1. IAEA E-learning Program
Safety and Quality in Radiotherapy

2. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Sections:
11.1 On-line resources at the IAEA
11.2 IAEA’s Postal Dosimetry Audit
11.3 Quality Assurance Team for Radiation Oncology (QUATRO)
11.4 Other resources

3. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Sections:
11.1 On-line resources at the IAEA
11.2 IAEA’s Postal Dosimetry Audit
11.3 Quality Assurance Team for Radiation Oncology (QUATRO)
11.4 Other resources
And now we’ll turn our attention to another IAEA initiative: The Quality Assurance Team for Radiation Oncology – QUATRO.

4. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
OBJECTIVES
To briefly review the role of and rationale for a clinical audit.
To describe the IAEA’s QUATRO audit process.
Here is what we will do in this section. We will briefly review the role of and rationale for a clinical audit and we will describe the IAEA’s QUATRO audit process.

5. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
OBJECTIVES
To briefly review the role of and rationale for a clinical audit.
To describe the IAEA’s QUATRO audit process.
First of all, we will review the role of and rationale for a clinical audit.

6. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Optimum and Safe Radiotherapy
Optimum, safe radiotherapy is predicated on delivering the correct dose to the correct anatomical region whilst sparing normal, non-cancerous tissue.
We noted earlier in this module that the fundamentals of optimum, safe radiotherapy are delivering the correct dose to the correct anatomical region whilst sparing normal, non-cancerous tissue.

7. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Optimum and Safe Radiotherapy
While accurate machine calibration is a necessary condition for optimum safe radiotherapy, it is not, on its own, sufficient.
We also noted that while accurate machine calibration is a necessary condition for optimum safe radiotherapy, it is not, on its own, sufficient.

8. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Optimum and Safe Radiotherapy
Even when the treatment machine is correctly calibrated, errors may be introduced somewhere along the complex chain of clinical processes.
Even when the treatment machine is correctly calibrated, errors may be introduced somewhere along the complex chain of clinical processes.

9. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Clinical Audits
A clinical audit is a comprehensive assessment of the complete patient pathway through radiotherapy, specifically looking for strengths, weaknesses and opportunities for improvement.
A clinical audit is a comprehensive assessment of the complete patient pathway through radiotherapy, specifically looking for strengths, weaknesses and opportunities for improvement

10. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Quality Assurance Team for Radiation Oncology
The IAEA has been contributing to improving quality and safety in radiotherapy since 1969 through its dosimetry audits.
Looking at the history of the QUATRO program we note that the IAEA has been making a contribution to improving quality and safety in radiotherapy since 1969 through its dosimetry audits. We saw this in the previous section.

11. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Quality Assurance Team for Radiation Oncology
The IAEA has been making a contribution to quality and safety in radiotherapy since 1969 through its dosimetry audits.
As a result of its international profile, the IAEA received requests to provide more comprehensive clinical audits in radiotherapy to encompass the complete patient care pathway.
An advisory committee of radiotherapy professionals was convened to develop an appropriate programme.
As a result of its international profile, the IAEA received requests to provide more comprehensive clinical audits in radiotherapy to encompass the complete patient care pathway.
In response to these requests, an advisory committee of radiotherapy professionals was convened to develop an appropriate audit programme.

12. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Quality Assurance Team for Radiation Oncology
In 2007 the IAEA published “Comprehensive Audits of Radiotherapy Practices: A Tool for Quality Improvement”. 1
Thus was The Quality Assurance Team for Radiation Oncology – QUATRO - born. In 2007, the IAEA published a document entitled “Comprehensive Audits of Radiotherapy Practices: A Tool for Quality Improvement”

13. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
OBJECTIVES
To briefly review the role of and rationale for a clinical audit.
To describe the IAEA’s QUATRO audit process.
Next, let us look at the IAEA’s QUATRO audit process.

14. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
How does it work?
The process starts with a request to the IAEA from a radiotherapy centre in an IAEA Member State to conduct a clinical audit.
The government of the country where the radiotherapy centre is located must approve the request’s for a QUATRO audit.
The IAEA will consider the request within its mandate and availability of resources.
So, how does the QUATRO programme work? The process starts with a request to the IAEA from a radiotherapy centre in an IAEA member state to conduct a clinical audit.
The government of the country of the radiotherapy centre must approve the request’s for a QUATRO audit.
The IAEA will consider the request within its mandate and availability of resources.

15. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
How does it work?
If the request for an audit is approved by the IAEA, the next 2 steps are:
The radiotherapy centre will submit background information, such as numbers of patients, staff and machines to IAEA.
An audit team is identified comprised of a radiation oncologist, medical physicist and radiotherapy technologist.
If the request for an audit is approved by the IAEA, the next 2 steps are:
The radiotherapy centre will submit background information, such as numbers of patients, staff and machines to IAEA.
An audit team is identified comprised of a radiation oncologist, medical physicist and radiotherapy technologist.

16. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
How does it work?
The audit team will plan for a visit to the radiotherapy centre.
The on-site review usually lasts five days.
The review employs a standardised approach to evaluate centre infrastructure, patient related and equipment related procedures, as well as professional training programmes.
There are 37 checklists used during the review.
The on-site visit starts with an orientation to the purpose and conduct of the audit for the staff.
Documentation is reviewed and a cross-section of staff interviewed.
Once the audit team has all the necessary information a visit to the radiotherapy centre will be scheduled. The on-site review is scheduled at a mutually convenient time and lasts five days.
The review employs a standardised approach to evaluate centre infrastructure, patient related and equipment related procedures, as well as professional training programmes. 37 checklists are used during the review.

17. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
How does it work?
The audit team will plan for a visit to the radiotherapy centre.
Dosimetric measurements are made and quality control records are reviewed by the audit physicist.
The on-site component of the audit concludes with an exit briefing with the staff at which the main findings are outlined.
A detailed, typically 40 page, report is prepared by the audit team.
The report is reviewed by a consultant, appointed by the IAEA, before submission to the requesting radiotherapy centre.
The report contains commendations for superior performance together with recommendations for quality improvement to the centre, the relevant government and the IAEA.
The on-site visit starts with an orientation to the purpose and conduct of the audit for the staff.
Documentation is reviewed and a cross-section of staff interviewed.
Dosimetric measurements are made and quality control records are reviewed by the audit physicist.
The on-site component of the audit concludes with an exit briefing with the staff at which the main findings are outlined.
A detailed, typically 40 page, report is prepared by the audit team.
The report is reviewed by a consultant appointed by the IAEA before submission to the requesting radiotherapy centre. The report contains commendations for superior performance together with recommendations for quality improvement to the centre, the relevant government and the IAEA.

18. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Typical Report Contents
1. OBJECTIVES OF THE AUDIT 2. DESCRIPTION OF AUDIT ACTIVITIES 3. GENERAL DISCRIPTION OF THE FACILITY 4. FINDINGS AND RESULTS OF THE QUATRO AUDIT 4.1. INFRASTRUCTURE 4.2. PATIENT RELATED PROCEDURES 4.3. EQUIPMENT RELATED PROCEDURES 4.4. TRAINING PROGRAMMES 5. CONCLUSIONS 6. SUMMARY OF RECOMMENDATIONS 6.1. THE RADIOTHERAPY DEPARTMENT 6.2. THE GOVERNMENT 6.3. IAEA Annex 1: QUATRO Comprehensive Audit Checklists Annex 2: Machine output measurements
And here’s what a typical report contains.

19. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
How does it work?
You can find out more at this website.
More details of the IAEA program can be found at:

20. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
How many centres have participated in this programme?
To date over 90 QUATRO audits have been conducted in 77 radiotherapy centres in Europe, Asia, Africa and Latin America.
So, how many centres have participated in this programme? To date over 90 QUATRO audits have been conducted in 77 radiotherapy centres in Europe, Asia, Africa and Latin America.
lower middle income
upper middle income
high income

21. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Has the audit programme yielded real benefits ?
Experience with 12 audits in Latin America has been summarized and published. 2
The big question is: Has the audit programme yielded real benefits? One indication of success is this publication describing experience with 12 audits in Latin America.

22. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Has the audit programme yielded real benefits ?
Experience with 12 audits in Latin America has been summarized and published.
These authors conclude: “The QUATRO audits proved to be a valuable tool for identifying weaknesses in infrastructure, human resources and procedures in radiotherapy centres. Follow-up visits conducted by the IAEA or by regional or local organizations are necessary in order to evaluate outcomes and sustainability of implemented recommendations.”
These authors conclude: The QUATRO audits proved to be a valuable tool for identifying weaknesses in infrastructure, human resources and procedures in radiotherapy centres. Follow-up visits conducted by the IAEA or by regional or local organizations are necessary in order to evaluate outcomes and sustainability of implemented recommendations.

23. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
Has the audit programme yielded real benefits ?
Further evidence of the effectiveness of the QUATRO programme comes from follow-up audits. Audited centres can request a follow-up audit to provide independent confirmation that significant improvements have been made. Follow-up audits have always resulted in more commendations for clinical programme strengths and fewer recommendations for improvement.
Further evidence of the effectiveness of the QUATRO program comes from follow-up audits. Audited centres can request a follow-up audit to provide independent confirmation that significant improvements have been made. Follow-up audits have always resulted in more commendations for clinical programme strengths and fewer recommendations for improvement. This observation suggests that such clinical audits are indeed an effective means for improving quality and safety in radiotherapy.

24. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
summary
We have:
Briefly reviewed the role of clinical audits in radiotherapy.
Described the IAEA’s QUATRO programme.
And, finally, here’s a summary of what we have covered in this Section. We have briefly reviewed the role of clinical audits in radiotherapy and described the International Atomic Energy Agency’s QUATRO programme.

25. Safety and Quality in Radiotherapy
MODULE 11: useful resources
Safety and Quality in Radiotherapy
Section 3: Quality Assurance Team for Radiation Oncology
References and additional resources
IAEA et al. Comprehensive Audits of Radiotherapy Practices: A Tool for Quality Improvement,
Rosenblatt E, Zubizarreta E, Izewska J, Binia S, Garcia-Yip F, and Jimenez P. Quality audits of radiotherapy centres in Latin America: a pilot experience of the International Atomic Energy Agency. Radiation Oncology, 10: