How do you maintainHow do you maintainHow do you maintain How do you maintain competency?competency?competency?competency?Dan Pavord, MS, DABRDan Pavord, MS, DABR

Vassar Brothers Medical CenterVassar Brothers Medical CenterViceVice--chair, AAPM Clinical Practice chair, AAPM Clinical Practice

CommitteeCommitteeCommitteeCommittee

Learning ObjectiveLearning ObjectiveLearning ObjectiveLearning Objective

To provide a clear understanding of howTo provide a clear understanding of howTo provide a clear understanding of how To provide a clear understanding of how to develop a competency programto develop a competency program

From WikipediaFrom WikipediaFrom WikipediaFrom Wikipedia

CompetenceCompetence is a standardizedis a standardizedCompetenceCompetence is a standardized is a standardized requirement for an individual to properly requirement for an individual to properly perform a specificperform a specific jobjob It encompasses aIt encompasses aperform a specific perform a specific jobjob. It encompasses a . It encompasses a combination of combination of knowledgeknowledge, , skillsskills and and behaviorbehavior utilized to improve performanceutilized to improve performancebehaviorbehavior utilized to improve performance. utilized to improve performance. More generally, competence is the state or More generally, competence is the state or quality of being adequately or wellquality of being adequately or wellquality of being adequately or well quality of being adequately or well qualified, having the qualified, having the abilityability to perform a to perform a specificspecific rolerolespecific specific rolerole..

From AAPMFrom AAPMFrom AAPMFrom AAPMMedical PhysicistsMedical PhysicistsIn the United States, medical physicists demonstrate In the United States, medical physicists demonstrate competence in their discipline by obtaining competence in their discipline by obtaining board board certificationcertification. Certification is a rigorous, multi. Certification is a rigorous, multi--year year

th t i id bl li i l ith t i id bl li i l iprocess that requires considerable clinical experience process that requires considerable clinical experience under supervision and passage of written and oral under supervision and passage of written and oral examinations.examinations. Medical physicists follow Medical physicists follow detailed detailed quality assurance and safety protocolsquality assurance and safety protocols establishedestablishedquality assurance and safety protocolsquality assurance and safety protocols established established to insure that cancer treatments with radiation are to insure that cancer treatments with radiation are conducted according to the prescription prepared by the conducted according to the prescription prepared by the physician for every treatment of every patient. Medical physician for every treatment of every patient. Medical p y y y pp y y y pphysicists follow physicists follow guidance from national standardsguidance from national standardsdocuments developed by the AAPM and in cooperation documents developed by the AAPM and in cooperation with other professional societies. The AAPM has with other professional societies. The AAPM has n me o ommittee dedi ted to q lit n en me o ommittee dedi ted to q lit n enumerous committees dedicated to quality assurance numerous committees dedicated to quality assurance and safety in radiation therapy.and safety in radiation therapy.

From AARTFrom AARTFrom AARTFrom AARTIs the Person Exposing You to Radiation Is the Person Exposing You to Radiation Q lifi d?Q lifi d?Qualified?Qualified?

(February 26, 2010) (February 26, 2010) —— Every day in the United States, Every day in the United States, ( y , )( y , ) y y ,y y ,tens of thousands of patients are exposed to ionizing tens of thousands of patients are exposed to ionizing radiation through radiation therapy, CT scans, x rays, radiation through radiation therapy, CT scans, x rays, mammograms, and other medical imaging and mammograms, and other medical imaging and therapeutic procedures Patients need to havetherapeutic procedures Patients need to havetherapeutic procedures. Patients need to have therapeutic procedures. Patients need to have confidence that the technologists caring for them have confidence that the technologists caring for them have the the credentialscredentials and and qualificationsqualifications to safely to safely administer radiation and that the equipment they areadminister radiation and that the equipment they areadminister radiation, and that the equipment they are administer radiation, and that the equipment they are using is properly calibrated and maintained to deliver using is properly calibrated and maintained to deliver radiation safely and within the proper dose parameters. radiation safely and within the proper dose parameters.

From ASTROFrom ASTROFrom ASTROFrom ASTROGOAL 3:GOAL 3: Shape the framework for delivery of quality patient care. Shape the framework for delivery of quality patient care. ASTRO ill d h l h h i h l h fASTRO ill d h l h h i h l h fASTRO will support and help shape comprehensive health reform. ASTRO will support and help shape comprehensive health reform. ASTRO will build a successful radiation oncology ASTRO will build a successful radiation oncology practice practice accreditation programaccreditation program in conjunction with the American College of in conjunction with the American College of Radiology. Radiology. ASTRO will work to promote and represent the practice of radiation ASTRO will work to promote and represent the practice of radiation oncology with respect to the American Medical Association, the oncology with respect to the American Medical Association, the Centers for Medicare and Medicaid Services and other payer Centers for Medicare and Medicaid Services and other payer communities, with governmental and regulatory entities, and within communities, with governmental and regulatory entities, and within , g g y ,, g g y ,health care reform, in general. health care reform, in general. ASTRO will continue to develop its ASTRO will continue to develop its comprehensive Maintenance of comprehensive Maintenance of Certification program to document clinical competencyCertification program to document clinical competency. . ASTRO will promote research funding for the fieldASTRO will promote research funding for the fieldASTRO will promote research funding for the field. ASTRO will promote research funding for the field. ASTRO will continue to advance its advocacy agenda. ASTRO will continue to advance its advocacy agenda. ASTRO will develop an evidenceASTRO will develop an evidence--based mechanism for improving the based mechanism for improving the patient care experience.patient care experience.p pp pASTRO will take the lead in developing radiation oncology ASTRO will take the lead in developing radiation oncology clinical clinical practice guidelines.practice guidelines.

From JCFrom JCFrom JCFrom JC

The elements of establishing The elements of establishing competencycompetency

Accreditation certification and MOCAccreditation certification and MOCAccreditation, certification, and MOCAccreditation, certification, and MOCFollow detailed QA and safety protocolsFollow detailed QA and safety protocolsF ll ti l t d dF ll ti l t d dFollow national standardsFollow national standardsPeer reviewPeer reviewCollect info from current and previous Collect info from current and previous employmentemploymentp yp yObservation, written and/or oral testsObservation, written and/or oral tests

The Steps to Maintaining CompetencyThe Steps to Maintaining CompetencyThe Steps to Maintaining CompetencyThe Steps to Maintaining Competency1)1) Establish the culture of safety.Establish the culture of safety.2)2) Make sure your P&P’s are current and contain adequate detail.Make sure your P&P’s are current and contain adequate detail.

Well documented P&P change process.Well documented P&P change process.Make sure you have detailed and documented P&P review Make sure you have detailed and documented P&P review and that they adhere to applicable standards.and that they adhere to applicable standards.

3)3) New staff evaluationNew staff evaluation))Document previous experience of new staff.Document previous experience of new staff.Make sure you have a detailed program to train new staff.Make sure you have a detailed program to train new staff.

4)4) Existing staff evaluationExisting staff evaluationEstablish minimum procedure levelsEstablish minimum procedure levelsEstablish minimum procedure levels.Establish minimum procedure levels.Observation, audits, written and/or oral testsObservation, audits, written and/or oral tests

5)5) Budget for outside reviews.Budget for outside reviews.Program (ACR Accreditation) and procedures (RPC/RDS Program (ACR Accreditation) and procedures (RPC/RDS

h t )h t )phantoms)phantoms)6)6) Establish proper training programEstablish proper training program

Budget for staff training.Budget for staff training.Document all education and training.Document all education and training.gg

7)7) Make sure that you have adequate staffing.Make sure that you have adequate staffing.Budget staff time for competenciesBudget staff time for competencies

Safety CultureSafety CultureSafety CultureSafety Culture

Adhering to a culture of safety is a competencyAdhering to a culture of safety is a competencyd e g to a cu tu e o sa ety s a co pete cyd e g to a cu tu e o sa ety s a co pete cyTop down enforcement of safety firstTop down enforcement of safety firstZero tolerance for short cutsZero tolerance for short cutsAll staff empowered to stop a procedureAll staff empowered to stop a procedureSecond checks and timeoutsSecond checks and timeoutsMake sure staff do not operate outside their Make sure staff do not operate outside their scope of practicescope of practice

ll d d h f &ll d d h f &Well documented change of P&P processWell documented change of P&P processExpectations for staffExpectations for staff

Sample ExpectationsSample ExpectationsSample ExpectationsSample Expectations

Policies and ProceduresPolicies and ProceduresPolicies and ProceduresPolicies and ProceduresHow can you determine competency if it is not clear How can you determine competency if it is not clear y p yy p ywhat is required?what is required?“Able to perform IMRT QA” is not sufficient.“Able to perform IMRT QA” is not sufficient.“Able to perform IMRT QA on a TomoTherapy unit with“Able to perform IMRT QA on a TomoTherapy unit withAble to perform IMRT QA on a TomoTherapy unit with Able to perform IMRT QA on a TomoTherapy unit with version 3.4 software using PTW 729 with version 4.03b version 3.4 software using PTW 729 with version 4.03b software using 2%/2mm criteria, etc…” is the level of software using 2%/2mm criteria, etc…” is the level of detail needed Each staff member should not be makingdetail needed Each staff member should not be makingdetail needed. Each staff member should not be making detail needed. Each staff member should not be making it up as they go.it up as they go.Annual review of P&P’s by all staff documented.Annual review of P&P’s by all staff documented.Review of P&P’s by new staff documented before Review of P&P’s by new staff documented before allowing staff to work independently. allowing staff to work independently.

How important are good P&P’s?How important are good P&P’s?How important are good P&P s?How important are good P&P s?

From B G Clark et al Radiotherapy and Oncology 95 (3): 344-349From B.G. Clark et al, Radiotherapy and Oncology 95 (3): 344 349

Sample new staff competency check listlist

Minimum Procedure LevelsMinimum Procedure LevelsMinimum Procedure LevelsMinimum Procedure LevelsIf you have not done something in the last 12 If you have not done something in the last 12 y gy gmonths, are you still competent?months, are you still competent?Establish minimum procedure levels for staff. If Establish minimum procedure levels for staff. If they do not perform the required number perthey do not perform the required number perthey do not perform the required number per they do not perform the required number per year, they must reyear, they must re--credential.credential.–– Should be at least 1.Should be at least 1.

T k th h d t i f tT k th h d t i f tTrack through dept info systemTrack through dept info system–– i.e. use QCL’s in Mosaiqi.e. use QCL’s in Mosaiq

Establish a detailed portfolio of the number ofEstablish a detailed portfolio of the number ofEstablish a detailed portfolio of the number of Establish a detailed portfolio of the number of procedures done by each staff member.procedures done by each staff member.–– They can use this to document their experience if They can use this to document their experience if

they change jobs Important for licensingthey change jobs Important for licensingthey change jobs. Important for licensing.they change jobs. Important for licensing.

AuditsAuditsAuditsAudits

Provide feedback on how well P&P’s areProvide feedback on how well P&P’s areProvide feedback on how well P&P s are Provide feedback on how well P&P s are understood and implemented.understood and implemented.Benchmark staffBenchmark staffBenchmark staff.Benchmark staff.

Outside Peer ReviewOutside Peer ReviewOutside Peer ReviewOutside Peer Review

Feedback on how well your P&P’s reflect bestFeedback on how well your P&P’s reflect bestFeedback on how well your P&P s reflect best Feedback on how well your P&P s reflect best practice or how well your system is performing.practice or how well your system is performing.ACR accreditationACR accreditationACR accreditationACR accreditationRPC reviewsRPC reviewsASTRO PAAROT program (PerformanceASTRO PAAROT program (PerformanceASTRO PAAROT program (Performance ASTRO PAAROT program (Performance Assessment for the Advancement of Radiation Assessment for the Advancement of Radiation Oncology Treatment)Oncology Treatment)ACR RACR R--O PEERO PEERTMTM

Physicist Peer Review (see AAPM TG 103, 2005)Physicist Peer Review (see AAPM TG 103, 2005)y ( , )y ( , )

Outside peer review, what to expect. Outside peer review, what to expect. AAPM TG 103 lAAPM TG 103 lAAPM TG 103 as an example.AAPM TG 103 as an example.

Independent check of machine outputIndependent check of machine outputdepe de t c ec o ac e outputdepe de t c ec o ac e outputChart auditsChart auditsReview of QC and QAReview of QC and QAQ QQ QAssessment of adequate documentationAssessment of adequate documentationCompliance with state and federal lawCompliance with state and federal lawReview of professional development, licenses, Review of professional development, licenses, etc.etc.

f d ff df d ff dReview of adequate staffing and coverageReview of adequate staffing and coverageAssessment of adequate resourcesAssessment of adequate resources

ACR AccreditationACR AccreditationACR AccreditationACR Accreditation

11. What can my practice begin doing to11. What can my practice begin doing to11. What can my practice begin doing to 11. What can my practice begin doing to prepare for an ACR accreditation survey?prepare for an ACR accreditation survey?A: Review the ACR Practice Guidelines andA: Review the ACR Practice Guidelines andA: Review the ACR Practice Guidelines and A: Review the ACR Practice Guidelines and Technical Standards for Radiation Oncology on Technical Standards for Radiation Oncology on the ACR Web site at www.acr.org and the AAPM the ACR Web site at www.acr.org and the AAPM Task Group Reports (in particular TGTask Group Reports (in particular TG--21, TG21, TG--51, 51, TGTG--40, and TG40, and TG--53) and incorporate these into 53) and incorporate these into your facility’s operational policies andyour facility’s operational policies andyour facility’s operational policies and your facility’s operational policies and procedures.procedures.

From ACR FAQ

What can an outside audit do for What can an outside audit do for ??you?you?

28% 14% 29% 25%

How many of you were in 14-29% Fail group?

From Ibbott et al, IJROBP, 71(1)

Still not convinced?Still not convinced?Still not convinced?Still not convinced?

Lesson LearnedLesson LearnedLesson LearnedLesson Learned

Have an outside audit done beforeHave an outside audit done beforeHave an outside audit done before Have an outside audit done before implementing new technologyimplementing new technologyWill help spot hidden errors in yourWill help spot hidden errors in yourWill help spot hidden errors in your Will help spot hidden errors in your processprocess

Education and TrainingEducation and TrainingEducation and TrainingEducation and Training

ConferencesConferencesConferencesConferences–– Require staff to communicate what was Require staff to communicate what was

learnedlearnedlearnedlearned

Vendor trainingVendor trainingRequire someone on your staff receiveRequire someone on your staff receive–– Require someone on your staff receive Require someone on your staff receive training directly from vendortraining directly from vendorSend your staff or document training of aSend your staff or document training of a–– Send your staff or document training of a Send your staff or document training of a staff member at previous jobstaff member at previous job

Adequate StaffingAdequate StaffingAdequate StaffingAdequate Staffing

ACR dataACR dataACR dataACR dataLots of data related to nursing error rates Lots of data related to nursing error rates and staffing levelsand staffing levelsand staffing levelsand staffing levelsNo reason to think any different for others No reason to think any different for others

Solo Practitioners, the need for Solo Practitioners, the need for i l ii l ispecial attentionspecial attention

Is a specific concern for PhysiciansIs a specific concern for PhysiciansIs a specific concern for Physicians, Is a specific concern for Physicians, Physicists, Dosimetrists, and NursesPhysicists, Dosimetrists, and NursesWho evaluates performance?Who evaluates performance?Who evaluates performance?Who evaluates performance?Who provides peer review?Who provides peer review?Guidelines (see AAPM report 80, 2003)Guidelines (see AAPM report 80, 2003)

From AAPM Report 80From AAPM Report 80From AAPM Report 80From AAPM Report 80

Medical Physics Solo Practitioners, Data Medical Physics Solo Practitioners, Data f 2008 AAPM lf 2008 AAPM lfrom 2008 AAPM salary surveyfrom 2008 AAPM salary survey

Degree and Degree and tifi titifi ti

NumberNumber % of total (for % of total (for th t d / tth t d / t

Median years Median years iicertificationcertification that degree/cert that degree/cert

combination)combination)experienceexperience

MS, noneMS, none 204204 52%52% 33

MS, certifiedMS, certified 495495 56%56% 1616

PhD, nonePhD, none 8080 21%21% 44PhD, nonePhD, none 8080 21%21% 44

PhD, certifiedPhD, certified 295295 36%36% 1515

T t lT t l 10741074 55% ( f ll RO55% ( f ll RO 1010TotalTotal 10741074 55% (of all RO 55% (of all RO physicists)physicists)

1010

That means there are at least (not all physicists are AAPM membersThat means there are at least (not all physicists are AAPM members and returned the survey)142 facilities (~6%) with solo physicists that are not certified and have less than 5 years experience!

Time BurdenTime BurdenTime BurdenTime Burden

P&P update and reviewP&P update and reviewP&P update and reviewP&P update and reviewDocumentationDocumentationP f i th t iP f i th t iPerforming the competenciesPerforming the competencies

Cost BurdenCost BurdenCost BurdenCost Burden

ACR Accreditation ~$20 000 initial thenACR Accreditation ~$20 000 initial thenACR Accreditation, ~$20,000 initial then ACR Accreditation, ~$20,000 initial then ~$10,000 every 3 years~$10,000 every 3 yearsPhysics peer review $1000Physics peer review $1000 $3000?$3000?Physics peer review, $1000Physics peer review, $1000--$3000?$3000?TLD output verification, ~$600/linacTLD output verification, ~$600/linacPhantom verification for IMRT, SRS, etc., Phantom verification for IMRT, SRS, etc., ~$550/check~$550/checkEducation and training, ~$1000Education and training, ~$1000--$3000/year/professional$3000/year/professional$ /y /p$ /y /p

ConclusionsConclusionsConclusionsConclusions

Establish clear detailed policy andEstablish clear detailed policy andEstablish clear, detailed policy and Establish clear, detailed policy and procedures.procedures.Follow established standards (ACR AAPMFollow established standards (ACR AAPMFollow established standards (ACR, AAPM, Follow established standards (ACR, AAPM, ASTRO, etc.).ASTRO, etc.).H i t l d t l ditH i t l d t l ditHave internal and external audits.Have internal and external audits.Make sure your staff members are Make sure your staff members are competent, your patients depend on it.competent, your patients depend on it.

LinksLinksLinksLinks

RDS ServicesRDS ServicesRDS ServicesRDS Serviceshttp://www.mdanderson.org/educationhttp://www.mdanderson.org/education--andand--research/resourcesresearch/resources--forfor--professionals/scientificprofessionals/scientific--resources/coreresources/core--facilitiesfacilities--andand--services/radiationservices/radiation--resources/coreresources/core facilitiesfacilities andand services/radiationservices/radiationdosimetrydosimetry--services/radiationservices/radiation--therapytherapy--machines/index.htmlmachines/index.htmlACR Guide to Medical Physics Professional PracticeACR Guide to Medical Physics Professional PracticeACR Guide to Medical Physics Professional Practice ACR Guide to Medical Physics Professional Practice http://www.acr.org/SecondaryMainMenuCategories/Busihttp://www.acr.org/SecondaryMainMenuCategories/BusinessPracticeIssues/FeaturedCategories/GroupPractice/gunessPracticeIssues/FeaturedCategories/GroupPractice/guide medphys.aspxide medphys.aspx_ p y p_ p y pACR FAQACR FAQhttp://www.acr.org/accreditation/radiation/ro_faq.aspxhttp://www.acr.org/accreditation/radiation/ro_faq.aspx

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