A patient safety education program in a medical physics residency

Abstract Education in patient safety and quality of care is a requirement for radiation oncology residency programs according to accrediting agencies. However, recent surveys indicate that most programs lack a formal program to support this learning. The aim of this report was to address this gap and share experiences with a structured educational program on quality and safety designed specifically for medical physics therapy residencies. Five key topic areas were identified, drawn from published recommendations on safety and quality. A didactic component was developed, which includes an extensive reading list supported by a series of lectures. This was coupled with practice‐based learning which includes one project, for example, failure modes and effect analysis exercise, and also continued participation in the departmental incident learning system including a root‐cause analysis exercise. Performance was evaluated through quizzes, presentations, and reports. Over the period of 2014–2016, five medical physics residents successfully completed the program. Evaluations indicated that the residents had a positive experience. In addition to educating physics residents this program may be adapted for medical physics graduate programs or certificate programs, radiation oncology residencies, or as a self‐directed educational project for practicing physicists. Future directions might include a system that coordinates between medical training centers such as a resident exchange program.

Although the need for quality and safety education is apparent, most residency programs currently lack a formal program for supporting this learning. 9,10 In evaluations during a one-day safety course for physician and physics residents, only 22% of participants agreed with the statement "I have adequate education in quality improvement for my current role." 9 A recent survey of medical and physics residents in the US also noted that only 40% of medical physics residents agreed with the statement that "formal teaching of patient safety" was adequate in their program. 10 Although some reports have appeared providing recommendations for a safety and quality education curriculum, 2,11 specific details are lacking and, to our knowledge, no report has yet appeared in the literature describing experiences with formal patient safety educational programs in radiation oncology residencies.
The purpose of this report was to share experience with a patient safety and quality education program developed at the University of Washington specifically for medical physics residents.
While the main focus of this report is on the medical physics residency program, the experience may be useful for physician residencies and may be relevant to Maintenance of Certification through the ABR and practice accreditation programs such as APEx, in which patient safety and quality of care is a key pillar. 12

| ME TH ODS
The patient safety and quality educational program consists of a didactic component (reading and lectures on fundamental concepts) coupled with practice-based learning. The majority of this content is delivered in the form of a mentored rotation that is one month in duration, and there is also a component which extends throughout the residency and includes participation in the departmental incident learning program.
In designing an educational program around a broad subject like patient safety and quality, it is important to select appropriate topic areas of focus. This is particularly important in the context of a medical physics residency program. Since most programs are 24 months, the total time dedicated specifically to patient safety and quality education will necessarily be limited. In formulating focus topics we consulted the following resources: AAPM Report No. 249 on guidance for CAMPEP-accredited residencies, 2 the CAMPEP residency standards, 3 the "Safety is No Accident" report from ASTRO, 12 the report of AAPM Task Group 100, 7 and the AAPM 2013 Summer School Proceedings on Quality and Safety. 13 Additionally, the study of Dunscombe 8 provides a broad summary and references to the literature, which is valuable. Table 1 shows the five topic focus areas selected for the program. The resulting topic areas are very similar to those proposed by Yeung and Greenwalt,11 are consistent with the recommendations from the ACGME for Pathways to Excellence, 1 and include the specific safety-related topics listed in the CAMPEP residency standards. 3 The topic focus areas in Table 1 were grounded in a didactic component of the program that included a series of readings (see the citations in Table 1) and six lectures. A "flipped classroom" arrangement was used whereby the lectures were recorded, and the resident reviewed them in advance. 14 This allows for a more rich discussion of the topics during inperson meetings. These lectures and discussions were supplemented with online video lecture resources, primarily from the AAPM virtual library (aapm.org), which includes presentations from a variety of speakers (28 lectures are found between 2010 and 2015 under the keywords "patient safety"). Another resource is vimeo.com where much of the same content is available also to non-AAPM members (e.g., search "AAPM patient safety"). Another resource (not listed in the tables below) is the Learning program on Safety and Quality the from the International Atomic Energy Agency, IAEA (https://rpop.iaea.org/RPOP/RPoP/Conte nt/News/e-learning.htm). This course consists of 12 modules, seven of which are focused on incident learning. A certificate is available after the course is complete.
A project-based learning component builds on and reinforces the base knowledge of concepts and content areas of the didactics.
T A B L E 1 Topic areas for the patient safety and quality educational program. Reference materials are assigned as reading materials (c.f. Table 2).

Topic area
Learning objectives Reference materials

Accidents and outcomes
• Appreciate a few select watershed accidents in radiation oncology and the associated issues.
• Understand the data linking quality of treatment with outcomes.
• Know the various types of events, near-misses and incidents, and how these are monitored in clinical practice.
• Appreciate the difference between identifying an error (e.g., QA) and addressing the drivers of error.

| 269
During the one-month rotation each resident is expected to complete one project in one of the topic areas in In addition to the rotation project, the resident participates in the incident learning program of the department. This includes attendance at the weekly safety committee meetings where near-miss events are discussed and analyzed. The department operates a highvolume near-miss incident learning system where approximately 25 quality reports are analyzed every week. 15 The resident is expected to be involved in at least one root-cause analysis (RCA) exercise, usually motivated by findings in the incident learning system. Since reportable medical incidents are exceedingly rare in this clinic, the RCA exercise often focuses on a potentially serious near-miss event.
This has the advantage of allowing the resident to analyze a case Feedback about performance and the rotation from the mentor to the resident and also from the resident to the program director. If the resident fails to meet the educational objectives, a plan for remediation is in place which involves further study and project work. To date, however, this has not been necessary. Table 2 provides an example, detailed schedule for the one-month rotation including topic areas and assignments.

| RESULTS
The program was developed in an iterative manner, with feedback from the residents being used to develop it into the form outlined here. One example of this was a request from the residents that they attend all weekly meetings of the departmental incident learning program starting from the beginning of the residency instead of only during the rotation since this was viewed as a rich learning environment. This is now a residency program-level expectation. The residents start by observing these meetings and later, as their general clinical experience grows, they participate and contribute more actively to the discussion.  patient in vivo dosimetry checks. In one case the project was reported as a manuscript, 16 and provided the opportunity to compare the results of FMEA with clinical experience by way of incident learning, which revealed some novel insights. Feedback from residents about the rotation was positive, for example, "a very useful and well-done rotation."

| DISCUSSION
The structured educational program on quality and safety described here has been in place since 2014 and is well-received by medical physics residents. A key feature of the program is a concentrated rotation lasting one-month with learning objectives focused on topic areas that are important for a medical physicist in clinical practice.
The program also includes continuous learning through active participation in the departmental near-miss incident learning system.
This program is designed to address the gap in quality and safety education in residencies that has been reported in recent studies. 9,10 In one of these, a national survey of physician and physics residents, a majority of respondents reported that formal teaching of patient safety was inadequate in their program. 10 The need for a structured learning program is also motivated by the requirements of residency accrediting bodies, 1,3 the recent trends around reimbursement models that include quality reporting components (e.g., MACRA in the USA), and the need for physicians and physicists to serve as leaders in this arena. 5,6 Training is listed as a key component in essentially all reports providing recommendations around patient safety. 8 The program described here is also part of a broader movement to include specialized rotations in medical physics residencies and to share curricular ideas, as recently highlighted in an AAPM symposium. 17 These specialized rotations include not only quality and safety but also clinical shadowing, introductory rotations, and other topics.
One of the strong-points of the program described here is the focus area of incident learning and root-cause analysis (RCA). This aspect of the program benefits from the incident learning system operated by the department. 15 This is a high-volume system focused on near-miss reports that provides unique opportunities for learning 18 and is especially valuable for residents. Incident learning and RCA are particularly important for several reasons: it is one of the pillars of safety and a requirement for practice accreditation, 12 it is not well understood or utilized by trainees in general, 19 and it is one of the safety topics with the largest gaps in understanding and comfort among residents within radiation oncology. 10 A recent survey of physician and physics residents suggested that programs with an incident learning system are more effective at providing education in safety and quality. 10 Although there may be a variety of factors accounting for this correlation, one reason is that participation in a clinical incident learning safety program engages the learner because the incidents are so relevant to radiotherapy practice.
The effectiveness of incident learning is supported by many educational theories and principles. For example, Experiential Learning, as described by Kolb 20 requires not only hands-on practice, but a cycle of (a) participating in a concrete experience, (b) reflective observation, (c) abstract conceptualization to make sense of the experience and finally, (d) active experimentation, where the experience is tried again, applying the new insights gained from steps 2 and 3. This cycle is remarkably similar to a Plan, Do, Study, Act (PDSA) cycle of quality improvement. Learning is very contextual, and is more effective when the learner is situated in the professional practice, and they can participate in its activities, such as the apprenticeship model of resident and fellow education. They also learn more when the content is legitimate and meaningful, as it is with RCA of safety incidents, even if they are still under supervision and still somewhat peripheral to the action. 21 However, as trainees advance through a program, they also need to solidify their learning not just through activities and tasks, but also understanding the culture and context, which is especially important for incident learning and safety. 22 To our knowledge, there is no report in the literature which describes the details of a formal patient safety educational program in radiation oncology residencies. Several related reports have appeared, however. Across healthcare in general there are reports about the experience of residents particularly in the realm of practice-based quality improvement and associated metrics. 23 Yeung and Greenwalt 11 have proposed a framework specific to radiation oncology that would satisfy ACGME requirements for patient safety and Center for Assessment of Radiological Sciences PSO system (carspso.org). Related to this is the need for a strong culture of safety, which is a driving force for quality care. Culture of safety has been linked to patient outcomes 29 and has been specifically mentioned in the radiation oncology context. 5,24 While this report has focused on medical physics residents, parts of the program described here may have a broader applicability.
Parts of the program may be adapted to serve the continuing medical education needs of faculty and staff (see Appendix A). It may also be possible to adapt the program for physician residents, but changes would need to be made including a modification of the topic focus areas (e.g., Table 1). For instance, incident learning should include the issue of error disclosure and professional aspects. 30 Principles of error proofing (Table 1 & 2, for example, bar-rier analysis, QA, and automatic error detection) could be modified to have less of a physics focus, and quality audits could be modified to focus less on commissioning and phantoms and more on issues like physician peer review. 31,32 Adapting aspects of the curriculum may also be of interest to graduate or certificate program directors.
There are some limitations to this study. One important limitation is that not all safety-related topics can be included in an educational program like the one presented here, and Table 1 should not be taken as an exhaustive list. For example, one topic which is not included is statistical process control. This technique, which has attracted attention recently, involves analyzing and tracking the results of some procedure or test over time to establish clinical action levels 33 and has an analog with physician-reported performance metrics, which have been called for in the context of trainee education. 23 While such topics are called for in some reports, 11 it must be acknowledged that not all aspects of patient safety and quality of care can be included in a relatively focused educational program like the one described here.
The program described here is expected to evolve and develop further. One future direction might be a distributed program that is coordinated between a few centers. This might include a combined teaching component, which leverages the expertise of faculty at various centers, and/or a resident exchange program which facilitates a shared learning experience. Another direction may be to encourage partnerships between physician and physics residents to conduct projects together. Any future effort would benefit from a certification process such as that eLearning course from the IAEA (https:// rpop.iaea.org/RPOP/RPoP/Content/News/e-learning.htm).

CONFLI CT OF INTEREST
The authors declare no conflict of interest.

B | APPROACH
Example: I will develop the structure for an educational program for residents in our medical physics program. This will consist of a onemonth rotation. The rotation will include a series of background readings on quality and safety. In this SDEP I will also develop a series of four lectures to support this learning. A future SDEP project (planned for next year) is to develop a rotation project centering on failure mode and effects analysis (FMEA) which will allow the resident to experience hands-on learning.
C | EVALUATION OF ACHIEVEMENT 1 | Prospective statement (provided when SDEP is initiated) Example: I will assemble a list of readings and review them myself in detail. I will develop and deliver four power-point lectures. At the end of the rotation, residents will provide an evaluation of the rotation which will help assess the success of this project. Example: The project addresses the important need for a structured program in quality and safety for radiation oncology physics residents. This is expected to have a significant impact on their understanding as they move toward more independent practice.

| Final statement (provided when SDEP is completed)
Example: The implementation of this program has helped residents to better understand key concepts in patient safety and quality of care.
They have mastered the key concepts and have a basic facility with some of the tools for quality management. The program has also provided an opportunity for mentors to further learn these topics in detail.