Prospective peer review as a component of a comprehensive quality program to reduce risk in the delivery of radiotherapy.

Purpose: Reducing error risk in the delivery of radiation therapy requires a comprehensive program to manage the numerous hand-offs and work to implement a contemporary radiation therapy treatment plan. We have developed such a plan and will report on its key components, with attention to (contour) peer review over a 10-year period in a large, academic, multi-site department. Principles driving success will be reviewed.

Methodology: Starting 15 years ago, the department developed a comprehensive QI program based on six-sigma to implement the No-Fly policy for treatment planning. Implicit is that no work is rushed, and patient start appointments will be moved to accommodate late work. Additionally, treatment directives have been developed and are used in order to set treatment expectation, enhance planning efficiencies and to set standards for the techs and nurses during treatment. It was determined about 12 years ago that contour peer review of the prescription and contours is needed to truly improve the treatment planning quality and timeliness of work. We will review this experience based on the grading system of the peer-review process.

Results: Of the 20,069 cases within our department underwent prospective multi-disciplinary peer review and are assigned a grade (A, B, C). “A” cases require no changes, “Bs” require minor modification, and “Cs” require major modification, prior to treatment planning. 15,659 (78%) were curative and were analyzed. The fraction of A’s decreased from 74.8% (baseline), to 64.5% (follow-up), while B’s increased from 19.4% to 35.4%, and C’s decreased from 5.8% to 0.1%. There was a decrease in the percentage of A’s from the baseline to the follow-up period regardless of plan type (complex versus intermediate versus simple). There was a decrease in percentage of A’s among specialists from baseline to follow-up (78.2% to 67.7%, p< 0.002) and among generalists from baseline to follow-up (69.7% to 61.7%, p< 0.002).

Conclusions: The implementation and continued evolution of the No-Fly policy serves as a model for how best to safely and consistently provide a high quality treatment plan for all patients. Peer review serves an integral component of this process and remains critical for finding and fixing upstream opportunities that ultimately enchase the treatment plan for each patient. This approach requires buy-in and a safety-first culture, but does not require anything more than the will to do best for our patients. And as such, others should consider implementation of No-Fly principles, including peer review.

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