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Pretreatment Peer Review: A Way to Increase Efficiency and Effectiveness of Departmental Peer Review
Poster Viewing E541
Volume 96 Number 2S Supplement 2016 lay solely with departmental leadership to follow-up on and address incidents. A few still expressed fear of retribution, describing being told not to document an incident by a co-worker. Other barriers such as time and accessibility were commonly described. Learning was often described as increased awareness, resulting from expanded communication, and less frequently from explicit teaching. Practice improvement was rarely perceived as learning. Conclusion: Overall, the opportunity to influence patient safety was perceived as highly relevant by participants. Barriers included logistics and inadequate feedback, but also, despite marked progress, some persistence of hierarchical beliefs and behaviors more consistent with “shame and blame” culture. These results identify the need for procedural, cultural, and educational changes, e.g., web access, more specific and timely feedback to clearly demonstrate positive outcomes, and more transparency, to be made within the department so that all staff members continue to feel comfortable reporting incidents and meaningfully engaging in the system. Author Disclosure: A. Novak: None. J. Zeng: None. E.C. Ford: Leadership in AAPM; American Association of Physicists in Medicine. L. Jordan: None. L. Holland: None. G.M. Kane: None.
3326 Pretreatment Peer Review: A Way to Increase Efficiency and Effectiveness of Departmental Peer Review N. Pham,1 J.A. Asper,2 M. Bonnen,1 and P.M. Jhaveri1; 1Baylor College of Medicine, Houston, TX, 2South Texas Radiation Therapy, Houston, TX Purpose/Objective(s): Peer review is utilized as a valuable tool to assure quality in cancer treatment decisions. At our facility chart rounds has historically accounted for a total of 6% in changes in patient plans. Our department sought to enhance our peer review program with the introduction of a pre-treatment peer review and stereotactic peer review programs. Our goal was to capture 15% of all patients treated. Here, we describe the value of pre-treatment peer review. Materials/Methods: We initiated a peer review program with prospective data collection in August 2014. Our peer review clinics include: chart rounds, pre-treatment peer review, and stereotactic peer review programs. Chart rounds consist of weekly meetings where all patients on treatment are reviewed and include only teams of physicians based on subsite. Pretreatment peer review consists of cases with increased complexity, or questions about appropriateness or technique. Stereotactic peer review consists of all stereotactic cases treated. Both pre-treatment and stereotactic peer review include all radiation oncologists regardless of subsite treated, residents, PA’s, physics, and dosimetry teams. Since August 2014, there are 1052 patients presented at our peer review conference. Out of these patients, 133 patients (12.6%) were selected to be presented at the pre-treatment conference. Components of peer review discussed were treatment intent, appropriateness of radiation therapy, organ at risk/target delineation, and proposed dose/fractionation. Changes were stratified into major and minor changes. Major changes included 1cm field change or change in site or subsites treated. Minor changes include <1cm field change or total dose or fraction size change. A sub-category, labeled as other, included items that were recommended by group. Results: Of the 1052 patients who underwent peer review, 7% had changes recommended, which is consistent with the previously recorded values. However, the frequency of change was 10 times higher for cases that were reviewed in pre-treatment rounds, compared chart rounds (31% vs. 3%). Most of the changes were minor (83%), but 17% of all changes were major and thought to be of a magnitude that could potentially affect therapeutic outcome or normal tissue toxicity. Other items listed as changes in care included: recommended referral, imaging, and pathological second opinion. Conclusion: The addition of pre-treatment peer review for provider selected cases proved valuable and effective. Although the percent of overall changes were not significantly altered, the introduction of pretreatment peer review resulted in a 50% reduction in on-treatment chart round changes. This reduction provides value in both patient safety and clinical efficiency.
Author Disclosure: N. Pham: None. J.A. Asper: None. M. Bonnen: None. P.M. Jhaveri: None.
3327 Does Peer-Review of Radiation Treatment Plans Impact Clinical Care? A Systematic Review of the Literature K. Brunskill,1 G. Boldt,1 T. Nguyen,2 A. Louie,1 and D.A. Palma3; 1 Department of Radiation Oncology, London Health Sciences Centre, London, ON, Canada, 2London Health Sciences Centre, London, ON, Canada, 3Department of Radiation Oncology, Western University, London, ON, Canada Purpose/Objective(s): Peer-review of radiation plans is recommended as an approach to improving patient safety and quality of care. However, peer-review rounds are resource-intensive, and their impact on clinical care is not well-quantified. The objective of this study was to undertake a systematic review of the literature to assess the impact of peer-review on clinical care. Materials/Methods: A systemic review of the literature was conducted according to PRISMA guidelines, including MEDLINE, EMBASE, and abstracts from relevant radiation oncology meetings. For inclusion, studies were required to report the impact of physician peer-review on at least one element of treatment planning (e.g. target volume/organ-at-risk delineation, dose prescription, or dosimetry). Surveys in which radiation oncologists were asked to estimate the impact of peer-review on treatment planning were also included to ascertain physician perspective on the clinical impact of peer review. Studies reporting central review of contours in clinical trials were excluded. All proportions reported represent weighted averages across studies. Results: The initial search yielded 882 potentially eligible studies. Fulltext review was performed independently by two researchers, with discrepancies settled by a third. In total, 16 studies met inclusion criteria and were included in the final analysis. Twelve studies, involving 12,239 patients, reported patient outcomes whereas, four surveys reported oncologists’ estimates of clinical impact. Studies were recent, with the majority (75%) published since 2010. Twelve studies reported on multiple tumor sites, while single-site studies included head and neck (nZ1), lung (nZ2), and breast (nZ1). In most studies, peer-review occurred before the start of radiotherapy or within the first few fractions. Overall, peer-review resulted in modifications to 10.7% of patient plans. Five studies differentiated between minor versus major changes and reported averages of 7.5% minor changes and 2.5% major changes. From the survey studies, oncologists estimates that modifications occurred in 6% of treatment plans. Conclusion: Based on a systematic review of the literature, peer-review results in changes in clinical care in approximately 1 out every 9 cases overall, with major changes in approximately 1 out of every 40 cases. Further research is required to determine the essential elements of peerreview, and to assess the impact of peer review on clinical outcomes. Author Disclosure: K. Brunskill: None. G. Boldt: None. T. Nguyen: None. A. Louie: None. D.A. Palma: None.
3328 Failure Mode and Effects Analysis: A Community Practice Perspective B. Schuller, A. Burns, E.A. Ceilley, A. King, J. LeTourneau, A. Markovic, L. Sterkel, B. Taplin, J. Wanner, and J.M. Albert; Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO Purpose/Objective(s): To evaluate the feasibility of implementing failure mode and effects analysis (FMEA) in a small community practice setting. We further aimed to identify key steps and define important details regarding the technique as we completed our first FMEA evaluation, with the goal of informing development of similar process evaluation initiatives for other interested groups. Materials/Methods: First, an FMEA facilitator was identified who received extensive training at the AAPM Summer School. To build consensus, early efforts focused on department education and emphasized
Volume 96 Number 2S Supplement 2016 lay solely with departmental leadership to follow-up on and address incidents. A few still expressed fear of retribution, describing being told not to document an incident by a co-worker. Other barriers such as time and accessibility were commonly described. Learning was often described as increased awareness, resulting from expanded communication, and less frequently from explicit teaching. Practice improvement was rarely perceived as learning. Conclusion: Overall, the opportunity to influence patient safety was perceived as highly relevant by participants. Barriers included logistics and inadequate feedback, but also, despite marked progress, some persistence of hierarchical beliefs and behaviors more consistent with “shame and blame” culture. These results identify the need for procedural, cultural, and educational changes, e.g., web access, more specific and timely feedback to clearly demonstrate positive outcomes, and more transparency, to be made within the department so that all staff members continue to feel comfortable reporting incidents and meaningfully engaging in the system. Author Disclosure: A. Novak: None. J. Zeng: None. E.C. Ford: Leadership in AAPM; American Association of Physicists in Medicine. L. Jordan: None. L. Holland: None. G.M. Kane: None.
3326 Pretreatment Peer Review: A Way to Increase Efficiency and Effectiveness of Departmental Peer Review N. Pham,1 J.A. Asper,2 M. Bonnen,1 and P.M. Jhaveri1; 1Baylor College of Medicine, Houston, TX, 2South Texas Radiation Therapy, Houston, TX Purpose/Objective(s): Peer review is utilized as a valuable tool to assure quality in cancer treatment decisions. At our facility chart rounds has historically accounted for a total of 6% in changes in patient plans. Our department sought to enhance our peer review program with the introduction of a pre-treatment peer review and stereotactic peer review programs. Our goal was to capture 15% of all patients treated. Here, we describe the value of pre-treatment peer review. Materials/Methods: We initiated a peer review program with prospective data collection in August 2014. Our peer review clinics include: chart rounds, pre-treatment peer review, and stereotactic peer review programs. Chart rounds consist of weekly meetings where all patients on treatment are reviewed and include only teams of physicians based on subsite. Pretreatment peer review consists of cases with increased complexity, or questions about appropriateness or technique. Stereotactic peer review consists of all stereotactic cases treated. Both pre-treatment and stereotactic peer review include all radiation oncologists regardless of subsite treated, residents, PA’s, physics, and dosimetry teams. Since August 2014, there are 1052 patients presented at our peer review conference. Out of these patients, 133 patients (12.6%) were selected to be presented at the pre-treatment conference. Components of peer review discussed were treatment intent, appropriateness of radiation therapy, organ at risk/target delineation, and proposed dose/fractionation. Changes were stratified into major and minor changes. Major changes included 1cm field change or change in site or subsites treated. Minor changes include <1cm field change or total dose or fraction size change. A sub-category, labeled as other, included items that were recommended by group. Results: Of the 1052 patients who underwent peer review, 7% had changes recommended, which is consistent with the previously recorded values. However, the frequency of change was 10 times higher for cases that were reviewed in pre-treatment rounds, compared chart rounds (31% vs. 3%). Most of the changes were minor (83%), but 17% of all changes were major and thought to be of a magnitude that could potentially affect therapeutic outcome or normal tissue toxicity. Other items listed as changes in care included: recommended referral, imaging, and pathological second opinion. Conclusion: The addition of pre-treatment peer review for provider selected cases proved valuable and effective. Although the percent of overall changes were not significantly altered, the introduction of pretreatment peer review resulted in a 50% reduction in on-treatment chart round changes. This reduction provides value in both patient safety and clinical efficiency.
Author Disclosure: N. Pham: None. J.A. Asper: None. M. Bonnen: None. P.M. Jhaveri: None.
3327 Does Peer-Review of Radiation Treatment Plans Impact Clinical Care? A Systematic Review of the Literature K. Brunskill,1 G. Boldt,1 T. Nguyen,2 A. Louie,1 and D.A. Palma3; 1 Department of Radiation Oncology, London Health Sciences Centre, London, ON, Canada, 2London Health Sciences Centre, London, ON, Canada, 3Department of Radiation Oncology, Western University, London, ON, Canada Purpose/Objective(s): Peer-review of radiation plans is recommended as an approach to improving patient safety and quality of care. However, peer-review rounds are resource-intensive, and their impact on clinical care is not well-quantified. The objective of this study was to undertake a systematic review of the literature to assess the impact of peer-review on clinical care. Materials/Methods: A systemic review of the literature was conducted according to PRISMA guidelines, including MEDLINE, EMBASE, and abstracts from relevant radiation oncology meetings. For inclusion, studies were required to report the impact of physician peer-review on at least one element of treatment planning (e.g. target volume/organ-at-risk delineation, dose prescription, or dosimetry). Surveys in which radiation oncologists were asked to estimate the impact of peer-review on treatment planning were also included to ascertain physician perspective on the clinical impact of peer review. Studies reporting central review of contours in clinical trials were excluded. All proportions reported represent weighted averages across studies. Results: The initial search yielded 882 potentially eligible studies. Fulltext review was performed independently by two researchers, with discrepancies settled by a third. In total, 16 studies met inclusion criteria and were included in the final analysis. Twelve studies, involving 12,239 patients, reported patient outcomes whereas, four surveys reported oncologists’ estimates of clinical impact. Studies were recent, with the majority (75%) published since 2010. Twelve studies reported on multiple tumor sites, while single-site studies included head and neck (nZ1), lung (nZ2), and breast (nZ1). In most studies, peer-review occurred before the start of radiotherapy or within the first few fractions. Overall, peer-review resulted in modifications to 10.7% of patient plans. Five studies differentiated between minor versus major changes and reported averages of 7.5% minor changes and 2.5% major changes. From the survey studies, oncologists estimates that modifications occurred in 6% of treatment plans. Conclusion: Based on a systematic review of the literature, peer-review results in changes in clinical care in approximately 1 out every 9 cases overall, with major changes in approximately 1 out of every 40 cases. Further research is required to determine the essential elements of peerreview, and to assess the impact of peer review on clinical outcomes. Author Disclosure: K. Brunskill: None. G. Boldt: None. T. Nguyen: None. A. Louie: None. D.A. Palma: None.
3328 Failure Mode and Effects Analysis: A Community Practice Perspective B. Schuller, A. Burns, E.A. Ceilley, A. King, J. LeTourneau, A. Markovic, L. Sterkel, B. Taplin, J. Wanner, and J.M. Albert; Department of Radiation Oncology, McKee Medical Center, Banner Health, Loveland, CO Purpose/Objective(s): To evaluate the feasibility of implementing failure mode and effects analysis (FMEA) in a small community practice setting. We further aimed to identify key steps and define important details regarding the technique as we completed our first FMEA evaluation, with the goal of informing development of similar process evaluation initiatives for other interested groups. Materials/Methods: First, an FMEA facilitator was identified who received extensive training at the AAPM Summer School. To build consensus, early efforts focused on department education and emphasized