Quality Management 2017

IQS linked to Lean

Mixed Prisma / fishbone analysis:

▪

Man: Unreliable!

▪

Material (patient): Tried marking the (new) isocenter >> extra marking/tattoos give more confusion, especially in small shift Method: Tried orange form on charts of patient with shift >> today is common use SOP reduced “no shift applied”, wrong shift remains. Machine: Shift entered in treatment couch control (TCSA, Theraview®)

▪

▪

Multi-disciplinary decision: RO, physicists, RTT’s, management and industry involved.

Continuous Improvement: Methods

Incident Registration

Discussion