50 Years of the IAEA/WHO postal dose audit programme for radiotherapy: what can we learn from 13756 results?

Background: The IAEA/WHO postal dose audit programme has been operating since 1969 with the aim of improving the accuracy and consistency of dosimetry in radiotherapy in low-income and middle-income countries world-wide. This study summarises the 50 years' experience of audits and explores the quality of reference dosimetry in participating radiotherapy centres throughout the years.Material and methods: During the IAEA/WHO postal audits the dose determined from the mailed dosimeter is compared with that stated by the participant. Agreement to within ±5% is regarded acceptable whilst deviations outside ±5% limits trigger follow-up actions. Of particular interest in this study was the dependence of clinical dosimetry quality on factors related to the centre infrastructure and expertise in dosimetry of its staff.Results: The IAEA/WHO dose audit programme noted great increase in the overall percentage of acceptable results from about 50% in its early years to 99% at present, although there is some variability of results amongst participating countries. Whereas results for younger radiotherapy machines show the agreement rate between the measured and the stated doses well above 90%, for those over 20 years old the rate dropped to <80%. Linac dosimetry was always better than 60Co dosimetry and multi-machine centres generally performed better than single machine centres equipped with cobalt alone. Second and subsequent participation in audits showed higher quality dosimetry than the first participation. The implementation of modern dosimetry protocols resulted in more accurate dosimetry than the use of the older protocols.Conclusions: Over the 50 years that the IAEA has accumulated dosimetry audit data, practices in radiotherapy centres have significantly improved. Higher quality dosimetry confirmed in audits is generally associated with better infrastructure and adequate dosimetry expertise of medical physicists in participating centres.

An IAEA survey of radiotherapy practice including quality assurance extent and depth.

Background: The IAEA recommends a quality assurance program in radiotherapy to ensure safe and effective treatments. In this study, radiotherapy departments were surveyed on their current practice including the extent and depth of quality assurance activities.Methods: Radiotherapy departments were voluntarily surveyed in three stages, firstly, in basic facility information, secondly, in quality assurance activities and treatment techniques, and thirdly, in a snapshot of quality assurance, departmental and treatment activities.Results: The IAEA received completed surveys from 381 radiotherapy departments throughout the world with 100 radiotherapy departments completing all three surveys. Dominant patterns were found in linac-based radiotherapy with access to treatment planning systems for 3D-CRT and 3D imaging. Staffing levels for major staff groups were on average in the range recommended by the IAEA. The modal patient workload per EBRT unit was as expected in the range of 21-30 patients per day, however significant instances of high workload (more than 50 patients per day per treatment unit) were reported. Staffing levels were found to correlate with amount of treatment equipment and patient workload. In a self-assessment of quality assurance performance, most radiotherapy departments reported that they would perform at least 60% of the quality assurance activities itemized in the second survey, with particular strength in equipment quality control. In a snapshot survey of quality assurance performance, again equipment quality control practice was well developed, particularly for the treatment equipment.Conclusions: The IAEA surveys provide a snapshot of current radiotherapy practice including quality assurance activities.

Development and first application of an audit system for screening programs based on the PRECEDE-PROCEED model: an experience with breast cancer screening in the region of Lombardy (Italy).

BACKGROUND: High participation and performance are necessary conditions for the effectiveness of breast cancer screening programs. Here we describe the process to define and test a planning software application and an audit cycle based on the PRECEDE-PROCEED model applied to improving breast cancer screening. We developed a planning software application following the phases of the PRECEDE-PROCEED model. The application was co-designed by local cancer screening program coordinators. An audit model was also developed. The revised application and the audit model were tested by all the coordinators of 15 breast cancer screening programs in the region of Lombardy in a 3-day workshop. The project plans produced using the application were compared with those produced in the previous year for clarity and completeness. RESULTS: The 9 phases of the PRECEDE-PROCEED model were adapted to screening as follows: 1) identification of program goals (i.e., participation, sensitivity, false positive); 2) epidemiological issues; 3) best practices analysis; 4) evidence-based actions to be implemented in the screening center and the relationships with partners and stakeholders; 5) priority setting and identification of solutions for each issue; 6) definition of indicators; 7) monitoring; 8) evaluation; 9) impact assessment. The application automatically generated reports for each phase. During the audit cycle, the regional health authority negotiated the targets to be reached with local authorities and collected the improvement plans generated by the application. The plans produced after the application was adopted were more standardized and had clearer indicators for monitoring and evaluation compared to those produced in the previous year. CONCLUSIONS: The software application helps standardize criteria for planning interventions to improve screening programs and facilitates the implementation of the audit cycle.

Development of a quality improvement audit tool for the primary care of children with chronic wet cough using a modified Delphi consensus approach.

AIM: In the absence of quality indicators (QIs) for the management of chronic wet cough, our study's aim was to determine whether consensus on QIs reflecting good primary health care, prior to referral for children with chronic wet cough, can be achieved. METHODS: A questionnaire consisting of 10 QIs was developed by a clinical working group based on current evidence and guidelines on the management of chronic wet cough in children. Each indicator reflected the quality of care provided to children with chronic wet cough in primary care prior to referral. A modified Delphi consensus questionnaire was undertaken involving expert paediatric respiratory clinicians and general paediatricians who graded the importance of each indicator for the purposes above. We a priori defined that consensus was considered achieved if >75% agreed on the indicator. RESULTS: Twenty-two specialists (from Brisbane, Melbourne, Perth and Canberra) participated in the survey. The cumulative number of years of their respiratory experience was 324 and that of general clinical practice was 504. Consensus was achieved in all 10 QIs, with 6 reaching 100% agreement. Mean agreement for the 10 items was 97%. CONCLUSION: As complete consensus was achieved on these QIs, it can be used as a provisional clinical audit tool and can guide the development of a robust audit tool for primary care clinical practice to assist with quality improvement initiatives.

First-line managers' experience of the use of audit and feedback cycle in specialist mental health care: A qualitative case study.

BACKGROUND: Audit and feedback was the main strategy to facilitate implementation of The National Guideline for Persons with Concurrent Substance Use Disorders and Mental Disorders in specialist mental health services. Studies have shown that leadership support contributes to implementation success. The aim of the study was to explore how first-line managers in a District Psychiatric Centre experienced using audit and feedback cycle. METHOD: The study had a qualitative case study design with individual interviews with five first-line managers from a District Psychiatric Centre in Norway. Qualitative content analysis was conducted. RESULTS: First-line managers were positive to contribute to better practice for the patient group and apply available tools. Four themes emerged: 1) Lack of endurance, where first-line managers saw their role as being process leaders, but failed to persist, 2) Lack of support in the process, where first-line managers called for a stronger organisational focus 3) Lack of ownership, where first-line managers felt the process was imposed on them, and 4) Lack of leader autonomy, where first-line managers seemed insecure about their role between professional leadership and own management. CONCLUSION: First-line managers were not sufficiently experienced or equipped to solve the implementation process satisfactorily. They were torn between different commitments, without the autonomy to act as process drivers or facilitators, and without taking the necessary leadership role. The potential impact of the use of audit and feedback may thus not be fully realized, in part, because of limited organisational support and capacity to respond effectively.

Implementing iRound: A Computer-Based Auditing Tool.

Many hospitals use rounding or auditing as a tool to help identify gaps and needs in quality and process performance. Some hospitals are also using rounding to help improve patient experience. It is known that purposeful rounding helps improve Hospital Consumer Assessment of Healthcare Providers and Systems scores by helping manage patient expectations, provide service recovery, and recognize quality caregivers. Rounding works when a standard method is used across the facility, where data are comparable and trustworthy. This facility had a pen-and-paper process in place that made data reporting difficult, created a silo culture between departments, and most audits and rounds were completed differently on each unit. It was recognized that this facility needed to standardize the rounding and auditing process. The tool created by the Advisory Board called iRound was chosen as the tool this facility would use for patient experience rounds as well as process and quality rounding. The success of the iRound tool in this facility depended on several factors that started many months before implementation to current everyday usage.

New workflows for clinical video recordings in cleft care.

The Cleft team at Cambridge University Hospitals (CUH), Cleft.NET.East (CNE), were experiencing many technical issues with their video recording systems and processes, resulting in poor record keeping and audit performance. It became apparent that the equipment needed to be updated and replaced, with new workflows implemented to improve the quality and consistency in patients' records. Following a review carried out with the Cleft team, equipment was identified and workflows were implemented which improved the processes already in place. These changes have resulted in improved quality of records, better audit performance; time saved for key clinicians, more efficient running of clinics and improved patient experience.

The Australian and New Zealand Audit of Surgical Mortality-birth, deaths, and carriage.

OBJECTIVE: This article outlines the formation of the Australian and New Zealand Audit of Surgical Mortality (ANZASM) and describes its objectives, governance, functioning and challenges. BACKGROUND: A nationwide audit of surgical mortality provides an overview of the leading causes of death in patients who require surgical care. It identifies system or process errors, trends in deficiency of care and helps develop strategies to reduce deaths in the surgical arena. METHODS: A standardized tool is used to systematically collect data after every surgical death. Patient details are reviewed by a peer surgeon (and in certain cases a second) to identify issues with patient management and hospital processes. The treating surgeon is then offered confidential feedback and alternate views on patient management. RESULTS: From January 2009 to December 2012, 19,096 deaths were reported to the ANZASM. Eighty-six percent of the audited deaths occurred in patients requiring an emergency admission. Significant criticism of patient care was reported in 13% of cases with 16% of clinical issues perceived to be preventable. Western Australia, which first began the audit process, has shown a 30% reduction in surgical deaths. CONCLUSIONS: Nationwide mortality audits are a useful and worthwhile exercise. Recommendations identified in the audit reports direct educational workshops and seminars to address these issues. They allow Departments of Health to make informed decisions in their hospitals. Through this model, and the lessons learnt, we would encourage other countries planning to set up their own audits to follow a similar concept.

Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby.

BACKGROUND: While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking. METHODS: We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality. RESULTS: Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed. CONCLUSIONS: Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

Experiences with maternal and perinatal death reviews in the UK--the MBRRACE-UK programme.

Established in 1952, the programme of surveillance and Confidential Enquiries into Maternal Deaths in the UK is the longest running such programme worldwide. Although more recently instituted, surveillance and confidential enquiries into perinatal deaths are also now well established nationally. Recent changes to funding and commissioning of the Enquiries have enabled both a reinvigoration of the processes and improvements to the methodology with an increased frequency of future reporting. Close engagement with stakeholders and a regulator requirement for doctors to participate have both supported the impetus for involvement of all professionals leading to greater potential for improved quality of care for women and babies.

The experience of the implementation of perinatal audit in Moldova.

The Beyond the Numbers project in Moldova implemented perinatal mortality audit as a means to improve maternity and newborn care. Key activities for this project included training in audit, the setting up of audit committees, implementation of the review of cases and dissemination of information. During the project, a significant reduction was noted of perinatal deaths at term (from 37 weeks gestation and birthweight of ≥2500 g) by 1.5 per 1000; from 5.1 per 1000 in 2006 to 3.6 per 1000 in 2013.

The Moldovan experience of maternal death reviews.

A Confidential Enquiry into Maternal Deaths is an anonymous, multidisciplinary and systematic review of all cases of maternal mortality. This paper describes one such process implemented at national level in Moldova. Its aim was to conduct an in-depth review of the underlying causes and circumstances surrounding each mother's death to learn lessons to improve care in future. Its findings showed that deaths were predominantly due to direct obstetric causes, especially haemorrhage and sepsis, and adverse social determinants, particularly poverty and migration also played a decisive role in more than half of the cases. The final report identified potentially remediable actions and the key areas requiring interventions by the health sector, administrators and the community. Its recommendations have enabled the implementation of some solutions to help prevent future maternal deaths, including the development of evidence-based clinical guidelines.

Surveyors' perceptions of the impact of accreditation on patient safety in general practice.

OBJECTIVES: To explore Australian General Practice Accreditation Limited (AGPAL) surveyors' perceptions of the impact of accreditation on patient safety and to elicit suggestions for improving patient safety in Australian general practices. DESIGN, SETTING AND PARTICIPANTS: We conducted semi-structured telephone interviews with a purposive national sample of 10 AGPAL surveyors from 2 July to 14 December 2012. All interviews were audio recorded, transcribed and summarised. RESULTS: All participants agreed that accreditation has improved general practices' performance in quality and safety. Participants noted specific areas that need further attention, including sufficient evidence for clinical risk management, which half the participants estimated occurs in about 5%-10% of Australian general practices. Tangible evidence of patient safety activities included having a significant incidents register, providing documentation of near misses, slips, lapses or mistakes, and engaging in regular clinical meetings to discuss incidents and how to avoid them in the future. Participants agreed that the accreditation process could be improved through the inclusion of tighter clinical safety indicators and the requirement of verifiable evidence of a working clinical risk management system. CONCLUSIONS: Accreditation has had a positive role in improving quality and safety in general practice. The inclusion of tighter indicators that require verifiable evidence will be a step forward. The Australian Primary Care Collaboratives (APCC) Program has an opportunity to build on its previous success in general practice quality improvement to further enhance patient safety in general practice.

Key elements of high-quality practice organisation in primary health care: a systematic review.

OBJECTIVES: To identify elements that are integral to high-quality practice and determine considerations relating to high-quality practice organisation in primary care. STUDY DESIGN: A narrative systematic review of published and grey literature. DATA SOURCES: Electronic databases (PubMed, CINAHL, the Cochrane Library, Embase, Emerald Insight, PsycInfo, the Primary Health Care Research and Information Service website, Google Scholar) were searched in November 2013 and used to identify articles published in English from 2002 to 2013. Reference lists of included articles were searched for relevant unpublished articles and reports. DATA SYNTHESIS: Data were configured at the study level to allow for the inclusion of findings from a broad range of study types. Ten elements were most often included in the existing organisational assessment tools. A further three elements were identified from an inductive thematic analysis of descriptive articles, and were noted as important considerations in effective quality improvement in primary care settings. CONCLUSION: Although there are some validated tools available to primary care that identify and build quality, most are single-strategy approaches developed outside health care settings. There are currently no validated organisational improvement tools, designed specifically for primary health care, which combine all elements of practice improvement and whose use does not require extensive external facilitation.

Minimizing preventable trauma deaths in a limited-resource setting: a test-case of a multidisciplinary panel review approach at the Komfo Anokye Teaching Hospital in Ghana.

OBJECTIVE: Our objectives were to determine the proportion of preventable trauma deaths at a large trauma hospital in Kumasi, Ghana, and to identify opportunities for the improvement of trauma care. METHODS: A multidisciplinary panel of experts evaluated pre-hospital, hospital, and postmortem data of consecutive trauma patients who died over a 5-month period in 2006-2007 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For preventable and potentially preventable deaths, deficiencies in care that contributed to their deaths were identified. RESULTS: The panel reviewed 231 trauma deaths. Of these, 84 charts had sufficient information to review preventable factors. The panel determined that 23 % of trauma deaths were definitely preventable, 37 % were potentially preventable, and 40 % were not preventable. One main deficiency in care was identified for each of the 50 definitely preventable and potentially preventable deaths. The most common deficiencies were pre-hospital delays (44 % of the 50 deficiencies), delay in treatment (32 %), and inadequate fluid resuscitation (22 %). Among the 19 definitely preventable deaths, the most common cause of death was hemorrhage (47 %), and the most common deficiencies were inadequate fluid resuscitation (37 % of deficiencies in this group) and pre-hospital delay (37 %). CONCLUSIONS: A high proportion of trauma fatalities might have been preventable by decreasing pre-hospital delays, adequate resuscitation in hospital, and earlier initiation of care, including definitive surgical management. The study also showed that preventable death panel reviews are a feasible and useful quality improvement method in the study setting.

Review of radiation therapy services for neurofibromatosis (NF2) patients in England.

OBJECTIVE: It is widely accepted that stereotactic radiosurgery (SRS) is less effective in controlling NF2-related vestibular schwannomas (VS-NF2), than sporadic VS. Concerns persist regarding the risks of malignant transformation and the development of secondary tumours. In recent years there has been an increase in the number of centres offering SRS and fractionated stereotactic radiotherapy (SRT) services for VS. The NF2 National Commissioning Group service framework has recommended limiting radiation therapies for VS-NF2 to SRS (Gamma Knife) provided in Sheffield. The aims of this review were to: 1) Establish the current provision of SRT and SRS services in England. 2) Determine the radiation therapies employed for NF2 patients since 2000. 3) Determine the feasibility of identifying a national cohort of NF2 patients in England who have received radiation therapy since 2000. METHODS: The lead clinicians managing VS patients in the major regional neurosurgical units in England, and those providing SRS services to NF2 patients were contacted and when possible, databases were examined. RESULTS: A total of 18 NHS centres and 2 private centres were included. This included the four NF2 'hub centres' (Cambridge, London, Oxford and Manchester). Their NF2 databases identified 4, 8, 23 and 42 VS-NF2 treatments with SRS or SRT, respectively since 2000. Eleven centres reported that they had referred VS-NF2 patients exclusively to Sheffield. Each estimated that they had referred no more than one patient per year. The survey identified four Gamma Knife Centres and six Linac SRS/SRT centres with the capacity to treat VS and VS-NF2 patients. Of these, four centres confirmed that they had treated VS-NF2 patients. CONCLUSION: Since 2000 fewer than 100 SRS and SRT treatments have been undertaken for VS-NF2 patients. Approximately 60% of these have been performed in Sheffield. There is considerable uncertainty regarding the role of radiation therapy in the management of VS-NF2 and consequently a range of views and practice.

[Internal audit--the foundation of healthcare quality management in health care].

The paper proved the need for internal audit as the basis for quality control of medical care in a health facility, developed the project milestones and explains what needs to be taken into account at every stage during its implementation.

Pressing pause: CMS slows RAC... for now.

The federal government plans some tweaks to the Medicare audit program. Hospital officials say it's a good first step, but want larger reforms.