Evidence Indicator 1.1: Comprehensive Patient Evaluation. Does all this information need to be included in the consultation note? What if it is documented in other encounters?
APEx requires documentation of each component of 1.1, evaluated by the radiation oncologist, before simulation or any pre-treatment preparation. Items may be documented in initial consults, subsequent encounters and/or informed consent, if it occurs prior to simulation. Documentation must include one of the following for each component:
- Positive findings (e.g., allergic to contrast, previous radiation treatment).
- Pertinent negative (e.g., no known allergies, menopause 2002, no implantable cardiac device).
- Non-applicable references (e.g., lab results N/A).
- Confirmation of review (e.g., MRI Pelvis with contrast 3/27/15 reviewed).
Evidence Indicator 3.2: Timeout Process. We do a timeout for every patient but do not record it anywhere. How is this checked in APEx?
APEx requires that a patient time out is performed before every treatment/procedure and verifies patient identification, correct treatment site, correct patient positioning and treatment parameters at the console. There are many ways this documentation may be evidenced (e.g., checklist, sign-off, daily alert acknowledgment).
Evidence Indicator 5.2: Professional Qualifications. We have two dosimetrists; one is Board certified and the other is not. Will this prevent accreditation?
APEx requirements for certification and licensure are consistent with ASTRO’s Safety is No Accident publication. For all disciplines, the employee must either have the relevant professional certification or be eligible for certification. For any staff member who does not possess a certification, the ROP must have a policy on the process for obtaining certification, with specific timelines for any individual to become certified, and supervision requirements, until Board certification is obtained
Evidence Indicator 7.5.1: APEx requires ROPs to participate in a patient safety organization (PSO). What is a PSO and what if our ROP doesn’t participate in a patient safety organization?
APEx encourages reporting to a patient safety organization (Evidence indicator 7.5). RO-ILS is a free patient safety initiative housed on Clarity PSO and created by ASTRO and AAPM, therefore meeting the requirement for 7.5.1. This program is dedicated to reducing medical errors by providing a platform for reporting safety events in a secure and non-punitive environment, gaining legal protection as afforded by the Patient Safety and Quality Improvement Act. There is no information shared between APEx and RO-ILs.
To learn more about the RO-ILS program, please visit www.astro.org/roils.
Evidence Indicator 13.1-4: Peer Review. Do we need to have a peer review for all disciplines at our facility?
The requirement within the APEx program is an intra-disciplinary peer-to-peer review process for at least the radiation oncologists, medical physicists, radiation therapists and dosimetrists. To be compliant, there must be an opportunity for staff to learn from other similarly qualified staff members (i.e., physicist-physicist, therapist-therapist, physician-physician). Information on peer review process for each professional group should include the form chosen (i.e., retrospective, current or prospective), what is reviewed, and the frequency of review.
Evidence Indicator 13.1-4: Peer Review. Is chart rounds an example of peer review?
If chart rounds are performed as an inter-disciplinary meeting, then it does not automatically meet the requirement of 13.1 for all professional disciplines.
To demonstrate compliance, there must be a learning opportunity between similarly qualified staff members (i.e., physicist-physicist, therapist-therapist, physician-physician, dosimetrist-dosimetrist). Multiple members of a professional discipline, reviewing tasks performed by that professional group, must be present for the activity to be applicable. In many instances, chart rounds are classed as intra-disciplinary for radiation oncologists, if there is more than one radiation oncologist in attendance, but would not be applicable for medical physicists, radiation therapists and dosimetrists.
Evidence Indicator 14.1: Patient Consent. APEx requires that consent is current (i.e., is signed within 60 days before treatment.) What does this mean? What is the expectation when the consent is older than 60 days?
To maintain a valid informed consent, APEx requires the informed consent to be signed 60 days before the first day of actual treatment. If there is a delay, and this time frame exceeds 60 days, the expectation is that the informed consent is updated or redone prior to treatment.
If the ROP has a different time frame such as 30 or 90 days, this is also compliant as long as it is documented in a formal policy.