How centres in Atlantic Canada used the Quality Assurance Guidelines for Canadian Radiation Treatment Programs to move the needle on quality improvement
In 2015, CPQR undertook a broad review of radiation oncology programs (ROP) to identify uptake and impact across the country. In Atlantic Canada, various radiation treatment programs used this audit as an opportunity to develop informal best practices for compliance with the key quality indicators (KQIs) contained QRT. Following independent submission of the CPQR audit, four Dalhousie University affiliated ROP distributed across 3 provinces met via videoconference as part of a Radiotherapy Quality Assurance Committee (RTQAC) community of practice (COP), to review individual centre responses and discuss successes and challenges to regional compliance with each indicator. These 4 centres chose to conduct a second audit after that meeting to determine whether the discussion had changed the perception of compliance rates.
CPQR sat down with Dr. Amanda Caissie, a radiation oncologist at Saint John Regional Hospital to see how this process helped her centre!
Q: Before you conducted the first audit, how successful did you think your centre was in meeting the KQIs?
A: Saint John Regional Hospital is a small hospital in a province with limited resources so I expected we may be having challenges with certain KQI due to such resource limitation. Our local RTQAC’s initial audit actually resulted in an 85% compliance which was close to the national average.
Q: When you all got together in person, how did the discussion go?
A: We started by sharing the results of the initial audit with each other. We had some centres that thought they were spot on with their compliance, others who ranked themselves critically and had lower scores. When we started going through the KQIs one by one we started seeing adjustments to our scores. For example – the KQI requiring written policies and procedures that address RT incidents: initially most of us felt that we met that criterion. Then we discussed – when had these last been reviewed and updated? Were they being used actively? Was there awareness of their existence? We found that there was a difference between doing something, and doing it well. Three quarters of us changed our response from a “yes” to a “no” as a result of that discussion.
Q: And how do you think the face to face discussion helped?
A: It is not a bad thing to say “no”, we are not adequately meeting this KQI. To me that means you are continuously striving to do better. Soon after initiation of group discussions, we realized that our centre had been somewhat overly optimistic with the KQI compliance scores. Is it a 90% “yes” or a 10% “yes”-perhaps the latter should be a “no” and we have actually started rating our “no” scores more descriptively on a scale of 0-10 so we can see our continuous improvements with certain challenging KQI. There is a risk to being overly optimistic in self-audit: resources cannot be allocated to gaps as needed if it falsely appears as though all objectives are already being met.
The group discussion also highlighted the fact that we do not have to work in silos, reinvent the wheel or duplicate scarce resources. We are lucky to be a small, tight knit region and all four centres are helping by sharing tips for success or resources such as policies.
Q: And where do you go from here?
A: As a result of the audit process, our RTQAC COP plans to meet regularly to determine how we can assist as individual centres are implementing processes to improve compliance with the QRT guideline and prepare for Accreditation Canada auditing that is starting this year.
I would argue that the group discussion was as important as the individual centre self-audit. It started a lot of dialogue about the KQI and other CPQR quality initiatives. All centres eventually want to go beyond basic Accreditation Canada expectations, and raise the bar to hold themselves to higher standards. It was felt that quality improvement initiatives should be ongoing and not only a focus at time of Accreditation Canada preparation. I am in the process of preparing a manuscript that details our process, so others can learn from our positive experience.