Clinical risk analysis of the patient’s path in an Advanced Radiotherapy Center (A.R.C.) through F.M.E.A. method

Starting from the increasing requirement of efficient access to healthcare, the study aims to assess the current standard procedures in order to optimize safety and quality.The decision to study the patient's process in Radiotherapy (RT) by FMEA methodology (Failure Mode and Effect Analysis), in order to identify and manage the risks for patients, arose from an interest of both the Radiotherapy Division and the Management of the European Institute of Oncology (IEO) IRCSS of Milan (Italy) in consideration of its high activity and of the volume of patients treated. The department has undergone a remarkable change in the last seven years, by increasing the number of accelerators and the number of patients treated, which rose from 2.197 (2011) to 3.194 (2017).Treatment modalities and timing of each session have changed: nowadays the majority of the patients receive highly complex treatments (intensity-modulated radiotherapy, image-guided radiotherapy, stereotactic radiotherapy, etc.).PurposeThe purpose of this study is to define an instrument of practical use and maintenance, for the proactive management of clinical risk by analysing the patient’s care path in RT: from his medical examination to the discharge and the next follow-up visits.The instrument was tested by handing it out to employees in the form of a questionnaire, trying to involve a significant pool of professionals.Materials and methodsStarting from previous Institutional experiences of FMEA studies in other clinical areas, we decided to:make-up several multidisciplinary working groups (with one or two members of each professional level) in order to define the sub-processes, the failure mode and the impact of potential damage.propose the participation of radiotherapy professionals in defining the frequency of the failure mode in their experience, using questionnaires and scales of predefined values.To define the value "potential damage" and the attribution of the frequency of occurrence of the various failure modes, we sought to minimize a potentially non-voluntary effect of mitigating the risk due to the awareness of the correlations between frequency of occurrence and damage.Therefore, the professionals involved were not aware of the results.ResultsThe study was carried out with great participation from the professionals involved in the patient's path (88,6% of the staff involved in the study responded to the questionnaires administered in the first part of the study; 69,7% was the rate of participation in the second part). This result allowed to overcome the subjective limitations due to the low numerical representation and the lack of objective epidemiological data concerning the near miss. Forty-four criticalities were found (14% of all the failure) and required intervention planning.ConclusionThis work led to the definition of a model with analytical description and quantification of the clinical risk for all the failure modes by "Risk Priority Number" (RPN) of all the sub-processes of the patient's path. Starting from the significant result of the areas requiring intervention, we could identify several improvement actions to reduce clinical risk. The model allows a dynamic management of clinical risk linked to a specific process and it could be exported to other Radiotherapy Centers.Starting from the increasing requirement of efficient access to healthcare, the study aims to assess the current standard procedures in order to optimize safety and quality.The decision to study the patient's process in Radiotherapy (RT) by FMEA methodology (Failure Mode and Effect Analysis), in order to identify and manage the risks for patients, arose from an interest of both the Radiotherapy Division and the Management of the European Institute of Oncology (IEO) IRCSS of Milan (Italy) in consideration of its high activity and of the volume of patients treated. The department has undergone a remarkable change in the last seven years, by increasing the number of accelerators and the number of patients treated, which rose from 2.197 (2011) to 3.194 (2017).Treatment modalities and timing of each session have changed: nowadays the majority of the patients receive highly complex treatments (intensity-modulated radiotherapy, image-guided radiotherapy, stereotactic radiotherapy, etc.).PurposeThe purpose of this study is to define an instrument of practical use and maintenance, for the proactive management of clinical risk by analysing the patient’s care path in RT: from his medical examination to the discharge and the next follow-up visits.The instrument was tested by handing it out to employees in the form of a questionnaire, trying to involve a significant pool of professionals.Materials and methodsStarting from previous Institutional experiences of FMEA studies in other clinical areas, we decided to:make-up several multidisciplinary working groups (with one or two members of each professional level) in order to define the sub-processes, the failure mode and the impact of potential damage.propose the participation of radiotherapy professionals in defining the frequency of the failure mode in their experience, using questionnaires and scales of predefined values.To define the value "potential damage" and the attribution of the frequency of occurrence of the various failure modes, we sought to minimize a potentially non-voluntary effect of mitigating the risk due to the awareness of the correlations between frequency of occurrence and damage.Therefore, the professionals involved were not aware of the results.ResultsThe study was carried out with great participation from the professionals involved in the patient's path (88,6% of the staff involved in the study responded to the questionnaires administered in the first part of the study; 69,7% was the rate of participation in the second part). This result allowed to overcome the subjective limitations due to the low numerical representation and the lack of objective epidemiological data concerning the near miss. Forty-four criticalities were found (14% of all the failure) and required intervention planning.ConclusionThis work led to the definition of a model with analytical description and quantification of the clinical risk for all the failure modes by "Risk Priority Number" (RPN) of all the sub-processes of the patient's path. Starting from the significant result of the areas requiring intervention, we could identify several improvement actions to reduce clinical risk. The model allows a dynamic management of clinical risk linked to a specific process and it could be exported to other Radiotherapy Centers

Analisi del rischio clinico del percorso del paziente in un centro di radioterapia avanzata mediante metodologia F.M.E.A.

Starting from the increasing requirement of efficient access to healthcare, the study aims to assess the current standard procedures in order to optimize safety and quality.The decision to study the patient's process in Radiotherapy (RT) by FMEA methodology (Failure Mode and Effect Analysis), in order to identify and manage the risks for patients, arose from an interest of both the Radiotherapy Division and the Management of the European Institute of Oncology (IEO) IRCSS of Milan (Italy) in consideration of its high activity and of the volume of patients treated. The department has undergone a remarkable change in the last seven years, by increasing the number of accelerators and the number of patients treated, which rose from 2.197 (2011) to 3.194 (2017).Treatment modalities and timing of each session have changed: nowadays the majority of the patients receive highly complex treatments (intensity-modulated radiotherapy, image-guided radiotherapy, stereotactic radiotherapy, etc.).PurposeThe purpose of this study is to define an instrument of practical use and maintenance, for the proactive management of clinical risk by analysing the patient’s care path in RT: from his medical examination to the discharge and the next follow-up visits.The instrument was tested by handing it out to employees in the form of a questionnaire, trying to involve a significant pool of professionals.Materials and methodsStarting from previous Institutional experiences of FMEA studies in other clinical areas, we decided to:make-up several multidisciplinary working groups (with one or two members of each professional level) in order to define the sub-processes, the failure mode and the impact of potential damage.propose the participation of radiotherapy professionals in defining the frequency of the failure mode in their experience, using questionnaires and scales of predefined values.To define the value "potential damage" and the attribution of the frequency of occurrence of the various failure modes, we sought to minimize a potentially non-voluntary effect of mitigating the risk due to the awareness of the correlations between frequency of occurrence and damage.Therefore, the professionals involved were not aware of the results.ResultsThe study was carried out with great participation from the professionals involved in the patient's path (88,6% of the staff involved in the study responded to the questionnaires administered in the first part of the study; 69,7% was the rate of participation in the second part). This result allowed to overcome the subjective limitations due to the low numerical representation and the lack of objective epidemiological data concerning the near miss. Forty-four criticalities were found (14% of all the failure) and required intervention planning.ConclusionThis work led to the definition of a model with analytical description and quantification of the clinical risk for all the failure modes by "Risk Priority Number" (RPN) of all the sub-processes of the patient's path. Starting from the significant result of the areas requiring intervention, we could identify several improvement actions to reduce clinical risk. The model allows a dynamic management of clinical risk linked to a specific process and it could be exported to other Radiotherapy Centers.Lo studio nasce dalla volontà di garantire costantemente elevati standard di sicurezza e qualità delle cure in uno scenario di incremento della domanda sanitaria che richiede, anche, mantenimento di processi produttivi efficienti.La decisione di studiare il processo del paziente in Radioterapia mediante la metodologia FMEA (Failure Mode and Effect Analysis) al fine di identificare e gestire i rischi per i pazienti è scaturita da un interesse della Divisione di Radioterapia e del Management dell’Istituto Europeo di Oncologia (IEO) IRCCS di Milano in considerazione degli alti volumi di attività: il reparto ha subito una notevole trasformazione nel corso degli ultimi sette anni, aumentando il numero di acceleratori ed il numero di pazienti trattati, passando da 2.197 (2011) a 3.194 (2017).Sono cambiate le modalità di terapia e le tempistiche di ogni seduta, infatti la maggior parte dei pazienti attuali riceve trattamenti di alta complessità (radioterapia a intensità modulata, radioterapia guidata dalle immagini, radioterapia stereotassica, etc.).Obiettivo dello studioLo scopo di questo lavoro è definire uno strumento di pratico utilizzo e manutenzione per la gestione proattiva del rischio clinico, mediante l’analisi dell’intero percorso radioterapico del paziente: dalla sua prima visita medica sino alla dimissione e successivi follow-up; e testarlo somministrandolo, sotto forma di questionario, ai dipendenti, cercando di coinvolgere rappresentanze numericamente significative di professionisti.Materiali e metodiFacendo tesoro di altre esperienze di studi FMEA già condotti in Istituto in altri ambiti, si è deciso di:costituire più gruppi di lavoro multidisciplinare (con uno o due componenti di ogni professione) al fine di definire i sotto-processi, i modi di errore e l’entità del danno potenziale.proporre a tutti i professionisti sanitari della radioterapia la partecipazione alla definizione della frequenza dei modi di errore nel loro vissuto, utilizzando questionari e scale di valori predefinite.Per la definizione del valore “danno” e l’attribuzione della frequenza ponderata di accadimento dei vari Failure mode si è voluto evitare l’effetto, potenzialmente involontario, di mitigazione del rischio dovuto alla presa di consapevolezza delle correlazioni tra frequenza di accadimento e danno.I professionisti coinvolti non erano a conoscenza dei risultati ottenuti.RisultatiLo studio è stato effettuato con una partecipazione ampia dei professionisti coinvolti nel percorso del paziente (88,6% del personale coinvolto nello studio ha risposto ai questionari somministrati nella prima parte dello studio; il 69,7%, invece, è stato il tasso di partecipazione nella seconda parte dello studio), consentendo quindi di superare i limiti soggettivi dovuti alla scarsa rappresentatività numerica dei professionisti solitamente coinvolti ed alla mancanza di dati statistici oggettivi sui near miss. Sono state individuate 44 criticità (14% di tutti i Failure studiati) che richiedono la pianificazione di intervento.ConclusioniIl lavoro ha portato alla definizione di un modello con analitica descrizione e quantificazione del rischio clinico per tutti i modi di errore mediante un “Risk Priority Number” (RPN) di tutti i sotto-processi del percorso del paziente, dal quale emerge che le aree di criticità che necessitano di un intervento sono ridotte. Sono state individuate diverse azioni di miglioramento per ridurre il rischio clinico. Il modello consente una gestione dinamica nel tempo del rischio clinico legato ad un determinato processo e trasferibile presso altre radioterapie