Provisional Accreditation

Transcription

1 August 14, 2017 Sudhakara Dandala Northern Arizona Tumor Institute 1100 Gail Gardner Way Prescott, AZ Dear Sudhakara Dandala: The American College of Radiation Oncology Accreditation Program conducted a peer review of your practice, including site visit on July 24, The location of the practice is: Northern Arizona Tumor Institute 1100 Gail Gardner Way Prescott, AZ Based on the review components, the Board of Chancellors of the American College of Radiation Oncology has awarded your practice Provisional Accreditation that will be valid from August 1, 2017 to September 30, To satisfy requirements for Full Accreditation, certain corrective actions are required and must be completed prior to the September 30, 2018 deadline. Any corrective action that has patient safety implications must be addressed immediately. Enclosed is a brief report for your records, which identifies the required corrective actions and may contain other comments and recommendations that we feel will help your practice. Documentation of the required corrective actions must be provided within one year. Unless this is achieved, your practice will be denied accreditation. This accreditation decision is based upon the information submitted in your application materials and the findings of the site surveyors. As significant changes in your practice, including key personnel turnover or change of ownership, may affect the accreditation status, it is incumbent upon you to notify ACRO Accreditation when such changes occur. It is our hope that your physicians, physicists, and staff have found this peer review evaluation worthwhile in providing the best possible standard of care for your patients. We welcome comments and suggestions on improving our accreditation process. It is the American College of Radiation Oncology s desire to make this process a learning experience. Sincerely yours, Norman Wallis, PhD Executive Director Copies: ACRO Executive Committee, ACRO Accreditation Medical Director, ACRO Accreditation Medical Physics Director, ACRO Accreditation Administrative Director

2 ACRO ACCREDITATION REPORT for Northern Arizona Tumor Institute Prescott, AZ August 10,

3 Accreditation Report Practice Name: Northern Arizona Tumor Institute Practice Coordinator: Sudhakara Dandala Practice Address: 1100 Gail Gardner Way, Prescott, AZ Accreditation Status Awarded: Provisional Accreditation from August 1, 2017 through September 30, This peer review report has three sections: Physics Review, Administrative Review, and. Medical Review. All required corrective actions identified must be addressed in order to achieve Full Accreditation. Any recommendations and/or comments offered are to assist you in improving the quality of patient care at your practice and do not affect your practice accreditation status. Physics Review Required Corrective Actions: 1. Implementation of an acceptable QA program for the Linac (month and annual based on AAPM TG-142), for the CT based on TG-66 and for the TPS based on TG-53 presetting conclusive results comparing to baselines within the tolerance levels recommended the AAPM protocols. Provide a Policy and Procedure detailing the measurements and analysis to remove this deficiency. 2. Review and rewrite the outdated policies and procedures to reflect the actual policies and procedures in place for this site. Provide the revised Policy and Procedure to remove this deficiency. 3. Implement a MD peer review. Provide a Policy and Procedure detailing this review and initial data for 5 patients to remove this deficiency. 4. The IMRT/VMAT policy and procedure shall be reviewed to include the criteria for accepting the TPS plans (i.e. 95% pass rate at 3%/3mm), and the reports shall have physician signature. Provide Policy and procedure for this item and data for 5 patients to remove this deficiency. 5. Implement a policy/procedure to record treatment variances and any deviation from the normal workflow and practice. Provide the Policy and Procedure including form to be used in the record of treatment variances to remove this deficiency. Recommendations/Comments: 1. Implement a physics peer review. 2. Consider upgrade the IMRT/QA software. 3. Implement a random chart review of completed charts and present the relevant findings, if any, on CQI meetings. 4. When reapplying, upload to ACRO database the current status of personnel, equipment, instruments and techniques for this site. The same recommendation applies for the other site (Prescott Valley). 5. It is recommended to participate in the ASTRO ROILS system (incident learning). 2

4 Administrative Review Required Corrective Actions: 1. New policies must be developed and/or updated. Establish procedures and documentation for timely review of policies and procedures by staff. To remove this requirement, submit P&P and any supporting documentation to ACRO. 2. A double identification and/or time out is not performed prior to the patient entering the treatment room or CT simulator. Documentation of all of this procedures is not noted in chart and is crucial to patient care. To remove this requirement, submit P&P and any supporting documentation to ACRO. 3. There is documentation of therapists pre-treatment and weekly chart checks. However, an additional safety procedure of taking the time to say, 'Correct patient, treatment site, dose, gantry angle, do you agree?' before you beam on is not being done. To remove this requirement, submit P&P and any supporting documentation to ACRO. 4. Establish documentation for IGRT as to what the therapists should be matching to (bone, soft tissue, and markers). To remove this requirement, implement IGRT/Filming policy and send documentation of 5 IGRT charts showing where the physician documents as to what the therapists should be matching. Recommendations/Comments: 1. Staffing: At all times there should be at minimum, two radiation therapists treating each patient. Based on the census and no radiation oncology nurse, it is suggested that therapy staffing should be addressed for the safe operation of this facility. 2. Simulation: Require daily QA worksheet for CT sim to document lasers checks are being performed. 3. Require documentation of date the water bath is cleaned and maintained. 4. Physician simulation orders of the process need to indicate: a. an additional patient identifier (MR#). b. documentation of CT slice thickness for the study. c. date completed and signed by the therapist and/or physician performing the procedure. 5. : Vac-locs are used for immobilization and they are hung from a rack in an orderly and clean manner in the linear accelerator room. That is not the case for H&N masks that were on the floor. Devise a storage method where the masks are up and off the floor. 6. Documentation is critical to ensure accuracy and completeness of the treatment record as well as evidence of compliance. a. Implement a process so that two (2) therapists initials are recorded in ARIA. The department follows a policy requiring two therapists to treat each patient, but it is not recorded in the treatment document. b. Document bolus when used on treatment days. 7. Competencies: The staff completes radiation safety training on an annual basis. There is no documentation of annual mandatory competency assessments, trainings and inservices for each employee. This type of practice is essential to maintain and improve professional competence and knowledge. 8. Facilities: Require a venting hood in the block cutting room. Medical Review Medical review Average: 88.80%_. 3

5 Required Corrective Actions: None Recommendations/Comments: 1. Please Review charts #16-054PV as it fell below the 75-point passing threshold. Consultation If you need an explanation on any required corrective actions identified, please contact the ACRO Accreditation Coordinator to schedule a brief no-cost consultation with an appropriate member of the accreditation team. If recommendations/comments are offered these are for you to consider as part of the peer review process, but do NOT affect your accreditation status. Thank you for inviting ACRO Accreditation to undertake a peer review of your practice. If you have any comments on how we can improve the process please send these by to Norman Wallis, PhD, Executive Director, nwallis@acro.org. END 4

6 Patient Reference: P No review history is available for this patient data GENITOURINARY CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated no aua, shim 2 /5 Relevant physical findings Appropriate staging Pathology report/surgical reports Appropriate patient selection for treatment/discussion of options Simulation Appropriate consent form listing side effects Appropriate treatment plan note at least document adt data 3 /5 Appropriate simulation note/process Planning Appropriate treatment prescription Appropriate dose constraints (if IMRT): Appropriate treatment technique Appropriate contouring Appropriate treatment fields 1/2

7 Review criteria P Appropriate dose/fractionation Appropriate dosimetry Appropriate treatment verification Weekly on-treatment documentation/daily dose log/physics chart reviews Chart rounds/case peer review Summary summary Follow-up plan General Comments Total 95/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: 2/2

8 Patient Reference: P No review history is available for this patient data GENITOURINARY CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated no shim Relevant physical findings Appropriate staging Pathology report/surgical reports Appropriate patient selection for treatment/discussion of options Simulation Appropriate consent form listing side effects Appropriate treatment plan note adt not in control but could make recs on duration Appropriate simulation note/process Planning Appropriate treatment prescription Appropriate dose constraints (if IMRT): Appropriate treatment technique Appropriate contouring Appropriate treatment fields 1/2

9 Review criteria P Appropriate dose/fractionation Appropriate dosimetry Appropriate treatment verification Weekly on-treatment documentation/daily dose log/physics chart reviews Chart rounds/case peer review Summary summary Follow-up plan General Comments Total 96/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: 2/2

10 Patient Reference: P No review history is available for this patient data LUNG CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated Relevant history included. Symptoms and ROS included as well as tobacco history Relevant physical findings Thoracic exam included Appropriate staging Appropriate staging though actual reports missing Pathology report/surgical reports Appropriate documentation of primary and or tissue included Appropriate patient selection for treatment/discussion of options Appropriate patient selection for treatment and Discussion of options included Simulation Appropriate consent form listing side effects Appropriate consent form listing side effects also included Appropriate treatment plan note Rationale for intended dose/fractionation, technique and concurrent use of chemotherapy included Appropriate simulation note/process Appropriate simulation note/process included but no CT slice thickness Planning Appropriate treatment prescription Appropriate treatment prescription accelerated somewhat but reasonable Appropriate dose constraints: Dose constraints appear to be acceptable Appropriate treatment technique IMRT. Reasonable technique. Appropriate contouring Normal tissues outlined Appropriate treatment fields Appropriate treatment fields (IMRT) 1/2

11 Review criteria P Appropriate dosimetry DVH/isodose distribution/dose constraints appear appropriate Appropriate treatment verification Use port films/portal imaging on first day and then weekly and documented Weekly on-treatment documentation/daily dose log/physics chart reviews Weekly on-treatment documentation included Chart rounds/case peer review Chart rounds included Summary summary summary complete Follow-up plan Follow-up plan documented Overall appropriateness of care Overall appropriate care, though somewhat unconventional dose fractionation. General Comments Total 97/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: 2/2

12 Patient Reference: P No review history is available for this patient data LUNG CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated Relevant history and tobacco history stated, along with ROS Relevant physical findings thoracic exam included Appropriate staging CXR, CT chest and brain done. Reports not included. Pathology report/surgical reports Pathology report included Appropriate patient selection for treatment/discussion of options Appropriate patient selection for treatment approach with discussion of technique Simulation Appropriate consent form listing side effects Appropriate consent form included Appropriate treatment plan note Appropriate treatment plan note include with rationale for intended dose/fractionation, technique and concurrent use of chemotherapy. Appropriate simulation note/process Appropriate simulation note/process included but slice thickness not included Planning Appropriate treatment prescription Appropriate treatment prescription 60 Gy/2 Gy Appropriate dose constraints: Appropriate dose constraints: reasonable Appropriate treatment technique Appropriate treatment technique (IMRT) Appropriate contouring Normal tissues outlined as solid structures, including the lung, spinal cord, heart Appropriate treatment fields Fields appropriate (IMRT) 1/2

13 Review criteria P Appropriate dosimetry DVH included but difficult to read Appropriate treatment verification Used port films/portal imaging on first day and then weekly and documented Weekly on-treatment documentation/daily dose log/physics chart reviews Weekly on-treatment documentation included Chart rounds/case peer review Chart rounds done Summary summary summary complete Follow-up plan Follow-up plan included Overall appropriateness of care Care appropriate overall General Comments Total 97/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: 2/2

14 Patient Reference: PV No review history is available for this patient data GYNECOLOGIC CANCER CHART REPORT See the report for your patients Review criteria PV H&P Relevant history stated Postop Uterus Stage 3B. Grade 1. Relevant physical findings Pelvic exam at consultation "Deferred" until day of simulation. No pelvic exam findings noted at simulation. 2 /5 Appropriate staging Pathology report/surgical reports/laboratory reports Appropriate patient selection for treatment/discussion of options Pelvic XRT and Chemotherapy. Brachytherapy omitted because there was no cervical involvement. Simulation Appropriate consent form listing side effects Site specific consent used. Side effects also dictated in consult note. Appropriate treatment plan note Clinical treatment planning note in chart. Appropriate simulation note/process Vaginal marker was used. Planning Appropriate dose and fractionation 50.4 Gy / 28 Fractions. Appropriate dose constraints IMRT (VMAT) was utilized. There was a DVH with graphs of bladder, rectum and Femurs ; but there were no proposed dose constraints listed. 2 /5 Appropriate treatment volume and/or fields Appropriate treatment technique VMAT Appropriate contouring IMRT (VMAT) was utilized. There was a DVH with CTV and PTV. 1/2

15 Review criteria PV Appropriate dosimetry IMRT (VMAT) was utilized. There was a DVH with graphs of bladder and rectum; but there were no proposed dose constraints listed. 3 /5 Appropriate treatment verification VMAT. KV/KV imaging daily. CBCT on day 1 and weekly. Weekly on-treatment documentation/daily dose log/physics chart reviews Chart rounds/case peer review Weekly chart rounds. Patient had also been evaluated by a GYN Oncologist. Summary summary Follow-up plan Overall appropriateness of care General Comments Total 91/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

16 Patient Reference: P No review history is available for this patient data GYNECOLOGIC CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated Intact Cervix Stage 2B Relevant physical findings Pelvic exam was performed. Appropriate staging Pathology report/surgical reports/laboratory reports Appropriate patient selection for treatment/discussion of options External Beam (Pelvis), Chemotherapy and Brachytherapy (Done at another facility) Simulation Appropriate consent form listing side effects Site specific Consent form was used; and side effects were listed in the consult note. Appropriate treatment plan note Separate clinical treatment planning note was present. Appropriate simulation note/process Vaginal marker was used. Planning Appropriate dose and fractionation Pelvic IMRT 50.4 Gy. Brachytherapy was done elsewhere. Appropriate dose constraints IMRT (VMAT). planning note said that the plan satisfied constraints for the Rectum, Bladder and Small Bowel. The dose constraint used were not listed. The DVH had graphs for the Rectum and Bladder - but not for the Small Bowel. 3 /5 Appropriate treatment volume and/or fields Appropriate treatment technique IMRT (VMAT) Appropriate contouring CTV and PTV were contoured 1/2

17 Review criteria P Appropriate dosimetry IMRT (VMAT). planning note said that the plan satisfied constraints for the Rectum, Bladder and Small Bowel. The dose constraint used were not listed. The DVH had graphs for the Rectum and Bladder - but not for the Small Bowel. 3 /5 Appropriate treatment verification Daily on line imaging (KV/KV). Weekly on-treatment documentation/daily dose log/physics chart reviews Chart rounds/case peer review Chart rounds notes were present. Patient was also evaluated by a GYN Oncologist and another Radiation Oncologist (for brachytherapy). Summary summary Follow-up plan Followup note present. Note documented that the patient had completed HDR Brachytherapy (30 Gy / 6 Fractions) at another facility. Overall appropriateness of care Good documentation of coordination of care with Gyn Oncology and Second Radiation Oncologist, who performed the HDR Brachytherapy. General Comments Total 94/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

18 Patient Reference: PV No review history is available for this patient data GASTRO-INTESTINAL CANCER CHART REPORT See the report for your patients Review criteria PV H&P Relevant history stated no history of anal sphincter function, IBD, CEA 3 /5 Relevant physical findings sphincter tone not described Appropriate staging not clear is CT scan, PET, anoscopy were performed. no lab results. 1 /5 Pathology report/surgical reports Appropriate patient selection for treatment/discussion of options Simulation Appropriate consent form listing side effects Appropriate treatment plan note no mention of specific chemo agents, frequency. prone not discussed 3 /5 Appropriate simulation note/process no CT sim parameters described, no prone 3 /5 Planning Appropriate treatment prescription no target volume coverage prescribed. Total dose 63 Gy - unclear why the dose exceeded Gy. 3 /5 Appropriate dose constraints I did not see dose constraints listed 1 /5 Appropriate treatment technique Unclear why perineal boost using electrons was used - this is not standard 3 /5 Appropriate contouring Appropriate treatment fields Appropriate dosimetry 1/2

19 Review criteria PV Appropriate treatment verification I did not see images to review?? 1 /5 Weekly on-treatment documentation/daily dose log/physics chart reviews Chart rounds/case peer review I did not see this documented?? 1 /5 Summary summary Follow-up plan Overall appropriateness of care 3 /5 General Comments Total 68/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

20 Patient Reference: P No review history is available for this patient data GASTRO-INTESTINAL CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated no history of anal sphincter function, IBD 3 /5 Relevant physical findings Appropriate staging Pathology report/surgical reports biopsy indicated "at least high grade dysplasia" Appropriate patient selection for treatment/discussion of options Simulation Appropriate consent form listing side effects Appropriate treatment plan note not prone, no anal maker, not details about chemotherapy 3 /5 Appropriate simulation note/process no indication of CT sim scan parameters, anal marker, prone, contrast 1 /5 Planning Appropriate treatment prescription no target volume coverage prescription Appropriate dose constraints Appropriate treatment technique Appropriate contouring Appropriate treatment fields Appropriate dosimetry Appropriate treatment verification 1/2

21 Review criteria P Weekly on-treatment documentation/daily dose log/physics chart reviews Chart rounds/case peer review Summary summary Follow-up plan Overall appropriateness of care General Comments Total 87/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: 2/2

22 Patient Reference: No review history is available for this patient data LYMPHOMA/SARCOMA CHART REPORT See the report for your patients Review criteria H&P Relevant history stated Relevant physical findings Appropriate work-up and staging evaluation Pathology report/surgical reports Appropriate patient selection for treatment/discussion of options Appropriate consent form listing side effects Simulation Planning Appropriate treatment plan note Appropriate simulation note/process Planning Appropriate treatment prescription Appropriate dose constraints Appropriate treatment technique Appropriate contouring Appropriate treatment fields Appropriate dosimetry Did not see any dose constraints in chart. 3 /5 Appropriate treatment verification Weekly on-treatment documentation/daily dose log/physics chart reviews 1/2

23 Review criteria Chart rounds/case peer review Summary summary Follow-up plan Overall appropriateness of care General Comments Generally a good chart. Only missing data was normal OAR dose constraints. Total 84/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

24 Patient Reference: P No review history is available for this patient data LYMPHOMA/SARCOMA CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated Relevant physical findings Appropriate work-up and staging evaluation Pathology report/surgical reports Appropriate patient selection for treatment/discussion of options Appropriate consent form listing side effects Simulation Planning Appropriate treatment plan note Appropriate simulation note/process Planning Appropriate treatment prescription Appropriate dose constraints Appropriate treatment technique Appropriate contouring Appropriate treatment fields Appropriate dosimetry Appropriate treatment verification Weekly on-treatment documentation/daily dose log/physics chart reviews 1/2

25 Review criteria P Chart rounds/case peer review Summary summary Follow-up plan Overall appropriateness of care General Comments Good chart. Total 89/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: 2/2

26 Patient Reference: P No review history is available for this patient data BREAST CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history Only missing element is GYN history. Relevant physical findings and Appropriate imaging Pathology and surgery reports Surgical report is missing. Staging Patient selection for treatment/discussion of options Alternative of mastectomy not mentioned. Simulation Consent form plan note Curative intent implied in clinic notes. Simulation note/process Planning prescription Appropriate hypofractionation dosing. technique FIF IMRT with opposed tangents. Contouring fields Dose constraints, treatment plan documentation, and dosimetry Tumor bed boost En face electron beam plan. 1/2

27 Review criteria P verification Weekly portal imaging ordered, though I could not find evidence in treatment record of films being checked. On-treatment review, physics chart check, and daily dose log Chart rounds/peer review Weekly chart review sheet included. Summary summary Follow-up plan One month follow-up plan included. Overall Appropriateness of Care Only a few missing elements of documentation. Otherwise an excellent treatment plan. General Comments Total 94/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

28 Patient Reference: P No review history is available for this patient data BREAST CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history Missing elements are pertinent negatives for breast symptoms and GYN history. Relevant physical findings and Appropriate imaging Pathology and surgery reports Surgical report is not present. Staging Patient selection for treatment/discussion of options Alternative of mastectomy not discussed. Simulation Consent form plan note Curative intent implied in clinic notes. Simulation note/process Planning prescription Appropriate whole breast hypofractionation with boost. technique FIF IMRT with opposed tangent fields. Contouring fields Dose constraints, treatment plan documentation, and dosimetry Tumor bed boost En face electrons. 1/2

29 Review criteria P verification Weekly portal films ordered though documentation in the treatment record not given. On-treatment review, physics chart check, and daily dose log Chart rounds/peer review Summary summary Follow-up plan Plan to follow-up with referring physician documented. Overall Appropriateness of Care A few missing elements of documentation, but overall a good treatment plan. General Comments Total 93/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

30 Patient Reference: P No review history is available for this patient data HEAD & NECK CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated Quantification of tobacco usage and time frame not stated. Relevant physical findings Inadequate description of inspection of oral cavity and oropharynx. Apparent tumor size by palpation noted. No indirect or fiberoptic exam nor was there any description of same by ENT. 2 /5 Appropriate staging Stage IV but no TNM stated anywhere in chart. 3 /5 Pathology report/surgical reports Appropriate patient selection for treatment/discussion of options Simulation Appropriate consent form listing side effects Appropriate treatment plan note No specific description of dose to various sites. Only total dose to primary described. 2 /5 Appropriate simulation note/process CT simulation done, no slice thickness reported. No images provided. Stated scanned: Head and neck to upper chest. 2 /5 Planning Appropriate treatment prescription 1.8 Gy/fx. No deduction. Appropriate dose constraints (if IMRT): Appropriate treatment technique IMRT Appropriate contouring Obviously contouring was done but only one slice (3 axis view) was provided (central axis) for primary field and one slice for boost field. I cannot determine adequacy of GTV from information provided. 2 /5 Appropriate treatment fields See same comment above. 2 /5 Appropriate dosimetry Based on DVH, dose was approptiate. 1/2

31 Review criteria P Appropriate treatment verification Weekly on-treatment documentation/daily dose log/physics chart reviews Chat rounds. Weekly physics check. No physics QA information provided. Chart rounds/case peer review Summary summary Follow-up plan Overall appropriateness of care Probably adequate. Probably just lack of providing enough documentation (need more images, more physics info, better description of exam) instead of not doing that at all. 3 /5 General Comments Total 79/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

32 Patient Reference: P No review history is available for this patient data PALLIATIVE CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated Relevant physical findings with good overall evaluation looking at general health Brief PE. H & N description marginal. By combining CT scan results plus PE, one can derive a reasonable description of the area involved but not from PE itself. 2 /5 Appropriate staging Pathology report/surgical reports Appropriate patient selection for treatment/discussion of options Simulation Appropriate consent form listing side effects Appropriate treatment plan note Appropriate simulation note/process Simulation order sheet blank. Simulation note does not describe extent of scan or slice thickness. 2 /5 Planning Appropriate treatment prescription Believe Gy doses appropriate for this patient. Advanced H & N site plus mediastinal and axillary adenopathy. Concurrent chemorx given. Area treated encompassed larynx, hypopharynx and part of neck for symptoms related to mass effect, narrowing of airway and upper esophagus. Appropriate dose constraints: Appropriate treatment technique IMRT. Appropriate contouring Difficult to evaluate. Given very limited 3-view slices (one for primary site plus one for boost field) it is not possible to fully appreciate GTV, PTV and CTV. 2 /5 Appropriate treatment fields Moot point considering large and diffuse areas of apparent involvement. Area treated covered site(s) of immediate concern, i.e., airway and esophageal entrance plus massive cervical adenopathy. Other areas of significant disease included mediastinal nodes and axillary nodes which currently asymptomatic did not require coverage at the time of treatment. Appropriate dosimetry 1/2

33 Review criteria P Appropriate treatment verification Weekly ports. I would much prefer daily imaging on all H & N IMRT but in this palliative situation, an argument could be given that this would not be absolutely necessary. 3 /5 Weekly on-treatment documentation/daily dose log/physics chart reviews No physics QA data provided. Chart rounds/case peer review Weekly chart rounds. Summary summary Follow-up plan Patient hospitalized prior to last planned treatment fraction. No followup after that available. Overall appropriateness of care Appropriate. But, dataset does include all information that I believe would be useful in determining area simulated, adequacy of treatment planning (evaluation of GTV, PTV, CTV), physics QA for IMRT. General Comments Total 87/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2

34 Patient Reference: P No review history is available for this patient data PALLIATIVE CANCER CHART REPORT See the report for your patients Review criteria P H&P Relevant history stated No performance status indicated for this palliative brain met case Relevant physical findings with good overall evaluation looking at general health Did not document a CNS exam for a patient with multiple brain mets 3 /5 Appropriate staging Staging was apparently done but no imaging reports available - only mentioned in the HPI 3 /5 Pathology report/surgical reports Multiple pathology reports included with molecular testing for lung adeno Appropriate patient selection for treatment/discussion of options whole brain palliative treatment plan discussed with patient and documented well Simulation Appropriate consent form listing side effects Appropriate for brain simulation Appropriate treatment plan note Rationale was appropriate and dose/fractionation was reasonable. Appropriate simulation note/process Sim note is appropriate Planning Appropriate treatment prescription 300 cgy x 10 was given Appropriate dose constraints: No structures were contoured other than body so there were no constraints listed 3 /5 Appropriate treatment technique opposed lats are reasonable though usually better to have divergence posterior with slight table kick to prevent divergence into the lenses. However, the fields spared the orbit completely (with potential undercoverage at the cribiform plate) Appropriate contouring Did not contour anything other than body. At minimum, brain should have been contoured and probably lenses to make sure the coverage was appropriate 3 /5 Appropriate treatment fields Reasonable assuming no temporal lobe lesion that might have been undercovered. 1/2

35 Review criteria P Appropriate dosimetry No DVH for brain included (only showed body which is not helpful). The MLC's were very tight on the cribiform plate and although brain may have been covered by 95%, we do not know for sure. In addition, the imaging was likely weekly and so we are not sure how well the patient was set up each day. bottom line, I am concerned that part of the brain was undercovered. 3 /5 Appropriate treatment verification Unclear what type of imaging was performed. The on treatment note states reviewed weekly port films and IGRT, but the form appears to be a worksheet and no notation is included. I assume that it was weekly, but images were not shown. 3 /5 Weekly on-treatment documentation/daily dose log/physics chart reviews The weekly on treatment notes were included and done 3 times during the 10 treatments. Weekly physics check appears to have been done though the resolution of the screen capture is difficult to read. Chart rounds/case peer review Chart rounds was performed in the second week and upon conclusion of the treatment. Would be better to do the chart rounds in first week of therapy. Summary summary Documented Follow-up plan Documented Overall appropriateness of care approach was appropriate but field design and lack of contouring the target was problematic. No imaging report for CNS and lack of neuro exam in any note is also problematic. 3 /5 General Comments Block edge could have covered the brain better and provided some leeway with interfraction motion. If brain was contoured, they may have noted the undercoverage. No Neuro exam for a patient with brain mets is disappointing. Total 81/100 American College of Radiation Oncology 5272 River Road, Suite 630 Bethesda, MD (fax) Support: support-acro@equal-estro.org 2/2