Dr. Tripuraneni: Thank you. I have been a radiation oncologist for 30 years. I became involved with practice accreditation about 20 years ago. I have been a part of probably more than 100 practice accreditations. That is one of the most satisfying volunteer opportunities I have done in the field. No other opportunity exists for a radiation oncology team member to be able to objectively assess their peer’s practice and observe their systems, procedures and team and be a part of their quality improvement efforts. More importantly, as a radiation oncologist, whenever I participate in a facility visit for a peer’s practice, I learn a great many things, which allows me be reflective of my own practice and which improves the quality of care that I deliver for my patients.
ASTRO is the largest radiation oncology society in the world with more than 10,000 members. ASTRO is involved in the various aspects of radiation oncology practice, from education, government relations and health policy to research and quality improvement. It is only natural for ASTRO to develop a practice accreditation program that will help radiation oncology practices improve the safety and quality of care.
In October 2012, the ASTRO Board decided to endorse and create an ASTRO accreditation program that is called APEx. Both Dr. Jim Hayman and I were asked to chair the interdisciplinary APEx work group which developed the process. The work group spent the past three years developing APEx with the focus on creating measurable, evidence-and consensus-based standards that emphasize a professional commitment to safety and quality. The work group was very cognizant of assessing the feasibility of the standards regardless of the size or structure of the radiation oncology practice -- freestanding, community based and academic. This year has been an exciting year for APEx! It is operational, and we are currently accepting applications and scheduling facility visits for this fall. We should have the first set of final determinations for practices by the end of this year.
ASTRO: Thank you. Why do you think it’s important for radiation oncology practices to become accredited?
Dr. Tripuraneni: The accreditation program encourages radiation oncology practices to identify areas of quality improvement within their systems, policies and procedures, which will assist in minimizing the variance in the delivery of care. The practice accreditation process specifically looks at the facility by objectively assessing the radiation oncology care team, and their policy and procedures.
The 16 APEx standards describe a multidisciplinary approach to care that focuses on quality measurement to encourage safe, effective and peer-reviewed radiation oncology care. Accreditation demonstrates respect for protecting the rights of the patient and the responsiveness to a patient’s needs and concerns.
ASTRO: So the ASTRO APEx program is based on a set of 16 standards, which are organized around five pillars. First, the process of care. Second, the radiation oncology team. Third, safety. Fourth, quality management. Fifth, patient-centered care. Tell us a little bit about how these standards were developed.
Dr. Tripuraneni: The APEx program was based on Safety is No Accident: A Framework for Quality Radiation Oncology and Care, popularly known as the “Blue Book,” which was developed by ASTRO and endorsed by all of the radiation oncology societies in the United States, consisting of physicians, medical physicists, radiation therapists, dosimetrists, nurses and administrators. This document was actually developed over three years. The safe delivery of radiation therapy is exceedingly complex. This “Blue Book” was designed to address specific requirements for a contemporary radiation oncology facility, in terms of structure, technical process and a safe environment to deal with radiation therapy. White papers and consensus practice guidance for radiation oncology, such as AAPM Task Group Reports, the Agency for Healthcare Research and Quality and National Quality Forum measures and recommendations were also used in the development process.
The first pillar is the process of care. The process of care in radiation oncology sets a conceptual framework for the safe delivery of radiation therapy for all patients. This pillar covers patient evaluation, care coordination follow-up, treatment planning, patient-specific safety intervention and safe practices in treatment preparation delivery.
The second pillar is the radiation oncology team. The radiation oncology team works to provide every patient undergoing radiation treatment with the appropriate level of medical, emotional and psychological care before, during and after the treatment through a collaborative multidisciplinary approach.
The third pillar is safety. A radiation oncology practice creates an interdisciplinary, team-based culture of safety and continuously reviews, monitors and updates all aspects of safety.
Pillar number four is quality management. The radiation oncology practice has a quality management program that includes the facility, equipment, information management, treatment procedures and processes and peer review.
The fifth pillar is patient-centered care. The APEx patient-centered care standard aims to make our care safer by promoting effective communication, coordination of the care and, more importantly, engaging the patients and families as partners in the care.
ASTRO: What is unique about ASTRO’s practice accreditation program, APEx?
Dr. Tripuraneni: We have worked very hard to set the APEx program apart. First and foremost, as I mentioned previously, we used Safety Is No Accident, white papers and consensus practice guidance for radiation oncology to guide our standards. Also, in our program, we have incorporated a self-assessment module that practices go through after completing the application. This helps identify their strengths and gaps in compliance with the standards, and allows them to implement a quality improvement initiative prior to the facility visit. As part of the commitment to quality improvement, ASTRO also offers a Facility Self-assessment PQI template, a free companion offering to the facility self-assessment component of APEx. It guides participants through the required steps to complete an American Board of Radiology (ABR) qualified PQI project towards fulfilling the Part IV Practice Quality Improvement (PQI) requirements of Maintenance of Certification (MOC).
APEx was designed with the various structures of radiation oncology practices in mind. The interdisciplinary work group was very cognizant of assessing the feasibility of the standards regardless of the size or structure of the radiation oncology practice. In development of the program, testing was meaningfully conducted in various practice structures within radiation oncology to evaluate suitability; feasibility testing was conducted with a freestanding practice, and community-based and academic practices participated in beta testing. The Practice Accreditation Committee is comprised of all members of the radiation oncology team and each practice type is represented.
Another important component are the surveyors. We have developed a very robust training program for the surveyors. They have to go through a rigorous process before they can become an APEx surveyor.
I think these things set APEx apart as a radiation oncology accreditation program.
ASTRO: Surveyors have an important function in accreditation. Do APEx surveyors go through an orientation before they are approved?
Dr. Tripuraneni: Absolutely. Becoming an APEx surveyor is a pretty rigorous process, and you must be a radiation oncology team member and have been practicing for a minimum of five years. You must be an active ASTRO member. But most importantly, you will go through a comprehensive orientation process that is a 20-module program that requires an updated HIPPA training program and covers all the 16 standards of APEx. This is an important differentiating feature for APEx--that our surveyors will actually go through a comprehensive training program before they undergo a survey.
ASTRO: You mentioned the comprehensive self-assessment that practices must complete when they begin the accreditation process. What is the purpose of this, and how does the self-assessment benefit the facility?
Dr. Tripuraneni: The comprehensive self-assessment process is one of the differentiating features of the APEx program. Our goal was to provide the opportunity for the practice to identify quality improvement efforts to implement in their facility. By going through the self-assessment process, the facility will identify areas in which they have gaps in compliance with the standards so they can focus their quality improvement efforts. If a facility is not complying with the mandatory standards, they will know right away during the self-assessment process. That will actually give them the opportunity to take the next few months to modify or develop processes and implement those in order to demonstrate compliance with standards.
ASTRO: Please describe the APEx accreditation process, and how long it would typically take a facility to complete the process?
Dr. Tripuraneni: Typically, I would expect it to take about six to eight months, from the time the facility applies for the practice accreditation to when they receive their final determination.
The first element is to apply for the practice accreditation. The practice submits information about the facility, including the number of patients, treatment machines, personnel, etc. The facility signs a participation agreement and a HIPPA business agreement with ASTRO. Once we have received the payment, the practice receives the APEx self-assessment guide, which is a very comprehensive document providing a step-by-step process for completing the self-assessment. The self-assessment has three components – medical record review, document uploads and interview preparation. The facility will receive instant feedback on the medical records and interview preparation portions. Once the practice completes the self-assessment documentation uploads, ASTRO staff will review all of the documents and a feedback report will be provided. If it is noted there are areas for improvement or gaps in compliance with the standards, the facility will have another opportunity to complete the self-assessment.
Once they have met the minimum requirements, then the process of scheduling the facility visit will begin. This includes selecting dates and surveyors and conducting a pre-facility visit teleconference to prepare the facility for the visit. The facility visit always include a medical physicist. At the main facility, two surveyors will conduct the facility visit, a physicist and very often a radiation oncologist or another member of the team, such as a radiation therapist, nurse, dosimetrist or administrator. At the satellite locations, the facility visit will be conducted by a physicist.
Once the facility visit is complete, all the data from the self-assessment and the facility visit is objectively reviewed by the Practice Accreditation Committee and a final determination is issued. The practice accreditation committee makes the final determination of accredited, provisionally accredited or denied, and the facility is then notified. So, I think the length of time is very dependent on the facility; however on average it would take six to eight months from the initiation to the completion of the process.