Feature | July 22, 2009 | Cristen C. Bolan

Early technology adopters and thought leadership get top scores amongst radiation treatment centers.

The art of radiation therapy is finding the balance between speed and accuracy. The challenge is to deliver the optimal amount of dose with pinpoint precision and without damaging healthy surrounding tissue. This task is further complicated, however, by fiscal pressures that force clinicians to put a premium on patient throughput, narrowing that window of accuracy.
Radiation therapy professionals who possess critical thinking and strategic planning skills and who have access to the most advanced technology are best equipped to fuse art with science and find that balance between speed and accuracy. You will find the centers where these physicians and the technology reside in the United States in our annual review of the “Top Radiation Therapy Centers to Watch” in 2009.
This review recognizes the most forward-thinking U.S.-based cancer treatment centers, which have adopted advanced techniques and technology, such as volumetric-modulated arc therapy (VMAT), proton therapy, neutron therapy, and both intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT), to optimize treatment and make a difference in patient care.
While some of the high-profile radiation oncology centers in the United States are well known leaders, such as M.D. Anderson (Houston, Texas), the Memorial Sloan-Kettering Cancer Center (New York, N.Y.), Johns Hopkins Hospital (Baltimore, Md.) and the Mayo Clinic (Rochester, Minn.), Imaging Technology News also asked its readers to select centers they consider leaders. Readers nominated worthy facilities for this year’s “Top Radiation Therapy Centers to Watch” based on their achievements in innovation, operational efficiency, patient service and teamwork. From there, the editors have chosen the top facilities to watch in 2009, classifying them as influential market leaders. These sites are listed in alphabetical order, not according to rank.
Allegheny General Hospital, Pittsburgh, Penn.
Innovation: As a Center of Excellence working with Siemens Medical Solutions, USA, we were the third institution in the country to install megavoltage conebeam computed tomography (MVCT) solution to a linear accelerator. Using this technology, we developed proprietary processes for MVCT image review and for utilization of fluoroscopic cine for stereotactic body radiotherapy. We also improved the MVCT imaging process. We use PET/CT and SPECT imaging and are developing deformable registration technology. With the newest Siemens linear accelerator platform, we are helping to develop an imaging beam line, which will improve image quality from the MVCT. We are investigating use of an unflattened 6MV photon beam operating a dose rates up to 2000cGy/minute to reduce the effect of patient, organ or tumor motion on the treatment delivery and plan. We are the second site in the world to have integrated the Siemens Artiste Linear Accelerator with BrainLab, a cranial and body radiosurgery technology, and Vision RT, an infrared system allowing monitoring of patient motion during treatment.
Operational Efficiency: Eight years ago, we began developing an electronic medical record (EMR) in the LANTIS patient scheduling system. Today, the EMR is accessible across our network of nine clinics in western Pennsylvania and eastern Ohio. We have standardized modules for patient assessment, on treatment visits and follow-up visits, and have optimized clinical activities and use of patient data. We have order sets to assist in organizing individual patient simulation and treatment parameters. We developed a module in the EMR to track and sign off on laboratory and imaging studies. Our process correctly identifies patients on each clinic visit, and we have initiated “Pause for the Cause” so that no patient treatment proceeds without the therapist stopping to assure that the correct patient, treatment site and setup have been verified. All policies and patient charts are identical across the Network, which assures that as staff moves from site to site to provide coverage, there is no delay or compromise in patient care.
Customer Service: A patient-oriented Web site, provides information about each network site, the treating physicians, services and more. We maintain an active patient satisfaction survey and regularly compile and review results from the surveys. We periodically conduct time studies to identify deficits in management of patient flow. Informational pamphlets in the department provide patient-oriented literature on radiation, specific kinds of cancer, treatment side effects, diet and more.
Patient intake is initiated with our clerical and billing personnel who are patient advocates highly integrated into patient care, the patient’s overall well being and with the goal of the department to optimize and advance patient care. One of our rural sites is part of a pilot project utilizing a Patient Navigator to assist patients with access to care, insurance, transportation, and so on. We have instituted several disease-specific multidisciplinary tumor boards that incorporate representatives from surgical, medical and radiation oncology services for review of each new patient case or problem case.
Teamwork: With nine radiation oncology clinics and over 120 employees, we have the largest network in the country accredited by the American College of Radiology, which validated the QA procedures, standards of clinical and technical care and peer review procedures. Activities at each site are coordinated through site managers who meet weekly to discuss issues relevant to the network and to maintain close communication with the main clinic. Each year, all clinics are closed for one day and all employees return to Allegheny General Hospital for a day of education and advanced training. During this practicum, employees receive updated information about activities at each site, innovative procedures that are being instituted, changes in policies and standards of treatment and new technologies that are being employed. During individual afternoon breakout sessions for each employee group, including physicians, nurses, physicists, dosimetrists, therapists, billing personnel and clerical staff, there are opportunities for credentialing, specific training and in-depth discussions of unique problems and solutions relative to each group. This practicum promotes teamwork, uniformity and improved quality of care across the network.
Barnes-Jewish Hospital, St. Louis, Mo.
Innovation: Barnes-Jewish Hospital (BJH) invested in the first single-vault proton accelerator, the Still River Monarch 250. The unit has not yet been built and BJH has committed to getting the first installed unit. The system is unique for its small size and relatively low price, allowing it to be installed in a single vault. The Still River unit will allow BJH to select patients they think will benefit from protons, while treating the rest of the patients in a conventional but state-of-the art facility.
Operational Efficiency: BJH Radiation Oncology has developed and built a workflow management system that centers around a Web-based patient treatment plan monitoring database. Physicians, dosimitrists and physicists are able to track the patient treatment plan from simulation through planning and quality assurance. This system allows the staff to monitor workflow and develop statistics that enable them to detect bottlenecks and systematic problems. The department is also developing automated workflow management systems that will enable better and more thorough quality assurance and monitoring of treatment quality.
Customer Service: BJH and Washington University conduct routine satisfaction surveys and use those surveys to address patient satisfaction problems. Frequent monitoring and feedback from the surveys allow BJH to maximize patient satisfaction. The facility is designed to minimize the distance between the waiting areas, linear accelerators and exam rooms.
Teamwork: BJH and Washington University form an integral team to provide excellence in radiation oncology. Twice a month, the physics team runs linear accelerator warm-ups to allow therapists to attend a treatment safety refresher class.
Booker Cancer Center Location, Red Bank, N.J.
Innovation: 2009 technology upgrades include a CyberKnife upgrade, MultiPlan Treatment Planning System, InTempo Adaptive Imaging System, IRIS Variable Aperture Collimator to shorten treatment time and enable treatments that have proven to reduce the total radiation dose delivered to the patient by up to 80 percent. 800 MU/minute linear accelerator reduces beam-on time by 30 percent. IMRT/IGRT - two Varian 2100EX linear accelerators, both with IMRT fully operational and IGRT. On-Board Imager using CBCT (cone beam CT). Multislice (16) CT-simulator with 4D capability. Super Dimension, which has reduced the patient complications (pneumothorax) rate to 2-3 percent during the acquisition of lung biopsies and fiducial placement for the CyberKnife. Our affiliation with Fox Chase Cancer Center in Philadelphia, Penn., provides our adult patients with the opportunity to participate in clinical trials.
Operational Efficiency: By offering advanced CT imaging, advanced conventional radiation therapy treatment as well as the CyberKnife system, a more streamlined, efficient and productive service is achieved, expediting patient throughput and enhancing the facility’s bottom line. All scheduling and registration is handled within the department. Patients work only with the cancer center staff from scheduling to preregistration and billing.
Customer Service: Facility leaders monitor survey results, secret shopping techniques and face-to-face interviews to ensure that we are meeting the high standards we have set for ourselves. Patient satisfaction initiatives are developed and reviewed bimonthly and include: telephone answered within three rings; consultation available within 24 hours; physician follow-up call two days post consultation; private on-site parking; education materials, including DVDs, are provided; pre-registration and insurance authorization obtained by staff prior to treatments; all additional tests are scheduled for patients; patients are escorted; manager greets patients and provides telephone number for questions; social work and dietary consultations provided; transportation arrangements provided; flexible treatment schedule; 15 minute wait time per appointment; refreshments provided in waiting room; warm blankets provided before and during treatments; graduation gift bag, including certificate, given at the end of treatment. We also provide emotional and spiritual support for the patients, caregivers and their families, including our award winning children’s art therapy program for ages 3-14. We also offer a family risk assessment program to test for a hereditary link for many types of cancer. Our certified genetic counselor meets with individuals to provide an initial consultation, coordinate lab work and review the results of the testing with the patient.
Teamwork: A physician liaison between the referring physicians and the cancer center assists with the team. Communication, educational opportunities, case studies and patient care issues are addressed in this collaborative effort. Department meetings are held once a week with representatives from administration, clinical, billing, clerical and nursing to ensure patient care, quality and flow is meeting our standards.
Emory Department of Radiation Oncology, The Emory Clinic, Atlanta, Ga.
Innovation: The Department of Radiation Oncology at The Emory Clinic has linear accelerators equipped with multileaf collimation, electronic portal imaging, and quality control software to avoid treatment errors. These linacs delivery treatment with low- and high-energy photons and a range of electron energies. Treatments are planned with a dedicated GE spiral CT scanner integrated with the AdvantageSim system. We also use IMRT.
Emory’s Radiation Oncology Department was the first facility in North America to install Varian Medical Systems’ On-Board Imager (OBI) device for delivering IGRT. In a study published in the Journal of the American College of Radiology, researchers used OBI to measure the time required to deliver image-guided treatments, showing the process can be efficiently integrated into the department’s normal clinical workflow.
Emory was the first cancer facility in Georgia to provide prostate cancer patients with the Calypso 4D Localization System. Emory performed the first frameless radiosurgery brain tumor treatment in Georgia. It was also the first medical facility in Georgia to install Rapid Arc by Varian Medical Systems. Emory has used stereotactic radiation therapy for brain tumors since 1989 using either a single treatment or in multiple treatments (fractionated stereotactic radiotherapy).
Brachytherapy is available, including both low dose rate (LDR) and high dose rate (HDR). The VeriSeed software for prostate brachytherapy is used for real-time treatment planning in the operating room to avoid errors and obtain better dose distributions.
Operational Efficiency: Emory uses ARIA, the Varian Oncology Medical record, to improve scheduling, document management, compliance and billing. Patients can check themselves in for daily treatment at a console at the front desk.
The department of radiation oncology operates two facilities in Atlanta, both of which are adjacent to hospitals that are part of the Emory Healthcare System. The Clifton Road campus is adjacent to Emory University Hospital and Egleston Children’s Hospital. The second facility is adjacent to Emory University Hospital Midtown. In addition, our physicians practice at the Veterans Administration Medical Center and the Edward C. Loughlin Radiation Oncology Center of Grady Memorial Hospital. All radiation oncologists in the department have active appointments with the Emory University School of Medicine.
Patient satisfaction scores have remained steadily high, over the 95th rating, even with the introduction of new technologies. There is a great emphasis on ensuring patients and their family members receive individualized attention and care, at the front desk as well as in treatment areas. The entire department of radiation oncology meets on a monthly basis to review patient satisfaction scores, patient progress, clinical trials and research progress.
Customer Service: Emory University Hospital recently earned a commendation from the American College of Surgeons Commission on Cancer (CoC). Only one in four hospitals that treat cancer patients receives this special approval.
Teamwork: Walter Curran, M.D., chair of Emory’s Department of Radiation Oncology, leads the development of multidisciplinary teams comprised of physicians from throughout Emory’s health system. Emory’s Winship Cancer Institute has built a team approach to treating patients with brain tumors, including neurosurgery, precise radiation treatment and chemotherapy. This approach has established Winship as a multidisciplinary referral center for the State of Georgia and beyond that can meet brain patients’ specialized care needs. This model is being replicated in all clinical disease sites. The department’s goal is to provide the highest quality patient care through clinical investigation and implementation of improved treatment planning and delivery technologies.
Wake Forest University Department of Radiation Oncology, Winston-Salem, N.C.
Innovation: The department of radiation oncology is part of the NCI-designated Comprehensive Cancer Center of Wake Forest University Baptist Medical Center for its innovation. Advanced systems include a dedicated PET/CT for 4D-PET-CT, 3.0 Tesla MRI for radiation treatment planning. Using new PET/CT and MRI simulators from GE Healthcare, the department is a GE Show Site — allowing other teams of radiation oncologists, physicists and staff to learn how we have implemented our technology. The Elekta AXESSE device for SBRT is the third in the U.S. Wake, and the new Elekta Gamma Knife Perfexion will replace the old Gamma Knife, complementing the Wake Forest Baptist Brain Tumor Stereotactic program — at 300 patients its one of the busiest centers nationwide. Using stereotactic therapy, and working with Elekta, will qualify the center as a Leksell Stereotactic Radiosurgery Center of Excellence, allowing brain tumor teams to visit and learn about the systems’ capabilities. The center has a Nucletron HDR brachytherapy unit and an Integrated Brachytherapy Unit (IBU). The IBU is one of four nationwide and the only one worldwide to have digital capabilities. The IBU works in conjunction with the HDR to allow real-time treatment planning and delivery in a single session. Wake Forest Baptist is also a Nucletron Reference and Training Site.
Operational Efficiency: As a radiation oncology and an imaging facility, Six Sigma and other institutional resources help ensure optimal workflow and productivity. One of the central reasons we have become a facility that is considered a Show Site, Reference Site and Center of Excellence is because of the operational efficiency we have been able to achieve. Prior to purchasing equipment, we analyzed clinic flow, patient flow, staffing considerations, coding and billing aspects and electronic medical records needs to ensure complete, efficient documentation and communication. Close collaboration with radiology MRI and PET/CT staff and radiation safety was essential for successful implementation of imaging in the radiation oncology setting. Radiation oncology formed the Bio-anatomic and Imaging Treatment (BAIT) Committee, which consists of representatives from MR and PET/CT simulators, physics, nursing, stereotactic coordinators, administration, scheduling, and ad-hoc representation from radiology. Equipment issues, patient safety issues and patient flow issues are brought to this committee for recommendations. A blood draw protocol was also devised. An RN is available to assist in all aspects of the patient process during contrasted imaging procedures.
Customer Service: Patient escorts provide wheelchairs, blankets, direction and valet parking services. Radiation oncology sends out patient satisfaction surveys to patients that have completed radiation therapy treatments. The nutritionist educates and facilitates the nutritional plan of care, working closely with those patients deemed at high risk by results of the nutritional assessment tool. The social worker assists the patient with issues that affect the ability to complete the treatment process. The Cancer Patient Support Program (CPSP) is available to cancer patients and families, and provides the Cancer Support Lounge that provides food, drink and a trained volunteer to assist the patient and family. Our Customer Service Champions program educates selected staff on how to assist patients/families with various concerns. The “Get a Lift” program promotes patient comfort and safety as well as employee safety by providing easier methods of transferring patients from wheelchairs and/or stretchers to the simulator couch, treatment couch, or exam table and back again.
Teamwork: The department of radiation oncology completed a department retreat in an effort to create more teamwork and a successful venture in which all members of the staff are rededicated and share the same stated vision: To deliver state of the art radiation therapy with compassion. Throughout the year, staff members are recognized for going “above and beyond” expectations to ensure the optimal delivery of care for the radiation patients. Our staff works collaboratively with faculty in other oncology specialties to optimize patient care. The Clinical Efficiency Committee is a shared governance committee with representation from all sections of the department with the aim of increasing efficiency, disseminate information and serve as a forum for topic discussion. Wake Forest Baptist is a magnet designated hospital that attracts and retains talented registered nurses. This designation communicates to the community our commitment to high standards of patient care. The model of care at Wake Forest Baptist is relationship based care which provides care for the the patient/family, the team and each individual.

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