Click here to

Session: Establishing Efficient and Effective Systems for Policy and Procedures [Return to Session]

Establishing Efficient and Effective Systems for Policy and Procedures

P Halvorsen1*, M Bakhtiari2*, K Moore3*, (1) Beth Israel - Lahey Health, Burlington, MA, (2) William E. Kahlert Regional Cancer Center, Westminster, MD, (3) UC San Diego, La Jolla, CA


3:30 PM Policies and Procedures: Why Bother, and Why Should the Physicist Play a Key Role? - P Halvorsen, Presenting Author
3:45 PM Policies and Procedures: Developing Policies and Procedures That Work for Your Clinic - M Bakhtiari, Presenting Author
4:00 PM Policies and Procedures: Practical Strategies for Effective Implementation and Maintenance - K Moore, Presenting Author
4:15 PM Audience Q&A - M Bakhtiari, Presenting Author

SU-E-TRACK 1-0 (Sunday, 7/25/2021) 3:30 PM - 4:30 PM [Eastern Time (GMT-4)]

The phrase “Policies and Procedures” is viewed by many as a dry, administrative function without significant value to clinical practice. For many years, the primary focus of the AAPM’s task group activities was centered on equipment, with numerous recommendations for commissioning and ongoing quality control and quality assurance related to equipment safety and performance. Recent years have seen an increased recognition of the importance of process toward ensuring safety and consistent quality. The multi-society Safety is no Accident publication, the broad adoption of structured incident learning, and the publication of the Task Group 100 report have emphasized the risks of poorly defined workflows. This presentation will summarize what we have learned from recent initiatives and how policies and procedures fit into a comprehensive quality management system, with emphasis on the importance of accessible policies and procedures to guide clinical workflows.

While we have learned that policies and procedures provide value to clinical operations, where do they really fit in and how do they influence our actions? Developing effective policies and procedures is much more than just simply meeting an administrative checkbox. The culture of both the larger organization and in the immediate environment will influence design. Design of policies and procedures will clearly affect the effectiveness, so a suggested hierarchical structure of policy-procedure-work instruction-records will be presented. This presentation will look at where organizational management and task and technology factors may be organized to set team members to succeed rather than fail in the clinical process (notice, interpret, decide how to address a problem, develop an effective plan, or act on a developing problem).

The purpose of Policy and Procedure documents is to be used, practical considerations of how to craft them to be effectively integrated into normal clinical workflows must be considered. We will discuss examples of effective and ineffective Policy and Procedure documents, focusing on clarity (or lack thereof) in writing and presentation. Nearly as important as writing documents effectively are the processes for accessibility, version control, traceable approvals, and maintenance. We will discuss strategies for efficiently satisfying these criteria, with a focus on accessibility in a highly digitized, modern quality management system.

Learning objectives:

1. Importance of policies and procedures in a practice. Importance of following P&Ps in preventing incidents (data from RO-ILS will be presented). Get familiar with the differences between policies, procedures, and processes. Examples of “good” and “not so good” P&Ps.

2. Incorporating P&Ps into a quality improvement program (TG-100, FMEA and incident learning). The quality metrics for evaluating the P&Ps.

3. Standardization for Writing and editing P&Ps (formatting templates, outlines, terminologies, etc)

4. Document management systems; technical aspects of incorporating P&Ps into daily practice. Easy and quick access to P&Ps from different applications, platforms, and devices. Task management tools for easily assigning tasks and monitoring the performance of the P&Ps.



Not Applicable / None Entered.


Not Applicable / None Entered.

Contact Email