Safer radiation therapy treatment resulting from an equipment transition: A mixed-methods study.

PURPOSE: To realize individualized safe radiation therapy, reliable treatment equipment is essential in combination with a system-level improvement approach. We hypothesized that implementation of a system that integrated all required treatment equipment would result in improved safety and stability of the irradiation treatment process. METHODS AND MATERIALS: Seven accelerators, portal imaging, and the treatment planning software were replaced by an integrated system that included 6 accelerators. The number of reported safety incidents and root causes were recorded between 2010 and 2014. Time series analysis was performed, and quantitative results were explored by structured interviews. Additionally, downtime was recorded. RESULTS: From January 2010 to July 2014, 5085 incidents were reported. Reports related to the accelerators decreased from 33% (2010) to 20% (2013-2014) of total reports, whereas the number of delivered fractions per accelerator increased by 20% (2010: 643 per month; 2013: 795 per month). Reports related to portal imaging decreased from 16.5 reports per month (2010) to 3.1 (2013-2014). Of these portal imaging reports, 316 had at least 1 technical cause in 2010, which decreased to 13 in 2013-2014. Interviewees attributed the decreased reporting to the equipment transition, not to decreased safety awareness. Downtime decreased by 46%, from 5.4% in 2010 to 2.9% in 2013. CONCLUSIONS: The number of reported accelerator- and portal imaging-related incidents decreased significantly, whereas safety awareness remained stable. In addition, accelerator downtime decreased, possibly resulting in less rescheduling of patients and fewer disruptions of work processes. Therefore, we conclude that the risk for serious safety incidents and patient harm decreased after implementation of the new integrated system.

Improving linear accelerator service response with a real- time electronic event reporting system.

To track linear accelerator performance issues, an online event recording system was developed in-house for use by therapists and physicists to log the details of technical problems arising on our institution's four linear accelerators. In use since October 2010, the system was designed so that all clinical physicists would receive email notification when an event was logged. Starting in October 2012, we initiated a pilot project in collaboration with our linear accelerator vendor to explore a new model of service and support, in which event notifications were also sent electronically directly to dedicated engineers at the vendor's technical help desk, who then initiated a response to technical issues. Previously, technical issues were reported by telephone to the vendor's call center, which then disseminated information and coordinated a response with the Technical Support help desk and local service engineers. The purpose of this work was to investigate the improvements to clinical operations resulting from this new service model. The new and old service models were quantitatively compared by reviewing event logs and the oncology information system database in the nine months prior to and after initiation of the project. Here, we focus on events that resulted in an inoperative linear accelerator ("down" machine). Machine downtime, vendor response time, treatment cancellations, and event resolution were evaluated and compared over two equivalent time periods. In 389 clinical days, there were 119 machine-down events: 59 events before and 60 after introduction of the new model. In the new model, median time to service response decreased from 45 to 8 min, service engineer dispatch time decreased 44%, downtime per event decreased from 45 to 20 min, and treatment cancellations decreased 68%. The decreased vendor response time and reduced number of on-site visits by a service engineer resulted in decreased downtime and decreased patient treatment cancellations.

Lean methodology improves efficiency in outpatient academic uro-oncology clinics.

OBJECTIVE: To determine if lean methodology, an industrial engineering tool developed to optimize manufacturing efficiency, can successfully be applied to improve efficiencies and quality of care in a hospital-based high-volume uro-oncology clinic. METHODS: Before the lean initiative, baseline data were collected on patient volumes, wait times, cycle times (patient arrival to discharge), nursing assessment time, patient teaching, and physician ergonomics (via spaghetti diagram). Value stream analysis and a rapid improvement event were carried out, and significant changes were made to patient check-in, work areas, and nursing face time. Follow-up data were obtained at 30, 60, and 90 days. The Student t test was used for analysis to compare performance metrics with baseline. RESULTS: The median cycle time before the lean initiative was 46 minutes. This remained stable at 46 minutes at 30 days but improved to 35 minutes at 60 days and 41 minutes at 90 days. Shorter wait times allowed for increased nursing and physician face time. The average length of the physician assessment increased from 7.5 minutes at baseline to 10.6 minutes at 90 days. The average proportion of value-added time compared with the entire clinic visit increased from 30.6% at baseline to 66.3% at 90 days. CONCLUSION: Using lean methodology, we were able to shorten the patient cycle time and the time to initial assessment as well as integrate both an initial registered nurse assessment and registered nurse teaching to each visit. Lean methodology can effectively be applied to improve efficiency and patient care in an academic outpatient uro-oncology clinic setting.

A fuzzy inference system to evaluate contract service provider performance.

This paper puts forward a fuzzy inference system for evaluating the quality performance of service contract providers. An Application Service Provider was designed and put online, featuring surveys to establish the most useful indicators to evaluate the quality of the service. This model was implemented in 10 separate hospitals. As a result, the service cost-acquisition cost ratio in these cases was reduced from 16.14% to 6.09% in the period 2001-January 2003.

Ultraviolet light disinfection of hospital water for preventing nosocomial Legionella infection: a 13-year follow-up.

BACKGROUND AND OBJECTIVE: CDC has estimated that 23% of Legionella infections are nosocomial. When a new hospital was being constructed and a substantial increase in transplantation was anticipated, an ultraviolet light apparatus was installed in the water main of the new building because 27% of water samples from taps in the old hospital contained Legionella. This study reports the rate of nosocomial Legionella infection and water contamination since opening the new hospital. METHODS: Charts of all patients with positive Legionella cultures, direct immunofluorescent antibody (DFA), or urine antigen between April 1989 and November 2001 were reviewed. Frequencies of DFAs and urine antigens were obtained from the laboratory. RESULTS: None of the 930 cultures of hospital water have been positive since moving into the new building. Fifty-three (0.02%) of 219,521 patients had a positive Legionella test; 41 had pneumonia (40 community acquired). One definite L. pneumophila pneumonia confirmed by culture and DFA in August 1994 was nosocomial (0.0005%) by dates. This patient was transferred after prolonged hospitalization in another country, was transplanted 11 days after admission, and developed symptoms 5 days after liver transplant. However, tap water from the patient's room did not grow Legionella. Seventeen (2.5%) of 670 urine antigens were positive for Legionella (none nosocomial). Thirty-three (1.2%) of 2,671 DFAs were positive, including 7 patients (21%) without evidence of pneumonia and 6 (18%) who had an alternative diagnosis. CONCLUSION: Ultraviolet light usage was associated with negative water cultures and lack of clearly documented nosocomial Legionella infection for 13 years at this hospital.

Shutting down operating theater ventilation when the theater is not in use: infection control and environmental aspects.

OBJECTIVE: In hospital operating rooms (ORs), specially conditioned air is supplied to protect patients from airborne agents that may cause infections. This study investigated whether it is hygienically safe to shut down the air supply at night if measures are taken to ensure a timely restart before surgery is performed. DESIGN: Experimental study. SETTING: Neurosurgical OR of a German university hospital. METHODS: The ventilation system was switched off and restarted after 10 hours. Particles suspended in the air near the operating table were counted, OR temperature was measured, and settle plates were exposed and incubated. RESULTS: In 13 investigations, a median of 1.3 x 10(4) particles 0.5 microm/m3 or greater (range, 5.8 x 10(3) to 1.1 x 10(5)) were documented immediately after restart in the morning. After 10 minutes and subsequently, no test showed a particle count exceeding the threshold limit of 1.0 x 10(4) particles 0.5 microm/m3 or greater recommended by the German Society of Hygiene and Microbiology. Only a few colony-forming units (CFU) were detected per settle plate (median, 0 CFU/60 cm2; range, 0 to 8) and OR temperatures quickly reached normal levels. CONCLUSIONS: Shutting down OR ventilation during off-duty periods does not appear to result in an unacceptably high particle count or microbial contamination of the OR air shortly after the system is restarted. Because substantial energy and cost savings are likely, this should be considered in hygienically safe heating, ventilation, and air conditioning systems. However, normal ventilation should be established at least 30 minutes before surgical activity.

Assessing equipment repair and asset management.

As reimbursement continues to decline, healthcare managers are now forced to seek out and establish alternative means for ensuring optimal patient care delivery via maximized equipment uptimes, minimized downtimes, increased productivity and decreased expenses. And, while our benchmarking survey documented manufacturers' service contracts as the "best practice" for repair of equipment in radiation oncology, this method was also identified as the most costly. As a result, serious consideration must be given to alternate methods, irrespective of advantages and disadvantages. As a new industry-wide product, asset management is still another viable method and alternative for consideration with regard to equipment maintenance and repair.

A philosophical approach to treatment machine maintenance and breakdown.

Planned preventative maintenance (PPM), quality control (QC) checks and breakdown all contribute to the down-time of a radiotherapy treatment machine. Low levels of machine availability are unacceptable both clinically and financially. Clinical data demonstrate that, for many tumours, interruptions to treatment will result in reduced local control. Reductions to the gaps in treatment can be achieved by patient interchange between machines. Maintaining the maximum possible machine availability will reduce the potential for errors associated with the transfer of patients between machines, and reduce the cost of treatment. Practices for routine PPM and QC vary between hospitals. In this report, a rationale for breakdown and maintenance will be described. Based on the faults experienced on a Philips SL 75-5 and a Philips SL25 over a period of 3 years, the workload associated with routine maintenance and quality control are presented and the additional work associated with breakdown discussed. Faults have been categorized on a scale between catastrophe and maintainability. A demonstration of how this analysis can be used to assess the cost-benefits of proposed changes in working patterns by the extension or reduction of maintenance periods is provided. The results indicated that no gain would be made in changing from a 1-day to a 2-day per month PPM schedule.

Streamlining environmental safety in the operating room: a common bond between surgeons and hospital engineers.

The operating room presents environmental safety concerns unlike any problems in other parts of a health care facility. Special disciplines must be utilized to ensure that risk is minimized during surgery. This document addresses the needs of both the surgeon and the plant engineer in order for both groups to learn more about the other's concerns and problems.

New integrated gas turbine CHP (combined heat and power) and incinerator plant.

Despite the complex nature of the project, the clients brief of a 14 month design and installation period was achieved within the approved budget of 2.5 million pounds. Early performance figures indicate that the scheme is on target to achieve the original payback of under four years. Queen Elizabeth Hospital: installation of integrated combined heat and power plant. Client: Central Birmingham Health Authority. Consulting Engineers/Project Managers: Yates, Edge and Partners. Architects: Temple Cox and Nichols. Structural Engineers: Peel and Fowler. Quantity Surveyor: West Midlands Regional Health Authority.