3280 - A Radiation Oncologist's Guide to Quality Improvement in Secondary MRI Data Sets for Treatment Planning Based on FMEA Results

Purpose/Objective(s):

Magnetic Resonance Imaging (MRI) obtained from external imaging centers for radiation therapy (RT) can suffer from suboptimal image quality and geometric inaccuracies. These issues can lead to contouring/positioning errors, or can require repeat scans, delaying treatment and compromising patient care. The goal of this project is to improve image quality and minimize the need for repeat imaging for secondary MRIs used in RT.

Materials/Methods:

Failure Mode and Effects Analysis (FMEA) was used to identify common causes of poor MRI quality and rank them in order of impact based on occurrence, severity and detectability. Failure modes related to poor MRI quality, incorrect protocols, and scheduling delays were identified. We formed a multidisciplinary imaging quality team and introduced radiation oncology MR protocols review, standardized imaging orders, staff training, and machine quality checks to ensure adherence to RT needs and reduce repeat imaging.

Results:

FMEA identified 15 primary failure modes contributing to suboptimal image quality or workflow delays. The 2 highest Risk Priority Numbers (RPNs) and 5 of the top 10 RPNs were related to an order placed by internal or external medical staff. The highest RPNs were observed due to incorrect ordering for a diagnostic rather than a treatment planning (TP) MRI (RPN=245) and insufficient protocol optimization for TP scans (RPN=200). Additional failures at lower RPNs were found related to fiducial placements and quality control.

In response, we trained non-physician staff on TP’s imaging dataset requirements, created standardized imaging order forms, established QC checks, and performed a thorough review of RT MRI protocols. Staff were trained to check parameters relevant to RT planning. After implementation, the need for repeat MR scans fell from 5–10 per year to 0 in the following year, demonstrating how FMEA-based interventions and an MRI quality management program can enhance MRI quality for RT planning.

Conclusion:

By utilizing FMEA and instituting quality management protocols, we reduced the need for repeat MRIs and developed a framework for others to do their own FMEA. However, we suspect that the issues uncovered are not uncommon and certain steps can be taken to optimize the quality of MRIs received from outside centers based on our own investigation. These include, but are not limited to, standardization of templates for RT imaging orders, education of medical staff to properly use orders for patients who are likely to undergo RT, collaboration between specialties, education of staff regarding different needs of RT and diagnostic imaging, establishment of clear communication lines, performance by medical physicists of QC processes such as end to end testing and geometric distortion correction evaluation, and utilization of MR specific fiducials for RT fusions. FMEA and proactive collaboration has the potential to improve MRIs used for TP and to decrease the need for repeat imaging, benefiting the patient and the departments.