Radiation Protection inRadiation Protection in
RadiotherapyRadiotherapy
Part 12Part 12
Quality AssuranceQuality Assurance
...
Part 12: Quality assurance2Radiation Protection in Radiotherapy
QUALITY as a goalQUALITY as a goal
““The totality of featu...
Part 12: Quality assurance3Radiation Protection in Radiotherapy
What is Quality Assurance?What is Quality Assurance?
““All...
Part 12: Quality assurance4Radiation Protection in Radiotherapy
Quality AssuranceQuality Assurance
In the BSS seen in the ...
Part 12: Quality assurance5Radiation Protection in Radiotherapy
ObjectivesObjectives
To be familiar with the concepts of Q...
Part 12: Quality assurance6Radiation Protection in Radiotherapy
ContentsContents
1. Quality Assurance and the BSS1. Qualit...
Part 12: Quality assurance7Radiation Protection in Radiotherapy
1. Quality Assurance and the1. Quality Assurance and the
B...
Part 12: Quality assurance8Radiation Protection in Radiotherapy
QA and QCQA and QC
Quality Assurance is the overallQuality...
Part 12: Quality assurance9Radiation Protection in Radiotherapy
Quality Assurance and MedicalQuality Assurance and Medical...
Part 12: Quality assurance10Radiation Protection in Radiotherapy
Relevant for radiotherapyRelevant for radiotherapy
WORLD ...
Part 12: Quality assurance11Radiation Protection in Radiotherapy
BSS appendix II.23BSS appendix II.23
““Quality assurance ...
Part 12: Quality assurance12Radiation Protection in Radiotherapy
Consequences for radiotherapyConsequences for radiotherap...
Part 12: Quality assurance13Radiation Protection in Radiotherapy
BSS appendix II.23BSS appendix II.23
““Quality assurance ...
Part 12: Quality assurance14Radiation Protection in Radiotherapy
Consequences for radiotherapyConsequences for radiotherap...
Part 12: Quality assurance15Radiation Protection in Radiotherapy
Treatment recordsTreatment records
Must contain allMust c...
Part 12: Quality assurance16Radiation Protection in Radiotherapy
BSS appendix II.23BSS appendix II.23
““Quality assurance ...
Part 12: Quality assurance17Radiation Protection in Radiotherapy
Consequences for radiotherapyConsequences for radiotherap...
Part 12: Quality assurance18Radiation Protection in Radiotherapy
2. QA systems2. QA systems
Many QA systems exist - oneMan...
Part 12: Quality assurance19Radiation Protection in Radiotherapy
Good QA systems inGood QA systems in
radiotherapyradiothe...
Part 12: Quality assurance20Radiation Protection in Radiotherapy
ISO 9000ISO 9000
Comprehensive set of standards for QACom...
Part 12: Quality assurance22Radiation Protection in Radiotherapy
A Comprehensive QualityA Comprehensive Quality
Assurance ...
Part 12: Quality assurance23Radiation Protection in Radiotherapy
A Comprehensive QA ProgramA Comprehensive QA Program
typi...
Part 12: Quality assurance24Radiation Protection in Radiotherapy
QA Committee MembershipQA Committee Membership
Must repre...
Part 12: Quality assurance25Radiation Protection in Radiotherapy
Quality Assurance CommitteeQuality Assurance Committee
Sh...
Part 12: Quality assurance26Radiation Protection in Radiotherapy
Quality Assurance CommitteeQuality Assurance Committee
Se...
Part 12: Quality assurance27Radiation Protection in Radiotherapy
Action levelsAction levels
Are quantitativeAre quantitati...
Part 12: Quality assurance28Radiation Protection in Radiotherapy
QA Committee reviewQA Committee review
Where “Action Leve...
Part 12: Quality assurance29Radiation Protection in Radiotherapy
Documentation for the QualityDocumentation for the Qualit...
Part 12: Quality assurance30Radiation Protection in Radiotherapy
Policies and Procedures ManualPolicies and Procedures Man...
Part 12: Quality assurance31Radiation Protection in Radiotherapy
Policies and Procedures ManualPolicies and Procedures Man...
Part 12: Quality assurance32Radiation Protection in Radiotherapy
Policies and Procedures ManualPolicies and Procedures Man...
Part 12: Quality assurance33Radiation Protection in Radiotherapy
Quality Assurance TeamQuality Assurance Team
Includes all...
Part 12: Quality assurance34Radiation Protection in Radiotherapy
Responsibility ChartResponsibility Chart
Leer
Area
Profes...
Part 12: Quality assurance35Radiation Protection in Radiotherapy
Quality Assurance TeamQuality Assurance Team
Each member ...
Part 12: Quality assurance36Radiation Protection in Radiotherapy
Quality AuditQuality Audit
““A systematic and independent...
Part 12: Quality assurance37Radiation Protection in Radiotherapy
Quality AuditQuality Audit
Ideally performed by someone o...
Quality Assurance does notQuality Assurance does not
stop here!stop here!
The Quality Assurance Committee andThe Quality A...
Part 12: Quality assurance39Radiation Protection in Radiotherapy
Continuous Quality ImprovementContinuous Quality Improvem...
Part 12: Quality assurance40Radiation Protection in Radiotherapy
And finally: QA is not a threat, it isAnd finally: QA is ...
Part 12: Quality assurance41Radiation Protection in Radiotherapy
3. Quality Control in radiotherapy3. Quality Control in r...
Part 12: Quality assurance42Radiation Protection in Radiotherapy
QC should ensure every step inQC should ensure every step...
Part 12: Quality assurance43Radiation Protection in Radiotherapy
Human errors in data transfer during the preparation
and ...
Part 12: Quality assurance44Radiation Protection in Radiotherapy
QC activities in radiotherapyQC activities in radiotherap...
Part 12: Quality assurance45Radiation Protection in Radiotherapy
QC activitiesQC activities
Must be planned prospectivelyM...
Part 12: Quality assurance47Radiation Protection in Radiotherapy
External Beam RadiotherapyExternal Beam Radiotherapy
Exam...
Part 12: Quality assurance48Radiation Protection in Radiotherapy
Test of optical componentsTest of optical components
Used...
Part 12: Quality assurance49Radiation Protection in Radiotherapy
Alignment of lasers for patientAlignment of lasers for pa...
Part 12: Quality assurance50Radiation Protection in Radiotherapy
Quality Control - WeeklyQuality Control - Weekly
Check of...
Part 12: Quality assurance51Radiation Protection in Radiotherapy
Example forExample for
weekly QCweekly QC
summarysummary
...
Part 12: Quality assurance52Radiation Protection in Radiotherapy
Quality Control - MonthlyQuality Control - Monthly
Dosime...
Part 12: Quality assurance53Radiation Protection in Radiotherapy
Quality Control - MonthlyQuality Control - Monthly
Safety...
Part 12: Quality assurance54Radiation Protection in Radiotherapy
Quality Control - MonthlyQuality Control - Monthly
Field ...
Part 12: Quality assurance55Radiation Protection in Radiotherapy
Quality Control - AnnualQuality Control - Annual
Dosimetr...
Part 12: Quality assurance56Radiation Protection in Radiotherapy
How to decide on frequency forHow to decide on frequency ...
Part 12: Quality assurance57Radiation Protection in Radiotherapy
Time requirements for QCTime requirements for QC
External...
Part 12: Quality assurance58Radiation Protection in Radiotherapy
QC for BrachytherapyQC for Brachytherapy
SourcesSources
T...
Part 12: Quality assurance59Radiation Protection in Radiotherapy
QC for BrachytherapyQC for Brachytherapy
SourcesSources
C...
Part 12: Quality assurance60Radiation Protection in Radiotherapy
QC for Brachytherapy Sources-QC for Brachytherapy Sources...
Part 12: Quality assurance61Radiation Protection in Radiotherapy
QC for Remote AfterloadingQC for Remote Afterloading
Befo...
Part 12: Quality assurance62Radiation Protection in Radiotherapy
QC for Remote AfterloadingQC for Remote Afterloading
Week...
Part 12: Quality assurance63Radiation Protection in Radiotherapy
QC for Remote AfterloadingQC for Remote Afterloading
Annu...
Part 12: Quality assurance64Radiation Protection in Radiotherapy
QC DocumentationQC Documentation
Forms shall beForms shal...
Part 12: Quality assurance65Radiation Protection in Radiotherapy
Examples forExamples for
formsforms
Part 12: Quality assurance66Radiation Protection in Radiotherapy
Forms are useful for all testsForms are useful for all te...
Part 12: Quality assurance67Radiation Protection in Radiotherapy
Special equipment andSpecial equipment and
proceduresproc...
Part 12: Quality assurance68Radiation Protection in Radiotherapy
A note on action levelsA note on action levels
Not too ti...
Part 12: Quality assurance69Radiation Protection in Radiotherapy
Not only treatment units require QC:Not only treatment un...
Part 12: Quality assurance70Radiation Protection in Radiotherapy
CT scannerCT scanner
Image qualityImage quality
Scaling a...
Part 12: Quality assurance71Radiation Protection in Radiotherapy
QC for Dosimetry EquipmentQC for Dosimetry Equipment
Loca...
Part 12: Quality assurance72Radiation Protection in Radiotherapy
QC for Measuring EquipmentQC for Measuring Equipment
Auto...
Part 12: Quality assurance73Radiation Protection in Radiotherapy
Clinical QCClinical QC
Not only physicsNot only physics
a...
Part 12: Quality assurance74Radiation Protection in Radiotherapy
Chart RoundsChart Rounds
Regular review of patientsRegula...
Part 12: Quality assurance79Radiation Protection in Radiotherapy
4. QA and radiation protection4. QA and radiation protect...
Part 12: Quality assurance80Radiation Protection in Radiotherapy
QA inQA in
medicalmedical
exposuresexposures
Physical QAP...
Part 12: Quality assurance81Radiation Protection in Radiotherapy
QA Program: Arrangements to beQA Program: Arrangements to...
Part 12: Quality assurance82Radiation Protection in Radiotherapy
Also the radiation protectionAlso the radiation protectio...
Part 12: Quality assurance83Radiation Protection in Radiotherapy
The cost of QAThe cost of QA
Dedicated staff - qualificat...
Part 12: Quality assurance84Radiation Protection in Radiotherapy
What do we get?What do we get?
Yes, correct - lots of doc...
Part 12: Quality assurance85Radiation Protection in Radiotherapy
The benefits of QAThe benefits of QA
Benefits for the dep...
Part 12: Quality assurance86Radiation Protection in Radiotherapy
Additional benefitsAdditional benefits
CredibilityCredibi...
Part 12: Quality assurance87Radiation Protection in Radiotherapy
Involvement of AdministrationInvolvement of Administratio...
Part 12: Quality assurance88Radiation Protection in Radiotherapy
But - Beware the Administration “TickBut - Beware the Adm...
Part 12: Quality assurance89Radiation Protection in Radiotherapy
What do we risk without aWhat do we risk without a
Qualit...
Part 12: Quality assurance90Radiation Protection in Radiotherapy
What do we risk without aWhat do we risk without a
Qualit...
Part 12: Quality assurance91Radiation Protection in Radiotherapy
Where to get more informationWhere to get more informatio...
Part 12: Quality assurance92Radiation Protection in Radiotherapy
WHO (World Health
Organisation). Quality
Assurance in
rad...
Part 12: Quality assurance93Radiation Protection in Radiotherapy
SummarySummary
Quality Assurance is an essential part of ...
Any questions?Any questions?
QuestionQuestion
Please give an example for the conceptPlease give an example for the concept
of Continuous Quality Improv...
Part 12: Quality assurance96Radiation Protection in Radiotherapy
Example… just one of manyExample… just one of many
A cent...
Part 12: Quality assurance97Radiation Protection in Radiotherapy
AcknowledgmentAcknowledgment
Lee Collins, Westmead Hospit...
Upcoming SlideShare
Loading in...5
×

12. Medical exposure: Quality assurance (2,359 KB)

467

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
467
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
34
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Part 12: QA
    Activity: lecture
    Objectives:
    To become familiar with the concepts of Quality Assurance as a multidisciplinary activity and its interrelation with radiation protection in radiotherapy.
    To be familiar with quality assurance procedures as a tool for reviewing and assessing the overall effectiveness of a radiation protection program.
    To be able to understand the need for and role of specific tests in the context of quality control and be able to identify appropriate national and international protocols for this task
    To be aware of the need for involvement of professionals in a quality assurance program and for radiation protection
    Duration: 3 hours
    Materials and equipment needed: slide projector
    References: BSS and publications given at the end of the lecture
  • The illustration shows the ‘head in the sand’ mentality. Quality assurance enables us to face reality...
  • This is a very important slide - the context of medical exposure is relevant for the whole part 12.
    The second point relates to a ‘meta’ QA. QA does not only apply to radiotherapy activities but also to radiation protection and the lecturer could mention that in this context the QA activities also will need a check: are they effective in enhancing radiation protection?
  • Quality assurance is given a high importance in the BSS context - it is part of the managerial requirements.
    The lecturer should point out that this fact (managerial requirement) does not imply that QA is a ‘top down’ process (workers wait until management instigates a QA program). The idea of QA is that everyone at all levels MUST be actively involved.
  • The following section always presents quotes from BSS and then tries to relate this back to radiotherapy practice. The lecturer is encouraged to use her/his own experience to expand on this.
  • More references given at the end of the lecture and also part of the handout.
  • More on this in section 3 of the lecture
  • Commissioning data provides the basis of the tests chosen (what appears to be most in need of testing?) AND the benchmark quantitative data.
  • The lecturer may want to point out that a treatment record could also be electronically, as it is the case with many record and verify systems. However, in practice a paper record is just as good.
  • The slide illustrates the fact that ISO standards are often incorporated into national standards - this makes them legally binding locally.
  • The second message - while obvious - is important. The cost of a major accident exceeds the cost to instigate a good QA system by far.
  • The lecturer can introduce this by asking: “QA is good, but HOW are we going about to commence it…”
  • This slide can be included if time permits - it is relevant particular if the participants are administrators or medical physicists who would instigate the implementation.
  • These points are discussed in more detail in the following slides
  • An important slide - the lecturer should take some time to take the participants through it.
  • Represent the department means: should have representation form all major professional groups in the department. It also indicates that this includes all levels of staff (eg unionized, managerial, part time).
  • The last point is only an example. It is likely that every clinic will adopt an action level for output - however, the actual level can be different (compare next slide) and must be agreed on locally.
  • The topic of action levels will be revisited in part 18 of the course.
  • <number>
    Terms of referecne are discussed in more detail in part 18 of the course. There also an example for a radiation safety committee will be developed.
  • The lecturer should point out that the QA team is different from the QA committee. The QA team is responsible for performing the QA activities.
  • European Society for Therapeutic Radiology and Oncology (ESTRO) Advisory Report to the Commission of the European Union for the 'Europe Against Cancer Programme'. Quality Assurance in radiotherapy. Radiother. Oncol. 35: 61-73; 1995.
  • The first two examples are dose verification services.
    The calibration of a radiation beam is checked using TLDs. More information on this was given in part 10, lecture 2 on dosimetry.
  • This is a very important point - quality assurance is never complete. It is an on-going process which must take into account new information and new equipment (hardware and software) as it becomes available.
  • The no parking symbol illustrates the fact that one cannot stand still in QA.
  • The last two points are important: openness must be encouraged. Any problem becomes worse if it is not addressed.
  • The lecturer can point out that it is beyond the scope of the course to introduce any of the QA protocols in much detail. Here, the general ideas shall be dealt with, the protocols shown here provide guidance on the set-up of a QA program which must be specific for the circumstances a radiotherapy department is in. The references shown are:
    Institute of Physical Sciences in Medicine. Commissioning and quality assurance of linear accelerators, IPSM report 54. York: IPSM; 1988.
    AAPM task group 40: Kutcher GJ, Coia L, Gillin M, Hanson W, Leibel S, Morton RJ, Palta J, Purdy J, Reinstein L, Svensson G, et al. Comprehensive QA for radiation oncology: report of AAPM therapy committee task group 40. Med Phys 1994;21:581-618.
    International Atomic Energy Agency. Design and implementation of a radiotherapy programme: clinical, medical physics, radiation protection and safety aspects. IAEA-TECDOC 1040, Vienna 1998.
    Not shown but equally important is:
    WHO (World Health Organisation). Quality Assurance in radiotherapy. Geneva 1988.
    Participants should have access to all of them.
  • This is an interesting article which is mentioned as it focuses on the point that QA is not just required for hardware but also for information flow.
    The complexity of the information flow chain in radiotherapy can be enormous (in particular in advanced treatment such as IMRT). It is essential to ensure that all transmission of information is accurate. Record and verify systems (such as Varis or Impac) are useful in this context.
  • The lecture can use slides from part 10.3 to complement the present lecture. This may be essential if part 10 of the course is abbreviated. For this purpose, QA is dealt with in a separate slide series X.3.C
  • The lecturer must point out that the activities suggested on the following slides are suggestions only. The same applies for the practical exercises.
    They must be modified and agreed upon locally.
  • A slide currently hidden but included in the handout for reference.
  • These checks are usually quickly done.
    The picture shows a device for daily output consistency checks - it is a based on a sealed ionization chamber (no temperature/pressure correction necessary) and features a large read-out which can be seen through the patient monitoring video system.
  • The test tool (= jig) allows to check field size for different collimator and gantry angles, allows to verify the optical distance indicator for different gantry angles and allows to perform a check of all lasers for patient alignment.
    Tests with a similar tool will be part of a practical exercise.
  • The laser must be horizontal/vertical at least for distances which are compatible with typical patient size.
  • The couch movements are often used for patient positioning eg when lining up the patient to an anatomical landmark or tattoo and then shifting the patient x cm longitudinally.
  • Part of handout slides - the participants are encouraged to produce their own chart in a practical exercise.
  • Both % depth dose and flatness symmetry can verify the radiation energy. Flatness is usually a rather sensitive test as the flattening filter is energy sensitive.
  • Shown is a tool for cross hair alignment checks
  • Shown is a tool to verify field size and distance indicators
  • In particular for a badly performing unit, or a unit which has failed often on previous tests, one may need to spend considerably longer time.
    The picture is just an illustration.
  • This slide switches the considerations form external beam to brachytherapy.
    Shown is a Mentor 125-I seed.
  • Shown is a radiation monitor with a hand held probe
  • The form shown is a good example - it is clearly laid out and uses graphics. A brief graphical description of the test (cross hair centre variation with gantry position) is shown.
    Most importantly, the ‘bottom line’ is: Action required?
  • Constantinou C. Protocol and procedures for quality assurance of linear accelerators. Brockton: Constantinou; 1994. Available from Medical Physics Publishing, Madison.
  • More information on these tests is given in the companion course of diagnostic radiology
  • The test tool shown has different sections:
    The front section which is visible checks alignment and CT numbers for 4 test objects.
    Other sections check spatial and contrast resolution.
    The whole phantom is made from water equivalent material.
  • The illustration shows a PTW electrometer and a pin-point chamber
  • Barometer can be checked against a meteorological station close - however, care must be taken that the correct units are used and appropriate corrections eg for altitude are applied.
  • Explained in more detail on the next slide
  • By doing this chart rounds not only can improve clinical practice and help to develop good local protocols, it is also possible that the round pick up physical problems such as the ones discussed in the next part of the course (13) on accidents.
  • Explained more in the next slide
    Verification - as test of a large part of a chain at once - is an additional QA check suitable for audits. It does NOT replace QA activities for individual steps.
  • The lecturer can point out that these very points make verification as defined here highly suitable for external audits.
  • More details on this are provided in part 10 lecture 2 of the course.
  • QA in medical exposures is the main topic of the present lecture.
    Requirements for practices are covered throughout the course while safety of sources and occupational exposure have their own parts (15 and 8, receptively) in the course
  • It is not necessary for the participants to understand the flow chart in detail. It is from a publication by W Leer. Important is to show how a flow chart can map a process. Protocols are developed to guide the practice within and QA activities must check that the process achieves its objective.
  • This is part of a ‘critical ‘ approach.
  • Redundancy in the context of the second point means there should be a second piece of equipment which can perform the same (or at least a similar) function as the equipment in use. This allows cross checks and ensures the availability of a back-up.
    The bottom line for many people - it is important to discuss costs/benefit also for QA. It is hoped that the following slides can be used to stimulate discussion amongst the participants.
  • Prevention of accidents is not mentioned here on purpose even if it is a very important outcome of QA. It would be excellent if the participants note this (prompted or un-prompted by the lecturer).
    Accidents are covered in the last slides of the talk.
  • It should not be difficult to convince management about the need for QA. It helps everyone. Typically only the expenditures and resources necessary to perform it are a matter of discussion. This can be resolved by a scientific approach which assesses QA needs and resources and prioritize the activities needed.
  • Part of the handout - no need to be able to read or copy this here.
  • A final reference
  • Other features could be added as required locally
  • The question should stimulate discussion using the participants own experience. As CQI is the topic, participants can bring in ‘success stories’ which will help to re-enforce the message of QA as something positive.
    If no examples are forthcoming, the lecturer could illustrate the concept by the following example:
    A centre intends to improve treatment set-up. The measure patient positioning using port films on 20 patients eg of the prostate. The random variations are of the order of 8mm and the systematic error on average 9mm.
    The systematic error could at least partially attributed to different couch sag in simulator and treatment unit. This is reflected in update procedures.
    A repeat test show that not only the systematic but also the random uncertainty have improved (the latter potentially because of heightened awareness). The smaller random variation allows to pick up other systematic errors…
    In addition to this the positive experience leads to the same tests to be done for other treatment sites...
  • …this is a true story form the author’s experience in the case of prostate cancer patients’ set-up.
  • Transcript of "12. Medical exposure: Quality assurance (2,359 KB)"

    1. 1. Radiation Protection inRadiation Protection in RadiotherapyRadiotherapy Part 12Part 12 Quality AssuranceQuality Assurance IAEA Training Material on Radiation Protection in Radiotherapy
    2. 2. Part 12: Quality assurance2Radiation Protection in Radiotherapy QUALITY as a goalQUALITY as a goal ““The totality of features orThe totality of features or characteristics that bear on our ability tocharacteristics that bear on our ability to satisfy the stated or implied goal ofsatisfy the stated or implied goal of effective patient care.”effective patient care.” Comprehensive QA for Radiation Oncology,Comprehensive QA for Radiation Oncology, AAPM Task Group 40, 1994AAPM Task Group 40, 1994 To ensure the goal is reached requiresTo ensure the goal is reached requires a fully implemented Quality Assurancea fully implemented Quality Assurance program throughout the facility.program throughout the facility.
    3. 3. Part 12: Quality assurance3Radiation Protection in Radiotherapy What is Quality Assurance?What is Quality Assurance? ““All those planned and systematicAll those planned and systematic actions necessary to provideactions necessary to provide confidence that a product or service willconfidence that a product or service will satisfy given requirements for quality.”satisfy given requirements for quality.” ISO 9000ISO 9000
    4. 4. Part 12: Quality assurance4Radiation Protection in Radiotherapy Quality AssuranceQuality Assurance In the BSS seen in the contextIn the BSS seen in the context of medical exposure as essentialof medical exposure as essential for radiation protection of thefor radiation protection of the patientpatient Quality Assurance and Control isQuality Assurance and Control is also important to assess thealso important to assess the overall effectiveness of protectionoverall effectiveness of protection and safety measuresand safety measures
    5. 5. Part 12: Quality assurance5Radiation Protection in Radiotherapy ObjectivesObjectives To be familiar with the concepts of Quality Assurance as a multidisciplinary activity and its interrelation with radiation protection in radiotherapy. To be familiar with Quality Assurance procedures as a tool for reviewing and assessing the overall effectiveness of a radiation protection program. To be able to understand the need for and role of specific tests in the context of Quality Control and be able to identify appropriate national and international protocols for this task To be aware of the need for involvement of professionals in a Quality Assurance program and for radiation protection
    6. 6. Part 12: Quality assurance6Radiation Protection in Radiotherapy ContentsContents 1. Quality Assurance and the BSS1. Quality Assurance and the BSS 2. QA systems2. QA systems 3. Quality Control in radiotherapy3. Quality Control in radiotherapy External Beam RTExternal Beam RT BrachytherapyBrachytherapy 4. QA and radiation protection4. QA and radiation protection
    7. 7. Part 12: Quality assurance7Radiation Protection in Radiotherapy 1. Quality Assurance and the1. Quality Assurance and the BSS (Managerial Requirements)BSS (Managerial Requirements) BSSBSS 2.29.2.29. “Quality assurance programmes“Quality assurance programmes shall be established that provide, asshall be established that provide, as appropriate:appropriate: (a) adequate assurance that the specified(a) adequate assurance that the specified requirements relating to protection and safetyrequirements relating to protection and safety are satisfied; andare satisfied; and (b) quality control mechanisms and procedures(b) quality control mechanisms and procedures for reviewing and assessing the overallfor reviewing and assessing the overall effectiveness of protection and safetyeffectiveness of protection and safety measures.measures.””
    8. 8. Part 12: Quality assurance8Radiation Protection in Radiotherapy QA and QCQA and QC Quality Assurance is the overallQuality Assurance is the overall process which is supported by Qualityprocess which is supported by Quality Control activitiesControl activities Quality Control describes the actualQuality Control describes the actual mechanisms and procedures by whichmechanisms and procedures by which one can assure qualityone can assure quality
    9. 9. Part 12: Quality assurance9Radiation Protection in Radiotherapy Quality Assurance and MedicalQuality Assurance and Medical ExposureExposure BSS appendix II.22. “Registrants and licensees, inBSS appendix II.22. “Registrants and licensees, in addition to applying the relevant requirements foraddition to applying the relevant requirements for quality assurance specified elsewhere in thequality assurance specified elsewhere in the Standards,Standards, shall establish a comprehensive qualityshall establish a comprehensive quality assurance programme for medical exposuresassurance programme for medical exposures withwith the participation of appropriate qualified experts inthe participation of appropriate qualified experts in the relevant fields, such as radiophysics orthe relevant fields, such as radiophysics or radiopharmacy, taking into account the principlesradiopharmacy, taking into account the principles established by the WHO and the PAHO.”established by the WHO and the PAHO.” You must establish a QA program!
    10. 10. Part 12: Quality assurance10Radiation Protection in Radiotherapy Relevant for radiotherapyRelevant for radiotherapy WORLD HEALTH ORGANIZATION, Quality Assurance in Radiotherapy, WHO, Geneva (1988). PAN AMERICAN HEALTH ORGANIZATION, Publicación Cientifica No. 499, Control de Calidad en Radioterapia: Aspectos Clínicos y Físicos, PAHO, Washington, DC (1986).
    11. 11. Part 12: Quality assurance11Radiation Protection in Radiotherapy BSS appendix II.23BSS appendix II.23 ““Quality assurance programmes forQuality assurance programmes for medical exposures shall include:medical exposures shall include: (a) measurements of the physical parameters of the(a) measurements of the physical parameters of the radiation generators, imaging devices andradiation generators, imaging devices and irradiation installations at the time ofirradiation installations at the time of commissioning and periodically thereafter;commissioning and periodically thereafter; (b) verification of the appropriate physical and(b) verification of the appropriate physical and clinical factors used in patient diagnosis orclinical factors used in patient diagnosis or treatment; …”treatment; …” Check machine and data!
    12. 12. Part 12: Quality assurance12Radiation Protection in Radiotherapy Consequences for radiotherapyConsequences for radiotherapy A good acceptance testing andA good acceptance testing and commissioning program is fundamentalcommissioning program is fundamental for any QA activitiesfor any QA activities QA activities are typically a subset ofQA activities are typically a subset of the tests and procedures used for thethe tests and procedures used for the commissioning of a unitcommissioning of a unit QA applies to both physical and clinicalQA applies to both physical and clinical aspects of the treatmentaspects of the treatment
    13. 13. Part 12: Quality assurance13Radiation Protection in Radiotherapy BSS appendix II.23BSS appendix II.23 ““Quality assurance programmes forQuality assurance programmes for medical exposures shall include:medical exposures shall include: ...... (c)(c) written recordswritten records of relevant procedures andof relevant procedures and results;results; (d) verification of the appropriate(d) verification of the appropriate calibrationcalibration andand conditions of operation of dosimetry andconditions of operation of dosimetry and monitoring equipment; .…”monitoring equipment; .…”
    14. 14. Part 12: Quality assurance14Radiation Protection in Radiotherapy Consequences for radiotherapyConsequences for radiotherapy Treatment records must be kept of allTreatment records must be kept of all relevant aspects of the treatment - includingrelevant aspects of the treatment - including Session and Summary Record informationSession and Summary Record information Records all treatment parametersRecords all treatment parameters Dose CalculationsDose Calculations Dose MeasurementsDose Measurements Particular emphasis is placed on QA ofParticular emphasis is placed on QA of dosimetrydosimetry
    15. 15. Part 12: Quality assurance15Radiation Protection in Radiotherapy Treatment recordsTreatment records Must contain allMust contain all relevant informationrelevant information Can be in electronicCan be in electronic formatformat
    16. 16. Part 12: Quality assurance16Radiation Protection in Radiotherapy BSS appendix II.23BSS appendix II.23 ““Quality assurance programmes forQuality assurance programmes for medical exposures shall include:medical exposures shall include: ...... andand (e) as far as possible, regular and independent(e) as far as possible, regular and independent quality audit reviewsquality audit reviews of the quality assuranceof the quality assurance programme for radiotherapy procedures”programme for radiotherapy procedures”
    17. 17. Part 12: Quality assurance17Radiation Protection in Radiotherapy Consequences for radiotherapyConsequences for radiotherapy A QA system itself and its outcomesA QA system itself and its outcomes must be critically reviewedmust be critically reviewed External audits are recommended toExternal audits are recommended to verify that the checks are not only doneverify that the checks are not only done but that they also achieve what they arebut that they also achieve what they are supposed to dosupposed to do Every good system requires anEvery good system requires an independent look at timesindependent look at times
    18. 18. Part 12: Quality assurance18Radiation Protection in Radiotherapy 2. QA systems2. QA systems Many QA systems exist - oneMany QA systems exist - one important example is the ISOimportant example is the ISO 9000 system9000 system They are highly successful inThey are highly successful in manufacturing industrymanufacturing industry because they do improvebecause they do improve productivity and avoid costlyproductivity and avoid costly mistakesmistakes
    19. 19. Part 12: Quality assurance19Radiation Protection in Radiotherapy Good QA systems inGood QA systems in radiotherapyradiotherapy Improves workImproves work practicespractices Would haveWould have prevented most ofprevented most of the major accidentsthe major accidents
    20. 20. Part 12: Quality assurance20Radiation Protection in Radiotherapy ISO 9000ISO 9000 Comprehensive set of standards for QAComprehensive set of standards for QA (mainly in manufacturing and service(mainly in manufacturing and service industry)industry) AdaptedAdapted e.g.e.g. by ESTRO to theby ESTRO to the radiotherapy environmentradiotherapy environment European Society for Therapeutic Radiology and Oncology (ESTRO) Advisory Report to the Commission of the European Union for the 'Europe Against Cancer Programme'. Quality Assurance in radiotherapy. Radiother. Oncol. 35: 61-73; 1995.
    21. 21. Part 12: Quality assurance22Radiation Protection in Radiotherapy A Comprehensive QualityA Comprehensive Quality Assurance ProgramAssurance Program The details of such a program are oftenThe details of such a program are often wrapped up in a “Code of Practice”.wrapped up in a “Code of Practice”. ““Quality Assurance in Radiotherapy”,Quality Assurance in Radiotherapy”, ESTRO Advisory Report, 1995ESTRO Advisory Report, 1995 ““Comprehensive QA for RadiationComprehensive QA for Radiation Oncology: Report of AAPM RadiationOncology: Report of AAPM Radiation Therapy Committee Task Group 40”, 1994Therapy Committee Task Group 40”, 1994 ““Quality Assurance in Radiotherapy”,Quality Assurance in Radiotherapy”, WHO, 1988WHO, 1988
    22. 22. Part 12: Quality assurance23Radiation Protection in Radiotherapy A Comprehensive QA ProgramA Comprehensive QA Program typically comprisestypically comprises Quality Assurance CommitteeQuality Assurance Committee Policies and Procedures ManualPolicies and Procedures Manual Quality Assurance teamQuality Assurance team Quality auditQuality audit ResourcesResources
    23. 23. Part 12: Quality assurance24Radiation Protection in Radiotherapy QA Committee MembershipQA Committee Membership Must represent the many disciplines within theMust represent the many disciplines within the departmentdepartment Should be chaired by the Head of DepartmentShould be chaired by the Head of Department As a minimum must include a medical doctor, aAs a minimum must include a medical doctor, a physicist, a radiotherapy technologist and anphysicist, a radiotherapy technologist and an engineer responsible for service and maintenanceengineer responsible for service and maintenance Must be appointed and supported by seniorMust be appointed and supported by senior managementmanagement Must have sufficient depth of experience toMust have sufficient depth of experience to understand the implications of the processunderstand the implications of the process Must have the authority and access to the resourcesMust have the authority and access to the resources to instigate and carry out the QA processto instigate and carry out the QA process
    24. 24. Part 12: Quality assurance25Radiation Protection in Radiotherapy Quality Assurance CommitteeQuality Assurance Committee Should ‘represent’ the departmentShould ‘represent’ the department Should be ‘visible’ AND accessible to staffShould be ‘visible’ AND accessible to staff Oversees the entire Quality Assurance programOversees the entire Quality Assurance program Writes policies to ensure the quality of patientWrites policies to ensure the quality of patient carecare Assists staff in tailoring the program to meet theAssists staff in tailoring the program to meet the needs of the Department (using publishedneeds of the Department (using published reports as a guide)reports as a guide) Monitor and audit the program to ensure thatMonitor and audit the program to ensure that each component is being performed andeach component is being performed and documenteddocumented
    25. 25. Part 12: Quality assurance26Radiation Protection in Radiotherapy Quality Assurance CommitteeQuality Assurance Committee Set agreed “Action Levels”Set agreed “Action Levels” Example: Physics is given the authority toExample: Physics is given the authority to ensure correct accelerator outputensure correct accelerator output For the daily output check two “Action Levels”For the daily output check two “Action Levels” are setare set For any daily measurement which exceeds 2% butFor any daily measurement which exceeds 2% but less than 4%, treatment may continue but theless than 4%, treatment may continue but the Senior Physicist responsible must be notifiedSenior Physicist responsible must be notified (immediately)(immediately) For any daily measurement which exceed 4%,For any daily measurement which exceed 4%, treatment must STOP immediately and thetreatment must STOP immediately and the problem investigated by the Senior Physicistproblem investigated by the Senior Physicist responsibleresponsible
    26. 26. Part 12: Quality assurance27Radiation Protection in Radiotherapy Action levelsAction levels Are quantitativeAre quantitative Reflect the required outcomeReflect the required outcome Are informed by the achievableAre informed by the achievable outcomeoutcome Must be unambiguousMust be unambiguous Should be easy to understandShould be easy to understand
    27. 27. Part 12: Quality assurance28Radiation Protection in Radiotherapy QA Committee reviewQA Committee review Where “Action Levels” have been exceededWhere “Action Levels” have been exceeded Where set procedures have been discovered to beWhere set procedures have been discovered to be faultyfaulty After a review, recommendations must be formulatedAfter a review, recommendations must be formulated in writing for improving the QA programin writing for improving the QA program When errors are discovered the fault often lies in theWhen errors are discovered the fault often lies in the process rather than in the action of individualsprocess rather than in the action of individuals
    28. 28. Part 12: Quality assurance29Radiation Protection in Radiotherapy Documentation for the QualityDocumentation for the Quality Assurance CommitteeAssurance Committee Terms of ReferenceTerms of Reference The Committee must meet at establishedThe Committee must meet at established intervals and retain for audit purposes theintervals and retain for audit purposes the minutes of its meetings, actionsminutes of its meetings, actions recommended and the results attained.recommended and the results attained. In short, there is a QA program for the QAIn short, there is a QA program for the QA CommitteeCommittee
    29. 29. Part 12: Quality assurance30Radiation Protection in Radiotherapy Policies and Procedures ManualPolicies and Procedures Manual This manual contains clear and conciseThis manual contains clear and concise statements of all the policies andstatements of all the policies and procedures carried out in theprocedures carried out in the DepartmentDepartment Reviewed (typically) yearlyReviewed (typically) yearly Updated as procedures changeUpdated as procedures change PoliciesandProcedures Manual
    30. 30. Part 12: Quality assurance31Radiation Protection in Radiotherapy Policies and Procedures ManualPolicies and Procedures Manual As a minimum, sections should exist forAs a minimum, sections should exist for Administrative proceduresAdministrative procedures Clinical proceduresClinical procedures Treatment proceduresTreatment procedures Physics proceduresPhysics procedures Radiation safetyRadiation safety
    31. 31. Part 12: Quality assurance32Radiation Protection in Radiotherapy Policies and Procedures ManualPolicies and Procedures Manual It must be “signed off” by the Head ofIt must be “signed off” by the Head of Department and appropriate section headsDepartment and appropriate section heads It is important that all staff haveIt is important that all staff have “ownership” to the manual - it should“ownership” to the manual - it should reflect the opinions of all and be agreed toreflect the opinions of all and be agreed to by allby all A list of all copies of the Manual and theirA list of all copies of the Manual and their locations must be kept to ensure that eachlocations must be kept to ensure that each copy is updatedcopy is updated
    32. 32. Part 12: Quality assurance33Radiation Protection in Radiotherapy Quality Assurance TeamQuality Assurance Team Includes all disciplinesIncludes all disciplines Well defined responsibility and reportingWell defined responsibility and reporting structurestructure Each member of the team mustEach member of the team must Know his/her responsibilityKnow his/her responsibility Be trained to perform themBe trained to perform them Know what actions are to be taken shouldKnow what actions are to be taken should a test or action be outside the preseta test or action be outside the preset “action levels”“action levels”
    33. 33. Part 12: Quality assurance34Radiation Protection in Radiotherapy Responsibility ChartResponsibility Chart Leer Area Professional
    34. 34. Part 12: Quality assurance35Radiation Protection in Radiotherapy Quality Assurance TeamQuality Assurance Team Each member of the team must alsoEach member of the team must also Have at least some understanding of theHave at least some understanding of the consequences when tests or actions areconsequences when tests or actions are outside the “action levels”outside the “action levels” Maintain records documenting theMaintain records documenting the frequency of performance, the results andfrequency of performance, the results and the corrective action taken if necessarythe corrective action taken if necessary
    35. 35. Part 12: Quality assurance36Radiation Protection in Radiotherapy Quality AuditQuality Audit ““A systematic and independentA systematic and independent examination and evaluation to determineexamination and evaluation to determine whether quality activities and resultswhether quality activities and results comply with planned arrangements andcomply with planned arrangements and whether the arrangements arewhether the arrangements are implemented effectively and are suitableimplemented effectively and are suitable to achieve the objectives.”to achieve the objectives.” ““Quality assurance in radiotherapy.”, Radiother. Oncol., 1995Quality assurance in radiotherapy.”, Radiother. Oncol., 1995 Do you do what you say you do?
    36. 36. Part 12: Quality assurance37Radiation Protection in Radiotherapy Quality AuditQuality Audit Ideally performed by someone outsideIdeally performed by someone outside of the organisationof the organisation ExamplesExamples IAEA/WHO TLD program for check of doseIAEA/WHO TLD program for check of dose in therapy unitsin therapy units EQUAL program in EuropeEQUAL program in Europe Audits of clinical trials participationAudits of clinical trials participation
    37. 37. Quality Assurance does notQuality Assurance does not stop here!stop here! The Quality Assurance Committee andThe Quality Assurance Committee and the Quality Assurance team mustthe Quality Assurance team must continuously monitor new informationcontinuously monitor new information and implement this in their proceduresand implement this in their procedures
    38. 38. Part 12: Quality assurance39Radiation Protection in Radiotherapy Continuous Quality ImprovementContinuous Quality Improvement CQI - many other acronyms are available for thisCQI - many other acronyms are available for this Part of virtually all QA systemsPart of virtually all QA systems Improved methods on cancer patient managementImproved methods on cancer patient management are documented in clinical trial reports.are documented in clinical trial reports. Quality assurance protocols are continuously underQuality assurance protocols are continuously under development in many countriesdevelopment in many countries Regular Quality Assurance meeting for all membersRegular Quality Assurance meeting for all members of a Sectionof a Section Continuing education - lectures, workshops, journalContinuing education - lectures, workshops, journal clubs and must be available for all staffclubs and must be available for all staff
    39. 39. Part 12: Quality assurance40Radiation Protection in Radiotherapy And finally: QA is not a threat, it isAnd finally: QA is not a threat, it is an opportunityan opportunity It is essential in a QA program that allIt is essential in a QA program that all staff feel free to report errorsstaff feel free to report errors A non threatening environment mustA non threatening environment must existexist Reward honesty with encouragementReward honesty with encouragement Education is the key, not punishmentEducation is the key, not punishment
    40. 40. Part 12: Quality assurance41Radiation Protection in Radiotherapy 3. Quality Control in radiotherapy3. Quality Control in radiotherapy Many documents exist that specify what QCMany documents exist that specify what QC activities should be performed inactivities should be performed in radiotherapy…radiotherapy…
    41. 41. Part 12: Quality assurance42Radiation Protection in Radiotherapy QC should ensure every step inQC should ensure every step in the treatment chain...the treatment chain... e.g.: check source activity e.g.: hand calculation of treatment time
    42. 42. Part 12: Quality assurance43Radiation Protection in Radiotherapy Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: "garbage in, garbage out" Leunens, G; Verstraete, J; Van den Bogaert, W; Van Dam, J; Dutreix, A; van der Schueren, E Department of Radiotherapy, University Hospital, St. Rafaël, Leuven, Belgium Abstract Due to the large number of steps and the number of persons involved in the preparation of a radiation treatment, the transfer of information from one step to the next is a very critical point. Errors due to inadequate transfer of information will be reflected in every next step and can seriously affect the final result of the treatment. We studied the frequency and the sources of the transfer errors. A total number of 464 new treatments has been checked over a period of 9 months (January to October 1990). Erroneous data transfer has been detected in 139/24,128 (less than 1%) of the transferred parameters; they affected 26% (119/464) of the checked treatments. Twenty-five of these deviations could have led to large geographical miss or important over- or underdosage (much more than 5%) of the organs in the irradiated volume, thus increasing the complications or decreasing the tumour control probability, if not corrected. Such major deviations, only occurring in 0.1% of the transferred parameters, affected 5% (25/464) of the new treatments. The sources of these large deviations were nearly always human mistakes, whereas a considerable number of the smaller deviations were, in fact, consciously taken decisions to deviate from the intended treatment. Nearly half of the major deviations were introduced during input of the data in the check-and-confirm system, demonstrating that a system aimed to prevent accidental errors, can lead to a considerable number of systematic errors if used as an uncontrolled set-up system. The results of this study show that human mistakes can seriously affect the outcome of patient treatments.(ABSTRACT TRUNCATED AT 250 WORDS) [Journal Article; In English; Netherlands] Radiother. Oncol. 1992: > 50 occasions of data transfer from one point to another for each patient! If one of them is wrong - the overall outcome is affected
    43. 43. Part 12: Quality assurance44Radiation Protection in Radiotherapy QC activities in radiotherapyQC activities in radiotherapy Three general areas:Three general areas: Physical dosimetryPhysical dosimetry Treatment planning (dealt with part 10Treatment planning (dealt with part 10 lecture 3C of the course)lecture 3C of the course) Patient treatmentPatient treatment
    44. 44. Part 12: Quality assurance45Radiation Protection in Radiotherapy QC activitiesQC activities Must be planned prospectivelyMust be planned prospectively dailydaily weeklyweekly monthlymonthly annuallyannually whenever needed…whenever needed… The following isThe following is only a suggestion!only a suggestion!
    45. 45. Part 12: Quality assurance47Radiation Protection in Radiotherapy External Beam RadiotherapyExternal Beam Radiotherapy Examples for daily QCExamples for daily QC SafetySafety door and other interlocksdoor and other interlocks radiation warning lightsradiation warning lights audiovisualaudiovisual radiation area monitorradiation area monitor Radiation constancy checkRadiation constancy check Mechanical/optical “pointers”Mechanical/optical “pointers” PTW Linacheck
    46. 46. Part 12: Quality assurance48Radiation Protection in Radiotherapy Test of optical componentsTest of optical components Used for patientUsed for patient set-upset-up EssentialEssential Easy to performEasy to perform Jigs availableJigs available RMI test tool
    47. 47. Part 12: Quality assurance49Radiation Protection in Radiotherapy Alignment of lasers for patientAlignment of lasers for patient set-upset-up Should point to theShould point to the isocentreisocentre Check also lineCheck also line widthwidth Check lineCheck line alignment at leastalignment at least 20cm beyond20cm beyond isocentreisocentre Gammex laser and test tool
    48. 48. Part 12: Quality assurance50Radiation Protection in Radiotherapy Quality Control - WeeklyQuality Control - Weekly Check of source positioning (cobalt 60)Check of source positioning (cobalt 60) Couch movements (lateral, vertical,Couch movements (lateral, vertical, longitudinal)longitudinal)
    49. 49. Part 12: Quality assurance51Radiation Protection in Radiotherapy Example forExample for weekly QCweekly QC summarysummary From Constantinou 1992From Constantinou 1992
    50. 50. Part 12: Quality assurance52Radiation Protection in Radiotherapy Quality Control - MonthlyQuality Control - Monthly DosimetryDosimetry Output constancyOutput constancy Backup monitorsBackup monitors Central axis %DD constancyCentral axis %DD constancy Flatness/symmetry constancyFlatness/symmetry constancy Timer end effectTimer end effect
    51. 51. Part 12: Quality assurance53Radiation Protection in Radiotherapy Quality Control - MonthlyQuality Control - Monthly Safety interlocksSafety interlocks emergencyemergency wedge etcwedge etc Light/ radiation field coincidenceLight/ radiation field coincidence ScalesScales Isocentre positionIsocentre position Cross hair positionCross hair position PTW
    52. 52. Part 12: Quality assurance54Radiation Protection in Radiotherapy Quality Control - MonthlyQuality Control - Monthly Field size indicatorsField size indicators Distance measuring indicatorsDistance measuring indicators Jaw symmetryJaw symmetry Latching of wedges, trays etc.Latching of wedges, trays etc. Wedge position (factors etc.)Wedge position (factors etc.) Test of optical componentsTest of optical components Used for patientUsed for patient set-upset-up EssentialEssential Easy to performEasy to perform Jigs availableJigs available RMI test tool RMI
    53. 53. Part 12: Quality assurance55Radiation Protection in Radiotherapy Quality Control - AnnualQuality Control - Annual DosimetryDosimetry SafetySafety MechanicalMechanical These checks are a scaled down version of the commissioning checks. It is a major QC exercise and is intended to validate the unit for another twelve months.
    54. 54. Part 12: Quality assurance56Radiation Protection in Radiotherapy How to decide on frequency forHow to decide on frequency for tests?tests? Likelihood of failureLikelihood of failure Severity of the consequences ifSeverity of the consequences if something goes wrongsomething goes wrong Ease of the test - resources requiredEase of the test - resources required This depends on local circumstances!!!This depends on local circumstances!!!
    55. 55. Part 12: Quality assurance57Radiation Protection in Radiotherapy Time requirements for QCTime requirements for QC External beam per megavoltage unitExternal beam per megavoltage unit daily: 30 minutesdaily: 30 minutes weekly: 2 hoursweekly: 2 hours monthly: > 4 hoursmonthly: > 4 hours annual: 2 days +annual: 2 days + These are estimates only - a qualifiedThese are estimates only - a qualified expert must decide on the actualexpert must decide on the actual requirements for a particular treatmentrequirements for a particular treatment unitunit Siemens Primus Linac
    56. 56. Part 12: Quality assurance58Radiation Protection in Radiotherapy QC for BrachytherapyQC for Brachytherapy SourcesSources The following QC should be done onThe following QC should be done on receipt of the sources and documentedreceipt of the sources and documented Physical/chemical formPhysical/chemical form Source encapsulationSource encapsulation Radionuclide distribution and uniformityRadionuclide distribution and uniformity AutoradiographAutoradiograph Uniformity of activity amongst seedsUniformity of activity amongst seeds Visual inspection of seeds in ribbonsVisual inspection of seeds in ribbons Mentor
    57. 57. Part 12: Quality assurance59Radiation Protection in Radiotherapy QC for BrachytherapyQC for Brachytherapy SourcesSources CalibrationCalibration Do on receipt and documentDo on receipt and document Ideal - every sourceIdeal - every source Long half-life sources (Long half-life sources (e.g.e.g. Cs 137)Cs 137) AllAll Short half-life sources (Short half-life sources (e.g.e.g. I 125)I 125) If only a few, do them allIf only a few, do them all If a large number, do a sampleIf a large number, do a sample e.g.e.g. 10%10% Nucletron
    58. 58. Part 12: Quality assurance60Radiation Protection in Radiotherapy QC for Brachytherapy Sources-QC for Brachytherapy Sources- multiple seedsmultiple seeds Suggested calibration tolerancesSuggested calibration tolerances IdealIdeal mean of batch (3%)mean of batch (3%) Deviation from mean (5%)Deviation from mean (5%) PracticalPractical Review manufacturer’s documentation forReview manufacturer’s documentation for tolerancestolerances Review ALL the manufacturer’sReview ALL the manufacturer’s documentationdocumentation
    59. 59. Part 12: Quality assurance61Radiation Protection in Radiotherapy QC for Remote AfterloadingQC for Remote Afterloading Before each treatment dayBefore each treatment day Room safety door interlocksRoom safety door interlocks Lights and alarmsLights and alarms Radiation monitorRadiation monitor Console functionsConsole functions Visual inspection of source guidesVisual inspection of source guides Verify accuracy of ribbon preparationVerify accuracy of ribbon preparation Gammasonics
    60. 60. Part 12: Quality assurance62Radiation Protection in Radiotherapy QC for Remote AfterloadingQC for Remote Afterloading WeeklyWeekly Accuracy of source and dummy loadingAccuracy of source and dummy loading Source positioningSource positioning At each source change or quarterlyAt each source change or quarterly CalibrationCalibration Timer functionTimer function Accuracy of source guides and connectorsAccuracy of source guides and connectors
    61. 61. Part 12: Quality assurance63Radiation Protection in Radiotherapy QC for Remote AfterloadingQC for Remote Afterloading AnnualAnnual Dose calculation algorithmDose calculation algorithm Simulate emergency conditionsSimulate emergency conditions Verify source inventoryVerify source inventory
    62. 62. Part 12: Quality assurance64Radiation Protection in Radiotherapy QC DocumentationQC Documentation Forms shall beForms shall be established to guideestablished to guide the processthe process easy to follow (eveneasy to follow (even late in the eveninglate in the evening after normalafter normal treatment hastreatment has finished)finished) diagrams usefuldiagrams useful
    63. 63. Part 12: Quality assurance65Radiation Protection in Radiotherapy Examples forExamples for formsforms
    64. 64. Part 12: Quality assurance66Radiation Protection in Radiotherapy Forms are useful for all testsForms are useful for all tests Simple ticks may be sufficient Empty space for comments and drawings
    65. 65. Part 12: Quality assurance67Radiation Protection in Radiotherapy Special equipment andSpecial equipment and proceduresprocedures All equipment and all proceduresAll equipment and all procedures should be testedshould be tested To design a QC protocol, one needs toTo design a QC protocol, one needs to fully understand the goals and all stepsfully understand the goals and all steps of the procedureof the procedure Requires a qualified expertRequires a qualified expert Action levels should be setAction levels should be set
    66. 66. Part 12: Quality assurance68Radiation Protection in Radiotherapy A note on action levelsA note on action levels Not too tight - one must be realisticNot too tight - one must be realistic about what can be achievedabout what can be achieved Not too lax - one must identifyNot too lax - one must identify unsatisfactory practiceunsatisfactory practice As the practice improves, the actionAs the practice improves, the action levels may be tightenedlevels may be tightened
    67. 67. Part 12: Quality assurance69Radiation Protection in Radiotherapy Not only treatment units require QC:Not only treatment units require QC: SimulatorSimulator Appropriate sections from the QCAppropriate sections from the QC activities for a treatment unitactivities for a treatment unit kVp and mAs calibrationkVp and mAs calibration Image intensifier quality checksImage intensifier quality checks Automatic exposure control if applicableAutomatic exposure control if applicable Film processorFilm processor
    68. 68. Part 12: Quality assurance70Radiation Protection in Radiotherapy CT scannerCT scanner Image qualityImage quality Scaling andScaling and deformationdeformation Transfer of dataTransfer of data Transfer of patientTransfer of patient (is positioning OK, is(is positioning OK, is couch on CT andcouch on CT and linac identical?)linac identical?) Gammex RMI CT test tool
    69. 69. Part 12: Quality assurance71Radiation Protection in Radiotherapy QC for Dosimetry EquipmentQC for Dosimetry Equipment Local standardLocal standard 2 yearly calibration2 yearly calibration Field instrumentsField instruments yearly calibrationyearly calibration LinearityLinearity LeakageLeakage RecombinationRecombination PTW
    70. 70. Part 12: Quality assurance72Radiation Protection in Radiotherapy QC for Measuring EquipmentQC for Measuring Equipment Automated scannersAutomated scanners Positional accuracyPositional accuracy AlignmentAlignment Accuracy of data analysisAccuracy of data analysis AccessoriesAccessories ThermometerThermometer BarometerBarometer
    71. 71. Part 12: Quality assurance73Radiation Protection in Radiotherapy Clinical QCClinical QC Not only physicsNot only physics and dosimetry mustand dosimetry must be subject to QC,be subject to QC, also clinicalalso clinical managementmanagement A good way to doA good way to do this are ‘chartthis are ‘chart rounds’rounds’
    72. 72. Part 12: Quality assurance74Radiation Protection in Radiotherapy Chart RoundsChart Rounds Regular review of patientsRegular review of patients Can be all patients or randomlyCan be all patients or randomly selected patientsselected patients Should include all patients withShould include all patients with unexpected severe complicationsunexpected severe complications
    73. 73. Part 12: Quality assurance79Radiation Protection in Radiotherapy 4. QA and radiation protection4. QA and radiation protection Quality assurance is essential for aQuality assurance is essential for a functioning system of radiation protectionfunctioning system of radiation protection The BSS identifies the following areas inThe BSS identifies the following areas in particular:particular: Requirements for PracticesRequirements for Practices Safety of SourcesSafety of Sources Medical ExposureMedical Exposure Occupational ExposuresOccupational Exposures
    74. 74. Part 12: Quality assurance80Radiation Protection in Radiotherapy QA inQA in medicalmedical exposuresexposures Physical QAPhysical QA as discussedas discussed beforebefore Process QAProcess QA Leer
    75. 75. Part 12: Quality assurance81Radiation Protection in Radiotherapy QA Program: Arrangements to beQA Program: Arrangements to be required from the licenseerequired from the licensee Procedures to establish patient identity Procedures to ensure accordance with prescription by a medical practitioner Procedures to ensure that radiation sources, including equipment can only be purchased from manufacturers and distributors authorized by the Regulatory Authority
    76. 76. Part 12: Quality assurance82Radiation Protection in Radiotherapy Also the radiation protectionAlso the radiation protection program itself requires QAprogram itself requires QA Check that the program meets itsCheck that the program meets its objectivesobjectives Document improvementsDocument improvements Document and rectify deficienciesDocument and rectify deficiencies Raise awarenessRaise awareness
    77. 77. Part 12: Quality assurance83Radiation Protection in Radiotherapy The cost of QAThe cost of QA Dedicated staff - qualifications, trainingDedicated staff - qualifications, training and numbersand numbers Equipment - include allowance forEquipment - include allowance for redundancyredundancy Time - commissioning, QA, reports,Time - commissioning, QA, reports, meetings, trainingmeetings, training
    78. 78. Part 12: Quality assurance84Radiation Protection in Radiotherapy What do we get?What do we get? Yes, correct - lots of documentation. But there are other benefits...
    79. 79. Part 12: Quality assurance85Radiation Protection in Radiotherapy The benefits of QAThe benefits of QA Benefits for the departmentBenefits for the department improved management systemimproved management system improved communicationimproved communication improved safetyimproved safety less duplication and wasteless duplication and waste Benefits to patientsBenefits to patients optimized procedureoptimized procedure re-assurancere-assurance
    80. 80. Part 12: Quality assurance86Radiation Protection in Radiotherapy Additional benefitsAdditional benefits CredibilityCredibility Potential to attract funding (and accountPotential to attract funding (and account for it…)for it…) Participation in multicenter clinical trialsParticipation in multicenter clinical trials Regular updates and audits to continueRegular updates and audits to continue the improvementsthe improvements Pride and confidence of staffPride and confidence of staff
    81. 81. Part 12: Quality assurance87Radiation Protection in Radiotherapy Involvement of AdministrationInvolvement of Administration Without the support of the Administration theWithout the support of the Administration the financial resources will not be made availablefinancial resources will not be made available The AAPM considers this to be so importantThe AAPM considers this to be so important that in their Quality Assurance policy theythat in their Quality Assurance policy they make the very first section “Part A: Informationmake the very first section “Part A: Information for Radiation Oncology Administrators”.for Radiation Oncology Administrators”. ““Educate those who control funding”Educate those who control funding” Comprehensive QA for Radiation Oncology, Task Group 40, 1994Comprehensive QA for Radiation Oncology, Task Group 40, 1994
    82. 82. Part 12: Quality assurance88Radiation Protection in Radiotherapy But - Beware the Administration “TickBut - Beware the Administration “Tick in the Box” syndrome!in the Box” syndrome! Administration will agree with QAAdministration will agree with QA They may even insist upon itThey may even insist upon it Without education they will not understandWithout education they will not understand what that really means in our environmentwhat that really means in our environment Most administrators equate QA with anMost administrators equate QA with an “audit”“audit” Many simply require the right boxes getMany simply require the right boxes get ticked so they can be seen to do have doneticked so they can be seen to do have done their job - this is not enough...their job - this is not enough...
    83. 83. Part 12: Quality assurance89Radiation Protection in Radiotherapy What do we risk without aWhat do we risk without a Quality Assurance Program?Quality Assurance Program? Exeter, UKExeter, UK New cobalt 60 source installedNew cobalt 60 source installed Over the next 5 months, 207 patients wereOver the next 5 months, 207 patients were overdosed by 25% due to an incorrectoverdosed by 25% due to an incorrect calibrationcalibration Contributing factorsContributing factors Calibration details not recordedCalibration details not recorded Little documentation or protocolsLittle documentation or protocols
    84. 84. Part 12: Quality assurance90Radiation Protection in Radiotherapy What do we risk without aWhat do we risk without a Quality Assurance Program?Quality Assurance Program? Exeter: Contributing factors (cont.)Exeter: Contributing factors (cont.) Reduced staffing levels (money)Reduced staffing levels (money) No independent check of calculationsNo independent check of calculations No independent check calibrationNo independent check calibration It was detected during a Nation wideIt was detected during a Nation wide survey!survey!
    85. 85. Part 12: Quality assurance91Radiation Protection in Radiotherapy Where to get more informationWhere to get more information AAPM task group 40: Kutcher GJ, Coia L, Gillin M, Hanson W, Leibel S, Morton RJ, Palta J, Purdy J, Reinstein L, Svensson G, et al. Comprehensive QA for radiation oncology: report of AAPM therapy committee task group 40. Med Phys 1994;21:581-618. AAPM task group 53: Fraas, B. et al. Quality assurance for clinical radiotherapy treatment planning. Med. Phys. 25: 1773-1829; 1997. AAPM task group 56: Nath R.; Anderson L.; Meli J.; Olch A.; Stitt J. A.; Williamson J. Code of practice for brachytherapy physics: report of the AAPM Radiation Therapy Committee Task Group No 56. Med. Phys. 24:1558-98; 1997. ACPSEM Position Paper: Millar M, Cramb J, Das R, Ackerly T, Brown G, Webb D. ACPSEM Position Paper: Recommendations for the safe use of external beams and sealed brachytherapy sources in radiation oncology. Aust.Phys.Eng.Sci.Med. 1997; 20 (Supp): 1-35 Institute of Physical Sciences in Medicine. Commissioning and quality assurance of linear accelerators, IPSM report 54. York: IPSM; 1988. International Standards Organisation. Quality management and quality assurance standards. ISO 9000 series. PAN AMERICAN HEALTH ORGANIZATION, Publicación Cientifica No. 499, Control de Calidad en Radioterapia: Aspectos Clínicos y Físicos, PAHO, Washington, DC (1986).
    86. 86. Part 12: Quality assurance92Radiation Protection in Radiotherapy WHO (World Health Organisation). Quality Assurance in radiotherapy. Geneva 1988.
    87. 87. Part 12: Quality assurance93Radiation Protection in Radiotherapy SummarySummary Quality Assurance is an essential part of radiotherapyQuality Assurance is an essential part of radiotherapy It affects all aspects including the radiation protectionIt affects all aspects including the radiation protection programprogram There are many different standards and guidelinesThere are many different standards and guidelines for specific QA activities - it requires a qualifiedfor specific QA activities - it requires a qualified expert to choose the most appropriate for a particularexpert to choose the most appropriate for a particular centercenter QA requires and encourages regular external auditsQA requires and encourages regular external audits QA is a continuous process - it is aimed at achievingQA is a continuous process - it is aimed at achieving improvements not laying blame.improvements not laying blame.
    88. 88. Any questions?Any questions?
    89. 89. QuestionQuestion Please give an example for the conceptPlease give an example for the concept of Continuous Quality Improvement fromof Continuous Quality Improvement from your practice.your practice.
    90. 90. Part 12: Quality assurance96Radiation Protection in Radiotherapy Example… just one of manyExample… just one of many A centre intends to improve treatment set-up. The measureA centre intends to improve treatment set-up. The measure patient positioning using port films on 20 patientspatient positioning using port films on 20 patients e.g.e.g. of theof the prostate. The random variations are of the order of 8mm and theprostate. The random variations are of the order of 8mm and the systematic error on average 9mm.systematic error on average 9mm. The systematic error could at least partially attributed to differentThe systematic error could at least partially attributed to different couch sag in simulator and treatment unit. This is reflected incouch sag in simulator and treatment unit. This is reflected in update of the procedures.update of the procedures. A repeat test shows that not only the systematic but also theA repeat test shows that not only the systematic but also the random uncertainty have improved (the latter potentiallyrandom uncertainty have improved (the latter potentially because of heightened awareness). The smaller randombecause of heightened awareness). The smaller random variation allows to pick up other systematic errors…variation allows to pick up other systematic errors… In addition to this the positive experience leads to the sameIn addition to this the positive experience leads to the same tests to be done for other treatment sites...tests to be done for other treatment sites...
    91. 91. Part 12: Quality assurance97Radiation Protection in Radiotherapy AcknowledgmentAcknowledgment Lee Collins, Westmead Hospital,Lee Collins, Westmead Hospital, SydneySydney Lyn Oliver, Royal North Shore Hospital,Lyn Oliver, Royal North Shore Hospital, SydneySydney
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×