| 1. We are a new center, all processes are being reviewed for improvement. |
| 2. Increase patient education by Therapist to decrease confusion by new patients. |
| 3. Compliance with physicians standard to see patients once per week
Gamma Knife patients that expire within 3 months of treatment: is there a commonality?
Implementation of IMRT, dose reduction to critical structures and acute/late side effect comparision to 3-d conformal treatment
IMRT Prostate patient field placement with the use of gold markers: what type of shift are required and how can the number of shift be reduced
Pain ManagmentInterventions |
| 4. 1.Reengineer patient registration process
2.Implement digital port review system
3.Commission and release virtual wedges
4.Evaluate & standardize IMRT process including immobilization, treatment planning, treatment, QA and patient education
|
| 5. Redesigning the Treatment Booklet in order to accommodate and improve documentation by staff/physician/physicist.
Review and improvements of usage of computer system scheduling system to include pertinent codes to identify patient needs, such as: special needs patient(~); breast pt.(+);, chemo&RT (&)pt., etc. |
| 6. 1. Demonstrated ability with Emergency Shutdown procedures of all treatment related equipment. Specifically, MD, Physicist, Therapists, demonstrated emergency shutdown of simulator and linear accelerators, can use table emergency down equipment.
2. Patient satisfaction
3. Retrospective outcome studies for primary breast treatment, and rectum treaments (performed by physicians and tumor registry) |
| 7. getting charges out faster and more accuratley
moving to electronic treatment record |
| 8. Chart review for completness
Documentation of patient problems/outcome
Multidisciplinary Meeting and improvements due to the meeting |
| 9. Accuracy of isocenter placement via CT usin LAP lasers and varios immobilzation devices. |
| 10. time from consultation to start time
dictation process |
| 11. Utilization of Lantis QA |
| 12. Chart Audit
Billing
Towns Served
Physicians Ref patients
Educational Activities
Nursing Admission/ Pain Goal
|
| 13. Scheduling improvement, Time study for pre-RT process, revenue cycle |
| 14. Implementing International Standard of Positioning and Tattooing based on our results from the Port Film Study. |
| 15. Medical record documentation of pain assessment, intervention, re-assessment. |
| 16. BLOOD IRRADIATION PROGRAM IMPLEMENTATION
BRACHYTHERAPY IMPLEMENTATION
IMRT IMPLEMENTATION |
| 17. Patient flow, reduction of patient wait times, reduction of repeat port films, nursing assessment issues |
| 18. N/A |
| 19. Weekly SSD checks on all port on every patient.
Post radiation treatment follow-up to check symptom
management and skin care.
Mid-treatment education check of patient to confirm
compliance with recommended site-specific guideline and
skin care. |
| 20. IMRT process flows |
| 21. Streamline front desk process/patient registration
Improve efficiencies in planning process from nursing, dosimetry/physics to therapist |
| 22. IMRT QA Process(Improving it)
Quality Checklists for all staff for all new patients
Repeat port process
Patient Satisfaction with physician |
| 23. Patient Satisfaction
Wait Times compared with 3 other facilites
Prostate Brachytherapy timliness of completing chart
Standardization of Breast set ups
Standardization of charting and documentation among three facilities
Physics QA chart review
Ease of patients finding the department
|
| 24. Dosimetry badges returned to company
Patient satisfaction
CBCs being initiated by physicians
Port film retakes |
| 25. Patient Satisfaction |
| 26. Track patient side effects for those who have recieved conformal 3D to prostate vs. IMRT to prostate. |
| 27. Chart Documentation (phone calls, orders, etc)
Billing flags to identify possible billing errors
Electronic Medical Record
Work log task groups
Patient financial Estimates |
| 28. Mobile HDR to 4 sites instead of three stationairy units at three sites. |
| 29. 1) Safety issues tracked by safety committee
2) Tracking insurance rejections
3) Tracking requests for additional information on insurance claims
4) Sewer problems
5) Mail problems
6) Head & Neck recurrences
7) Coding study for glioblastomas
8) Amifostine skin reactions
9) Patient wait times from appointment time to treatment
10) Patient satisfaction study |
| 30. Lab value protocol |
| 31. Press Ganey Patient Satisfaction
Monitoring patient wait times
Revamping of our scheduling process
Documentation and billing chart checks
|
| 32. Press Ganey Patient Satisfaction
Monitoring patient wait times
Revamping of our scheduling process
Documentation and billing chart checks
|
| 33. Pt/treatment site identification (preventing wrong pt/wrong site treatment)
|
| 34. IMRT delivery time reduction (ongoing project)
Timeliness of dictated reports (ongoing)
Outpatient auto queueing by barcode (new)
Reduction in consult to initial tx time (new)
Protocol data management QA (Annual)
External beam chart audit (monthly)
Brachy chart audit (ongoing)
Coding and billing audits (annual compliance audit and weekly reviews)
EPID implementation
Operations committee (operational, capital and personnel reviews, policy development, incident reviews)
|
| 35. block scanning
identifying pt's enter Linac room with Scanner gun
digital films
IMRT |
| 36. Customer service, patient education, chart readiness prior to CT Sim, chart readiness prior to 1st treatment. |
| 37. Treatment record updated to exclude any abbreviations and
also decrease hand writtne orders. Make it easier to read and understand orders, |
| 38. Patient and Staff satisfaction
Closed medical record review using Joint Commission standards
Accuracy rates- repeat isodose plans/chart check corrections
Medical Necessity Losses |
| 39. Dietary referrals
Skin education
Denials |
| 40. patient satisfaction, pain control |
| 41. Documentation |
| 42. Documentation |
| 43. Registration process
More accurate breast set-ups
Better pain control
Billing audits of all treatment charts |
| 44. implemented a paperless and filmless environment |
| 45. Chart Audits for thoroughness of information
QA of treatment charts before initial treatment
Barcoding for calling up patient's treatment record
|