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SAVI Quality Assurance Using Failure Modes and Risk Analysis Methodology

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H Norris

H Norris*, V Gutti , G Palaniswaamy , Baylor Scott & White Health Vasicek Cancer Center, Temple, TX


PO-BPC-Exhibit Hall-4 (Saturday, March 5, 2016)  Room: Exhibit Hall

Purpose: Standardized work and processes for radiation therapy are instrumental in providing high quality patient care in an efficient manner. We are developing standardized procedures for brachytherapy, stereotactic, and IMRT treatments based on process mapping, GEMBA and FMEA. In this abstract, we present our work on workflow standardization for brachytherapy SAVI program for breast treatments. Scope of our work is directed towards reduction of human error and prevention of failures; establish standardized procedures, personnel training and high quality patient care.

Methods: The entire process for SAVI treatment at our clinic was mapped by defining the 27 tasks in total performed by physicians, nurses, therapists and physicists. Descriptions of tasks and roles were outlined. Performing GEMBA for each task, we identified “pain points” or potential modes of failure. We then compared the observed procedures with written departmental procedures and checklists, updating and/or establishing new procedures and policies. We are conducting FMEA with a quantitative RPN ranking to create and evaluate process controls to prevent potential failure modes from reaching the patient. As part of continuing process evaluation, we will track failure modes (e.g. re-plan or cancelled treatment) and compare rates with those prior to establishing this standardized work and processes.

Results: A clear SAVI treatment process map was established with assigned task owners. For each task, a standard work procedure and relevant checklists were established. Personnel involved in SAVI treatment processes (simulation process, treatment planning, and delivery) are trained with new established workflow and procedures geared towards high quality patient care.

Conclusions: Standard work procedures can lead to efficient, improved quality and performance in the radiation oncology setting. Established standard workflow at our clinic keeps members of the SAVI team clear of their roles and process, help reduce potential modes of failure and in turn improve quality of patient care.

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