The 3 Day Rule

IMG_1189I’m just back to Charlotte from my week at the Summer School in Colorado Springs. Having the lamb burger and Hoptimum at The Liberty. Good week, good to be home.

The School was terrific if a bit evangelical. I was grateful to have the chance to voice a skepticism from the podium and appreciate Bruce Thomadsen’s openness to including my dissenting POV in the official program.

I’ll be saying more about this I expect but at the moment I have a very specific axe to grind.

Part of the week’s work was group exercises, some of which involved analysis of accident case reports. One of those involved a 300 times 10 emergency cord compression Friday evening start which was a 5 cm geometric miss for 3 fractions before the error was caught Monday morning by the physics second check.

Our breakout group, under my heavy-handed influence, was the only one of about 25 to identify the “3rd fraction policy” as most significant contributing factor to the incident. I was surprised how much this troubled me. Until I thought more about it. Then I just got riled up.

This 3 fraction thing…

As best I can tell the policy that “physics second check must be done by the 3rd fraction” tumbles from some (perceived or real) billing compliance guidance, not at all from any sort of safety concerns. Lets take a closer look at this.

One of the threads running through the Summer School was the quite right notion that our processes ought to be designed with intent to meet operational requirements including both safety and efficiency. Let’s engineer the process, based on evidence and analysis, to optimize outcome. I can support this notion.

So why do we do physics second checks? Is it just to withstand a billing audit? Or is there some role for the physics second check in the Quality Management of routine treatment delivery? I’d say the latter. I’d go so far as to say that, along with RTT pre-treatment review, physics second checks are the crucial quality and safety gatekeeping function between the development of a treatable plan and its delivery. As such it is rightly positioned in the workflow BEFORE the first treatment. Always. Full stop.

As a QM step, physics plan check after the delivery of 2 or 3 fractions can only hope, at best, to occasionally discover and document errors already made. How is that practice remotely defensible? Look, either we’re part of a lean QM system or we’re not, and if we’re not then the system has to be designed to always have someone else do the independent quality and safety assessment of the plan before the first treatment, though I can’t imagine what other specialty might adequately fill that role.

I say that the physics check needs to happen before the first treatment if it is to be an effective impediment to compromised quality and safety. But more importantly, EVERY patient deserves the same protections afforded by the standard quality management process. The fact that a patient presents with an urgent need at 4:00 on Friday does not conceivably justify routing that patient’s care to a less effective pathway. I’d go so far as to say that the urgent or otherwise exceptional treatment start needs EXTRA care and scrutiny from the physics check as the likelihood of error-under-pressure upstream is increased.

This is a technical issue but is also an ethical issue. How does one conscience the idea that because a patient’s presentation is urgent but inconvenient, the quality review can wait while the treatment proceeds? What code of practice condones that mindset?

If physics checks are important (they are) and are meant to screen against harm (they are) then they need to be done before first beam-on for EVERY plan. I’m having a hard time imagining a plausible counter argument.

We spent the week discussing all manner of tools and strategies to use in engineering a safer process. The apparent consensus that physics check catching a geographic miss after 3 of 10 fractions is somehow less important than other technical details that are in play for all patients all the time seems to me a case of “keeping one’s eye on the wrong ball.” Either physics plan review before the first treatment is a crucial step all the time, or the process needs to be engineered so that physics check is never crucial.

I understand the argument that sometimes the timing is such that a physicist is just not available. I question that – if a physician can be scheduled to be available then so can a physicist. But let’s concede that it does happen from time to time. My recommendation is that there always be a hard stop in place that prevents treatment without a positive physics approval, and that the physician have the administrative privileges to provide that approval in the case where no physicist is available. This does not frankly prevent treatment, but does explicitly place the onus on the MD to make the (well-documented) call that the urgency of treatment supersedes the need for standard quality management process.


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