Radiation Oncology Incident Learning System Update
Currently, a national incident learning system dedicated to radiation oncology does not exist. As part of its Target Safely plan, ASTRO committed to forming a national incident learning system, which has resulted in the Radiation Oncology Incident Learning System (RO-ILS). The RO-ILS is a patient safety organization (PSO) designed to improve the safety and quality of radiation oncology. PSOs are established within the confines of the Patient Safety and Quality Improvement Act of 2005 (PSQIA) to improve quality and safety through the collection and analysis of data on patient events. The PSQIA was enacted in response to the 1999 Institute of Medicine (IOM) report "To Err is Human: Building a Safer Health System." The IOM report highlighted a serious need to capture information that would improve health care quality and reduce harm to patients. PSOs are organizations that share this goal, and are certified by the Agency for Healthcare Research and Quality (AHRQ). PSOs are designed to create a secure, non-punitive environment where clinicians and health care organizations can collect, aggregate and analyze data to identify and reduce the risks and hazards associated with patient care.
Data, reports, records and other information that could improve patient safety or quality and are either assembled by a provider and reported to a PSO or developed by the PSO to conduct patient safety activities are called patient safety work product (PSWP). PSWP does not include the patient’s underlying medical records or information collected independently from the PSO reporting system (even if that information is itself reported to the PSO). PSWP is privileged and confidential. Information that is privileged cannot be compelled for production or use in a legal proceeding. Similarly, information that is confidential might be subject to compulsory production but must continue to be protected from public disclosure. Generally, PSWP is not subject to discovery, subpoena, order or disclosure under the Freedom of Information Act and is not admissible as evidence in any proceeding including professional disciplinary proceedings. While this provision preempts state and federal laws, state and federal medical error reporting requirements are not preempted. Practically, this means that providers who report to a PSO cannot rely on its data protections to shield it from reporting to state or federal agencies (NRC, FDA), and providers must maintain two sets of information: PSWP and non-PSWP that can be used for state and other federal reporting requirements.
In April, 2013, after a rigorous Request For Proposal process, ASTRO signed a contract with Clarity PSO, a division of Clarity Group, Inc., to provide PSO services to the radiation oncology community. In addition, recognizing the importance of physicists in the quality of radiation oncology care delivery, ASTRO has signed a Memorandum of Understanding with the American Association for Physicists in Medicine (AAPM), solidifying AAPM’s support in this project. Most recently, in early September 2013 the RO-ILS began Beta Testing. All participating providers, including Beta Testers are required to sign a contract with Clarity PSO. This contract provides the confidentiality and privilege protections afforded to the providers under the PSQIA. All participants will receive reports bench marking reports and reports containing data specific to their institution. Modifications to RO-ILS will be made based upon the Beta Testers’ experiences, before the full launch of RO-ILS to the radiation oncology community. We expect the full launch to take place during the first quarter of 2014.
As a component of RO-ILS, ASTRO will be establishing the Radiation Oncology Healthcare Advisory Council (RO-HAC). This group will assist with the initial triage of events within the RO-ILS, and perform root-cause analysis of select events. The make-up of the RO-HAC will include all members of the radiation oncology team. View more information, including how to apply to become a member of the RO-HAC.
While some medical institutions have developed their own reporting systems, the RO-ILS will ensure that the information gathered is synthesized in such a way that its dissemination provides excellent education for practitioners, while at the same time protecting those who are reporting events. To learn more about the RO-ILS, please be sure to attend the following the following sessions at ASTRO’s Annual Meeting in Atlanta:
- Featured Lecture: "Patient Safety Organizations Overview" William B. Munier, MD, MBA, Director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality
Monday, September 23 - 8:00 a.m. - 9:00 a.m. in room B406
- Panel 10: "Safety First: Using a National Patient Safety Organization to Improve the Quality of Care"
Monday, September 23 - 4:00 p.m. - 5:30p.m. in Thomas Murphy Ballroom 4
For more information, please email us.