Peer review and performance improvement in a radiation oncology clinic

A program was implemented in the Radiation Oncology Division at Naval Medical Center San Diego to document baselines for process improvement and fairly assess physician supervisory performance for recredentialing. This program was based on criteria established by the American College of Radiology (ACR). In addition to weekly chart rounds with peer review of films and charts while patients are on treatment, a new mechanism of peer review post-therapy was instituted. All patients completing therapy have this peer review prior to final disposition of their charts. Data are now readily available for physician recredentialing. Further, several points of inconsistent chart documentation have been identified and remedied. This mechanism is a simple and efficient way to ensure continuing patient care within ACR standards.