Striving to Fill in Gaps between Clinical Practice and Standards: The Evolution of a Pan-Canadian Approach to Patient-Reported Outcomes Use.

Despite the known importance and necessity of the standardized collection and use of patient-reported outcomes (PROs), there remain challenges to successful clinical implementation. Facilitated through a quality improvement initiative spearheaded by the Canadian Partnership for Quality Radiotherapy (CPQR), and now guided by the Canadian Association of Radiation Oncology (CARO)'s Quality and Standards Committee, patient representatives and early-adopter radiation treatment programs continue to champion the expansion of PROs initiatives across the country. The current review discusses the evolution of a pan-Canadian approach to PROs use, striving to fill in gaps between clinical practice and guideline recommendations through multi-centre and multidisciplinary collaboration.

Patient Engagement: an Assessment of Canadian Radiotherapy Programs' Current Practices, Perceived Barriers, and Facilitators.

Patient engagement and education have been mandated across Canadian radiation oncology programs (ROP). Guidance documents include the 2014 Canadian Association of Radiation Oncology (CARO) Radiation Therapy Patient Charter, the 2016 Canadian Partnership for Quality Radiotherapy (CPQR) Patient Engagement Guidelines (PEG) for Canadian Radiation Treatment Programs, and Accreditation Canada's 2017 refresh of Cancer Care Standards. Since little is known regarding uptake of these guidance statements, Canadian ROP were surveyed to assess current patient engagement and education practices. An e-survey was sent to Canadian ROP (n = 44). The survey focused on awareness and uptake of the CARO Patient Charter, CPQR PEG, and patient education practices. Survey development was guided by these documents and expert consensus, including CARO's Quality and Standards Patient Education/Engagement working group. Many (71%) responding ROP were familiar with the CARO Patient Charter, while 24% reported use. More than half (53%) of ROP were aware of the CPQR PEG, but approximately third (37%) had previously completed a self-audit. Most (88%) ROP view a pan-Canadian, evidence-based approach to educational materials beneficial and feasible (80%), with the majority (89%) willing to share their best practices across the radiotherapy community. Patient engagement and education are nationally mandated and supported by guidance documents. However, gaps have been identified across ROP for awareness and use of available tools, as well as uptake of their processes critical to quality of care. Understanding current practices will inform CPQR/CARO-supported pan-Canadian initiatives to optimize uptake, including development of CPQR Patient Education Guidance for Canadian Radiation Treatment Programs.

Pan-Canadian Survey of Medical Radiation Technologist's Views Toward Evidence-Based Practice, Research, Barriers, and Enablers.

OBJECTIVES: To examine the attitudes, perceptions, enablers/barriers, and level of uptake of evidence-based practice (EBP) and research within the medical radiological technologist (MRT) community in Canada. METHODS: Using the Canadian Association of Medical Radiation Technologists' e-mail distribution list, all members were sent an invitation and link to an online electronic survey. The survey included demographics and questions asking participants about their perceptions of EBP, research, and barriers. Data were analyzed with descriptive statistics and partial proportional odds models. RESULTS: Four hundred and forty-four completed surveys were available for analysis. Respondents showed good distribution among professions and geographical location. Eighty-four percent of respondents indicated having a good grasp of the concept of EBP. A majority of the respondents (>70%) in all the professions strongly agreed/agreed that all MRTs should practice in an evidence-based manner. Eighty percent of respondents strongly agreed/agreed that there is a link between EBP and research. There was a statistically significant association between the current level of knowledge to develop a research project and level of academic research education received, research culture in the department, and the presence of barriers. Partial proportional odds model indicates participants were more likely to have a good grasp of EBP and have strongly agreed/agreed that they should practice in an evidence-based manner if they were a radiation therapist, have medium-high current levels of research knowledge, or were a permanent full-time employee. In addition, radiation therapists were at least 4 times more likely to participate in research as a primary or coinvestigator, compared to other MRT professions. Most frequently identified extrinsic barriers to EBP/research included lack of time, heavy workload, lack of leadership support, and workplace attitudes/culture. Extrinsic success factors included access to a mentor, dedicated time, collaboration, and support from management and peers. Intrinsic success factors were as follows: self-motivation, sense of inquiry/curiosity, and satisfaction with creating patient or workplace change based on research. CONCLUSIONS: This pan-Canadian, interprofessional survey highlights the current landscape with respect to perceptions and uptake of EBP and research among MRTs. Results of this study may offer MRTs, employers, educational facilities, and professional bodies insight into strategies that can be undertaken to improve MRT research participation across professions.

Staffing Levels and Workload for Radiation Therapists in Canada.

PURPOSE: The safe delivery of radiation therapy is dependent in part on the provision and organization of oncology professionals. General recommendations for staffing of radiation oncologists, medical physicists, and radiation therapists have been published, but most of these provide little detail, especially in the case of radiation therapists (RTs). In Canada, there are no guidelines or national standards for the staffing of RTs, and there is a paucity of Canadian data on the existing staffing levels of RTs and the models used to establish these levels. This project sought to identify and compare the staffing models used for Canadian RTs, and the staffing levels and workload resulting from these models. METHODS AND MATERIALS: In January 2016, a survey was sent to managers of the 46 radiation treatment centres in Canada. This survey sought information on a range of staffing and practice variables for the fiscal year 2014/2015. Respondents were requested to provide the staffing model used for RTs at each centre and enough additional information to calculate the staffing levels and workload resulting from their staffing model. The survey included further variables that had the potential to influence staffing levels and workload, and centres were compared to establish if these variables did indeed impact staffing. RESULTS: Of the 46 centres contacted, 37 centres responded, representing an 80.4% response rate. Survey results showed there are a variety of ways used to determine staffing across the country. Twenty of the 37 responding centres include some type of workload measurement in their staffing model, whereas 17 centres base staffing solely on historic levels or operating funds. There is a great deal of variation in the staffing levels and workload of RTs in Canada, with staff at some centres planning and treating twice the number of patients as RTs at other centres. Radiation therapist staffing levels at most radiation treatment centres in Canada are below the level recommended in recent publications. Differences in staffing levels or workload could not be accounted for by treatment complexity, number of specialty programs, use of relief staff, or number of RTs working in specialty nontreatment roles. CONCLUSIONS: A high degree of variability in staffing levels and workload exists for RTs in Canada, which is not explained by differences in patterns of practice. It is likely that workload for RTs exceed safe levels at some Canadian centres. It is recommended that treatment centres use an up-to-date staffing model for RTs and continue to review staffing levels at regular intervals.

Patterns of Practice in Canadian Radiation Treatment Centres: Results of a National Survey.

PURPOSE: Radiation therapy has changed rapidly over the past decade due to the application of technological advances. A survey was conducted of radiation treatment centres in Canada to establish current patterns of practice across the country. Areas of inquiry included treatment techniques and image verification, as well as roles and responsibilities of radiation therapists (RTs). METHODS AND MATERIALS: In January 2016, a survey was sent to managers of the 46 radiation treatment centres in Canada. This survey sought information on a range of staffing and practice variables for the fiscal year 2014/2015. RESULTS: Of the 46 centres contacted, 37 centres responded, representing an 80.4% response rate. Survey results showed that the use of volumetric arc therapy and intensity-modulated radiation therapy is common across Canada for several anatomic sites, as well as the use of daily pretreatment image verification. A high degree of variability exists for imaging modality (two dimensional vs. three dimensional) for some sites, including brain, head and neck, and lung. RTs' responsibilities have expanded uniformly across the country, with RTs involved in organ-at-risk contouring and on-treatment image approval at the majority of centres. Despite this role expansion, specialty roles in areas of quality and applications expertise are still rare. CONCLUSIONS: Radiation therapy in Canada has transitioned to high-technology treatment techniques with relative consistency across the country. There is, however, variation in the imaging modality used for daily verification. Canada may benefit from consensus guidelines on the application of three-dimensional imaging for treatment verification. While RTs have expanded their responsibilities, role definition for RTs working in supervisory or supporting positions has not kept pace at many centres and it is unclear if RTs are supported in their expanded accountabilities.

Virtually Certified: Development of an Online Oral Examination Phase for a National Advanced Practice Certification Model for Radiation Therapists in Canada.

Following development of a framework to establish the scope of advanced practice for radiation therapists (APRTs), a Canadian certification process was built. This involved three independently-assessed phases: professional portfolio, case submission, and oral examination. The oral examination was to test the candidate's knowledge and capacity for decision-making. Development and piloting involved 3 elements: 1) content development, including relevant case selection, with accompanying high-fidelity imaging and resources; 2) harnessing of technology and ensuing logistics, given the desire to offer the examination online, maximizing accessibility and minimizing resources; and 3) examiner recruitment and preparation, involving a national call for interprofessional examiners, to assess across the spectrum of competencies. Each element was approached systematically, with modifications made iteratively. Three overarching challenges required ongoing attention and consideration: resource-intensiveness of building and validating cases, ensuring applicability and relevance of case content and "answers" across practice environments, and preparation of non-radiation therapist (oncologist and physicist) examiners regarding APRT standards. The resultant examination model is thought to be a robust assessment tool, well-regarded by candidates and examiners as fair and transparent, and complementary to the other certification phases. A consultatory pilot process supported establishment of a robust framework that is believed to be defensible and preliminarily valid.

Improving patient outcomes and radiotherapy systems: A pan-Canadian approach to patient-reported outcome use.

Standardized collection and use of clinical patient-reported outcomes (PRO) have potential to benefit the care of individual patients and improve radiotherapy system performance. Its centralized health-care system makes Canada a prime candidate to take a leader and collaborator role in international endeavors to promote expansion of patient-reported outcome collection and use in radiotherapy. The current review discusses the development of a pan-Canadian approach to PRO use, through a quality improvement initiative led by the Canadian Partnership for Quality Radiotherapy (CPQR), a unique partnership of Canadian radiotherapy professional organizations (Canadian Association of Radiation Oncology-CARO, Canadian Organization of Medical Physicists-COMP, and the Canadian Association of Medical Radiation Technologists-CAMRT).

Development of a Quality and Safety Competency Curriculum for Radiation Oncology Residency: An International Delphi Study.

PURPOSE: To develop an entry-to-practice quality and safety competency profile for radiation oncology residency. METHODS AND MATERIALS: A comprehensive list of potential quality and safety competency items was generated from public and professional resources and interprofessional focus groups. Redundant or out-of-scope items were eliminated through investigator consensus. Remaining items were subjected to an international 2-round modified Delphi process involving experts in radiation oncology, radiation therapy, and medical physics. During Round 1, each item was scored independently on a 9-point Likert scale indicating appropriateness for inclusion in the competency profile. Items indistinctly ranked for inclusion or exclusion were re-evaluated through web conference discussion and reranked in Round 2. RESULTS: An initial 1211 items were compiled from 32 international sources and distilled to 105 unique potential quality and safety competency items. Fifteen of the 50 invited experts participated in round 1: 10 radiation oncologists, 4 radiation therapists, and 1 medical physicist from 13 centers in 5 countries. Round 1 rankings resulted in 80 items included, 1 item excluded, and 24 items indeterminate. Two areas emerged more prominently within the latter group: change management and human factors. Web conference with 5 participants resulted in 9 of these 24 items edited for content or clarity. In Round 2, 12 participants rescored all indeterminate items resulting in 10 items ranked for inclusion. The final 90 enabling competency items were organized into thematic groups consisting of 18 key competencies under headings adapted from Deming's System of Profound Knowledge. CONCLUSIONS: This quality and safety competency profile may inform minimum training standards for radiation oncology residency programs.

A pan-Canadian survey of peer review practices in radiation oncology.

PURPOSE: Peer review (PR) of treatment plans has been recognized internationally as a key component of quality care in radiation oncology programs (ROPs). We conducted a survey of Canadian ROPs to describe current PR practices and identify barriers/facilitators to PR optimization. METHODS AND MATERIALS: A 42-item e-survey was sent to all Canadian ROPs (n = 44). Survey development was guided by expert consensus, literature review, and existing guidelines. One multidisciplinary response per ROP was requested. RESULTS: Response rate was 100.0% (44/44). All ROPs (100.0%) reported conducting some PR and rated its importance as 7/10 or higher (10 = extremely important). One-half of ROPs (52.3%) peer-reviewed >80% of curative treatment plans. ROPs reported performing PR "always/almost always" pretreatment (38.6%) or before 25% of radiation therapy delivery (52.3%). The majority of ROPs reported recommending major plan changes in <5% of plans (88.6%) and documenting findings in the medical record (58.1%). Barriers to PR were radiation oncologist availability (34.1%) and time constraints (27.3%). Facilitators included development of PR standards (97.7%) and education/support (90.9%). CONCLUSIONS: The ROPs perceive PR as highly important, but substantial variation in the extent, timing, and documentation of PR exists. The understanding of current PR activities, barriers, and facilitators will inform the development of initiatives to optimize PR in radiation oncology.

Investigating the Impact of Positron Emission Tomography-Computed Tomography Versus Computed Tomography Alone for High-risk Volume Selection in Head and Neck and Lung Patients Undergoing Radiotherapy: Interim Findings.

INTRODUCTION: The aim of this study was to quantify the impact of positron emission tomography-computed tomography (PET-CT) on clinical target volume (CTV) selection in non-small cell lung cancer (NSCLC) and head and neck squamous cell cancer (HNSCC) cancer patients. METHODS: Eight radiation oncologists with expertise in either NSCLC or HNSCC prospectively contoured target volumes with and without PET-CT findings. All volumes were contoured manually, and computed tomography (CT)-alone contours were identified as gross tumour volume CT and clinical target volume (CTV) CT, whereas those contoured with the aid of PET-CT were GTV PET and CTV PET. PET-CT contours were used for actual treatment delivery. Test treatment plans were generated based on the CT-alone volumes and applied to the final PET-CT contours. PET-CT had an impact if the test plans failed department quality assurance guidelines. For each patient, the dose to critical structures and any changes in the treatment plan were recorded. RESULTS: Eighty patients (49 HNSCC and 31 NSCLC) were analyzed. PET-CT impacted 42.9% of HNSCC cases and 45.2% of NSCLC cases. On average, PET-CT volumes were significantly larger than CT-alone volumes for HNSCC cases (P < .01) but not for NSCLC cases (P = .29). For organs at risk, no statistically significant differences were noted, with the exception of mean parotid dose for the right and left parotids (P = .0137and P = .0330, respectively). CONCLUSIONS: Interim analysis of data found that the use of PET-CT in the radiation therapy planning process impacted CTV selection, resulting in a major change in radiation therapy plans in 43.7% (HNSCC 42.9% and NSCLC 45.2%) of patients.

The Quest for Quality: Principles to Guide Medical Radiation Technology Practice.

Quality is a ubiquitous term in medical radiation technology; technologists, programs, and organizations emphasize the importance of "quality care," yet the concept of what is encompassed by the term, how it is built and measured, and who is the judge of whether it has been achieved, are often left undefined. This article will present theoretical definitions of quality, considering the value of professional, patient, and organization perspectives. Foundational quality principles and frameworks will be explored to highlight tools necessary to engage in "quality-related" activities and research at the individual, institutional, and systems level. Being equipped with an understanding of the work of Deming, the underpinnings of the lean strategy and the idea of continuous quality improvement will support technologists in contributing to evidence-based, high-quality, and safe practice. Building on these basics, concepts of complexity and standardization will be explored as they relate to achieving and maintaining quality given changing practice, focusing on personalized medicine, technological innovation, and best practice guidelines. Means to measure and evaluate quality will be presented, emphasizing the need for a structured approach. Using the work of the Canadian Partnership for Quality Radiotherapy as an example, key quality-related considerations, such as incident reporting, organizational structure, and quality culture will be discussed, with specific attention to roles within the team. When appropriately defined, measured, and evaluated, the quest for quality has the potential to improve safety and mitigate risk. Engaging technologists to assume strong roles in providing the highest quality of care will contribute positively at the level of the individual patient, the organization, and the system.