title: Quantification of the impact of multifaceted initiatives intended to improve operational efficiency and the safety culture: a case study from an academic medical center radiation oncology department.
abstract: OBJECTIVE
  We have systematically been incorporating several operational efficiency and safety initiatives into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful, metrics.
  
  
  METHODS
  The data from 5 quality improvement initiatives, each focused on a specific safety/process concern in our clinic, are presented. Data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using statistical analysis. Results from the Agency for Health Care Research and Quality (AHRQ) patient safety culture surveys administered during and after many of these initiatives were similarly compared.
  
  
  RESULTS
  (1) Workload levels for nurses assisting with brachytherapy were high (National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores >55-60, suggesting, "overwork"). Changes in work flow and procedure room layout reduced workload to more acceptable levels (NASA-TLX <55; P < .01). (2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range, 1-11) times per patient treatment to a mean <1 (range, 0-3; P < .001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (ie, delayed, on time). (3) The rates of replans by dosimetrists was reduced from 11% to 6% (P < .01) through a more systematic pretreatment peer review process. (4) Standardizing nursing and resident functions reduced patient wait times by ≈ 45% (14 min; P < .01). (5) Standardizing presimulation instructions from the physician reduced the number of patients experiencing delays on the simulator (>50% to <10%; P < .01). To assess the overall changes in "patient safety culture," we conducted a pre- and postanalysis using the AHRQ survey. Improvements in all measured dimensions were noted.
  
  
  CONCLUSIONS
  Quality improvement initiatives can be successfully implemented in an academic radiation oncology department to yield measurable improvements in operations resulting in improvement in patient safety culture.
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, North Carolina. Electronic address: bchera@med.unc.edu.
authors.forename: Bhishamjit S
authors.initials: BS
authors.lastname: Chera
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Lukasz
authors.initials: L
authors.lastname: Mazur
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Marianne
authors.initials: M
authors.lastname: Jackson
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Kinely
authors.initials: K
authors.lastname: Taylor
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Prithima
authors.initials: P
authors.lastname: Mosaly
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Sha
authors.initials: S
authors.lastname: Chang
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Kathy
authors.initials: K
authors.lastname: Deschesne
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Dana
authors.initials: D
authors.lastname: LaChapelle
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Lesley
authors.initials: L
authors.lastname: Hoyle
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Patricia
authors.initials: P
authors.lastname: Saponaro
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: John
authors.initials: J
authors.lastname: Rockwell
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Robert
authors.initials: R
authors.lastname: Adams
authors.affiliation: Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, North Carolina.
authors.forename: Lawrence B
authors.initials: LB
authors.lastname: Marks
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D001291:Attitude of Health Personnel; D001918:Brachytherapy / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D017598:Efficiency, Organizational / Q000592:standards / Q000706:statistics & numerical data; D057286:Electronic Health Records; D006801:Humans; D009726:Nurses / Q000706:statistics & numerical data; D061214:Patient Safety / Q000592:standards / Q000706:statistics & numerical data; D010820:Physicians / Q000706:statistics & numerical data; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D018787:Radiation Oncology / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D017751:Safety Management / Q000592:standards / Q000706:statistics & numerical data; D014481:United States; D016270:United States Agency for Healthcare Research and Quality; D057188:Workflow; D016526:Workload / Q000706:statistics & numerical data*