By Charlotte Raley, Quality Improvement Analyst, ASTRO
Accreditation’s importance is growing among radiation oncology practices for ensuring safety and quality of patient care. With the trend of practice consolidation and growth, ASTRO’s APEx - Accreditation Program for Excellence® has seen a surge in requests to synchronize new or acquired facilities into existing accreditation cycles. This reflects a practice’s desire to ensure continuous quality improvement and alignment of processes, especially for those with new facilities.
Previously, requests to add facilities to an existing accreditation had to wait until the next cycle, delaying the process of solidifying or aligning procedures in newly acquired or built facilities. To address this, APEx initiated a satellite synchronization process that allows practices to add new facilities to their current accreditation cycle. Any new satellite(s) will be assessed on their compliance with the APEx Standards, going through the same rigorous process as the previously accredited facilities. This process is open to APEx-accredited practices that want to add new facilities during the accreditation process or within the first three years of their four-year accreditation cycle.
The first practice to take advantage of this option was the Miami Cancer Institute. They opted to bring their new facility in Plantation, Florida, into alignment with their main facility in Miami, which received APEx accreditation in 2021 and was the first APEx-accredited proton center in south Florida. The newly added satellite at Plantation is also the first APEx-accredited facility in Broward County. We spoke with Alonso Gutierrez, PhD, MBA, Assistant Vice President, Chief Physicist at Miami Cancer Institute and Vice Chair of Medical Physics and Dosimetry at Florida International University, and Shandelle Castillo, MHA, Radiation Oncology Program Coordinator at Miami Cancer Institute, to get a firsthand account of what influenced their decision to choose APEx and their experience with the satellite synchronization process.
Gutierrez stated, “We wanted to have the same standards across all our radiation oncology centers within the Baptist Health South Florida enterprise and given that our satellite functions identically to our main site, just at a different physical location, it was something that was somewhat of a no-brainer for us to do.” Gutierrez says he expects that any future satellites within their network will also be APEx-accredited. “We didn’t really question [why APEx] because we feel it’s very RO-specific and RO-dedicated, and from a quality of standards perspective, we firmly believe in the practice standards that APEx sets forth [for patient care].”
When asked about the process itself, Castillo reported “the process was fairly easy; [ASTRO staff] gave us a timeline for everything and provided all the documentation that we needed, and then the on-site review was very well organized.” Gutierrez added, “We had a kickoff meeting to really talk about the expectations of [the process], and it was very much in sync with the main site accreditation, making it easy for us to leverage a lot of the work we had previously done.”
The process consists of a practice submitting an application for synchronization, paying an additional fee and scheduling an in-person facility visit. The visit results are sent to ASTRO’s Practice Accreditation Subcommittee and follows the normal process to determine the facility's accreditation status. If the facility receives full accreditation, it will be added and “synced” to the practice's cycle.
“Synchronization is a great word because it actually parallels the expectations of the main site, but it’s done at a level of efficiency. The process is done just as rigorously, but efficiently and streamlined, so redundancy gets minimized. You can focus on the key aspects of the program, knowing that the main site has already gone through the more demanding documentation and process development [components].”
The new APEx satellite synchronization process is intended for practices to maintain high standards of care as they grow and ensure those standards are maintained across all facilities within a practice. “We thought the process was well organized and well structured”, says Gutierrez. He notes that accreditation is important to patients as well. “They may not know what it entails, but for [us] to say [we’ve] gone through a rigorous process for high quality [care] adds credibility to the organization.”
If your practice could benefit from the APEx satellite synchronization process, contact ASTRO staff and get started today!
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.
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 Doriann Geller, ASTRO Communications staff
The COVID-19 pandemic has changed the way business is conducted in many sectors around the world. Medicine, hard hit in operational activities, embraced telemedicine for patient visits, as well as peer-to-peer consultation, to a greater extent than ever before. ASTRO’s APEx - Accreditation Program for Excellence® curtailed facility site visits in March 2020, when the public health emergency declaration brought travel to a halt and closed many workplaces throughout the United States. In December 2020, after strategic and logistical planning sessions, ASTRO pivoted to offering virtual facility visits, the final step toward APEx accreditation.
“ASTRO decided to offer virtual facility visits when on-site surveys are not possible because of visitor or travel restrictions related to the public health emergency,” said Samantha Dawes, ASTRO director of Quality Improvement. “Baptist MD Anderson staff were willing participants with APEx’s first virtual format, which enabled ASTRO staff to assess the remote processes at both a main site and satellite facility simultaneously.” As a result, Baptist MD Anderson Cancer Center, in Jacksonville, Florida, was the first facility to successfully complete the accreditation process virtually.
Baptist MD Anderson’s Michael Olson, MD, PhD, interim division head of Radiation Oncology, and Ann-Marie Grietens, MSN, RN, NE-BC, director of Radiation/Neuro Oncology and Social Services, discussed their accreditation journey and the virtual facility site visit by video conference earlier this year, in April.
The Baptist MD Anderson mission is to provide “care that surrounds our patient and families with everything they need, physically, spiritually, and emotionally.” Ms. Grietens, who was involved in the process from start to finish, said that the accreditation process directly supports that model. To fulfill their missions, they take all aspects of the patient’s journey into consideration and utilize many patient-centered resources, including chaplain and social work support, both of which are in Ms. Grietens’ area of responsibility, she explained. The accreditation process gave them the opportunity to “go back and explore those resources,” she said. “I didn't realize going through it, but the biggest benefit is just pulling the team together and focusing them around these ideas of quality and safety and reminding them that the patient really is at the center of everything.”
Baptist MD Anderson operates two clinics, a main clinic and the South satellite clinic, both of which went through the accreditation process simultaneously. Ms. Greitens remarked that the surveyors “were gracious enough to split out our medical records [review] on different days and times, and the physics interview on different days and times, as well. Because we share resources at both clinics, that allowed my medical records team to be able to do the medical records review for both areas.” She added, “I feel the virtual aspect really was beneficial ― they could do it in [the] virtual app from either location. And Dr. Olson, with the team interview for South [the satellite clinic], was able to call in to participate. I thoroughly enjoyed the virtual aspect of the survey.”
Dr. Olson concurred: “I'm the physician that did [the survey] downtown. Especially for the policy reviews, because it’s electronic and our information is electronic, the virtual format does facilitate some of that information sharing. Everyone's looking at the same screen. I think this process, at least part of it, really lends itself to the to the virtual environment very well.”
Ms. Dawes remarked that the staff at Baptist MD Anderson were “well prepared and enthusiastic throughout the entire accreditation process, which contributed to how smoothly it went, and provided great feedback for ASTRO to learn from.” That feedback included comments from Ms. Grietens, who suggested that facilities undergoing the virtual visit talk to their IT departments to make sure that they are able to upload contiguous, large documents to the platform to ensure that the videos and documentation stay together.
“When I was at South with our physicist, we walked through and did [the video] with my phone,” Ms. Grietens explained. “And then he and I actually came in and did the same thing on a weekend in our downtown clinic. Making sure that we labeled everything appropriately on the website when we were uploading everything was key.”
“It was made very straightforward,” observed Dr. Olson. “Having a virtual [site visit] allowed us to continue normal operations, to work in the meeting with the rest of our day. It was painless. We sat there, it was a conversation, it felt natural. We worked through all the survey questions together, and then we were done. I honestly couldn't believe, when it was all completed, how efficient and easy it really was.”
Ms. Grietens continued, “This was a very positive experience for my team, and I think that we gained a lot out of the preparation ― as much as the actual survey. I highly encourage anyone to follow in our footsteps and take the same journey because they won't regret it.”
Dr. Olson agreed. “I think this is a fabulous process. I honestly believe every center should seek accreditation. Whether they get it or not is not the point. It’s going through the process, that they think about the right questions, because these are the things that we should be focusing on for taking the best care of patients.”
To learn more about APEx, visit the APEx webpages, where you can also request a virtual information session for your team.