T. R. Meier1, A. D. Vassil2, L. M. Keller2, J. Sherman3, E. J. Murray1, T. Kovacs4, J. H. Suh5, and S. T. Chao5; 1Cleveland Clinic, Cleveland, OH, 2Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, 3OMPC Therapy, LLC, Columbus, OH, United States, 4Cleveland Clinic, Cleveland, OH, United States, 5Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH
Purpose/Objective(s): Variation in process and documentation cause gaps that lead to decreased patient safety and department efficiency. Safety risk can increase as enterprises grow and add regional centers. Implementation of an Intradepartmental Survey Program provides an opportunity to improve standardization of documentation and technique, review appropriateness of care, provide staff psychological safety and remain accreditation ready with the ultimate goal of providing the safest place for patients to receive treatment throughout the enterprise. Materials/
Methods: Our Intradepartmental Survey Program has been in place for 5 years and has performed 10 different department audits with the goal of surveying every center once between the three-year American College of Radiology (ACR) survey interval. Survey standards from the ACR and the American Association of Physicists in Medicine (AAPM) were utilized for this program. A voluntary survey team from both main and regional centers was assembled from the following groups: physician, physicist, dosimetrist, and therapist. . The survey consisted of three parts: 1) an anonymous pre-site survey, which was sent to each department member asking 5 quality related questions such as commitment to quality and safety, just culture, and needed changes 2) a random sample of 8 charts per radiation oncologist, which are reviewed by surveyors and 3) an onsite survey with opportunities for question and answer conference and observation. Results: A final report is presented to the medical director of each center and manager. The report included feedback from each surveyor including a narrative of overall department function, strengths and recommendations, and findings of each chart reviewed. From our ten surveys completed to date, the physician and therapist groups have the most recommendations as noted in the table below. Based on the report, an action plan is generated by the surveyed center, listing improvement projects to address the recommendations from the report. Conclusion: Creation of our Intradepartmental Survey Program, which is one of our Continuous Quality improvement (CQI) projects, has unified main and regional sites to share best practices through standardization, which facilitates efficient safe practices. This program has also improved our just culture, a culture where individuals feel safe reporting and speaking about deviations and working together on opportunities of shared accountability.
