ACR/ASTRO Accreditation Program: An Overview Of Technical And . - AAPM

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Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012ACR/ASTRO Accreditation Program: AnOverview of Technical and Clinical ComponentsUSA Healthcare Commercial entityACR-ASTRO Radiation OncologyPractice Accreditation ProgramIndra J. Das, Ph.D. FACR, FASTRO(Indiana University School of Medicine, Indianapolis, IN)Patrick D. Conway, M.D, FACR(Gunderson Clinic, LaCross , WI)American College of Radiology Most hospitals are for profit Attempt to provide best care Minimize cost Innovative CompetitiveCompetition Find positive edge over otherscenters Get new technology Meet state or federal standards Avoid errors Get satisfaction survey AdvertiseMedical Errors and MediaNew YorkTimes Jan 26,2010 WaltDogdanich Newspaper Magazine, Flier Bill board InternetQuality & SafetyACR/ASTRO RadiationOncology PracticeAccreditation (ROPA)stands for such pillar

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012How to Provide Quality CareFederal guidelinesQuality & Safety tied toBilling & Reimbursement Second set of eyes Every calculation and procedureshould be double checked For sites, single staff, follow TG-103 Focus for root cause Good bookkeeping practice Periodic update on TechnicalStandards Follow ACR/ASTRO Guidelines andASTRO White papersSome states (NJ, NY) havealready mandated suchlawAll VA hospitals arerequired to have ACRAccreditationCare bill in Congress willmandate AccreditationSome statistics about the programAccredited Facilities363Facilities Under Review 114 Established in 1987 Originally based on “PATTERNS OF CARE”“Under Review” Collaborative with ASTRO 2008 Deferred/submitting corrective action Accreditation is a cooperative effortbetween the ACR and ASTRO to establish astrong foundation on which the radiationoncology practice accreditation programcan continue to grow and develop Site visit has not yet been completed Final report has not been written yetRadiation Oncology AccreditationProgram Growth 2006 – 2012*Accreditation Program GoalsApplications 250200150100*2012 FY Begins on July 12011-122010-112009-102008-092007-0802006-0750 Provide impartial, third party peer reviewEvaluate and promote quality of careRecommend practice improvementBe educational, not punitive

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012ACR-ASTRO Surveyor’s RequirementSurveyors must be: ABR Certified ACR or ASTRO Member In Active Practice in Radiation OncologyWhy is Accreditation Important? Evidence of achievement in the areas ofquality and patient safety Education and learning process for staff Demonstrates commitment on the part ofthe facility to meeting the highest standardsin the field of radiation oncology Enhances credibility in the eyes of the publicBenefits of Accreditation Offers specific recommendations forimprovement from experienced, practicingradiation oncologists and practicingphysicists Peer review forms can be used by thefacility as part of their continuing qualityimprovement activities Survey report to support requests forincreased staffing and equipmentimprovements/replacementsACR/ASTRO Radiation OncologyPractice Accreditation Program Web based program launched in January2011 Application, interview and data collectionforms, surveyor report and summary areall captured electronically No more paper Broader recognition by peers in the fieldACR-ASTRO accreditation outcomesACR-ASTRO Accreditation3 Categories: Accreditation Cycle is 3 years Accreditation Even if your facility is accredited,you will receive recommendationsfor improvement but no response isneeded Defer Denial of Accreditation

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012Deferral of Accreditation 90 days to submit Corrective ActionPlan (CAP) Following CAP approval by committee,the facility will receive a report andtheir ACR-ASTRO certificateCorrective Action Plans (CAP)Denial of Accreditation 90 days to submit CAP After committee approval of CAP,facility must participate in a follow upsurvey (6-9 months after response toCAP is received) Re-application fee ( 5000) requiredConsultative Survey Does not lead to accreditation Need to address each of therecommendations in the report May involve submission ofadditional documentation such asphysician peer review, physicsreport, etc.Multi Site Survey Criteria Includes all of the activities performed duringaccreditation but with a special emphasis onareas identified by facility as needing a morecomprehensive review 2 day survey with a 3 or 4 person teamSurvey Fees Single Medical Director Single Site 9500.00 Single Physics Group Each additional site 3000.00Includes surveyor travel Uniform charts, policies &procedures Distance between sites one hour

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012Application Part I and II Part I gathers information about yourfacility; staffing, equipment, physicallocation Part II includes specific questionsabout the practice such as your P&P,adherence to guidelines/standardsWhat happens during the on site survey?ACR-ASTRO AccreditationTo make the process as objective aspossible, recommendations are basedon data from ACR/ASTROGuidelines/Standards, ASTRO WhitePapers, AAPM reports, ACRAppropriateness Criteria-On Site Survey, cont. The site visit is always conducted by a radiationoncologist and medical physicist Physicist interview (time to be determinedon site) First activity will be an interview with key personnel(Chief MD, chief physicist, chief therapist, dosimetrist,RN, etc.) followed by a tour of facility Review of QA manuals, P&P, throughout day After completion of tour, surveyors will begin chartcheck. The facility must provide one or 2 staff to helpwith navigating through charts/EMR, etc. Facilities must provide Internet access as well login andpasswordAccreditation Standards & Guidelines Appropriateness Criteria (ACR) Practice Guidelines (ACR, ASTRO) Technical Standards (ACR) AAPM Task Group Reportsrecommendations such as TG-40, TG-142,TG-51, TG-53, TG-43, TG-103 White Papers (ASTRO) “Exit Interview” prior to departure withsame personnel from AM interview. Theteam will not give their recommendationsbut will use this opportunity to clarify anyissues, etc.What does the Medical Physicist review on site? Procedures for instrument calibration/periodicinstrument constancy checks Procedures for checking integrity of mechanicaland electrical patient care devices Procedures to verify manufacturer’sspecifications and establish performance valuesfor RT equipment Calculations related to patient dosimetry and/orphysics measurements (diodes, TLD, etc.)

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012Medical Physicist on sitePractice Guidelines - Radiation Oncology Radiation protection program 2D & 3D External Beam Quality management program for radiation therapyequipment, simulators, treatment planningsystems, and monitor unit calculation algorithms Intensity-Modulated Radiation Therapy(IMRT) This includes protocols and procedures for ensuringa consistent and safe fulfillment of the doseprescription Brachytherapy: HDR, LDR, Prostate etc Image-Guided Radiation Therapy (IGRT) SRS, SRT, SBRT, IMRS Documented program for electrical, mechanicaland radiation safety TBI, TSEIMedical Physicist on siteMedical Physicist on site NO Proton Beam Treatment Plan/MU Calculation ProceduresIMRT Documentation Double check of treatment plans/MUcalculations for accuracy prior to patienttreatment whenever possible but before thethird fraction Dose Volume constraints documented For 5 or fewer fractions, the calculation must bechecked prior to delivery of the first treatment Documentation of weekly physics chart check Documentation that physicist checked the chartwithin 1 week from end of treatmentACR Technical Standard for the Performance offor External Beam Therapy The medical physicist should engage in aformalized peer review on a regular basis. Physicists engaged in solo practice (being theonly qualified medical physicist at a facility, orserving as consultant providing the only medicalphysicist service to the facility) should followpublished AAPM recommendations, includingpeer review recommendations. (TG 103) Inverse planning performed Documentation includes: delivered doses tovolumes of target and non-target tissues, inthe form of dose volume histograms andrepresentative cross sectional isodosetreatment IMRT QA on phantom performedNon-compliance with ACR Guidelinesand StandardsSince the accreditation program is based onACR-ASTRO guidelines and standards, finalreports will contain recommendations thatlink to a guideline or standard. We will take alook at some frequently seen clinical andphysics recommendations. Not all of theseare “deal breakers”, in other words, leadingto denial of accreditation

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012Common Reasons for Deferral (Physics) Lack of physics coverage Lack of chart check and end of treatment Lack of second check of calculations No documented IMRT QAClinical ComponentsPatrick D. Conway, M.D, FACR No documented TPS QA No commissioning report No annual QA report No brachy-source calibrationRadiation Oncologist reviewRecommendationsCharts reviewed for: Completeness of H&P Medical Decision Making/Staging Simulation/PlanningWe will look at some key elements that arereviewed by the physician during the surveybased on ACR/ASTRO Guidelines and Standards On Treatment Visits Portal Imaging Completion Summary Follow UpPractice Guideline for CommunicationIncluded in H&P:Practice Guideline for CommunicationMedical Decision Making: Tobacco use for lung patients Staging Family hx/ hormonal status for breastpatients Plan of care (other tests needed,combined modality (chemotherapy) Potency status for prostate patients

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012Practice Guideline for Radiation OncologyPractice Guideline for 3-D External BeamRadiation Planning and Conformal TherapySimulationRadiation Oncologist responsibilities include: All set ups should be documented byproperly labeled photographs/diagrams andwhen appropriate, by standard images orDRRs. Contour critical normal structures not clearlydiscernible on treatment planning images Suitable Immobilization Review and approve all critical structures Prescribe target dose and limitations oncritical normal structures Signed and datedPractice Guideline for Radiation OncologyOn treatment visits: Should include Vitals/Current Dose/AnyTumor Response/Side Effects/Non MedicalIssues If visits are performed by the NursePractitioner, the ACR recommends that thephysician sign and date the note as evidenceof his/her evaluation of the patientPractice Guideline for CommunicationPractice Guideline for Radiation OncologyPortal Verification Images When portal images can be made, theyshould be taken every 5-10 treatmentsand for any new fields Signed and DatedPractice Guideline for CommunicationCompletion Summary Should Include:Follow Up: Total dose/ doses delivered totarget/tumor volumes and other keyorgans/elapsed daysIf the patient is not followed by theradiation oncologist after the initial followup visits, we want to see a follow up planand some notes from referring MDs/clinicto ensure continuity of care Relevant assessment of tolerance/progress Subsequent care plans Timely

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012CQI DOCUMENTATION MD Peer Review Chart Rounds Weekly Tumor Boards M & M Studies Focus StudiesPhysician Peer Review The recommended frequency is twiceyearly. This can be done during locumcoverage or through a contract with a local,perhaps, academic facility Documentation is the key Outcome StudiesPractice Guideline for Radiation OncologyM&M Conferences Review of any chart in which an incident report isfiled or in which there is a report of an accident orinjury to a patient. Review of unplanned interruptions duringtreatment; unusual or severe, early or latecomplications of treatment; and unexpected sideFocus StudiesFocus studies are basically quality improvementprojects. For example, 20% of patients are missingtheir weekly on treatment visit. A focus studywould identify this problem, take action to correctit, then measure the effectiveness of the actiontaken. 6 months later, for example, only 5% havemissed their on treatment visit.effects or deaths.Outcome Studies Review of outcome studies from the cancercommittee, tumor registry, or any othersection, department, or committee of anassociated hospital that includes radiationoncology patients. If not hospital based, the practice can designa study, for example, skin reactions in breastpatients following APBICommon Clinical Reasons for Deferral Lack of chart rounds Lack of established QA/CQICommittee/process Failure to follow ABS, ASTRO, ASTRO,AAPM guidelines for prostatebrachytherapy

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012Common Clinical Reasons for Deferral Radiation oncologist coverage isinadequate (not on site whenpatients simulated or treated) No physician peer review Lack of adequate prescriptions, suchas not signed, site/volume notstated, # of fractions, etc.R-O PEER R-O PEER is a program that allowsradiation oncologists to fulfill PartFour: Assessment of Performance inPractice for the Maintenance ofCertification (MOC) program for theAmerican Board of Radiology (ABR)through the Radiation OncologyPractice Accreditation ProgramACR/ASTRO Radiation OncologyPractice Accreditation Program ACR recommended mandatoryaccreditation of all facilities toLegislators ASTRO strongly recommendedaccreditation for all facilitiesFinal Report The final report is currently issued approximately8-12 weeks following the survey. The final report will contain: Accreditation Decision: PASS, DEFER, DENY Staffing/Resources Table Recommendations for improvement based onGuidelines/Standards and AAPM reports Link to Media Kit for marketing accreditationR O PEER Physicians applying for R O PEER can submit their application withthe facility’s application foraccreditation and will receive aseparate report after accreditationis granted Satisfies ABR requirement for asociety based project for MOCAdvantages to becoming a surveyor

Radiation Oncology Practice Accreditation (ROPA): Das & Conway, AAPM 2012How do I apply to become a surveyor? Complete the on-line application ication.pdf Once approved, successfully complete thesurveyor tutorial Participate in a site visit as a “trainee”How do I start the application processfor my facility? Visit the ACR web site and complete the on spx Once we have received your application and surveyfee, we will look for a survey team for one of thedates you have suggested You will be notified by e mail of the survey date (s)and surveyor team membersHow long does the survey take? A single site is completed in one day(generally 8 a.m. to 4 p.m.) ; multi sites varydepending on number of sites, MD andlocationQuestions?

Practice Accreditation Program Web based program launched in January 2011 Application, interview and data collection forms, surveyor report and summary are all captured electronically No more paper ACR-ASTRO accreditation outcomes 3 Categories: Accreditation Defer Denial of Accreditation ACR-ASTRO Accreditation Accreditation Cycle is 3 years

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