Quality systems Quality systems IAEA ICARO IAEA ICARO Vienna, - PowerPoint PPT Presentation

Quality systems Quality systems IAEA ICARO IAEA ICARO Vienna, 2009 Vienna, 2009

Quality Quality The standard of something as measured against other things of a similar kind; the degree of excellence of something System System A set of connected things or parts forming a complex whole; a set of things working together as parts of a mechanism or interconnecting network

Today’ ’s world s world Today � More control More control � � More transparency More transparency � � Benchmarking Benchmarking � � Litigations Litigations � Control of quality of care Control of quality of care Hospital performance indicators Hospital performance indicators

Quality assurance in assurance in Quality oncology oncology How do we assess quality we assess quality? ? How do � By By the results the results ( (outcome outcome)? )? � � By a structural By a structural analysis analysis? ? � � By By process process control? control? �

Outcome of colo of colo- -rectal rectal surgery surgery in in function function of of the the Outcome surgeon (n = 13) at the Royal Royal Infirmary Infirmary surgeon (n = 13) at the (Glasgow) in 645 consecutive consecutive patients for patients for the the (Glasgow) in 645 period 1974 1974- -1979. 1979. period lowest highest (%) lowest highest C u r a t i v e r e s e c t i o n r a t e Cu C ur ra at ti iv ve e r re es se ec ct ti io on n r ra at te e 40 76 C u r a t i v e r e s e c t i o n r a t e Cu C ur ra at ti iv ve e r re es se ec ct ti io on n r ra at te e 40 76 3 0 d m o r t a l i t y 30 3 0d d m mo or rt ta al li it ty y 8 30 3 0 d m o r t a l i t y 30 3 0d d m mo or rt ta al li it ty y 8 30 3 30 0 0d d d m m mo o or r rt t ta a al l li i it t ty y y i i in n n c c cu u ur r ra at a t ti i iv v ve e e 3 0 20 3 30 0 0d d d m m mo o or r rt t ta a al l li i it t ty y y i i in n n c c cu u ur r ra at a t ti i iv v ve e e 3 0 20 r e s e c t i o n re es se ec ct ti io on n r r e s e c t i o n re es se ec ct ti io on n r R a t e o f a n a s t o m o t i c l e a k Ra at te e o of f a an na as st to om mo ot ti ic c l le ea ak k R 0 25 R a t e o f a n a s t o m o t i c l e a k Ra at te e o of f a an na as st to om mo ot ti ic c l le ea ak k R 0 25 1 0 y s u r v i v a l i n c u r a t i v e 10 0y y s su ur rv vi iv va al l i in n c cu ur ra at ti iv ve e 1 20 63 1 0 y s u r v i v a l i n c u r a t i v e 10 0y y s su ur rv vi iv va al l i in n c cu ur ra at ti iv ve e 1 20 63 r e s e c t i o n re r es se ec ct ti io on n r e s e c t i o n re r es se ec ct ti io on n 2 y s u r v i v a l i n p a l l i a t i v e 2y y s su ur rv vi iv va al l i in n p pa al ll li ia at ti iv ve e 2 7 32 2 y s u r v i v a l i n p a l l i a t i v e 2y y s su ur rv vi iv va al l i in n p pa al ll li ia at ti iv ve e 2 7 32 r e s e c t i o n re r es se ec ct ti io on n r e s e c t i o n re r es se ec ct ti io on n Gillis C et al. Lancet 1991, 337 : 611

Outcome studies Outcome studies Clarke et al. Lancet, 2005

Outcome is the golden standard Outcome is the golden standard � However, it always comes too late and reflects However, it always comes too late and reflects � the past. the past. � Outcome depends on several factors: Outcome depends on several factors: � diagnosis, treatment (RT, CT, surgery), socio- - diagnosis, treatment (RT, CT, surgery), socio economic factors… …etc. etc. economic factors

3 year disease year disease- -free free survival survival in 3 in 3 pediatric solid pediatric solid 3 tumours in in function function of of the the care provider care provider tumours structure for structure for the period the period 1970 1970- -1979 in Canada. 1979 in Canada. 79 80 68 70 60 52 48 50 medulloblastoma 40 rhabdomyosarcoma Wilm's tumour 24 30 20 10 10 0 CC NCC Kramer S et al. J Clin Oncol 1984, 2 : 917

Infrastructure and process and process Infrastructure Survival of patients treated for aggressive lymphoma Cancer centre Formal protocol Cancer centre no protocol General centre Formal protocol General centre no protocol Recent analysis in UK of aggressive lymphoma tratment outcome, according to whether patients were treated in a cancer centre or not, with or without a formal protocol

Total Total Quality Quality Management Management

I. Aim of the organisation I. Aim of the organisation � Set aims in accordance with available structure Set aims in accordance with available structure � � Adapt infrastructure according to aims Adapt infrastructure according to aims � � Take local epidemiology into account Take local epidemiology into account � � Encourage responsibility sharing rather than Encourage responsibility sharing rather than � competitive development competitive development � Infrequent pathologies demand for centralised Infrequent pathologies demand for centralised � referral referral

II. Structure of the organisation II. Structure of the organisation � Organigram Organigram � (hierarchical, (hierarchical, L’homme se fâche La Formule du Sexe Pas de sexe L’homme fait une L’homme et la femme Le soir venu, l’homme La femme se fâche L’homme écoeure la nouvelle tentative ont prévu faire l’amour assumes qu’il peut femme sur les raisons functional) functional) ce soir. commencer tout de suite pour lesquelles elle ne veut pas faire l’amour Pas de sexe La femme relaxe pour un bon bout L’homme fait semblant de temps qu’il a oublié � Who is responsible for Who is responsible for L’homme présumes alors que le � temps est propice et fait une approche La femme est fatiguée L’homme s’endort L’homme fait des La femme suggère de L’homme trébuche sur le tapis avances directes faire le souper ensemble what? what? dans le but de montrer sa vulnérabilité Après plusieurs heures de préparation, ils L’homme découvre rapidement mangent L’homme fait sem- comment ils peuvent avoir du plaisir blant d’avoir faim Après, une bouteille de ensemble même sans sexe � Who is in charge of Who is in charge of vin est ouverte sur L’homme boit presque L’homme suggère � suggestion de l’homme La femme trouve toute la bouteile un bain ensemble ça charmant La femme est bien de cet avis L’homme tente de quality? L’homme propose une promenade quality? prendre un raccourci mais SEXE en présumant que cela la femme refuse la relaxera Le genou de l’homme guérit rapidement et il propose à la Après quelques verres de vin, femme de faire l’amour La femme commence L’homme propose un l’homme fait une immédiatement voyage à Venise «déclaration d’amour» à la femme à consulter des brochures

III. Obtaining and maintaining the means and III. Obtaining and maintaining the means and materials for radiotherapy treatment materials for radiotherapy treatment � Specification for equipment Specification for equipment � � Acceptance testing Acceptance testing � � Commissioning and de Commissioning and de- -commissioning commissioning � � On On- -going QC going QC � � Preventive maintenance program Preventive maintenance program � � Test after repair, etc Test after repair, etc… … �

IV. Process control IV. Process control � All activities, from the All activities, from the � moment a patient enters moment a patient enters the department until the department until he/she leaves it, should he/she leaves it, should be clearly stated, be clearly stated, described and recorded. described and recorded.

V. Knowledge and skills V. Knowledge and skills

VI. Control of the quality system VI. Control of the quality system � Regulatory Regulatory � � Quality indicators Quality indicators � � Internal audit Internal audit � � External audit External audit � � benchmarking benchmarking � Audit : systematic, independent and documented process for obtaining records, statements of fact or other relevant information and assessing them objectively to determine the extent to which specific requirements are fulfilled (ISO 17000)

Quality indicators Quality indicators � Relevant. Relevant. � � Reliable and accurate. Reliable and accurate. � � Able to detect opportunities for improvements Able to detect opportunities for improvements � or to confirm a satisfying or excellent level of or to confirm a satisfying or excellent level of quality. quality. � Acceptable by the providers and users. Acceptable by the providers and users. � � Usable in benchmarking programs. Usable in benchmarking programs. �