Patient Safety

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TU_26_3062 - The Complete Prospective QA Picture: The Importance of Physician Involvement in FMEA

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

The Complete Prospective QA Picture: The Importance of Physician Involvement in FMEA
C. R. Buckey, M. G. Foster, G. Penoncello, C. A. Schulz, P. Riopelle, P. Burris, R. Moore, and W. G. Rule; Mayo Clinic, Phoenix, AZ

Purpose/Objective(s): AAPM’s recently published TG-100 report lays out a framework for developing a prospective, risk-based quality assurance program. This approach introduces the interested audience to process mapping, Failure Modes and Effects Analysis (FMEA) and Fault Tree Analysis (FTA). This has been a hot topic among physicists, but perhaps has not garnered as much attention from physicians. We sought to perform a TG-100 style analysis throughout the introduction of a new modality, Total Skin Electron Therapy (TSE). Our stakeholders included physicists, therapists, dosimetrists, schedulers and the lead TSE physician. It was our hypothesis that active participation from a diverse team that included a physician would be the only way to ensure a comprehensive approach.

Materials/Methods: Our multidisciplinary group met over the course of 4 months; after the determination of clinical need, concurrent with the start of physics measurements, and prior to the first patient consultation. The group met for 2-4 hours weekly to work through the TG-100 recommended process, and sometimes worked individually offline as well. Process maps were divided into work areas, and were completed at a detail level sufficient to ensure understanding among non-experts.

Results: Throughout the process mapping phase, physician input was vital to determining our workflow for patients and staff. It became clear that the physician steps were well known only to the physician, and that they could benefit from additional QA. The scoring of O, S and D were done collaboratively by the multidisciplinary group, and non-experts consistently under-rated the values for areas outside their expertise—a common misconception being that second checks were in place for steps that actually had no redundancy. The physician-centric steps were some of the most lacking in this respect. Of our 58 process steps, 20 required physician action.

Conclusion: As we proceeded through the FMEA to the eventual creation of a prospective quality assurance paradigm, our hypothesis that would be essential to the creation of a safe and effective program, was repeatedly confirmed. The special knowledge and skills of our physician team member dramatically altered our of the workflow, the identification of the most at-risk process steps, and the determination of the most effective means to avoid inefficiency and error. The multidisciplinary nature of the group also gave important feedback to the physician, including a better understanding of the treatment options and modifications available, and how those decisions would affect the course of treatment. Left as a “physics activity” we would not have been successful at designing a quality management program that met the needs of our staff and patients. Additional outreach and training of physicians in the techniques of TG-100 will enhance safety and efficiency for patients and staff.

Author Disclosure: C.R. Buckey: None. G. Penoncello: None. P. Burris: None. R. Moore: None.

Courtney Buckey, PhD

Mayo Clinic Arizona

Disclosure:
Employment
Mayo Clinic in Arizona: Medical Physicist: Employee

Leadership
AAPM: TG-314

Presentation(s):

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