Quantification of the impact of multifaceted initiatives intended to improve operational efficiency and the safety culture: a case study from an academic medical center radiation oncology department.

PURPOSE: We have systematically been incorporating several operational efficiency and safety initiatives into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful, metrics. METHODS AND MATERIALS: The data from 5 quality improvement initiatives, each focused on a specific safety/process concern in our clinic, are presented. Data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using statistical analysis. Results from the Agency for Health Care Research and Quality (AHRQ) patient safety culture surveys administered during and after many of these initiatives were similarly compared. RESULTS: (1) Workload levels for nurses assisting with brachytherapy were high (National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores >55-60, suggesting, "overwork"). Changes in work flow and procedure room layout reduced workload to more acceptable levels (NASA-TLX <55; P < .01). (2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range, 1-11) times per patient treatment to a mean <1 (range, 0-3; P < .001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (ie, delayed, on time). (3) The rates of replans by dosimetrists was reduced from 11% to 6% (P < .01) through a more systematic pretreatment peer review process. (4) Standardizing nursing and resident functions reduced patient wait times by ≈ 45% (14 min; P < .01). (5) Standardizing presimulation instructions from the physician reduced the number of patients experiencing delays on the simulator (>50% to <10%; P < .01). To assess the overall changes in "patient safety culture," we conducted a pre- and postanalysis using the AHRQ survey. Improvements in all measured dimensions were noted. CONCLUSIONS: Quality improvement initiatives can be successfully implemented in an academic radiation oncology department to yield measurable improvements in operations resulting in improvement in patient safety culture.

The challenge of maximizing safety in radiation oncology.

There is a growing interest in the evolving nature of safety challenges in radiation oncology. Understandably, there has been a great deal of focus on the mechanical and computer aspects of new high-technology treatments (eg, intensity-modulated radiation therapy). However, safety concerns are not limited to dose calculations and data transfer associated with advanced technologies. They also stem from fundamental changes in our workflow (eg, multiple hand-offs), the relative loss of some traditional "end of the line" quality assurance tools (port films and light fields), condensed fractionation schedules, and an under-appreciation for the physical limitations of new techniques. Furthermore, changes in our workspace and tools (eg, electronic records, planning systems), and workloads (eg, billing, insurance, regulations) may have unforeseen effects on safety. Safety initiatives need to acknowledge the multiple factors affecting risk. Our current challenges will not be adequately addressed simply by defining new policies and procedures. Rather, we need to understand the frequency and causes of errors better, particularly those that are most likely to cause harm. Then we can incorporate principles into our workspace that minimize these risks (eg, automation, standardization, checklists, redundancy, and consideration of "human factors" in the design of products and workspaces). Opportunities to enhance safety involve providing support through diligent examinations of staffing, schedules, communications, teamwork, and work environments. We need to develop a culture of safety in which all team members are alerted to the possibility of harm, and they all work together to maximize safety. The goal is not to eliminate every error. Rather, we should focus our attention on conditions (eg, rushing) that can cause real patient harm, and/or those conditions that reflect systemic problems that might lead to errors more likely to cause harm. Ongoing changes in clinical practice mandate continued vigilance to minimize the risks of error, combined with new, nontraditional approaches to create a safer patient environment.