toward minimum practice standards in clinical medical...

Toward Minimum Practice Toward Minimum Practice Standards in Clinical Medical Standards in Clinical Medical

Physics:Physics:Response to an increasing focus on Response to an increasing focus on

reducing medical errors and reducing medical errors and validating professional competencevalidating professional competence

Per Halvorsen, MS, DABR, FACR, FAAPMOctober 2014

OutlineOutline How we got here:How we got here:

The national (and international) focus on medical The national (and international) focus on medical errors and quality in health careerrors and quality in health care

Federal legislative initiativesFederal legislative initiatives

State regulatory changes / legislationState regulatory changes / legislation

Private insurance companiesPrivate insurance companies

Professional society initiatives including AAPMProfessional society initiatives including AAPM

Medical Physics Practice GuidelinesMedical Physics Practice Guidelines

Next steps?Next steps?

The national/international focusThe national/international focus

Past 2 decades Past 2 decades focus on medical errors and focus on medical errors and healthcare quality (adverse incidents, studies by healthcare quality (adverse incidents, studies by US and European governmentUS and European government--supported supported groups).groups).

Result: increased concern with verifying the Result: increased concern with verifying the quality of healthcare delivery and healthcare quality of healthcare delivery and healthcare professionalsprofessionals’’ competence.competence.

The Institute of MedicineThe Institute of Medicine In 2000, the NASIn 2000, the NAS--

sponsored Institute of sponsored Institute of Medicine published its first Medicine published its first book in a series on book in a series on healthcare quality, titled healthcare quality, titled ““To err is humanTo err is human””. .

The Institute of MedicineThe Institute of Medicine

Concluded that Concluded that 98,000 patients die each year 98,000 patients die each year as a result of medical errors.as a result of medical errors.

Two key recommendations: Two key recommendations:

1.1. Standardize proceduresStandardize procedures

2.2. Regularly validate professional competence.Regularly validate professional competence.

The IAEAThe IAEA

Increased media focusIncreased media focus

Increased media focusIncreased media focus

CT perfusionCT perfusion

BrachytherapyBrachytherapy

SRSSRS

Congressional focusCongressional focus

Congressional focus Congressional focus –– of the of the unhelpful kindunhelpful kind……..

Increased device regulation likely:Increased device regulation likely:

Regulation of devices is not enough:Regulation of devices is not enough:

Most are Most are process failuresprocess failures resulting from resulting from inadequate SOPs, staffing, resources:inadequate SOPs, staffing, resources:

Federal legislationFederal legislation CARE bill: Current House and Senate versions CARE bill: Current House and Senate versions

are identical are identical –– progress being made toward progress being made toward passage in this session.passage in this session.

Charges the Secretary of HHS to implement Charges the Secretary of HHS to implement regulations to enforce a minimum education and regulations to enforce a minimum education and training standard for clinical professionals in training standard for clinical professionals in imaging and radiotherapyimaging and radiotherapy

CARE billCARE bill

CARE billCARE bill

The Alliance for CAREThe Alliance for CARE American Association of Medical American Association of Medical

AssistantsAssistants American Association of Medical American Association of Medical

DosimetristsDosimetrists American Association of Physicists in American Association of Physicists in

MedicineMedicine American Registry of Radiologic American Registry of Radiologic

TechnologistsTechnologists American Society of Radiologic American Society of Radiologic

TechnologistsTechnologists Association of Educators in Imaging Association of Educators in Imaging

and Radiologic Sciencesand Radiologic Sciences Association of Vascular and Association of Vascular and

Interventional RadiographersInterventional Radiographers Cardiovascular Credentialing Cardiovascular Credentialing

InternationalInternational Joint Review Committee on Education Joint Review Committee on Education

in Cardiovascular Technologyin Cardiovascular Technology Joint Review Committee on Education Joint Review Committee on Education

in Diagnostic Medical Sonographyin Diagnostic Medical Sonography

Joint Review Committee on Joint Review Committee on Education in Radiologic TechnologyEducation in Radiologic Technology

Joint Review Committee on Joint Review Committee on Education Programs in Nuclear Education Programs in Nuclear Medicine TechnologyMedicine Technology

Nuclear Medicine Technology Nuclear Medicine Technology Certification BoardCertification Board

Section for Magnetic Resonance Section for Magnetic Resonance Technologists of International Technologists of International Society of Magnetic Resonance in Society of Magnetic Resonance in MedicineMedicine

Society of Nuclear MedicineSociety of Nuclear Medicine--Technologist SectionTechnologist Section

Society for Radiation Oncology Society for Radiation Oncology Administrators Administrators

Society for Vascular UltrasoundSociety for Vascular Ultrasound Society of Diagnostic Medical Society of Diagnostic Medical

SonographySonography Society of Invasive Cardiovascular Society of Invasive Cardiovascular

ProfessionalsProfessionals

MIPPAMIPPA

Medicare Improvements for Patients and Medicare Improvements for Patients and Providers Act of 2008:Providers Act of 2008: Signed into law in July 2008Signed into law in July 2008 Requires practice accreditation for the Requires practice accreditation for the ““advanced advanced

imagingimaging”” modalities which includes CT, MR, and modalities which includes CT, MR, and Nuclear MedicineNuclear Medicine

Does not include xDoes not include x--ray, fluoroscopy, sonography, or ray, fluoroscopy, sonography, or anything in radiation oncologyanything in radiation oncology

Does not apply to hospitalsDoes not apply to hospitals

Accrediting bodies under MIPPA:Accrediting bodies under MIPPA: American College of RadiologyAmerican College of Radiology Intersocietal Accreditation CommissionIntersocietal Accreditation Commission The Joint CommissionThe Joint Commission RadSite (new)RadSite (new) The Problem/ConcernThe Problem/Concern

All have different requirements for All have different requirements for personnel personnel -- AAPM is on record indicating AAPM is on record indicating concern with not requiring board concern with not requiring board certification for medical physicistscertification for medical physicists

PossiblePossible national solution:national solution:

US Congress follows MIPPAUS Congress follows MIPPA’’s lead and requires s lead and requires accreditation for all imaging and radiation accreditation for all imaging and radiation therapy services in order to receive federal therapy services in order to receive federal dollars (MediCare).dollars (MediCare).

ASTRO, ACR and AAPM have committed to ASTRO, ACR and AAPM have committed to strengthening accreditation programsstrengthening accreditation programs

ASTROASTRO’’s position:s position:

ACRACR’’s position:s position:

AAPMAAPM’’s position:s position:

State regulationsState regulations

Professional Licensure or registry.Professional Licensure or registry.

More states are implementing strong More states are implementing strong definitions of a QMP, with Board definitions of a QMP, with Board certification the only pathway. certification the only pathway.

CRCPD SSRs incorporate QMP definitionCRCPD SSRs incorporate QMP definition

State regulationsState regulations

MA RegistryMA Registry

Accreditation: State lawsAccreditation: State laws

Accreditation Accreditation -- Private insurers: Private insurers: BCBS MABCBS MA

State State laws:laws:

California California (CT)(CT)

ASTROASTRO--AAPM:AAPM:Patient safetyPatient safety

•Staffing levels

•FMEA

•Error reporting

•Accreditation

•Standardization

•Checklists

ASTRO White PapersASTRO White Papers

•Checklists / Time-outs

•Adequate time

•Training / credentialing

•Error reporting

•Accreditation

ASRT White PaperASRT White Paper

•Staffing levels – min 2 / linac

•Training / credentialing

•Error reporting

•Accreditation

•Checklists / Time-outs

Medical Physics Practice GuidelinesMedical Physics Practice Guidelines

TG reports vs MPPGsTG reports vs MPPGs

TG reports are:TG reports are:

Intended to be technical reference for medical Intended to be technical reference for medical physicists physicists –– compendia of the known science on a compendia of the known science on a topic. topic.

Written by a core group of subjectWritten by a core group of subject--matter expertsmatter experts

Reviewed by subjectReviewed by subject--matter committee and matter committee and approved by one Councilapproved by one Council

TG reports vs MPPGsTG reports vs MPPGsMPPGs are:MPPGs are:

Developed following a structured process to Developed following a structured process to become consensus practice guidance documentsbecome consensus practice guidance documents

Developed with crossDeveloped with cross--Council participationCouncil participation

Open for review/comment by ALL membersOpen for review/comment by ALL members

Intended to be adopted by regulatory agencies Intended to be adopted by regulatory agencies and accrediting entitiesand accrediting entities

Updated regularly Updated regularly –– sunset dates / revision #sunset dates / revision #

Freely available to ALL Freely available to ALL –– not just AAPMnot just AAPM

MPPG vision/scopeMPPG vision/scope

MPPG development processMPPG development process1.1. Subcommittee on Practice Guidelines oversees Subcommittee on Practice Guidelines oversees

the process, includes members from TPC, IPC the process, includes members from TPC, IPC and GRAC.and GRAC.

2.2. Unique TG formed for each MPPG, with broadly Unique TG formed for each MPPG, with broadly representative membershiprepresentative membership

3.3. Common framework for all MPPGsCommon framework for all MPPGs

4.4. Other organizations invited to participateOther organizations invited to participate

5.5. Drafts reviewed by all Councils and by ALL Drafts reviewed by all Councils and by ALL members through Open Comment periodmembers through Open Comment period

6.6. Final approval by Professional CouncilFinal approval by Professional Council

7.7. Publication in JACMPPublication in JACMP

MPPG frameworkMPPG framework

Staffing needs, qualifications, and responsibilities Staffing needs, qualifications, and responsibilities clearly describedclearly described

Required resources and equipmentRequired resources and equipment

Staff training and validation methodsStaff training and validation methods

Initial MPPGsInitial MPPGs

In print (JACMP):In print (JACMP):

Imaging: CT protocol management and reviewImaging: CT protocol management and review

Therapy: LinacTherapy: Linac--based imagingbased imaging

In journal review:In journal review:

Safety ChecklistsSafety Checklists

Physicist Supervision (residents etc)Physicist Supervision (residents etc)

TPS dose model QATPS dose model QA

Initial MPPGsInitial MPPGs

New

MPPG Landing PageMPPG Landing Page

Initial MPPG excerptInitial MPPG excerpt

Initial MPPG excerptInitial MPPG excerpt

Medical Physicist Assistants: Medical Physicist Assistants: An inevitable consequence of An inevitable consequence of

the broader trend toward the broader trend toward extenders in healthcare?extenders in healthcare?

ACR Technical Standards:ACR Technical Standards:MPAsMPAs

NJ regs:NJ regs:MPAsMPAs

NJ regs:NJ regs:MPAsMPAs

Supervision / MPAsSupervision / MPAsBoard of Directors approved motion:Board of Directors approved motion:

Supervision / MPAsSupervision / MPAsDraft language for TX licensure hearings:Draft language for TX licensure hearings:

Supervision Supervision

Strong precedent in medicine Strong precedent in medicine –– CMS has defined CMS has defined 3 level of supervision: general, direct, personal.3 level of supervision: general, direct, personal.

AAPMAAPM’’s Professional Policy 18 incorporates the s Professional Policy 18 incorporates the CMS supervision levels for medical physics CMS supervision levels for medical physics –– will will be replaced by two MPPGs:be replaced by two MPPGs:

MPPG #4 defines supervision for residents and other MPPG #4 defines supervision for residents and other ““QMPQMP--track physiciststrack physicists””

MPPG #7 will define supervision for support personnel MPPG #7 will define supervision for support personnel such as Medical Physicist Assistants.such as Medical Physicist Assistants.

Path forward?Path forward? Minimum standards for practicing clinical Minimum standards for practicing clinical

medical physics will likely have the force of medical physics will likely have the force of regulation in most states within a decade.regulation in most states within a decade.

Major components:Major components:

Minimum education & training requirementsMinimum education & training requirements

Board certificationBoard certification

Supervision of delegated tasksSupervision of delegated tasks

Peer review at regular intervalsPeer review at regular intervals

Continuing professional development (MOC)Continuing professional development (MOC)

Error prevention programs will gain more Error prevention programs will gain more prominence.prominence.

How do we respond?How do we respond?

If If wewe (AAPM) do not define our profession, (AAPM) do not define our profession, others will do it for us.others will do it for us.

How do we respond?How do we respond?Current efforts:Current efforts:

QMP & Scope of PracticeQMP & Scope of Practice

Licensure / registration with strong templateLicensure / registration with strong template

ASTRO/ACR/IAC/TJC ASTRO/ACR/IAC/TJC –– strongstrong accreditationaccreditation

Develop Medical Physics Practice GuidelinesDevelop Medical Physics Practice Guidelines

Work with CRCPD (SSRs) & FDA (devices)Work with CRCPD (SSRs) & FDA (devices)

RORO--ILSILS

Congress: Congress:

CARE bill for Training & Education standardsCARE bill for Training & Education standards

Tie Medicare funding to accreditationTie Medicare funding to accreditation