The Self-Assessment Guide is proprietary information and is only shared with the ROPs once ASTRO has processed payment for the APEx program. You will have access to both the guide and the Self-Assessment phase of the program as soon as your payment is processed.

APEx accreditation is valid for four years from the date of the ROP's APEx determination.

Each ROP’s time frame varies and is dependent on several things, such as the amount of time and staff dedicated to the accreditation process and what level of standardization and documentation is already in place. For more detailed information about time frames, please see the APEx Annual Report.

Here are the four main phases of the APEx program and approximate time frames:

Application:

• Consists of general practice information, legal agreements and submission of payment.
• ASTRO suggests sending the legal agreements to legal representatives for review as soon as the ROP starts an application.
• The ROP can complete the practice information in one day. The information consists of the name/address of the facility(s), key personnel, annual number of new patients treated, treatments offered, equipment information and physician(s).
• From the time payment is posted by the practice until it clears the bank processing, it can take one to two weeks. ASTRO staff processes the payment in the APEx Portal as soon as it is received from the bank. After which the practice can start the Self-Assessment immediately.

Self-Assessment:

• Recently, ROPs seeking APEx accreditation have completed the Self-Assessment phase in an average of three months.
• Medical records and interview preparation can be completed in one day and have instantaneous results, once submitted.
• Document uploads require an eternal review once submitted. This usually takes between four to six weeks. ASTRO suggests uploading and submitting the document upload section first, then completing the medical records and interview preparation while the documents are under review.

Facility Visit Prep:

• Once the Self-Assessment is complete, the ROP representative enters 15 preferred dates into the APEx Portal and may select dates that are between two and six months in advance.
• Facility visits are usually finalized within four weeks of submitting potential dates.
• Approximately two weeks prior to the scheduled facility visit date, ASTRO staff will hold a teleconference with representatives from the ROP to discuss the itinerary and review application information.

Determination:

• The accreditation determination is sent four to six weeks after the facility visit.

APEx follows ASTRO’s 2018 Supervision White Paper on physician supervision. To meet the APEx requirement, a radiation oncologist should provide direct supervision, meaning they are immediately and physically, interruptible and able to furnish assistance and direction throughout the performance of a procedure. While APEx understands that a radiation oncologist may need to step away for a meeting or consultation with inpatients, a physician should be present at the facility to assure patient safety.

Exclusions may apply for facilities in rural exemption areas. Please contact ASTRO staff with any questions. 

The ROP submits an online application through the APEx Portal. To access the APEx Portal (hosted by MedConcert), click the green 'Facility Portal' button on the APEx Facilities webpage.

Please download the APEx Registration and Application Instructions before starting your application.

Satellite facilities that are located within 50 miles of a main facility, and meet all satellite requirements, may be included in the application as part of a multi-facility practice. Any application with a satellite location more than 50 miles will have the application placed on hold. Please contact ASTRO staff for further guidance.

ASTRO may accept a satellite that is located between 50-150 miles from the main facility if it meets all other satellite requirements. If accepted, there may be an additional fee of $3,000 for each satellite in this range. Satellite facilities located more than 150 miles from the main facility are required to do a separate application.

To make the APEx program scalable, ASTRO’s facility and business associate agreements must be used and ASTRO generally cannot accept changes to these agreements. Requests for changes and the circumstances warranting the changes may be submitted in the form of a contract addendum by email to Amy Nordeng, ASTRO Associate General Counsel. She can be reached by phone at 703-286-1676

The application fee for a main facility is $14,000. For satellites listed as part of the same multi-facility application, there is an additional charge of $5,000 per satellite. These prices are inclusive of all program-related expenses (e.g., program participation, surveyor travel costs) and is the only payment required throughout the four-year cycle.

A discount rate is available for entities consisting of more than ten (10) active facilities within the APEx program. Once ten facilities under the same ownership or affiliation have entered into facility agreements and submitted payment for the APEx program, ASTRO offers a discount of $2,000 off the price of any subsequent main facility and $1,000 off the price of any subsequent satellite(s) applying for APEx. ROPs must notify ASTRO of their eligibility for the discount rate at APEx Support prior to submitting payment.

For information on qualifications for discounts, please email APEx Support.

ASTRO currently has two options to submit payment for APEx.

1. The entire fee is paid during the application phase. If a practice chooses this option, there are no other costs associated with this accreditation process or during the four-year accreditation cycle. 
2. Until December 31, 2020, practices can take advantage of a partial payment option to reduce the upfront cost of the application fee. Half of the program fee is due during the application phase and the remaining balance is paid before scheduling the facility visit. The facility visit will not be scheduled until the balance has been paid.

A unique aspect of the APEx program is that ROPs must complete the Self-Assessment before scheduling a facility visit. The Self-Assessment is a self-study of the ROP’s compliance with the APEx Standards and is considered an essential component of the program. This process promotes quality improvement and leads to higher performance during the facility visit, as it allows the facility to implement changes or confirm their compliance with APEx Standards before the facility visit.

Level 1 evidence indicators are processes that are essential to daily practice (e.g., informed consent, treatment machine QA) and, therefore, have a higher compliance requirement than Level 2 evidence indicators within the APEx program. All evidence indicators must be attempted during the Self-Assessment and ROPs must demonstrate at least 85% compliance with Level 1 evidence indicators in each section of the Self-Assessment before being designated as ready for a facility visit.

Only the facility designated as the main facility will complete the Self-Assessment in a multi-facility application, as all facilities should follow the same policies and procedures. It is the responsibility of the ROP to disseminate program information to the satellite(s).

Although the medical record review is completed using only the medical records from the main facility, the document upload section reflects the policies and procedures used throughout the entire ROP. Some information about the satellites will be required during the document upload section such as processes for treatment modalities performed only at a satellite location, staffing information and external validations of machine output.

ROPs may choose up to fifteen potential facility visit dates once the Self-Assessment is completed. The facility visit date is selected from those dates and is based on the availability of the required surveyors for each ROP.

Yes. The main facility will have an all-day facility visit, while each satellite location will have a half-day facility visit. All facility visits in a multi-facility practice occur on the same day.

No. It takes 4-6 weeks after the facility visit to receive an APEx accreditation determination.

The ASTRO Practice Accreditation Committee is charged with reviewing blinded facility reports based on the facility visit survey, and they issue accreditation determinations. The committee is multi-disciplinary and includes radiation oncologists, medical physicists, radiation therapists and medical dosimetrists who are trained APEx surveyors.

Determinations are based on the facility visit scores and review of additional information. There are three levels of accreditation that may be awarded: full accreditation, provisional accreditation or denial.

No. A multi-facility practice will receive a single determination based on the lowest-performing facility.

Example: A multi-facility practice of four facilities applies to APEx accreditation. After the facility visit, three facilities receive full accreditation and one facility receives provisional accreditation. The entire multi-facility practice would be rewarded provisional accreditation.

ROPs that receive provisional accreditation must submit a corrective action plan (CAP) for low performing evidence indicators outlining how compliance will be achieved. CAPs are submitted and blinded before review by the Practice Accreditation Committee. If the CAP is accepted, the ROP will receive full accreditation.  If the ROP’s CAP is not accepted or not submitted within the time frame, the ROP is denied accreditation.

An ROP has the right to appeal their decision based on specific criteria (see APEx Procedures for more information). The appeal request must be submitted in writing to APEx Support within 30 days from the determination.

When submitting an appeal, please use APEx Appeal Guidelines on the requirements of an appeal request.

ASTRO recommends starting reaccreditation preparations 12 months before the expiration of a current accreditation cycle, to avoid a lapse in status. To initiate the process and start the application, an APEx Portal Administrator for your ROP clicks the Reaccreditation button on the Home tab of the APEx Portal.

During the application process, the ROP’s application is pre-populated with information from the initial accreditation application. While reviewing this information, the ROP can add/remove any satellites as required, including updating each facility’s information (e.g., treatment modalities, physicians).

Someone within your ROP may have already initiated the application, which freezes the APEx Portal for all remaining team members. You will not have access to the APEx Portal until ASTRO has processed the payment. At that time, your APEx Portal rights will be restored.

Yes. ROPs will begin by reviewing and submitting their application, legal agreements and payment to ASTRO. Once this is complete, the ROP will have access to the Reaccreditation Guide and the Self-Assessment phase of the program. Each ROP must complete the Self-Assessment to be deemed ready for scheduling a facility visit.

To avoid a lapse in your APEx accreditation status, the ROP should receive a reaccreditation determination before your current accreditation expires. Extensions of your accreditation status will be granted when 1) the facility visit is finalized before your expiration date and 2) the facility visit occurs within 90 days of your expiration date. Accreditation extensions are valid until a new determination is given.

Example: If an ROP’s accreditation is set to expire on March 31, an extension will be granted if a facility visit is finalized before March 31 and occurs before June 29.

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).

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).

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

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.

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.

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.

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.