Accreditation Is Coming

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1 Accreditation Is Coming Accreditation Is Coming Accreditation Is Coming

2 Yes, It Is! Currently, Accreditation is Voluntary However, Some of the Accrediting Organizations Are Lobbying the Congress to Adopt a Resolution to Make Accreditation Mandatory VA Radiation Oncology Facilities Have Already Adopted the ACR Accreditation.

3 Description and Requirements of Radiation Therapy Accreditation Programs: The Role of The Dosimetrist Mehdy Jabir, M.Phil., DABR, BABSNM Dade Moeller & Associates Gaithersburg, MD

4 Disclosures ACR Member ACRO Member Work for a Service Provider Company- Consultative Surveys, Participate in ACR and ACRO Programs Showing Any Device or Software Represents NO ENDORSEMENT

5 Accrediting Organizations: American College of Radiology ACR American College of Radiation Oncology ACRO The Joint Commission TJC

6 Accreditation, IT IS ALL ABOUT SAFETY, YOUR SAFETY, MY SAFETY AND PATIENTS SAFETY.

7 Benefits of Accreditation as per TJC: Helps organize and strengthen patient safety efforts Patient safety and quality of care issues are at the forefront of Joint Commission standards and initiatives. Strengthens community confidence in the quality and safety of care, treatment and services Achieving accreditation makes a strong statement to the community about an organization s efforts to provide the highest quality services.

8 Objectives Accreditation Requirements Reasons to Seek Accreditation Roles of Various Staff Members The Objectives are very wide ; I am available during this meeting for follow ups on the subject of Accreditation

9 This is a practical approach to accreditation: requirements, path to pass, pitfalls, etc.. I Shall Show You Some Cases That You May Want to Emulate or Avoid I Start With General Issues, and Then Go to Specifics No body is perfect, but we can pass

10 ACRO: Approximately 20% of all radiation facilities in the US are ACRO accredited or are in the review process. (ACR: Estimates 3000 Facilities in US, Only 10% Accredited). ACRO and ACR/ASTRO are evenly split. Over 40 applications for accreditation were received in June by ACRO, the largest number received in a month to date. Majority of ACRO Accreditation reports are given Provisional status. No Stat. on TJC.

11 Why Go Through Accreditation? Educational Bring Other Professionals in the field to Diagnose, Trouble Shoot and Improve Your Practice.

12 Consultative Survey Thorough Evaluation of the Center The Consultative Survey Is Followed by Comprehensive And Detailed Report, With Conclusions And Recommendations. It Is Recommended That Physics And Management Discuss The Findings Of This Report.

13

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15 Application: The Process Apply on Line Fees Enter Facility Personnel Information Submit required Data

16 Application: The Process Examination of Submitted Materials Onsite Survey Results: Pass, Deferred, Denied If Pass: Certificate.Valid for Three Years If Deferred: Appeal If Denied Failed: Resubmit

17 Application: The Process 1. Visit 2. Read and get very knowledgeable of the Process and requirements before you apply. 3. Talk, Talk, Talk and Continue Talk

18 Who Are The Personnel responsible and directly involved in the accreditation process: EVERYONE Therapists Radiation Oncologists Physicists Radiation Safety Officers Managers Nurses Dosmetrists

19 From the Start of the Accreditation Process, Who takes the lead?

20 Manpower The Accreditation Is a Lengthy and Demanding Process, And Requires Extensive Manpower. And So As a Dosimetrist: 1. Know Your Role And Responsibilities in the Process 2. Assess How Advanced You Are in Achieving the Goals Assigned to You? Generate a Time Line 3. Do You Need Help?

21 Application: Requirements 1: Personnel Systems Quality Control Documentations, such as P&P, Protocols,

22 Application: Requirements 2: 1. Policies & Procedures 2. Guidelines to Safe Practice NRC Safety Culture 3. Physicist and Physician Peer-Review 4. QC/QA for All Systems 5. Service Reports

23 Survey/Visit On the Day of the Survey: Surveyors Conduct Meetings, interviews, Visits, Verification of Documents, Check Charts (Paper or EMR)..

24 Staffing as per ACRO Staffing Per Number of New Patients Annually, 8 hour per day, five days per week. Radiation Oncologists per Medical Physicists per , (25% IMRT) Dosimetrists per , (25% IMRT) Nurses per Radiation Therapists per , (Minimum of 2), (25% IMRT) Simulation Staff per Brachytherapy Staff As needed

25 Personnel: Credentials Board Certification requirements for: Oncologists Therapists Physicists Nurses Dosimetrists

26 CMD or No CMD? As Per ACRO Manual: Medical dosimetrist: A Medical Dosimetrist should be certified by the Medical Dosimetrist Certification Board

27 Physicist Should Have Certification in Radiation Therapy by: ABR ABMP CCPM

28 Radiation oncologist peer review As Per ACRO: At least ten percent (10%) of all cases managed within a radiation oncology practice must be examined via a physician (Radiation Oncologist) peer review mechanism. Such peer review activities shall occur no less frequently than annually.

29 Physics Peer-Review Follow AAPM TG 103 Recommendations Perform On Annual Basis Should Be Detailed, And Examine: Routine Physics and Dosimetry Practices All QC Records and Protocols Radiation Safety Program and Records TPS QC Records Record & Verify System Imaging Systems QC..

30 TPS Treatment planning: The practice should demonstrate the following: Access to a computerized treatment planning system, on site or remote. Records of system commissioning, acceptance testing and beam data. Concordance of beam data with British Journal of Radiology 25 data for 5x5cm, 10x10cm, 20x20cm and 30x30cm fields.

31 Annual TPS Evaluation Annual TPS Performance Evaluation Performed by Dosimetrist and Physicist Most recent evaluation report should be available during the survey Deficiencies resolved and corrective measures taken.

32 Commissioning of the Treatment Planning System Should Not Be Confused With QC of the Treatment Planning System! Documentation of Full Commissioning of TPS Should Be Available for Review! Vender Commissioning!!??

33 R&V As Per ACRO, For The Record and verify systems: The practice should demonstrate the following when applicable: Records of acceptance testing and commissioning of the record and verify system. Backup records, either computerized or hard copy. Computer system security. Program of ongoing data accuracy monitoring.

34 Verification of monitor unit calculations for non-imrt clinical radiotherapy: Report of AAPM Task Group 114 The requirement of an independent verification of the monitor units MU or time calculated to deliver the prescribed dose to a patient has been a mainstay of radiation oncology quality assurance. The need for and value of such a verification was obvious when calculations were performed by hand using look-up tables, and the verification was achieved by a second person independently repeating the calculation. However, in a modern clinic using CT/MR/PET simulation, computerized 3D treatment planning, heterogeneity corrections, and complex calculation algorithms such as convolution/superposition and Monte Carlo, the purpose of and methodology for the MU verification have come into question. In addition, since the verification is often performed using a simpler geometrical model and calculation algorithm than the primary calculation, exact or almost exact agreement between the two can no longer be expected. Guidelines are needed to help the physicist set clinically reasonable action levels for agreement. This report addresses the following charges of the task group: 1 To re-evaluate the purpose and methods of the independent second check for monitor unit calculations for non-imrt radiation treatment in light of the complexities of modern day treatment planning. 2 To present recommendations on how to perform verification of monitor unit calculations in a modern clinic. 3 To provide recommendations on establishing action levels for agreement between primary calculations and verification, and to provide guidance in addressing discrepancies outside the action levels. These recommendations are to be used as guidelines only and shall not be interpreted as requirements American Association of Physicists in Medicine.

35 NOTE: The Second Check Should Be Independent And Effective

36 CME as per ACRO 11. Education Program: Continuing medical education (CME) programs are required for physicians, physicists, dosimetrists, nurses, and radiation therapy technology staff. This Program Should Adhere to Local Licensing Agency Requirements for CME.

37 Energy: FS/cm BJR Data 6 MV TMR 5x5 10x10 20x20 30x30 Source Clin BJR % dif Clin BJR % dif Clin BJR % dif Clin BJR % dif d=5cm d=10cm d=20cm d=30cm

38 EPID QC See TG-142 for Required Tests and Frequencies Commercial Software and Devices Are Available. Which One to Choose? Test: Spatial Resolution, Uniformity, Linearity, Spatial Distortion, Reproducibility of Position,

39

40 Radioactive Sources

41

42 Security Safety And Security Of Radioactive Sources Such As Ir-192, Cs-137,.. Should be Maintained.

43 ?

44

45 It Is Not Only External Beam Brachytherapy: HDR, LDR Radiopharmaceuticals: I-131 SIRSpheres.

46 HDR P&P HDR Treatment- Policies And Procedures: Should be Documented Clear, Explicit And Easy To Follow Should Carry The Name Of Your Facility!

47 Patient Radiation Survey Pre And Post HDR Treatment

48 A Few Questions That May Help Pass The Accreditation Survey: #1 Are Your OBI,CBCT and EPID Tests Performed As Per the Guidelines Of TG-142? And At The Frequency Required? Do Your IMRT Plans Meet Target Coverage and Critical Structures Sparing Objectives? Are SSDs Checked And Documented on Regular Basis? Do You Use The Appropriate Grid Resolution For all Plans?

49 A Few Questions contin: #2 Do You Perform The TPS Backups on Daily Basis, To Avoid Possible Loss of Patient Data? Do Your Patient Specific IMRT Plans meet the 3%, 3mm Gamma Criteria? Do You Radiologically Verify The Diameter of Cylinders Used In HDR for Every Fraction? Do Physics and Dosimetry Communicate and Consult Continuously and Effectively?

50 General Safety Concerns

51

52

53

54 End-to-End Performance Lucy Phantom for SRS E2E Test

55 E2E for SRS The test involves every step in the SRS process, including: MRI scan CT scan Target contouring on MRI scan MRI/CT image fusion Treatment planning Localization with either head frame or image guidance Dose delivery Measurements/ Verification

56 What is an End-to-End Testing? An end-to-end testing is method that tests the entire process from beginning to end in a real environment, which includes imaging system, software, operators, planning system, set up by therapists, delivery system,... With this test, you can check a complete application in an environment of man/machine interaction; as most of these tests are manual in nature.

57 Safety Culture The Nine Traits to Safety Culture. See The NRC Website on Safety Culture And Correlate With Accreditation Requirements. Accreditation Promotes Safety. And Safety Can Be Prepared for, It Is Not an Accident.

58

59 Radiation Safety Committee Do You Have A RSC Composition of the RSC, and Attendance Who Chairs the RSC? Frequency of the RSC Meetings Minutes of Meetings

60 I encourage you to read the AAPM reports TG 51 on Output Measurements A must for accreditation TG 119 on TPS QA TG 114 on MU Calculations TG 142 on QA for Medical accelerators TG 120 on IMRT QA

61 Accreditation should not be for marketing. Really?

62 ! Be There, Get Engaged and Feel The Process

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