JCAHO CQI -Reply

[Chris Alston <alstonc@odrge.odr.georgetown.edu>]

>Content-Disposition: inline
>Date:         Mon, 8 Dec 1997 13:40:43 -0500
>Reply-To: Medical Physics Mailing List <MEDPHYS@LISTS.WAYNE.EDU>
>Sender: Medical Physics Listserver <medphys@lists.wayne.edu>
>From: Mary Ellen McGary <MMcGary@HEALTH-FIRST.ORG>
>Subject:      JCAHO CQI -Reply
>To: Multiple recipients of list MEDPHYS <MEDPHYS@LISTS.WAYNE.EDU>
>
>
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>Dear Virgil and fellow MEDPHYSers,
>
>The last time the JCAHO visited my institution (1996), they really liked a
project that I
>presented.  I share it here as an example of what they are looking for
these days.
>
>At my institution, we do in vivo dosimetry on each field (once) for all
therapy patients.
>The bottom line is the ratio of measured dose (using a diode-based IVD
system) to the
>expected dose at dmax (derived from calculation based on the prescribed dose at
>depth).   When I took over my present position, the spread in this ratio
for all
>measurements was larger than I liked.  I was able to show the inspectors
plots of how
>the standard deviation of the measured/expected ratio decreased for all three
>accelerators over the course of several months.  The change was effected by
>fine-tuning correction factors for the diode system, fine-tuning the
calculation of dose
>at dmax, improving communication between the dosimetrists and therapists on
diode
>placement for each case, and educating the therapists on the importance of
diode
>placement, especially when wedges are used or the diode is placed off-axis.
>
>After a monotonic decrease of in the standard deviation of the
measured/expected
>ratios, we hit a low value (about 3 times less than the original s.d.)
which we have
>been able to maintain over many months, documenting the improvement was
>long-lived.
>
>Here's what I believe they liked about what I had done.
>1.  This project obvious relates to a very important measure of the
accuracy of the
>comprehensive patient treatment system (patient care).
>2.  All members of the technical staff (physicists, dosimetrists,
therapists) worked
>together as a team, each contributing what he/she could to improve the
situation
>(multi-disciplinary, team approach).
>3.  By reducing the spread in the data, we had fewer outliers (5%
tolerance) which
>resulted in a significant reduction in the amount of time physics and
therapy staff
>needed to invest in resolving discrepancies (cost), and more time became
available for
>direct patient care.
>4.  The mathematics were easy to understand.
>
>After I presented this, the JCAHO inspectors kept saying "Give that woman a
raise!"
>to every administrator they could find.   (Got pats on the back from
Administration, but
>no hard cash!!!)
>
>I hope this anecdote is helpful to you.  I look forward to hearing about
the positive
>experiences of others with the new JCAHO.  I need some new ideas!!!
>
>Regards,
>Mary Ellen
>
>
>_____________________________
>Mary Ellen Masterson-McGary
>Holmes Regional Medical Center
>Melbourne, FL
>e-mail: mmcgary@health-first.org
>
>>>> Virgil Willcut <Virgil.Willcut@SIH.NET> 12/08/97 08:40am >>>
>
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>     Colleagues,
>
>     I guess I wasn't explicit enough in my first message, so I will
>     elaborate.  We do track things like charting errors, block re-mounts,
>     first day treatmenter isocenter shifts, etc.  However, this didn't
>     impress the JCAHO people.  They wanted to see CQI projects which
>     clearly demonstrated that the CQI PROCESS was alive and well in our
>     department--namely, identifying a possible problem, statistically
>     verifying that a problem exists, postulating a solution to the
>     problem, implementing a "solution", then accruing more statistics to
>     demonstrate that solution had been in fact acheived.  While we
>     maintain statistics as mentioned above, these are not before and after
>     type statistics, just running statistics.  They said that this was a
>     HOT item for current JCAHO inspections  (actually, this and patient
>     confidentiality issues were the two hot topics we were told existed at
>     this time--we will have to change the way we register patients so that
>     all patient information is taken in a private room instead of at our
>     reception desk).
>
>     Once again, thanks for any input you can send my way regarding CQI
>     activities in your departments.
>
>     Virgil M. Willcut, MS, DABMP
>     virgil.willcut@sih.net
>