Continuous Quality Improvement
A quality management system for radiation oncology
A part of implementing a quality system, such as ISO 9001 or the ACHS Quality Standards, is implementing a mechanism by which the users of the quality system can learn from experience and developed the system over time into one which provides services of an even higher quality. This is termed quality improvement. Examples of improved quality by following this process can be reducing errors in service delivery, implementing techniques and technologies that have higher precision and accuracy, increasing efficiency and access, amongst others.
Quality improvement capacity needs to be aligned with professional receptiveness, leadership, technical expertise and survey data. It is important to remember that the patient is the greatest beneficiary of an optimal quality program46.
Without an explicit feedback mechanism in place, the evaluation of the outcomes of an existing system is not necessarily provided as feedback to the users. Part of any quality system is the ongoing review and audit cycle in which all the quality system documents and processes are regularly reviewed. In this regard the following should be undertaken:
A regular review of the Radiation Oncology Strategic Plan which includes an evaluation of the implementation of previous strategic plans;
A regular review of the Radiation Oncology Practice Standards which use information gained from implementing the standards to inform the review;
The development of a system by which workers on the floor are able to identify issues affecting service quality and to bring these rapidly to the attention of management with issues being escalated quickly and remedied promptly.
It should be recognised that, from a strategic point of view, the radiation oncology strategy and standards are part of the quality system and should be part of the evaluation and review process. The Radiation Oncology Practice Standards and the Tripartite Strategic Plan need to be included as part of the review and audit cycle and are incorporated in the strategic plan itself. This self-referential process is common to the quality manuals and similar established under existing quality standards, such as ISO 9001, and a similar quality system should be adopted.
Stakeholder submissions to the Tripartite Plan raised the quality imperative of a national radiation oncology incident monitoring system. Currently, generic incident monitoring and reporting systems exist in all healthcare facilities. Unfortunately, these systems were not designed for recording radiotherapy incidents and near misses.
Understanding why errors in radiation oncology occur and enhancing systems for error detection and harm minimisation play a central role in the delivery of quality services. Factors that can contribute to errors in radiation oncology include: lack of training, competence or experience; fatigue and stress; poor design and documentation of procedures; hierarchical departmental structure; staffing and skills levels; changes in process and others47. While local reporting, investigation and learning following an incident are important, it is likely that other centres are experiencing similar issues. The transfer of knowledge between radiation oncology facilities is important to make radiation oncology sector safer across Australia. The absence of a national incident monitoring system in Australia constrains analysis of systemic process issues. This means that such issues can remain unidentified and therefore unaddressed, putting patients at risk.
The potential of incident reporting systems to detect, monitor, and reduce the occurrence of incidents should be recognised. For example, the Radiation Oncology Safety Information System (ROSIS) has been widely used in Europe. ROSIS aims to reduce the occurrence of incidents in radiation oncology by:
Enabling the clinics to share reports on incidents with other clinics as well as with other stakeholders such as scientific and professional bodies
Collecting and analysing information on the occurrence, detection, severity and correction of radiotherapy related incidents
Disseminating these results and generally promoting awareness of incidents and a safety culture in radiation oncology48.
Going forward, the radiation oncology sector needs to adopt a more systematic approach to reporting and understanding the causes of errors and harm. Clear criteria and definitions need to be agreed to categorize different types of errors and their causes, and to be able to facilitate analyses that lead to methods of prevention36. The establishment of a national radiation oncology incident monitoring system would be a significant step in establishing and enhancing safe delivery of radiation oncology in Australia.