[PPT] - Quality systems Quality systems IAEA ICARO IAEA ICARO Vienna, PowerPoint Presentation

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Quality systems Quality systems

IAEA ICARO IAEA ICARO Vienna, 2009 Vienna, 2009

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Quality Quality System System

The standard of something as measured against

ther things of a similar kind; the degree of

excellence of something A set of connected things or parts forming a complex whole; a set of things working together as parts of a mechanism or interconnecting network

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Today Today’ ’s world s world

More control

More control

More transparency

More transparency

Benchmarking

Benchmarking

Litigations

Litigations Control of quality of care Control of quality of care Hospital performance indicators Hospital performance indicators

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Quality Quality assurance in assurance in

ncology
ncology

How do How do we assess quality we assess quality? ?

By

By the results the results ( (outcome

utcome)?

)?

By a structural

By a structural analysis analysis? ?

By

By process process control? control?

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Outcome Outcome of colo

f colo-
rectal

rectal surgery surgery in in function function of

f the

the surgeon surgeon (n = 13)

(n = 13) at the

at the Royal Royal Infirmary Infirmary (Glasgow) in 645 (Glasgow) in 645 consecutive consecutive patients for patients for the the period period 1974 1974-

1979.

1979.

lowest highest C C Cu u ur r ra a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n r r ra a at t te e e 40 76 3 3 30 0d d d m m mo

r

r rt t ta a al l li i it t ty y y 8 30 3 3 30 0d d d m m mo

r

r rt t ta a al l li i it t ty y y i i in n n c c cu u ur r ra a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n 20 R R Ra a at t te e e

f

f f a a an n na a as s st t to

m

m mo

t

t ti i ic c c l l le e ea a ak k k 25 1 1 10 0y y y s s su u ur r rv v vi i iv v va a al l l i i in n n c c cu u ur r ra a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n 20 63 2 2 2y y y s s su u ur r rv v vi i iv v va a al l l i i in n n p p pa a al l ll l li i ia a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n 7 32 lowest highest C C Cu u ur r ra a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n r r ra a at t te e e 40 76 3 3 30 0d d d m m mo

r

r rt t ta a al l li i it t ty y y 8 30 3 3 30 0d d d m m mo

r

r rt t ta a al l li i it t ty y y i i in n n c c cu u ur r ra a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n 20 R R Ra a at t te e e

f

f f a a an n na a as s st t to

m

m mo

t

t ti i ic c c l l le e ea a ak k k 25 1 1 10 0y y y s s su u ur r rv v vi i iv v va a al l l i i in n n c c cu u ur r ra a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n 20 63 2 2 2y y y s s su u ur r rv v vi i iv v va a al l l i i in n n p p pa a al l ll l li i ia a at t ti i iv v ve e e r r re e es s se e ec c ct t ti i io

n

n n 7 32

(%)

Gillis C et al. Lancet 1991, 337 : 611

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Outcome studies Outcome studies

Clarke et al. Lancet, 2005

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Outcome is the golden standard Outcome is the golden standard

However, it always comes too late and reflects

However, it always comes too late and reflects the past. the past.

Outcome depends on several factors:

Outcome depends on several factors: diagnosis, treatment (RT, CT, surgery), socio diagnosis, treatment (RT, CT, surgery), socio-

economic factors

economic factors… …etc. etc.

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3 3 year disease year disease-

free

free survival survival in 3 in 3 pediatric solid pediatric solid tumours tumours in in function function of

f the

the care provider care provider

structure structure for

for the period the period 1970 1970-

1979 in Canada.

1979 in Canada.

52 48 79 24 10 68 10 20 30 40 50 60 70 80 CC NCC medulloblastoma rhabdomyosarcoma Wilm's tumour

Kramer S et al. J Clin Oncol 1984, 2 : 917

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Infrastructure Infrastructure and process and process

Recent analysis in UK of aggressive lymphoma tratment

utcome, according to whether

patients were treated in a cancer centre or not, with or without a formal protocol Cancer centre no protocol General centre Formal protocol General centre no protocol Survival of patients treated for aggressive lymphoma Cancer centre Formal protocol

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Total Total Quality Quality Management Management

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I. Aim of the organisation
I. Aim of the organisation
Set aims in accordance with available structure

Set aims in accordance with available structure

Adapt infrastructure according to aims

Adapt infrastructure according to aims

Take local epidemiology into account

Take local epidemiology into account

Encourage responsibility sharing rather than

Encourage responsibility sharing rather than competitive development competitive development

Infrequent pathologies demand for centralised

Infrequent pathologies demand for centralised referral referral

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II. Structure of the organisation
II. Structure of the organisation
Organigram

Organigram (hierarchical, (hierarchical, functional) functional)

Who is responsible for

Who is responsible for what? what?

Who is in charge of

Who is in charge of quality? quality?

L’homme et la femme

nt prévu faire l’amour

ce soir. L’homme fait semblant qu’il a oublié Le soir venu, l’homme assumes qu’il peut commencer tout de suite La femme relaxe L’homme présumes alors que le temps est propice et fait une approche L’homme fait une nouvelle tentative Pas de sexe pour un bon bout de temps L’homme écoeure la femme sur les raisons pour lesquelles elle ne veut pas faire l’amour L’homme trébuche sur le tapis dans le but de montrer sa vulnérabilité La femme trouve ça charmant Le genou de l’homme guérit rapidement et il propose à la femme de faire l’amour L’homme découvre rapidement comment ils peuvent avoir du plaisir ensemble même sans sexe La femme suggère de faire le souper ensemble L’homme fait semblant d’avoir faim Après plusieurs heures de préparation, ils mangent L’homme fait des avances directes L’homme s’endort La femme est bien de cet avis L’homme propose une promenade en présumant que cela la relaxera L’homme se fâche L’homme propose un voyage à Venise La femme commence immédiatement à consulter des brochures L’homme tente de prendre un raccourci mais la femme refuse La femme est fatiguée L’homme boit presque toute la bouteile L’homme suggère un bain ensemble Après, une bouteille de vin est ouverte sur suggestion de l’homme Après quelques verres de vin, l’homme fait une «déclaration d’amour» à la femme SEXE La femme se fâche Pas de sexe

La Formule du Sexe

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III. Obtaining and maintaining the means and
III. Obtaining and maintaining the means and

materials for radiotherapy treatment materials for radiotherapy treatment

Specification for equipment

Specification for equipment

Acceptance testing

Acceptance testing

Commissioning and de

Commissioning and de-

commissioning

commissioning

On

On-

going QC

going QC

Preventive maintenance program

Preventive maintenance program

Test after repair, etc

Test after repair, etc… …

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IV. Process control
IV. Process control
All activities, from the

All activities, from the moment a patient enters moment a patient enters the department until the department until he/she leaves it, should he/she leaves it, should be clearly stated, be clearly stated, described and recorded. described and recorded.

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V. Knowledge and skills
V. Knowledge and skills

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VI. Control of the quality system
VI. Control of the quality system
Regulatory

Regulatory

Quality indicators

Quality indicators

Internal audit

Internal audit

External audit

External audit

benchmarking

benchmarking

Audit: systematic, independent and documented process for obtaining records, statements of fact or other relevant information and assessing them objectively to determine the extent to which specific requirements are fulfilled (ISO 17000)

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Quality indicators Quality indicators

Relevant.

Relevant.

Reliable and accurate.

Reliable and accurate.

Able to detect opportunities for improvements

Able to detect opportunities for improvements

r to confirm a satisfying or excellent level of
r to confirm a satisfying or excellent level of

quality. quality.

Acceptable by the providers and users.

Acceptable by the providers and users.

Usable in benchmarking programs.

Usable in benchmarking programs.

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AGAT R1 6-10 MV 6-10 MV 4 MV Clinac 2100

Total

Tota l N° o f RT treatm ents 1138 432 560 316 476

2922

N° of sessions 19980 10514 10590 7692 8214

56990

N° of fields 29476 36356 29666 25578 18790

139866

Average field/ fraction 1,5 3,5 2,8 3,3 2,9

2,45

Average session / pat ient 17,6 24,33 18,9 24,3 17,3

19,5

Average pat ient/ uni t

584

Average session / un it

27973

Benchmarking Benchmarking

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Surgery/radiotherapy delay Surgery/radiotherapy delay

4 6 5 7 15 10 7 7 8 10 7 11 13 10 9 7 8 12 11 12 6 10 6 6 11 N =

HOSPIT

25 23 21 19 17 15 13 11 9 7 5 3 1

DELAI

120 100 80 60 40 20

20

215 211 191 162 138 110 109 96 63 57 42 17

Group Statistics 100 37.0900 11.55146 1.15515 118 40.6780 12.86145 1.18399 100 61.3400 12.73682 1.27368 118 62.8729 11.51925 1.06043 INTERIOR 1 1 DELAI AGE N Mean

Std. Deviation
Std. Error

Mean

Belgian audit 2003/2004 (39 d) Belgian audit 2003/2004 (39 d)

Mean 39 days

Radiother Oncol. 2007; 83: 178-86

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The The incident triangle incident triangle

Critical incident

Major incident

Serious incident

incident

1 10 10 30 30 600 600

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Lack of QA program Lack of QA program

r QA program
r QA program

mismanaged mismanaged Audit why this accident did Audit why this accident did happen or why such happen or why such accidents happen? accidents happen? Preventive audit better. Preventive audit better.

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