EI 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).
EI 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).
EI 5.2: Professional Qualifications. We have two dosimetrists; one is Board certified and the other is not. Will this prevent accreditation?
The 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
EI 7.5.1: The ROP participates with a Patient Safety Organization (PSO). What is a PSO and what if our ROP doesn’t participate in a patient safety organization?
Patient Safety Organizations (PSOs):
- Share the goal of improving the quality and safety of health care delivery.
- Collect and analyze data to identify and reduce the risks and hazards associated with patient care.
- Create a secure, non-punitive environment through confidentiality and privilege protections.
The Radiation Oncology Incident Learning System, or 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.
EI 13.1-4: Peer Review for each professional discipline. Do we need to have a peer review for all disciplines at our facility?
The requirement within APEx 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.
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.
EI 14.1: Patient Consent. What does it mean that consent must be current? What happens 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.
It is also compliant if the ROP has a documented formal policy showing a different time frame, such as 30 or 90 days.