce issues are critical to the health of the specialty. Links to past Chairs’ remarks are at the end of this post. In January 2021, the Board released a position statement that was shared with ASTRO members, and it is worth revisiting.
- ASTRO Position Statement on the U.S. Radiation Oncology Workforce (January 2021)
Radiation oncology has long been a critical component of multidisciplinary cancer management, driven by clinical and scientific innovation. Recent advances in technology and our understanding of cancer biology have allowed radiation oncologists to offer more accurate and effective therapies, often in fewer total treatments than before, resulting in improved patient care.
ASTRO has observed growth in residency training positions over the past two decades. With more efficient treatment delivery, fewer radiation oncologists may be needed in the coming years. Residency training positions should be reserved for those who are enthusiastic about the field and should reflect the anticipated societal need for radiation therapy services. As we prepare the next generation of radiation oncologists for independent practice, we encourage stakeholders to carefully consider these aspects affecting our specialty as they review the size and scope of their training programs.
Additionally, ASTRO acknowledges the continued need to grow and nurture diversity within the next generation of our workforce. We serve diverse peoples, and our trainees and faculty should reflect that diversity. We are committed to addressing all aspects of bias as we seek to ensure equity and inclusion within our specialty and to improve health outcomes for all our patients.
Recognizing that more could be done, the ASTRO Board approved the creation of a task force to analyze the current and projected future status of the radiation oncology workforce, the potential oversupply of radiation oncologists and ways to inform and attract an appropriate number of interested medical students to the field. The task force, which we co-chair, includes representatives from ASTRO’s Workforce Subcommittee, ADROP, ARRO, CHEDI and SCAROP, as well as community practices.
Our first recommendation to the Board was to authorize a Request for Proposal (RFP) for an outside, independent analysis of the future requirements for the radiation oncology workforce. We felt an external independent analysis by professionals experienced in these complex studies would minimize bias and provide the most credible data to assess the supply and demand over the coming decade. The ASTRO Board approved the RFP, and we are pleased to report that after a national search, the Workforce Task Force recommended, and the Board approved, the funding and selection of an independent firm, Health Management Associates, to execute the study.
The task force also crafted a supplement to the ASTRO Position Statement, which provides more context about issues impacting residency training programs, including the size, selection process and scope of training programs. This new position statement is:
- ASTRO Statement on the U.S. Radiation Oncology Workforce (February 2022)
ASTRO continues to support the critical role of high-quality residency training to optimally educate and prepare our future workforce. It is a foundational principle that residency training positions should be filled by qualified candidates who are enthusiastic about the field. To that end, we encourage stakeholders to carefully consider the following factors as they evaluate the size, selection process and scope of their training programs:
- The quality and extent of each candidate’s interest in radiation oncology.
- How the specialty, as a whole, as well as individual programs, can engage, recruit and retain diverse applicants.
- Availability of sufficient resources for clinical operations so that the priority for residents is education.
- The future expected need for radiation oncologists.
- Whether participation in the SOAP is warranted and in the best long-term interest of providing quality training, innovation and patient care.
The ASTRO Board is committed to maintaining distance from the analysis to ensure that there are no perceptions of any internal influence. It is the intention of the ASTRO Workforce Task Force to regularly update ASTRO members about the progress of the study while maintaining the boundaries required to ensure that the analysis and recommendations remain the independent domain of the outside firm. Until then, we hope that programs take our updated position statement into consideration as they plan their programs for the years ahead.
Read previous posts:
The Future of our Field – Dr. Thomas Eichler, January 5, 2021
A Commitment to the Field - Dr. Theodore DeWeese, March 10, 2020
The Residency Training Landscape, Continued - Dr. Paul Harari, May 28, 2019
The Residency Training Landscape - Dr. Paul Harari, March 20, 2019
1. Robert Wood Johnson and NJ Medical School, New Jersey
2. Cleveland Clinic, Cleveland, Ohio
3. University of Maryland School of Medicine, Baltimore, Maryland