Practical implementation of quality improvement for high-dose-rate brachytherapy

High-dose-rate (HDR) brachytherapy is a high-risk procedure with serious errors reported in the medical literature. Our goal was to develop a quality improvement framework for HDR brachytherapy using a multidisciplinary approach. This work describes the time, personnel, and materials involved in implementation as well as staff-reported safety benefits of quality improvement checklists.

Quality improvement was achieved using a department-wide multidisciplinary approach. Process mapping of the entire HDR program, from initial scheduling through follow-up, was performed. The scope of the project was narrowed to the point of treatment delivery. Two types of multidisciplinary checklists were created: a safety-timeout checklist to ensure safety-critical actions were performed before treatment initiation; and detailed procedure checklists that served as written procedures for physicians, physicists, dosimetrists, and nurses. Implementation was carried out through initial training led by various staff members, creation of visual training guides, piloting and use of checklists for all treatments, and auditing of checklist compliance.

Process maps of the entire HDR program were generated and used to guide subsequent changes in the treatment delivery process. A single safety-timeout checklist and the individual procedure checklists were created and used at the time of treatment delivery. The 3-month audit showed that the safety-timeout checklist was used for 100% of treatment fractions. Individual procedure checklists were used for 85% of fractions. All cross-covering physicians and physicists continued to use these checklists 100% of the time. Staff survey results indicated improvements in safety and increased benefits for cross-covering staff.

In using a multidisciplinary approach to quality improvement, process mapping and comprehensive checklists for HDR treatment delivery have been implemented. This has resulted in improved practices that are optimal in our department. This experience can provide others with practical strategies toward implementing such changes in their own facilities.