Quality and Safety

The University of California, Irvine Medical Center is designated as a member of the Commission on Cancer by the American College of Surgeons (ACS). In achieving this recognition, UCI works with the ACS to register and track the treatments and outcomes of cancer patients. The goal of the program is to assess the quality of care across UCI as well as all member programs. In addition, physicians in the Department of Radiation Oncology at UCI have used this real-world data to conduct research and discover the optimal strategies for cancer treatments.

Patient safety events in health care, in terms of incidents, near misses, inefficiencies, or unsafe conditions, are a natural part of working in healthcare. After all, to err is human. The goal of the incident reporting system at UCI Radiation Oncology is to identify safety hazards and, consequently, develop interventions to mitigate these hazards and reduce harm in health care. Emphasizing a culture that focuses less on blame (and finger pointing) and more on collective reflection, teamwork, and the development of a foundation for quality improvement is at the heart of who we are at UCI Radiation Oncology.

As any seasoned pilot will tell you, pre-flight checklists are an essential link in the safety chain at all levels of aviation. Indeed, the idea of a pre-flight checklist was first introduced by management and engineers at Boeing Corporation in 1935 following a fatal crash of the prototype Boeing B-17 Wright Field in Dayton, Ohio. Both pilots in the aircraft were killed, and after investigation it was found that the pilots had forgotten to disengage the gust locks, devices which stop control surfaces moving in the wind while the plane is parked, prior to take-off. After this Boeing decided to have a set list of actions to be undertaken pre-flight, so that such a thing could never occur again. Thus, the pre-flight checklist was born and soon adopted by others throughout the aviation world.

While delivering radiation therapy is vastly different from flying airplanes, one can argue that it is just as technically complex and challenging, with just as many instruments, gadgets, and protocols that must be fine-tuned in working in sync to optimize operation. As with flying, delivering radiation requires a huge array of steps, each of which introduces the potential for error.

As a major component of our pre-emptive safety program in radiation oncology, the Department leadership initiated a series of “No Fly Rules” in October 2018 which were meant to institute a methodical system of checks in workflow, to enhance patient safety. This Department-wide initiative was instituted after a review of prior safety incidents. With the goal of ensuring that radiation therapy planning was never rushed and that corners were never cut, the specific rules were imposed that ensure that quality is optimized to the utmost. While compliance to the “No Fly Rules” remains a work in progress, notable improvements in performance have been observed suggesting that our patients benefit now more than ever.

UCI Radiation Oncology is committed to the development of continuous quality improvement as evident by the numerous committees and initiatives devoted to this task. Our overarching goal of patient safety is at the heart of everything we do. Some highlights of our quality and safety program are as follows:

• Executive quality council that meets monthly to review safety guidelines, policies and procedures, and feedback provided by patients, faculty, and staff.
• Customized, UCI Radiation Oncology-based near-miss and mistake-reporting database to systematically review operations and make improvements. Additionally, the Department utilizes the Safety and Quality Information System at UCI as supervised by the Chief Medical Officer.
• Patient Safety and Quality Improvement Departmental Conferences is held regularly to discuss side effects from treatment and any outcomes that were not intended.
• Weekly prospective peer review conference attended by physicians, physicists, and dosimetrists is held to ensure that all patients who start radiation have multiple reviews of the treatment plan.
• Dedicated physics team that works to ensure technical quality. Our world-class group of physics takes pride in doing much of the “behind the scenes” work with machine calibration, dose verification, and quality assurance.
• "Deep Dive" case reviews are conducted in addition to Morning Report Conferences which analyze details of treatment delivery and decision-making.
• Journal clubs of newly published articles focused on quality and safety occur on a monthly basis. These are designed to foster discussion and to create an environment of inquiry with respect to how quality and safety can be improved.
• A “Patient Experience” conference that occurs at the of each month to review patient comments, suggestions, and feedback, specifically for the purpose of improving the experience for all those who are treated at UCI.
• There are a number of Quality and Safety projects spearheaded by faculty and residents with direct patient care applications. For instance, one project is attempting to improve access to palliative care physicians for patients who are considering hospice; another is aiming to assess opinions on use of complementary and alternative medicine; one project evaluates hurdles to coordination of care for patients requiring concurrent chemotherapy; a more recent project is studying wait times for inpatients in need of transportation services.

Peer Review is an integral component of quality assurance at UCI Radiation Oncology. All patients who are beginning radiation have multiple sets of eyes reviewing and approving their treatment plans prior to delivery of care. At UCI Radiation Oncology, peer review conferences occur twice weekly and involve clinical presentations including sharing of technical details associated with treatment. While these conferences are led by physicians, representatives from all sections of the department are expected to attend. These meetings are specifically designed to ensure that the highest quality and most contemporary treatments are being delivered. They are meant to be “working conferences” as much as they are educational. From a practical standpoint, the peer review process enables the entire team at UCI Radiation Oncology to:

1. Review the radiation treatment plan for every patient treated prior to treatment start.
2. Review the brachytherapy plan for every patient treated.
3. Present the imaging data, target volumes, normal structures, and radiation doses for discussion.
4. Display additional technical details including beam arrangement, coverage of the tumor, tolerance of dose-limiting tissue adjacent to target volumes, and dose and fractionation prescriptions for comprehensive analysis.
5. Discuss the clinical data and evidence-based decision-making that was used for each patient.
6. Iron out any complexities and challenges that need further clarification so that any ambiguity is eliminated.
7. Gain input from all team members to optimize the treatment
8. Review clinical trials including eligibility criteria for each case.
9. Brainstorm about potential improvements that could be made.
10. Achieve a group consensus on radiation treatment prior to the delivery of care.

Process Improvement is a systematic approach to problem solving related to the assessment, analysis, and improvement of organizational processes. This is especially important at UCI Radiation Oncology, where technology-driven evolution of care occurs at breathtaking paces, changes to standards are constantly being introduced, and treatment becomes increasingly complex with each passing month. As most in the healthcare industry know, processes are always in a state of flux. Operations are incessantly changing, and new challenges invariably present themselves.

That is why it is so vital to continually monitor every facet of patient care for opportunities in process involvement. Process Improvement is a conclusive way to assess areas of weakness and take the appropriate steps to ensure that excellence is always achieved. At UCI Radiation Oncology, various tools such as Lean Six Sigma, Kaizen, Failure Mode and Effect Analysis, and Total Quality Management are used to provide a framework to assess performance improvement and maintain performance. By focusing on a continuous evaluation of processes, the Department can ensure that top-notch care is provided. At UCI, this process of quality improvement typically involves 3 steps:

The initial step in the assessment phase is to regularly review the policies and procedures related to workflow and operations. This will determine the established governance, as well as potentially identify areas in need of improvement. In many cases, Department “deep dives” are conducted which provide insight into how procedures can be refined to reflect more currently desired outcomes. Frequently, suggestions by patients instigate quality improvement processes. Only by measuring and comparing our existing performance based on metrics or key performance indicators (KPIs) with benchmarks of practice measures available within the industry can target goals be reliably developed. For instance, at UCI Radiation Oncology, KPIs that are constantly tracked include measures related to patient wait times, online communication lags, treatment delays, compliance with documentation, emergency hospitalizations, and unnecessary imaging. Additionally, a rigorous program for equipment calibration, treatment monitoring, and independent auditing exists to ensure performance is optimal and that the correct dosage of radiation is delivered. Discussions centered on KPIs typically occur at the weekly quality conference led by our Chief Quality Officers, Dr. Healy and Dr. Reilly.

1. Routinely evaluate processes to identify what might require tinkering

   The initial step in the assessment phase is to regularly review the policies and procedures related to workflow and operations. This will determine the established governance, as well as potentially identify areas in need of improvement. In many cases, Department “deep dives” are conducted which provide insight into how procedures can be refined to reflect more currently desired outcomes. Frequently, suggestions by patients instigate quality improvement processes. Only by measuring and comparing our existing performance based on metrics or key performance indicators (KPIs) with benchmarks of practice measures available within the industry can target goals be reliably developed. For instance, at UCI Radiation Oncology, KPIs that are constantly tracked include measures related to patient wait times, online communication lags, treatment delays, compliance with documentation, emergency hospitalizations, and unnecessary imaging. Additionally, a rigorous program for equipment calibration, treatment monitoring, and independent auditing exists to ensure performance is optimal and that the correct dosage of radiation is delivered. Discussions centered on KPIs typically occur at the weekly quality conference led by our Chief Quality Officers, Dr. Healy and Dr. Reilly.

2. Establish goal targets and propose adjustments

   The next phase of quality improvement at UCI Radiation Oncology involves establishing measurable goals for performance optimization with the input of all stakeholders including faculty, staff, and management. In this step, it is critical to identify and implement available technology or work tools to roll out initiatives that have the potential to improve automation and/or workflow efficiency. The impact on staffing, processes, and operations is then vetted. Typically, a quality “champion” is designated who has the responsibility of leading effort to assess the effect of any proposed intervention. Projects which have been conducted in the past include those focusing on patient transportation, room utilization, ancillary support, and wait times.

3. Continuous monitoring of progress

   Once the changes are implemented, the last step is to continually monitor the progress of improvement based on the metrics or KPIs established in the previous stages. This step is important because it will hold faculty and staff accountable for the productivity and quality standards developed. A regular cadence should be established for identifying, analyzing, and improving metrics and processes. Daily monitoring of the metric reporting will help determine if implemented changes are improving performance. This way, the Department can identify issues and work to fix the problem by fine-tuning processes and workflow based on performance comparison to departmental goals. Creating opportunities for faculty and staff involvement and idea engagement are keys to success in this important area.

Ultimately, sustainable, organizational improvement cannot be produced by a single memo or executive edict, but rather must be supported by an overall culture that embraces it. Above all, UCI Radiation Oncology recognizes that change is a natural part of healthcare, and only through a “all hands-on deck,” data-driven commitment to continuous quality improvement can the Department continue to maintain its lofty standards in the future.