Towards Safer Radiotherapy

Recommendation
All procedures should be documented and subject to review every two years or whenever
there are significant changes.
The radiotherapy department management structure should be reviewed every two years.
4.3.4 While the radiotherapy department can ensure the establishment of a quality management
system, it is vital that it is supported by the healthcare organisation at the highest level.
Responsibility for the control of the quality management system should be vested in a quality
management representative, appointed by the healthcare organisation, who is entrusted
with the necessary authority together with senior managers from the relevant operational
sections. The quality management representative should be a member of the radiotherapy
risk management committee which reports directly or ultimately to the clinical governance/
clinical risk assurance committee at the executive level of the healthcare organisation. Quality
policy and objectives should be reviewed at least annually. This review will include setting
objectives for the coming year that will demonstrate commitment to continual improvement.
28
Recommendation
Quality policy and objectives should be reviewed at least annually and reported to a
management representative appointed by the healthcare organisation.
4.3.5 For a quality management system to be effective, participation of all personnel within the
radiotherapy centre must be mandatory, and knowledge and understanding of the quality
policy disseminated to all staff. This should include training in how errors may occur in
radiotherapy and how they may be detected and prevented.
Recommendation
Training in the operation of the quality management system should be part of the
mandatory induction for all staff in each radiotherapy centre.
4.3.6 The IR(ME)R require detailed accountability. 32 This requirement may be fulfilled by a quality
system, but only after revision in the light of the regulations. A radiotherapy department
working under an accredited quality system will not necessarily satisfy all the requirements of
IR(ME)R.
4.3.7 Documentation
A key element of a quality system is its supporting documentation which must be maintained
by a robust system for document control. The documents should include:
• Quality management procedures and protocols (standardised operating procedures)
• Detailed work instructions
• Data sheets (such as machine output factors)
• Departmental forms, such as radiotherapy treatment request forms
Towards Safer Radiotherapy