Lukasz M. Mazur

Quantitative assessment of workload and stressors in clinical radiation oncology

PURPOSE Workload level and sources of stressors have been implicated as sources of error in multiple settings. We assessed workload levels and sources of stressors among radiation oncology professionals. Furthermore, we explored the potential association between workload and the frequency of reported radiotherapy incidents by the World Health Organization (WHO). METHODS AND MATERIALS Data collection was aimed at various tasks performed by 21 study participants from different radiation oncology professional subgroups (simulation therapists, radiation therapists, physicists, dosimetrists, and physicians). Workload was assessed using National Aeronautics and Space Administration Task-Load Index (NASA TLX). Sources of stressors were quantified using observational methods and segregated using a standard taxonomy. Comparisons between professional subgroups and tasks were made using analysis of variance ANOVA, multivariate ANOVA, and Duncan test. An association between workload levels (NASA TLX) and the frequency of radiotherapy incidents (WHO incidents) was explored (Pearson correlation test). RESULTS A total of 173 workload assessments were obtained. Overall, simulation therapists had relatively low workloads (NASA TLX range, 30-36), and physicists had relatively high workloads (NASA TLX range, 51-63). NASA TLX scores for physicians, radiation therapists, and dosimetrists ranged from 40-52. There was marked intertask/professional subgroup variation (P<.0001). Mental demand (P<.001), physical demand (P=.001), and effort (P=.006) significantly differed among professional subgroups. Typically, there were 3-5 stressors per cycle of analyzed tasks with the following distribution: interruptions (41.4%), time factors (17%), technical factors (13.6%), teamwork issues (11.6%), patient factors (9.0%), and environmental factors (7.4%). A positive association between workload and frequency of reported radiotherapy incidents by the WHO was found (r = 0.87, P value=.045). CONCLUSIONS Workload level and sources of stressors vary among professional subgroups. Understanding the factors that influence these findings can guide adjustments to the workflow procedures, physical layout, and/or communication protocols to enhance safety. Additional evaluations are needed in order to better understand if these findings are systemic.

Relating physician's workload with errors during radiation therapy planning.

PURPOSE To relate subjective workload (WL) levels to errors for routine clinical tasks. METHODS AND MATERIALS Nine physicians (4 faculty and 5 residents) each performed 3 radiation therapy planning cases. The WL levels were subjectively assessed using National Aeronautics and Space Administration Task Load Index (NASA-TLX). Individual performance was assessed objectively based on the severity grade of errors. The relationship between the WL and performance was assessed via ordinal logistic regression. RESULTS There was an increased rate of severity grade of errors with increasing WL (P value = .02). As the majority of the higher NASA-TLX scores, and the majority of the performance errors were in the residents, our findings are likely most pertinent to radiation oncology centers with training programs. CONCLUSIONS WL levels may be an important factor contributing to errors during radiation therapy planning tasks.

Evaluation of hospital medication inventory policies

As supply chain costs constitute a large portion of hospitals’ operating expenses and with

A task-member assignment model for complex engineering projects

27.7 billion spent by the US hospitals on drugs alone in 2009, improving medication inventory management provides a great opportunity to decrease the cost of healthcare. This study investigates different management approaches for a system consisting of one central storage location, the main pharmacy, and multiple dispensing machines located in each department. Each medication has a specific unit cost, availability from suppliers, criticality level, and expiration date. Event-driven simulation is used to evaluate the performance of several inventory policies based on the total cost and patient safety (service level) under various arrangements of the system defined by the number of drugs and departments, and drugs’ criticality, availability, and expiration levels. Our results show that policies that incorporate drug characteristics in ordering decisions can address the tradeoff between patient safety and cost. Indeed, this study shows that such policies can result in higher patient safety and lower overall cost when compared to traditional approaches. Additional insights from this study allow for better understanding of the medication inventory system’s dynamics and suggest several directions for future research in this topic. Findings of this study can be applied to help hospital pharmacies with managing their inventory.

Identifying factors and root causes associated with near-miss or safety incidents in patients treated with radiotherapy: A case-control analysis

Complex projects with large number of tasks usually require expertise from various functional departments. While the use of teams has become a common way in industry, the assignment of people to teams and tasks is an important step during the planning stage of a project. If a project does not have effective teams to work on it, the lack of communication and cooperation among team members could seriously delay the project completion. The objective of this paper is to develop a task-member assignment model for complex projects using genetic algorithm (GA). Three important team member characteristics (i.e. multifunctional knowledge, teamwork capabilities and working relationship) with quantifiable measures and each members workload schedule are used in the model for task-member assignments, so that the right team member will be selected for the right task at the right time. The effectiveness of the research model is demonstrated by a 27-task engineering project.

Applying Normal Accident Theory to radiation oncology: Failures are normal but patient harm can be prevented

PURPOSE To identify factors associated with a near-miss or safety incident (NMSI) in patients undergoing radiotherapy and identify common root causes of NMSIs and their relationship with incident severity. METHODS We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with an NMSI (n = 200; incident group) and a similar group of control patients (n = 200) matched in time, without an NMSI. A root cause and incident severity were determined for each NMSI. Univariable and multivariable analyses were performed to determine which specific factors were contributing to NMSIs. Multivariable logistic regression was used to determine root causes of NMSIs and their relationship with incident severity. RESULTS NMSIs were associated with the following factors: head and neck sites (odds ratio [OR], 5.2; P = .01), image-guided intensity-modulated radiotherapy (OR, 3; P = .009), daily imaging (OR, 7; P < .001), and tumors staged as T2 (OR, 3.3; P = .004). Documentation and scheduling errors were the most common root causes (29%). Communication errors were more likely to affect patients ( P < .001), and technical treatment delivery errors were most associated with a higher severity score ( P = .005). CONCLUSION Several treatment- and disease-specific factors were found to be associated with an NMSI. Overall, our results suggest that complexity (eg, head and neck, image-guided intensity-modulated radiotherapy, and daily imaging) might be a contributing factor for an NMSI. This promotes an idea of developing a more dedicated and robust quality assurance system for complex cases and highlights the importance of a strong reporting system to support a safety culture.

Quality Improvement in Hospitals: Identifying and Understanding Behaviors

There is growing recognition that patient safety is an urgent health care systems problem.1-4 As we in health care struggle to address this challenge, we might do well to consider the substantial work already done in non–health care settings to better understand and mitigate failures. Experts outside of health care largely embrace the Normal Accident Theory, initially proposed by Dr Charles Perrow in 1984, which provides a set of concepts and framework for analyzing failure potential within and between systems.5 Normal Accident Theory promotes the concept that failures in systems will occur and should be expected as part of normal operations. Systems are defined based on two key characteristics (Fig 1). First, systems in which failures propagate and interact predictably are considered linear; those in which failures behave unpredictably are interactively complex (Fig 1, x-axis). Second, systems that can adequately detect and respond to failures are loosely coupled, whereas systems that cannot detect and

Project task flow optimisation and departmental flow analysis using design structure matrix and genetic algorithm

Improving operational performance in hospitals is complicated, particularly if process improvement requires complex behavioral changes. Using single-loop and double-loop learning theory as a foundation, the purpose of this research is to empirically uncover key improvement behaviors and the factors that may be associated with such behaviors in hospitals. A two-phased approach was taken to collect data regarding improvement behaviors and associated factors, and data analysis was conducted using methods proposed by grounded theorists. The contributions of this research are twofold. First, five key behaviors related to process improvement are identified, namely Quick Fixing, Initiating, Conforming, Expediting, and Enhancing. Second, based on these observed behaviors, a set of force field diagrams is developed to structure and organize possible factors that are important to consider when attempting to change improvement behaviors. This begins to fill the gap in the knowledge about what factors drive effective improvement efforts in hospital settings.

The Promise and Burden of Peer Review in Radiation Oncology

Engineering projects often require a great deal of effort during the planning and designing stages to eliminate any unnecessary rework. To achieve satisfactory results in complex projects, project managers need to consider every possible rework (or feedback connections) throughout the entire project life cycle in addition to establishing the best project task flow. Therefore a project can be completed in a shorter time and lower cost without sacrificing the quality of the outcome. The objective of this paper is to develop an optimisation process for project task coordination using design structure matrix (DSM) and genetic algorithm (GA). DSM helps identify the relationships among project tasks. GA is used to help coordinate/optimise the project task structure in terms of task cost, task time and their coupling strength. This paper also shows our developed method is able to help the managers to enhance the level of cooperation among the related departments by a departmental flow analysis. The effectiveness of this model is demonstrated by an industry example.

Empirical Evaluation of Workload of the Radiation Oncology Physicist During Radiation Treatment Planning and Delivery

Peer review can be loosely defined as the process whereby providers evaluate the quality of their colleagues’ work to ensure that prevailing care standards are met. Typically, peer review is most valuable for the somewhat subjective aspects of work that are not readily amenable to objective assessment. In medicine, this is often done retrospectively through chart review after patients complete their treatment. This retrospective approach can be helpful to detect shortcomings that can be addressed (or to reinforce positive actions) to improve care for future patients. However, for an individual patient’s case, peer review done before therapy (or early during the course of therapy) is better than peer review done later or after therapy. Peerreviewinradiationoncologyappears to be a useful tool to improve patient care and has been strongly endorsed by several national and international organizations.As in medicine in general, peer review done before or early in the course of radiation treatment is likely to bemost useful. Indeed, radiation treatment plans that deviate from standard protocols are associated with inferior patient outcomes (ie, cancer control, survival), and prospective peer review holds promise to improve patient outcomes. Despite the promise of peer review, our field has not broadly embraced its full potential. For example, a survey of North American academic radiation oncology centersnotedmarkedvariation in theuseof peer review. Furthermore, based on discussions with colleagues nationally, most peer review appears to be done after rather than before treatment is initiated. Because there is much effort required to make adjustments in many of our cases (eg, with intensity-modulated radiation therapy), we suspect that modest changes typically are notmade, which thus reduces the utility ofpeer reviewdone after treatmenthasbeen started. In the article accompanying this editorial, Reddemanandcolleagues report onaquality improvement initiative to dramatically increase peer review activities in the 14 radiation oncology centers in theCanadian province of Ontario. Their vision was that all patients in Ontario receive peer review of their radiation plans. Over a 3to 4-year period, Cancer Care Ontario conducted a system-wide quality improvement initiative by using the Kotter eight-step change management process for organizational transformation. Several high-impact countermeasures were used: Empower/ equip each center to conduct peer review (education, training, tools, methods, workflows), create accountability by monitoring and publicly reporting (to patients) performance metrics (ie, percentage of radiation courses peer reviewed), and perform site visits. Before this initiative, only 11%of radiation oncology courses in 2010/2011 underwent peer review. As of 2014/2015, a substantial increase of approximately 60% was realized. In this regard, the initiative was successful. However, much interinstitutional variation was observed, and approximately 85% of the plan reviews were performed after patients had already received