Peer review practice
In respect to our Institution’s peer review process, we use specific strategies in hopes to decrease radiation treatment planning-related errors. Peer review of treatment plans consists of a three-step process before a stamp of approval is given to a specific plan testifying to its efficacy and safety. The review process is performed in the context of a multidisciplinary team that includes physicians, residents, physicists, and dosimetrists. This mode of peer review process ensures our department is providing consistent standards of practice, along with allowing the parties involved in planning to better prioritize and optimize their workload.
The first stage of peer review occurs for patients at “New Patients Case Conference” during which time a discussion is held about each new patient seen in the Department the follow. This conference occurs once a week at 8 am when the clinical schedule has been protected. During the conference, each patient’s history is reviewed briefly in addition to treatment intentions. The goals of the conference include recognition of proper diagnosis procedures, remaining work-up, appropriate treatment intent, development of comprehensive treatment plan, and finally, whether any radiation therapy treatment has justified intention, prescription and technique.
The second peer review stage is unique to this institution and has been described in the field of radiology [
16] as “Peer Review by Group Consensus.” Any case that is considered complex (i.e. IMRT, VMAT, SBRT, pediatric, retreatment, rare disease entity, etc.) must go through a multi-disciplinary treatment planning conference, which includes physicians, residents, physicists, and dosimetrists, to collectively analyze treatment plans via presentation software/hardware and remote conferencing with another department site. At least two physicians besides the patient’s attending physician are required for the case to be considered reviewed. Additionally, all available physician residents and the on-call physicist attend the conference. The planners, or their designees, are present during presentation of their respective treatment plans. Approximately 70% of our cases go through this planning conference. The use of multi-disciplinary peer review allows the physical and practical portions of the treatment plans to be evaluated in addition to the clinical components. During the peer review of a treatment plan, the gross tumor volume (GTV), clinical target volume (CTV), and planning target volumes (PTV) are first evaluated and either agreed or disagreed upon, while the relevant clinical information is shared by the attending and/or covering physician resident. Next, automated DVH analysis is reviewed based on color-coding and numerical results. With this automated information, the physicians can now determine whether further investigation of the plan needs to be pursued depending on what constraint is not passing. Finally, the isodose lines are evaluated in relation to coverage, homogeneity, proximity to organs at risk (OAR), and relationship to unspecified normal tissue regions. Plans are either collectively approved or sent back for re-planning. Any disagreement goes to a vote mediated by the chairperson of the department.
The third and final stage of peer review is the use of weekly chart rounds to evaluate all patients who have started a new treatment plan including new starts, boosts, brachytherapy, plan modifications, etc. During these rounds, documentation such as consent and pathology are reviewed in addition to portal imaging and cone beam CT shift trends. The overall appropriateness of the dose, treatment technique, and patient tolerance to treatment are also discussed. Any major unplanned interruptions or attendance issues are collectively reviewed for solutions and a morbidity and mortality review occurs after chart rounds for any patients who passed during the last week for identification of any potential role of radiation oncology or any other learning opportunity.