Enhancing your culture of safety and quality through practice accreditation.

Abstract

227 Background: To strengthen the culture of quality and safety in an NCI-designated, multi-institution radiation oncology network by obtaining accreditation. Methods: Accreditation was sought by our geographic diverse, but integrated cancer center network made up of 20 radiation oncology sites. Accreditation standards were reviewed and compared to the current practices in place. Each site was internally audited for compliance to these measures and a process of education for any noncompliance instances. After submitting the application for accreditation, the process began with data collection from all locations, which included staffing levels, services provided, treatment and physics equipment used, beam data, as well as numerous pieces of documentation for quality reports and regulatory documents. Patient data was then submitted from each location for physician peer review followed by an onsite visit by a physicist and administrator. Results: After several internal site visits and respective multidisciplinary meetings with site physicists and managers, all locations underwent a thorough evaluation by an accrediting body. This third party found the quality and safety of the organization to meet the minimum standards set forth. All 20 sites were therefore given the stamp of approval and accredited. Conclusions: Preparing for accreditation and going through this process greatly strengthened each of our sites’ culture of safety and quality. It enabled all of our locations to do an in depth self-evaluation as a form of self regulation and continuous quality improvement. It was an opportunity to ensure that we not only had the appropriate quality practices in place, but could show through documentation that we, in fact, were a quality organization. The lessons we have learned from this experience can be used as a model for individual and network sites to pursue practice accreditation in an era of increasing emphasis on safety and quality in radiation oncology.