American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Radiation Therapy Quality Assurance

A treating facility that is not accredited by the American College of Radiology, American Society for Radiation Oncology, or the American College of Radiation Oncology is required to audit and maintain reports of adherence to the following radiation quality assurance (QA) points. This information will be reviewed by the NAPBC surveyor during site visit.

Equipment

  • Daily, monthly, and annual physics calibration and output checks on all radiation equipment are performed that comply with the American Association of Physicists in Medicine guidelines (Machine-Specific QA).

Patient-Specific

  • Ensure system(s) for independent verification of initial dose calculations prior to administration of the third treatment and for weekly checks of all delivered doses.
  • Medical physicists supervise and approve calculations for all treatment plans.
  • Perform QA checks of intensity-modulated radiation therapy and stereotactic radiosurgery plans prior to treatment.
  • Policy and procedure in place for therapist staff to review plans to verify agreement between the radiation dose in the treatment plan and the treatment machine.
  • Perform a "time-out" prior to administration of therapy to verify the physician's written order, the prescribed dose programmed into the machine, and the patient identity for every new or changed treatment.

Personnel-Specific

  • Ensure proper credentialing based on field.
  • Conduct audits to ensure that staffing and time-out verifications are appropriate.
  • First treatment time-out audit
  • Daily treatment time-out audits
  • Staff a minimum of two therapists per treatment unit.

Overall Program

  • Formal QA and quality improvement program should include chart rounds, new patient rounds, and presentation at a morbidity and mortality conference.
  • Comply with regulatory requirements of accrediting agency.
  • Engage in a radiation oncology peer-review program that includes a focus on QA for a minimum of 10% of all cases managed within a radiation oncology practice.