TECHNICAL QUALITY ASSURANCE, RADIATION SAFETY AND QUALITY MANAGEMENT PROGRAM

Meets Procedural Requirements for JCAHO and ACR Accreditation in the Technical Aspects of Radiation Oncology

PART A:  QUALITY ASSURANCE PROGRAM

            I. QUALITY IMPROVEMENT COMMITTEE

                        A. Patient Safety and Medical/Health Care Error Reduction

            II. COMPREHENSIVE QUALITY IMPROVEMENT TEAM

            III. QUALITY ASSURANCE, RADIATION SAFETY, AND QUALITY

                 MANAGEMENT PROGRAM AUDITS

            IV. CONTINUING EDUCATION

            V. QUALITY ASSURANCE PROCEDURES

                        A. QA OF EXTERNAL BEAM RADIATION THERAPY EQUIPMENT

                                    1. General

                                    2. Test Frequency

                                    3. Tolerance Values

                                    4. QA of Linear Accelerators

                                                a. Daily: Therapist (Mechanical and Safety

                                                    Checks)

                                                b. Daily: Therapist (Output Constancy)

                                                c. Weekly: Therapist

                                                d. Monthly: Therapist

                                                e. Monthly: Physics Outputs

                                                f. Monthly: Physics Machine Checks

                                                g. Monthly: Physics MLC QA

                                                h. Annual: Physics

                                    5. QA of CT/Conventional Simulators

                                                a. Daily: CT Technologist

                                                b. Monthly: Physics

                                                c. Annual: Physics

                                    6. QA of Measurement Equipment

                                                a. Chamber and Electrometer System

                                                b. Daily Output Constancy Device

                                                c. Survey Meter

                                                d. Area Monitor

                                                e. Barometer/Thermometer

                                                f. Diagnostic Kit

                                    7. QA of Block Cutter

                                                a. General

                                                b. Periodic

                                                c. Monthly

                                    8. QA of Film Processor

                                                a. General

                                                b. Monthly

                        B. TREATMENT PLANNING COMPUTER SYSTEM

                                    1. Program Documentation

                                                a. Beam Data Library

                                                b. Operating Instructions and Data

                                                    Input/Output

                        C. QA OF CLINICAL ASPECTS

                                    1. Chart Review

                                                a. Basic Components of a Chart

                                                b. Overview of Chart Screening/Checking

                                    2. Chart Check Protocol

                                                a. Review of New or Modified Treatment

                                                    Field

                                                b. Weekly Chart Review

                                                c. Review at Completion of Treatment

                        D. VERIFICATION OF QUALITY ASSURANCE

PART B:  RADIATION SAFETY PROGRAM

            I. RADIATION SAFETY COMMITTEE

            II. RADIATION SAFETY OFFICER

            III. NORMAL OPERATING POLICIES AND PROCEDURES

                        A. ALARA

                                    1. Management Commitment

                                    2. Investigational Levels

                        B. PERSONNEL RADIATION MONITORING

                                    1. General

                                    2. Occupational Dose Limits

                                    3. Dose Limits for Public

                                    4. Dose to the Embryo/Fetus

                                    5. Determination of Prior Occupational Dose

                                    6. Frequency of Exchange

                                    7. Records and Reports

                        C. INSTRUMENTATION

                                    1. Warning Devices

                                    2. Area Monitors

                                    3. Survey Instruments

                        D. POSTINGS

                                    1. Signs and Labels

                                    2. Notices to Workers

                        E. SAFETY INTERLOCKS

                                    1. Console Keys

                                    2. Door Interlocks

                        F. TRAINING

                        G. RECORD AND VERIFY SYSTEM

            IV. EMERGENCY POLICIES AND PROCEDURES

                        A. POWER FAILURES

                                    1. Linear Accelerator

                                    2. Simulator

                        B. EQUIPMENT MALFUNCTION

                                    1. Area Monitor Failure

                                    2. Emergency Off Switches

                                    3. Other Equipment Malfunctions/Concerns

PART C:  QUALITY MANAGEMENT PROGRAM

            I. POLICIES AND PROCEDURES

                        A. LINEAR ACCELERATOR

                                    1. Electronic (Written) Prescription

                                    2. Patient Identification

                                    3. Plan Approval

                                    4. Checks and Verifications (Therapists)

                                                a. With R & V

                                                b. Without R & V

                                                c. Diode Point Measurements

                                    5. Questions

                                    6. Daily Treatment Record

                                                a. With R & V

                                                b. Without R & V

                                                c. Chart Utilization

                                    7. Chart Checks

                                    8. Checks and Verifications (Physics)

                                                a. Dose Calculation Checks

                                                b. Specifics of Dose Calculation Checks

                                                c. Wedge Checks

                                                d. Verification of Treatment Parameters

                        B. ORAL DIRECTIVES AND REVISIONS TO WRITTEN

                            PRESCRIPTIONS

                                    1. Oral Revisions

                                    2. Written Revisions

                                    3. Oral Directives

                        C. PERIODIC REVIEWS

                                    1. Review of Patient Administrations

                                    2. Review of QM Program

APPENDIX A: ROLES AND RESPONSIBILITIES

            I. Responsibilities of the Chief Radiation Oncologist

            II. Responsibilities of the Radiation Oncologist

            III. Responsibilities of the Radiation Oncology Physicist

            IV. Responsibilities of the Radiation Safety Officer

            V. Responsibilities of the Medical Radiation Dosimetrist

            VI. Responsibilities of the Radiation Therapist

APPENDIX B: DEFINITIONS

            I. QUALITY ASSURANCE DEFINITIONS

            II. RADIATION SAFETY DEFINITIONS

            III. QUALITY MANAGEMENT PROGRAM DEFINITIONS

APPENDIX C: FORMS

            NOTE: CONTAINS ALL FORMS FOR PERIODIC MACHINE AND

            EQUIPMENT QA, RADIATION SAFETY, AND QUALITY MANAGEMENT