In 2009, the United States Department of Veteran Affairs (VA) understood they needed to take action for its veterans with cancer. Technological advances implemented over the last decade have enabled physicians to more accurately target tumors with higher radiation doses, but the increase in dosage also carries a greater potential for harm if the target is missed. With radiation oncology services being provided by 38 VA medical centers and more than 100 contractors across the country, the VA realized the need to standardize their practices in order to ensure America’s veterans receive the safest, most effective cancer care possible.
As a result, the VA established a new Radiation Oncology program later that same year. Asked to lead it as national director was Michael Hagan, M.D., Ph.D., a professor of radiation oncology at Virginia Commonwealth University Massey Cancer Center and a Vietnam veteran. At the time, Hagan had been serving as chief of radiation oncology at Hunter Holmes McGuire VA Medical Center in Richmond, Virginia for 12 years, continuing a Massey-VA partnership established in 1989 in which Massey provides a full spectrum of cancer care for Central Virginia’s veterans, including access to cutting-edge clinical trials. Hagan has been at the helm of the program since.
“The Radiation Oncology Program was created to develop policies, guidelines and procedures to ensure that veterans are treated with radiation as safely and effectively as possible,” says Hagan. “But in order to do that, highly trained experts in medical physics are needed. That’s why I was very excited when Dr. Jatinder Palta agreed to serve as director of medical physics.”
Jatinder Palta, Ph.D., is a professor of radiation oncology at VCU Massey Cancer Center and is one of the nation’s leading medical physicists, whose primary research interests include the development and implementation of new radiation delivery methods and elimination of uncertainties in radiation delivery. Currently, the federal government does not have an Office of Personnel Management classification for medical physicists even though the VA currently employs them as contractors or under a different title. Establishing this classification will allow Hagan and Palta to attract to the VA the most qualified medical physicists. While Hagan and other leaders at the VA work to implement this change, Palta is serving the VA through a contract position with VCU Massey.
“I jumped at this opportunity because it gave me a chance to serve our veterans while also increasing the safety and effectiveness of radiation oncology across the country,” says Palta. “The VA is unique because it is a highly structured organization that allows for swift implementation of new policies. In turn, we are able to quickly test new treatment ideas to see what works, and that information can be used by major professional societies to make recommendations for physicians in community and academic health centers throughout the world.”
Partnering with professional societies such as the American Society for Radiation Oncology (ASTRO) and the American College of Radiology (ACR) is one of Hagan’s mandates, and he has been hard at work. When he started in his new role, Hagan made it a goal to have 100 percent of the VA’s treatment centers accredited by the ACR. In just three years, Hagan has met his goal. The only treatment centers not accredited are those that have not been in operation long enough to be evaluated.
Hagan did not stop there. He has also implemented a policy in which treatment centers are evaluated every three years by the MD Anderson Radiological Physics Center to ensure all radiotherapy planning and delivery systems are accurately calibrated and quality assured.
“The accreditation standards have created a market force that has also raised the quality of care provided by our contractors,” says Hagan. “Because they are required to provide care equal to or better than VA treatment facilities, contractors are becoming ACR accredited in order to meet the VA’s standards.”
Accreditation is not all that is being improved. Hagan and Palta are also developing the infrastructure needed to support extensive quality control and monitoring programs.
“Research has demonstrated that patient outcomes are best when treatment plans are reviewed by more than one physician,” says Palta. “We are piloting a program where any doctor in the VA can electronically send their patient’s treatment plan to another expert physician for review and receive feedback within 48 hours.” Mitchell Anscher, M.D., Florence and Hyman Meyers Chair of Radiation Oncology and program co-leader of Radiation Biology and Oncology at VCU Massey, is currently conducting peer reviews of treatment plans sent from three pilot centers. If successful, the program will be adopted throughout the VA.
Also in the pipeline is one of the largest error reporting systems ever created. While significant errors are rare and their reporting is already mandatory, Hagan and Palta are creating a Web-based process to prevent them before they occur. Research has shown that “close calls,” or near misses, occur more frequently than major mistakes. So, through voluntary, anonymous reporting the VA will create a database of all potential threats to patient safety in order to inform policies and procedures. One such policy already implemented is the requirement of a time-out procedure before treatments in which the care team confirms all the details of a patient’s treatment plan, much like procedures implemented to reduce surgical errors.
Additionally, Hagan is working to implement the first nationwide practice evaluation of all radiation oncology treatment centers operated by the VA. Because a process to evaluate an enterprise as large as the VA has never been established, Hagan is partnering with ACR to create a detailed assessment designed to report on the quality of treatments and patient outcomes at every VA medical center that provides radiation oncology. Once implemented, Hagan will be able to look at the care being provided at any VA medical center and compare it to national and global standards.
“We have come a long way in a few years, but still have work to do,” says Hagan. “When we started, we didn’t aim simply to improve services at the VA, we wanted to improve the entire field of radiation oncology and make the VA a model for establishing quality and efficiency improvements within any health system. The hard work of the radiation oncologists in VA medical centers has begun to pay off. The country can be proud of the cancer care its veterans receive.”