title: Journey Toward High Reliability: A Comprehensive Safety Program to Improve Quality of Care and Safety Culture in a Large, Multisite Radiation Oncology Department.
abstract: High-reliability organizations (HROs) focus on continuous identification and improvement of safety issues. We sought to advance a large, multisite radiation oncology department toward high reliability through the implementation of a comprehensive safety culture (SC) program at the University of Pennsylvania Department of Radiation Oncology.
  
  
  
  In 2011, with guidance from safety literature and experts in HROs, we designed an SC framework to reduce radiation errors. All state-reported medical events (SRMEs) from 2009 to 2016 were retrospectively reviewed and plotted on a control chart. Changes in SC grade were assessed using the Agency for Healthcare Research and Quality Hospital Survey. Outcomes measured included the number of radiation treatment fractions and days between SRMEs, as well as SC grade.
  
  
  
  Multifaceted safety initiatives were implemented at our main academic center and across all network sites. Postintervention results demonstrate increased staff fundamental safety knowledge, enhanced peer review with an electronic system, and special cause variation of SRMEs on control chart analysis. From 2009 to 2016, the number of days and fractions between SRMEs significantly increased, from a mean of 174 to 541 days (P < .0075) and 21,678 to 113,104 fractions (P < .0028) preintervention and postintervention, respectively. Agency for Healthcare Research and Quality results demonstrate a high patient SC grade over time.
  
  
  
  Our journey toward becoming an HRO has led to the development of a robust SC through a comprehensive safety framework. Our multifaceted initiatives, focusing on culture and system changes, can be successfully implemented in a large academic radiation oncology department to yield measurable improvements in SC and outcomes.
authors.affiliation: University of Pennsylvania, Philadelphia, PA; Bergendahl Institute, Avon Lake, OH; and The University of Texas MD Anderson Cancer Center, Houston, TX Kristina.Woodhouse@uphs.upenn.edu.
authors.forename: Kristina Demas
authors.initials: KD
authors.lastname: Woodhouse
authors.affiliation: University of Pennsylvania, Philadelphia, PA; Bergendahl Institute, Avon Lake, OH; and The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Edna
authors.initials: E
authors.lastname: Volz
authors.affiliation: University of Pennsylvania, Philadelphia, PA; Bergendahl Institute, Avon Lake, OH; and The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Amit
authors.initials: A
authors.lastname: Maity
authors.affiliation: University of Pennsylvania, Philadelphia, PA; Bergendahl Institute, Avon Lake, OH; and The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Peter E
authors.initials: PE
authors.lastname: Gabriel
authors.affiliation: University of Pennsylvania, Philadelphia, PA; Bergendahl Institute, Avon Lake, OH; and The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Solberg
authors.affiliation: University of Pennsylvania, Philadelphia, PA; Bergendahl Institute, Avon Lake, OH; and The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Howard W
authors.initials: HW
authors.lastname: Bergendahl
authors.affiliation: University of Pennsylvania, Philadelphia, PA; Bergendahl Institute, Avon Lake, OH; and The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Hahn
mesh_terms: D006801:Humans; D016522:Oncology Service, Hospital / Q000592:standards; D061214:Patient Safety; D058996:Quality Improvement; D018787:Radiation Oncology / Q000458:organization & administration / Q000592:standards*; D017751:Safety Management