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.

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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 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.

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.

An interview with Yoichi Watanabe, PhD, and David Hong, MD
By Randi Kudner, Senior Quality Improvement Manager

Yoichi Watanabe, PhD, has been involved in various aspects of radiation oncology accreditation in his many years at the University of Minnesota in Minneapolis. David Hong, MD, became interested in practice accreditation during his residency days at New York-Presbyterian Brooklyn Methodist Hospital and now works with Southeast Radiation Oncology Group in Charlotte, North Carolina. Both sat down with ASTRO’s Senior Quality Improvement Manager, Randi Kudner, to discuss the importance of accreditation and the practical improvements it can provide.

How did you become interested in practice accreditation?

DH: My department was due for re-accreditation towards the end of my second year in residency. It was the first I’d ever heard of the topic and I was surprised to learn that there were so many items material to the operation of radiation oncology practices that I’d never heard of or thought about. Figuring it would be better to learn about these sorts of things during residency than later as an attending, I approached our department chair Hani Ashamalla, MD, and asked to help. A year later, Dr. Ashamalla forwarded me an ASTROgram soliciting committee volunteers and encouraged me to apply. I was accepted by the Accreditation Committee and have since gained an appreciation that despite institutional variation, we all follow the same fundamental process of care and share similar day-to-day concerns.

YW: The University of Minnesota started the accreditation process in December 2015. At that time, accreditation was not popular among radiation oncology facilities in the Midwest, particularly in Minnesota. However, we saw an increasing concern for the safety of treatment in both the radiation oncology community and the potential patient population and felt the need to reexamine our current practice from a more objective point of view. Given the increased focus on safety and quality improvement in the field, we chose ASTRO’s Accreditation Program for Excellence (APEx^®) since the program was built upon Safety is No Accident: A Framework for Quality Radiation Oncology Care. Because APEx was new and no other institution in our area had such an accreditation, we envisioned an opportunity to prove the excellence of our practice. We expected at least two benefits with the application process. First, it would help to improve the quality of our clinical practice. Second, it could serve as an advertisement for our facility because of the strict accreditation requirement focused on the safety of radiation therapy. The fact that determinations in APEx are established through a committee review of a blinded facility report made it even more appealing for us as an objective program.

What is the value of accreditation in a radiation oncology practice?

YW: Accreditation is an external validation of quality, demonstrating the practice’s compliance with standards and best practices. The process allows for an objective, outside perspective that helps a practice identify strengths and weaknesses. It also shows patients that they can trust an organization and demonstrates to a community that the practice wants to provide the highest quality care possible. They respect that a practice has voluntarily undergone the process of meeting rigorous standards.

DH: It’s all about the effort put in. Done well, undergoing accreditation allows a radiation oncology practice to critically analyze, codify and improve policies and procedures, reduce variation through standardization of processes, and help establish a framework and culture of safety that can guide future practice improvement efforts. This does require a significant commitment of time and resources, but it’s a worthy investment. Providing this sort of structure was crucial to making our department a better place to work.

Both of you have gone through accreditation and been involved with APEx. What areas have you seen improve the most within your practice?

DH: The biggest change I witnessed was reduced friction and overall stress levels due to improved intradepartmental communication. Team members had a clearer understanding of what needed to be done and when. Patient wait times were reduced and our machines ran on schedule more often with less overtime and missed family time. Dosimetrists were able to deliver better plans faster after developing patient-specific planning directives. We were able to review our compliance and billing mechanisms and significantly improve our revenue cycle, primarily by improving documentation, pre-authorization, activity capture and auditing processes. We did not routinely use an incident learning system, but if we had, I believe that our rate of near-miss events would have been reduced dramatically. I could keep going, but in the end, I felt that going through an accreditation process served as a catalyst for improving most aspects of our practice’s operations over time.

YW: The review of procedure documents also significantly improved our practice. Our facility had most of the required documents already written, however, the policies and procedures were difficult to locate because of the lack of proper document management. Some had not been updated and others were never approved by management, so those were not officially used. The document preparation process was one of the most rewarding tasks because it required our team members to work together and understand our clinical process better while identifying our shortcomings and weaknesses. Through this exercise, our culture of teamwork was further improved for higher quality care.

Although we were proud of the quality care we provided to the patients, APEx made us identify and correct many deficiencies in our practice. We made changes and improvements in our daily practice, including:

• Adding radiation therapists to increase the number of staff available for treatment and simulation.
• Rewriting many existing, and developing many new, policy and procedure documents to clarify the procedures and meet the APEx requirements.
• Introducing a daily morning huddle to discuss the clinic schedule on that day.
• Forming a departmental safety committee; we meet quarterly to discuss the incidents reported to our incident reporting system and identify ways to improve the process.
• Adding an additional weekly chart round meeting to spend more time in reviewing treatment plans and the contours drawn by physicians for peer review of treatment planners and physicians.

Now we are more confident in our ability to provide the best care and service to our patients among many institutions in our local region and beyond.

Thank you both for sharing your insight into practice accreditation. There are many aspects for a practice to consider, and hopefully your experience will help other practices. Other than what you have already shared, what are your final comments?

YW: The most important requirement for successful completion of the accreditation process is the availability of a leader who drives the entire practice to work toward the goal. This encouragement and leadership will result in a willingness of departmental staff to participate in the process with the goal of success.

DH: Aside from the practice benefits, which are many, patients and referring providers expect safe, high quality services when entrusting us with their care. A convincing way of demonstrating this is through accreditation with a rigorous program.

Join the 110 facilities who chose to strengthen their practice and demonstrate that they provide the highest quality radiation oncology care by becoming an APEx accredited facility or network.