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Objectives & Outline

Objectives:

To understand safety, quality and their relationship.

To understand how quality and safety work within a system and a culture.

To understand how actions fail and how and why errors and events happen.

To understand how to use risk assessment to identify potentially hazardous parts of procedures and how to reduce the likelihood of errors and mistakes.

To understand the principles of quality assurance, quality control and quality management and how to develop an effective program for an individual facility.

To learn how to establish an error reporting system for a facility and how national reporting databases help prevent future events.

To understand how to perform root cause analysis.

To learn the tools for addressing safety and quality problems.

Program Outline

All sessions take place in Armstrong Theater unless otherwise noted.

Saturday, JUNE 15
6:30pm-8:00pm McHugh Commons and Alumni Plaza
Icebreaker Reception
Sunday, June 16
7:00am-8:00am Breakfast in Worner Campus Center
8:00am - 8:15am Welcome
8:15am - 9:45am SAM 1
1 SAM credit
Introduction and Perspective - Panel Discussion
Dunscombe, Williamson and Evans
1. Introduction to Quality and Safety
2. Quality in Radiotherapy - Physicist's Perspective
3. Quality in Radiotherapy - Physician's Perspective
9:45am - 10:00am Coffee Break
10:00am - Noon SAM 2
2 SAM credits
Systems and Culture - Panel Discussion
Caldwell, Johnson and Evans
4. Models for Clinical Responsibility
5. Work System Design
6. Safety Culture
7. Safety Culture Influence on System Design
12:00 Noon - 1:00pm Lunch in Worner Campus Center
1:30pm - 2:30pm Exercise 1: Work System Design
Johnson and Caldwell
2:30pm - 3:45pm SAM 3
2 SAM credits
Errors and Actions - Panel Discussion
Ouhib, Thomadsen, Brown and Dunscombe
8. Example Errors in Radiotherapy
9. Safety Guidance for Radiotherapy
10. Nature of Actions: What Actions Take
3:45pm - 4:00pm Coffee Break
4:00pm - 5:15pm SAM 3 cont'd Errors and Actions - Panel Discussion cont'd
Ouhib, Thomadsen, Brown and Dunscombe
11. Nature of Failures, Events, Terminology
12. Taxonomy
5:30pm - 6:30pm Dinner in Worner Campus Center
7:00pm - 8:30pm Refreshments and Informal Evening Discussion with Lecturers in McHugh Commons/Alumni Plaza
Monday, June 17
7:00am-8:00am Breakfast in Worner Campus Center
8:00am - 9:00am Exercise 2: Event Classification
Thomadsen
9:00am - 10:00am Risk Assessment - Panel Discussion
Huq, Ford, Brown,
13. Risk Assessment Introduction - TG 100
14. Process Mapping
10:00am - 10:15am Coffee Break
10:15am - 11:30am Exercise 3: Process Mapping
Ford and Brown
11:30am - Noon Risk Assessment - Panel Discussion cont'd
Rath
15a. FMEA
12:00 Noon - 1:00pm Lunch in Worner Campus Center
1:30pm - 2:45pm Exercise 4: FMEA
Rath
2:45pm - 3:45pm Risk Assessment - Panel Discussion cont'd
Rath, Huq
15b. FMEA (Wrap-up)
16. Fault Trees
3:45pm - 4:00pm Coffee Break
4:00pm - 5:15pm Exercise 5: Fault Tree
Huq
5:30pm - 6:30pm Dinner in Worner Campus Center
7:00pm - 8:30pm Refreshments and Informal Evening Discussion with Lecturers in McHugh Commons/Alumni Plaza
Tuesday, June 18
7:00am-7:45am Breakfast in Worner Campus Center
7:45am - 11:00am SAM 4
3 SAM credits
Development of a Quality Management Program - Panel Discussion
Palta, Bissonnette, Yorke, Fong de los Santos, Thomadsen, Ford and Rath
17. Quality Management Overview
18. Commissioning of Equipment
19. Commissioning of Procedures
20. Quality Control
21. Quality Assurance
22. General QM Tools and Approaches
9:30am - 9:45am Coffee Break
  SAM 4
cont'd
Development of a Quality Management Program - Panel Discussion cont'd
23. Checklists
24. Design of QM from the Risk Assessment
25. Quality and IT
11:00am - 12:15pm Exercise 6: QA and QC design
Palta, Bissonnette, Yorke, Fong de los Santos and Rath
12:15 Noon - 1:00pm Lunch in Worner Campus Center
Free Afternoon! Click here for ideas.
6:30pm - 9:00pm Night In on the Quad - Worner Campus Center Quad
6:30pm Dinner
7:30pm - 9:00pm Music will be provided by three musicians from The Colorado College Bluegrass Ensemble, an instrumental and vocal band which draws from traditional sources like Monroe, Flatt and Scruggs, Jimmy Martin, and the Stanley Brothers.
Wednesday, June 19
7:00am-8:00am Breakfast in Worner Campus Center
8:00am - 9:15am Exercise 7: QM Layout
Thomadsen
9:15am - 10:00am 26. Quality Audits and Accreditation
Sherouse
10:00am - 10:15am Coffee Break
10:15am - 11:45am Event Reporting Systems - Panel Discussion
Dunscombe, Mutic and Sutlief
27. Reporting System: Design for an Institution
28. Reporting System: Applications
29. Data Elements
30. National Reporting System
11:45am - Noon Exercise 8: Reporting Systems - Assignment
12:00 Noon - 1:00pm Lunch in Worner Campus Center
1:30pm - 2:30pm Exercise 8: Reporting Systems - Completion
Mutic and Sutlief
2:30pm - 3:30pm 31. Root Cause Analysis
Caldwell & Sutlief
3:30pm - 3:45pm Exercise 9: Root Cause Analysis - Set-up
3:45pm - 4:00pm Coffee Break
4:00pm - 5:15pm Exercise 9: Root Cause Analysis
Caldwell & Sutlief
5:30pm - 6:30pm Dinner in Worner Campus Center
7:00pm - 8:30pm Refreshments and Informal Evening Session with Lecturers in McHugh Commons/Alumni Plaza
Thursday, June 20
7:00am-8:00am Breakfast in Worner Campus Center
8:00am - 8:30am 32. In-house Training
Brown
8:30am - 10:00am Quality Improvement Paradigms Panel
33. Remediation: Principles of Error-proofing
34. Quality Improvement
35. Six Sigma
36. Lean
Fong de los Santos, Ford, Pawlicki and Sutlief
10:00am - 10:15am Coffee Break
10:15am - 10:45am Quality Improvement Paradigms Panel cont'd
10:45am - Noon Exercise 10: Remediation
Dunscombe and Ford
12:00 Noon - 1:00pm Lunch in Worner Campus Center
1:30pm - 2:15pm 37. Statistical Process Control
Pawlicki
2:15pm - 3:15pm Exercise 11: Statistical Process Control
Pawlicki
3:15pm - 3:45pm 38. Documentation
Mutic
3:45pm - 4:00pm Coffee Break
4:00pm - 4:45pm 39. Managing Change
Mundt
4:45pm - 5:00pm Final Issues
5:30pm - 6:30pm Dinner in Worner Campus Center
6:30pm - 8:00pm

Examples: Quality in Radiotherapy
40. QM for Radiotherapy
41. QM for IMRT
42. QM for Brachytherapy
Yorke, Williamson & Palta

Refreshments in Armstrong Theater Lobby immediately following.
Friday, June 21
Check-out of Campus Housing - Loomis Hall
Grab-and-go breakfast snacks and coffee will be available.