Navigating the APEx Journey: Insights from the Radiation Oncology Community

Embarking on the path toward ASTRO’s APEx – Accreditation Program for Excellence® is a transformative endeavor for any radiation oncology practice. This rigorous process sets a high standard for quality and safety in patient care. In this blog, we have the privilege of hearing from five members of the radiation oncology community who have successfully achieved APEx accreditation or are in the process of doing so. Their experiences shed light on how they learned about APEx, the pivotal factors that led to their decision to change accrediting bodies, and the challenges and triumphs encountered. Additionally, we gain insight into the unique aspects of APEx that set it apart from their previous accreditation experiences, like the Self-Assessment. Their collective experiences offer a roadmap for other practices that may be considering APEx. For more detailed information about each phase of the APEx process, visit About APEx.

About your decision to switch:

Douglas Prah, PhD: Was there a specific tipping point or deciding factor in changing accreditation programs?

Colleen A. F. Lawton, MD, FASTRO: I was involved in ASTRO leadership and wanted to be part of this critical initiative as soon as possible. We were ACR accredited since it began and highly value the accreditation process. The APEx process was more involved than ACR and thus we wanted to have this new level of accreditation that was Safety is No Accident based. So as soon as our ACR Accreditation was expiring we just changed to APEx.

Virginia Lockamy, PhD: Since our practice is in New Jersey, we had to wait for the state to recognize APEx before switching our accrediting body. [APEx has been accepted in all 50 states since 2021.]

Jennifer Tietz, RT(T) and Kileigh Peturis, MS: Participation in the RO-ILS program, excellent publications such as Safety is No Accident, and professional recommendations drove the switch. The radiation safety emphasis and APEx Standards were also factors.

Chris Channels, RT(T): In the last three cycles, ACR would approve us “conditionally,” creating much more work for us. It was almost as if that was their standard operating procedure, as we have always felt we do things correctly. We looked at other options, and APEx was very attractive to us.

Prah: Were there any key advocates for switching? What were the reasons voiced by your practice staff for or against changing accreditation programs? 

Tietz/Peturis: At the beginning of the process, there was apprehension about switching programs because the current agency was known, and we had built a solid relationship with the organization. In hearing from colleagues across the [Texas Oncology] network, APEx was comprehensive, patient-focused and streamlined with less administrative burden during the initial application process.

Channels: Our Medical Director and Radiation Director were the key advocates for switching programs. We wanted to make a change for two reasons. First, ACR kept giving us “conditional” approvals each cycle, so we decided to look at other options. Second, being under the ASTRO umbrella, we knew that APEx would be radiation oncology-focused, whereas ACR has a much broader scope. In addition, APEx’s attention to safety and quality attracted us, as that is our focus at HOA. It also allowed us to deeply dive into all our policies and procedures to update and improve upon what we were already doing. The guidance provided by APEx made this an easy process overall.

Lockamy: Fortunately, we had buy-in from the entire team. As a current APEx Surveyor, I was able to explain the benefits of the program and answer any questions/concerns. Our partners at Penn Medicine were also supportive of our switch to APEx as they are currently accredited by APEx as well. We felt that this program was more robust and more specific to radiation oncology as it was developed by ASTRO.

APEx Process — Team and Timing:

Prah: Who was involved in the actual APEx process? How was the work managed at your practice?

Tietz/Peturis: The Director of Radiation Services, Regional Chief Physicist and Chief Radiation Therapists were involved in completing the Self-Assessment. Monthly meetings are hosted. All electronic documentation is saved on SharePoint, and general information is shared via MS Teams.

Lawton: Physics, dosimetry, therapists, department managers and radiation oncologists. Initially, we had weekly meetings. Once we got accredited, roughly monthly.

Channels: Chief Physicist, Chief Radiation Therapist, Lead RTT and myself. Monthly meetings started about six months before our facility visit.

Lockamy: Our Assistant Vice President of Radiation Oncology, Director of Physics, Medical Director, two site managers, and one site supervisor were all part of the APEx Self-Assessment. We also enlisted a few therapists to assist with the chart review preparation. We met weekly to review our progress. We tracked our work in a spreadsheet and assigned owners to each section of the Self-Assessment.

Prah: How long did the Self-Assessment take? Was that more or less than your expectations? Why? 

Lockamy: The Self-Assessment took us three months to complete. This also included the medical record review preparation. The Medical Record Review [of the Self-Assessment] took the longest for us to complete, which was longer than we expected. The reason is that it was a more thorough and comprehensive review of the charts than required by our previous accrediting body.

Lawton: The Self-Assessment took longer than expected as many of our safety procedures were not documented well and needed to be added or updated.

Prah: What are some unique aspects of APEx compared to your previous experience? What changes did you see at your practice? 

Lawton: The discussions alone were helpful as we started to document and/or update documents of safety protocols. Once we had our documents done and accreditation obtained, updating the documents for future accreditation was much easier.

Lockamy: The entire process, from preparation to on-site facility visit, was more robust than our previous experiences. We implemented multiple changes to our practice in response to our preparation for the survey. For instance, our physicians were not always documenting pertinent negatives during their consults. We also reviewed our existing policies and procedures. Based on the guidelines provided by APEx, we revised multiple ones and developed new ones we lacked.

Prah: Were there any unexpected challenges in the transition process? If so, what? 

Channels: At first, applying for accreditation seemed daunting, but APEx makes the process seamless, and the ASTRO staff support was excellent. Any questions we had were answered in a timely manner, which helped us to keep moving forward. We were unsure how the Self-Assessment document upload would be reviewed. We kind of took the approach of “here is what we have” and submitted it. We did not pass the first time, but we refocused our efforts so that we could successfully complete that step of the process. 

Lawton: The biggest challenge was the time needed to do the initial work for the first APEx Accreditation. Having ACR Accreditation, we thought, would make this initial work for APEx easy, but that was wrong. APEx is much more detailed and totally worth the effort.

Prah: How was your experience with APEx Surveyors and the facility visit? 

Channels: Our experience with the [APEx] surveyors and facility visit was excellent. The surveyors did not seem to be looking for things that were wrong; they were more interested in how and why we did things at our facilities. We felt they were working with us instead of dissecting every little thing.

Prah: What was identified as a low-performing area during the Self-Assessment? How has your practice addressed that before or after the facility visit? Was there any unexpected feedback from the Self-Assessment or facility visit?

Lawton: A significant area of improvement was written documentation. This was especially true for our standing committees that performed valuable functions for our department, but whose function and operation were never explicitly documented. We mandated that committee charters be drafted, including a purview, scope, membership guidelines, quorum guidelines, procedural and operational format, and standing agenda outline. We renamed our Safety Committee to the Patient Safety and Quality Committee, including our Comprehensive Quality Management Program. We also formalized our Service and Technology and Implementation and Review Committee. The formalization also encouraged better communication within the greater department and more thorough documentation of meetings. Another significant improvement was the standardization of documentation across the practice within the medical record for consults and follow-up notes, as well as improving our written planning directive. The good news is that once the Self-Assessment is done, your site will have an excellent idea of your ability to get APEx accredited or what you need to do to improve.

Lockamy: We knew going into both the Self-Assessment and on-site facility visit that we were going to be marked as low-performing on the documented patient-specific planning directive. Our physicians were alerting our dosimetrists to what dose constraints they wanted but not in a formalized document. We had templates built and implemented by the facility visit to demonstrate to the surveyors.

Prah: How was the customer service from ASTRO? 

Channels: Overall, the experience was great. The material on the APEx website was very detailed and helped guide us through the process.

Lockamy: We had a few questions throughout the process and were able to reach out to APExSupport to have them addressed, whether through email or a meeting.

Tietz/Peturis: Thus far, the customer service has been prompt and professional, and has provided clear instructions for all inquiries.

Are you interested in transitioning to APEx from another radiation oncology accrediting body? Schedule a free one-on-one session with ASTRO staff to discover how APEx can benefit your practice. During the call, ASTRO staff will provide information tailored to your practice’s needs and goals. You can also request a teleconference with a knowledgeable radiation oncology professional from your chosen discipline by completing the peer-to-peer request form. This meeting will allow you to hear from your colleagues who have completed the APEx process. You can ask specific questions and learn from their experiences.




Douglas Prah, PhD
Associate Professor and Director of Advance Care and Technology
Department of Radiation Oncology
Froedtert & Medical College of Wisconsin
Milwaukee, Wisconsin

APEx Surveyor, ASTRO Practice Accreditation Subcommittee Member
Past Accreditation: ACR (1995-2018)
Current Accreditation: APEx (2019-2027)



Chris Channels, RT(T)
Director of Radiation and Imaging Services
Hematology-Oncology Associates of CNY
Syracuse, New York

Past Accreditation: ACR (2013-2022)
Current Accreditation: APEx (2022-2026)

Colleen A. F. Lawton, MD, FASTRO
Professor and Vice-Chair
Department of Radiation Oncology
Froedtert & Medical College of Wisconsin
Milwaukee, Wisconsin

Past Accreditation: ACR (1995-2018)
Current Accreditation: APEx (2019-2027)

Virginia Lockamy, PhD
Virtua Director of Physics and Penn Medicine Chief of Network Physics
Penn Medicine I Virtua Radiation Oncology
Voorhees, New Jersey

APEx Surveyor since 2019
Past Accreditation: ACR (2016-2022)
Current Accreditation: APEx (2022-2026)

Jennifer Tietz, RT(T)
Director of Radiation Services
Texas Oncology – Central Texas
Austin, Texas

Past Accreditation: ACRO (2017-2023)
Current Accreditation: APEx (Active Application)

Kileigh Peturis, MS
Chief Medical Physicist
Texas Oncology – Central Texas
Austin, Texas

Past Accreditation: ACRO (2017-2023)
Current Accreditation: APEx (Active Application)
Posted: November 14, 2023 | 0 comments

Miami Cancer Institute First to Use APEx's New Satellite Synchronization Process

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!

Posted: March 15, 2023 | 0 comments

Patient Safety Awareness Week for Radiation Oncology

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.

Posted: March 15, 2022 | 0 comments