quality in medical physics and beyond.amos3.aapm.org/abstracts/pdf/97-25907-353470-109866.pdf13...
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Quality in Medical Physics and Beyond.
Peter DunscombeUniversity of Calgary
AAPM Spring Clinical Meeting: 8th March 2015
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Disclosure
Peter Dunscombe
Director, TreatSafely, LLCDirector, Center for the Assessment of
Radiological Sciences.Occasional Consultant to IAEA and Varian.
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Objectives
• To explore the concept of quality in radiotherapy.
• To describe Donabedian’s dimensions of quality.
• To examine selected quality indicators in the U S, Europe and developing countries.
• To take a peek the AAPM’s Safety Profile Assessment results.
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Quality in Medical Physics and Beyond
Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Spring Clinical Meeting, March 2015
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
What is Quality?
Evidence for Quality?
Information about Quality?
What constitutes Quality?
Quality in Medical Physics and Beyond
Spring Clinical Meeting, March 2015
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
OutcomeSpring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
![Page 7: Quality in Medical Physics and Beyond.amos3.aapm.org/abstracts/pdf/97-25907-353470-109866.pdf13 Evidence for Quality? Evidence for Quality QA makes a clinical trial stronger: evidence-based](https://reader033.vdocuments.site/reader033/viewer/2022042311/5ed9005c6714ca7f4768f63d/html5/thumbnails/7.jpg)
Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
Outcome
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Accreditation
QUATRO
APEx
SPA
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
What is Quality?
Evidence for Quality?
Information about Quality?
What constitutes Quality?Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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What is Quality?
What is Quality?
• Quality of care is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
• Institute of Medicine. Volume 1. Committee to Design a Strategy for Quality Review and Assurance in Medicine, Institute of Medicine. Lohr, K. ed. Medicare: A Strategy for Quality Assurance. Washington, D.C.: National Academy Press,1990
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What is Quality?
Quality in Radiotherapy
• The degree to which radiotherapy is consistent with current professional knowledge
• The prescription is appropriate, i.e. evidence based.
• The prescription is delivered within consensus determined tolerances.
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
What is Quality?
Evidence for Quality?
Information about Quality?
What constitutes Quality?Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Evidence for Quality?
Evidence for Quality
QA makes a clinical trial stronger: evidence-based medicine in radiation therapy
Weber D, Tomsej M, Melidis C, Hurkmans C. Radiotherapy and Oncology 105 (2012) 4-8
• Analyzed 9 prospective clinical trial reports of violations and outcomes.• Major deviation rates from 11.8% to 48%• Major deviations (n=22) included:
• Excessive or incomplete tumor coverage.• 90% isodose surface not encompassing the planning target volume.• Total delivered dose of ±10% of prescribed randomized dose.• The use of block margins >5 cm.
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Evidence for Quality?
“These QA data stemming from prospective clinical trials show undisputedly that non adherence to protocol specified RT requirements is associated with reduced survival, local control and potentially increased toxicity.”
QA makes a clinical trial stronger: evidence-based medicine in radiation therapy
Weber D, Tomsej M, Melidis C, Hurkmans C. Radiotherapy and Oncology 105 (2012) 4-8
Evidence for Quality
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
What is Quality?
Evidence for Quality?
Information about Quality?
What constitutes Quality?Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Information about Quality?
Information about Quality?
Measuring the Quality of Care in Radiation OncologyJames A. Hayman, MD, MBA
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What is Quality?
Quality in Radiotherapy
• The degree to which radiotherapy is consistent with current professional knowledge
• The prescription is appropriate, i.e. evidence based.
• The prescription is delivered within consensus determined tolerances.
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Information about Quality?
Information about Quality?
• That safety in radiotherapy matters is self-evident.• We will explore the relationship between quality and
safety. • If we can convince ourselves that quality and safety
are largely different ways of looking at the same issue, i.e. the best outcome for the patient, then we can apply the recommendations for safer radiotherapy to quality radiotherapy.
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Information about Quality?
Quality in Radiotherapy
• The degree to which radiotherapy is consistent with current professional knowledge
• The prescription is appropriate, i.e. evidence based.
• The prescription is delivered within consensus determined tolerances.
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Information about Quality?
To explore this let’s just look at the technical aspects of radiation therapy:
Is the prescription delivered within consensus determined tolerances?
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Quality in Radiotherapy
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Information about Quality? 21
TargetDose
Benefit
Underdose Overdose
Our preferred world view: all patients receive beneficial treatments?
Our world view following the NYT articles: almost all patients receive beneficial treatments with a miniscule
number subject to harm?
Quality in Radiotherapy
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Information about Quality? 22
Or is this more realistic: there’s a continuous distribution from beneficial treatments to harmful treatments?
Benefit
Underdose OverdoseTargetDose
Quality in Radiotherapy
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If you believe this distribution there is no clear demarcation between quality radiotherapy and unsafe radiotherapy. Unsafe conditions can be viewed as a major compromise of quality.
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Harm Harm
Benefit
Underdose Overdose Target Dose
Quality in Radiotherapy
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Information about Quality?
What are we trying to accomplish?
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TargetDose
Harm Harm
Benefit
Underdose Overdose
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Information about Quality?
Information about Quality?
So, if you accept the relationship between quality and safety we can adopt many of the measures aimed at improving safety to improve quality too.
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
What is Quality?
Evidence for Quality?
Information about Quality?
What constitutes Quality?Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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What constitutes Quality?
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What constitutes Quality?
Report AdviceTowards safer Radiotherapy 37
Radiotherapy Risk Profile 15Preventing Accidental ….. 15Hendee and Herman 20Heirarchy of Actions 19ASTRO 6TG 100 5
Total 117
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What constitutes Quality?
Training (7)
Staffing/skills mix(6)
Documentation/SOP (5)
Incident Learning System (5)
Communication/questioning (4)
Check lists (4)
QC and PM (4)
Dosimetric Audit(4)
Accreditation (4)
Minimizing interruptions (3)
Prospective risk assessment (3
Safety Culture (3)
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
OutcomeSpring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Donabedian’s Outcomes Model
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• University of Michigan 1961-2000• Founder of the study of quality in
health care.• Coined the term “outcomes” to
refer to patient follow-up assessment.
• Modeled quality based on structure, process, and outcome.
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Care Process
Donabedian’s Outcomes Model
• Structure: all factors affecting care delivery.
• Process: all actions making up healthcare.
• Outcome: all effects on patients or populations.
Antecedent Conditions
Structure
Care Process Outcome
Patient Safety Management
Adapted from Battles 2003.
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
OutcomeSpring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Donabedian: Structure
Structure
• The necessary, but not sufficient, fundamentals of an organization for the delivery of quality.
• Fundamentals need to be present irrespective of volume.
• Providing an adequate structure is a management function.
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Donabedian: Structure
Structure
Examples of structural fundamentals are:• Equipment: e.g. calibrated linac inventory.• Staffing: appropriate numbers/ competence• Documentation: current and high quality
And• Radiation Safety Committee.• Staff continuing professional development program.• Safety Culture.
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
OutcomeSpring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Donabedian: Process
Process
• Processes happen within the structure and are focused on individual units (patients or equipment).
• # processes is volume dependent.• Processes are carried out by front line staff.
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Donabedian: Process
Process
Examples of processes are:• Controlling the quality of a particular linac.• Verifying the dose for an IMRT patient.
And• Planning a treatment for a patient• Delivering a treatment to a patient.
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
OutcomeSpring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Donabedian: Outcome
Outcome
• Measures of the effectiveness of the system• Outcomes can be patient related or
organizational
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Donabedian: Outcome
Patient Related Outcomes
Examples of Patient Related Outcomes are:• Survival.• Quality of life.• Re-admissions.• Patient satisfaction.
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Donabedian: Outcome
Organizational Outcomes
Examples of Organizational Outcomes• Postal dosimetry (IAEA program).• IROC Houston (formerly RPC) phantom results.And• Misadministrations.• Participation in advanced training• Publications.• Accreditation recommendations.
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Donabedian: Outcome
Organizational Outcomes
Examples of Organizational Outcomes• Postal dosimetry (IAEA program).• IROC Houston phantom results.
Organizational outcomes should be used in a feedback loop to improve the structure and process dimensions of quality.
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
Outcome
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Medical Physics Quality: Structure, Equipment
Global treatment machine inventory
Low and middle income countries* encompass 82% of the world’s population and experience 57% of the world’s cancer cases.One treatment machine per 1.4 x 106 inhabitants.
*GNI per capita ≤ $12,745 per annum
Clin Onc 27 (2015) 107-114
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Medical Physics Quality: Structure, Equipment
European treatment machine inventory
Radiotherapy and Oncology 112 (2014) 155-64
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Medical Physics Quality: Structure, Equipment
US treatment machine inventory
An Elekta presentation at ESTRO in 2012 stated that there were 12 machines per 106
Inhabitants in the US.
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Medical Physics Quality: Structure, Equipment
Treatment machine inventory
• Global (LMIC): 1.4 machines per 106
inhabitants• Europe: 5.3 (median) machines per 106
• US: 12 machines per 106
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49
Medical Physics Quality: Structure, Equipment
But, availability ≠ access
• Global (LMIC): 1.4 machines per 106
inhabitants• Europe: 5.3 (median) machines per 106
• US: 12 machines per 106
Treatment machine inventory
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50
Medical Physics Quality: Structure, Equipment
Currently 96% of results are within 5% acceptance limit after follow-up
Global (IAEA) machine calibration accuracy
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Medical Physics Quality: Structure, Equipment
European (France) machine calibration accuracy
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
88.0
90.0
92.0
94.0
96.0
98.0
2009 2010 2011 2012 2013 2014 2015
Res
ults
ove
r the
10%
lim
it (%
)
Res
ults
with
in 5
% li
mit
(%)
Year
Tests in France (mandatory - every 3 years)δ < 5%
δ > 10%
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52
Medical Physics Quality: Structure, Equipment
US (IROC) machine calibration accuracy
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53
Medical Physics Quality: Structure, Staffing
Global Medical Physics staffing
• Data from the DIRAC (IAEA) database –probably an underestimate.
• DIRAC (LMIC)*: 0.6 physicists per 106
population
*GNI per capita ≤ $12,745 per annum
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54
Medical Physics Quality: Structure, Staffing
European Medical Physics staffing
Radiotherapy and Oncology. 112 (2014) 178-86
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55
Medical Physics Quality: Structure, Staffing
U S Medical Physics staffing
• U S population: 320 x 106
• AAPM Therapy Physicists: 4200• 13 Medical Physicists per 106 inhabitants
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56
Medical Physics Quality: Structure, Staffing
Medical Physics staffing
• Global (LMIC): 0.6 physicists per 106 population• Europe: 11 physicists per 106 population• U S: 13 physicists per 106 population
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57
Medical Physics Quality: Structure, Staffing
But, quan�ty ≠ quality
• Global (LMIC): 0.6 physicists per 106 population• Europe: 11 physicists per 106 population• U S: 13 physicists per 106 population
Medical Physics staffing
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58
Medical Physics Quality: Structure, Documentation
Medical Physics: Structure: Documentation
58
Basic Cause Distribution
0
10
20
30
40
50
60
70
80
90
1 2 3 4 5 6 7 8 9 N/A
Basic Cause
Perc
enta
ge o
f Clin
ical
Rep
orts
Centre A
Centre B
1 Standards/Procedures Practices
2 Materials/Tools/Equipment3 Design4 Planning5 Communication6 Knowledge/Skill7 Capabilities8 Judgment9 Natural Factors
A comparison of the relative frequencies of Basic Causes of Incidents in two centres.
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59
Medical Physics Quality: Structure, Documentation
Medical Physics: Structure: Documentation
Most documented processes from 114 Safety Profile Assessment surveys
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60
Medical Physics Quality: Structure, Documentation
Medical Physics: Structure: Documentation
Least documented processes from 114 Safety Profile Assessment surveys
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61
Medical Physics Quality: Structure
Medical Physics: Structure
Opportunities for improvement • Equipment: More emphasis on machine
calibration at commissioning?• Staffing: More accessible approaches to
training and skill development?• Documentation: Boilerplate documents?
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
Outcome
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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63
Medical Physics Quality: Process
Could this be true?Medical Physics: Process: IMRT
7% and 4mm
Med Phys 40, 022101 (2013); doi: 10.1118/1.4773309
RPC/IROC H & N Phantom Results
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64
Medical Physics Quality: Process
Medical Physics: Process: IMRT
“The most common acceptance criteria and published actions levels therefore have insufficient, or at least unproven, predictive power for per-patient IMRT QA.”Per-beam, planar IMRT QA passing rates do not predict clinically relevant patient dose errorsNelms BE, Zhen H, Tome WA. Med Phys 38 (2011) 1037 – 1044
“The results of this study raise questions on the efficiency of IMRT patient specific checks in detecting important errors for the treatment outcome.”Relating dosimetric outcome to compliance with patient specific quality control in IMRTRangel A, Dunscombe P. Radioth Oncol 99 (Suppl 1) (2011) S512
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Medical Physics Quality: Process
Medical Physics: Process
Opportunities for improvement• Better understanding of process issues: TG-
100• Standardization: MPPG, i.TS• More research into the connection between
outcomes and QA.
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Medical Physics Quality: Process
Medical Physics: Process: TG 100
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67
Medical Physics Quality: Process
Medical Physics: Process: MPPG
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68
Medical Physics Quality: Process
Medical Physics: Process: i.treatsafely
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Structure
Process
Outcome
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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70
Medical Physics Quality: (Organizational) Outcome
Medical Physics: Outcome
Since 1969 the IAEA Dosimetry Laboratory has provided dosimetry audits to 2,150 radiotherapy
centres in low and middle income countries. This required 11,000 sets of TLDs
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Medical Physics Quality: (Organizational) Outcome
Medical Physics: Outcome
• IROC Houston worldwide monitoring– 3,237 distinct RT sites in database– 63% (2,046) monitored beam calibration
• ~14,000 – 15,000 beams annually– 33% (1,055) performed IMRT E2E phantom audit
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Medical Physics Quality: (Organizational) Outcome
Medical Physics: Outcome
We appreciate that among the about 1000 European centres, 70% at least have external dosimetry audits performed by national or international organisms.
Attila VERESEqual-Estro
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Medical Physics Quality: (Organizational) Outcome
Medical Physics: Outcome
• An external audit of radiation output is performed annually on all therapeutic beams: 94/114
• An external audit of radiation output is performed prior to clinical implementation of new treatment delivery equipment: 72/114
1.Strongly Agree 2. Agree 3. Neutral 4. Disagree 5. Strongly Disagreeê ê
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Medical Physics Quality: Structure, Equipment
Machine Physics: Outcome
• Global: >25% of centers monitored by IAEA• Europe: 70% of centers monitored.• U S (per IROC Houston database):
1628 institutions monitored by IROC Houston 793 institutions monitored by RDS
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Medical Physics Quality: (Organizational) Outcome
Medical Physics: Outcome
Opportunities for improvement:• Greater participation in dosimetry audits,
particularly at commissioning?• More comprehensive (non-reference
conditions) dosimetry audits.• Physics peer review.
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Medical Physics Quality: (Organizational) Outcome
Medical Physics: Outcome
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Accreditation
QUATRO
APEx
SPA
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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78
Radiotherapy Program Quality: Accreditation/Auditing
Data Source Document and Website Link Country/Region
American College of Radiation Oncology (ACRO)
Radiation Standards Medical Physics (external beam therapy) United States
American College of Radiology (ACR) Practice Guideline For Radiation Oncology United States
Canadian Partnership for Quality Radiotherapy
Quality Assurance Guidance for Canadian Radiation Treatment Programs
Canada
European Commission Guideline on Clinical Audit
European Guidelines on Clinical Audit for Medical Radiological Practices (Diagnostic Radiology, Nuclear Medicine and Radiotherapy)
Europe
IAEA (Quality Assurance Team for Radiation Oncology (QUATRO)
Comprehensive Clinical Audits of Diagnostic Radiology Practices: A Tool for Quality Improvement 1
International
National Cancer Review Programme Manual for Cancer Services (NCAT)
Manual for Cancer Services 2008: Radiotherapy Measures (Version 2)
United Kingdom
Royal Australian and New Zealand College of Radiologists (RANZCR)
Tripartite Radiation Oncology Practice Standards Australia, New Zealand
Practical Radiation Oncology 4 (2014) 208=2014
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79
Radiotherapy Program Quality: Accreditation/Auditing
Therapy
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80
Radiotherapy Program Quality: Accreditation/Auditing
• 7 accreditation/auditing protocols• 5 evaluators• 454 indicators/standards
Structure: 64%Process: 26%
Outcome: 10%Practical Radiation Oncology 4 (2014) 208=2014
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Accreditation
QUATRO
APEx
SPA
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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Radiotherapy Program Quality: QUATRO
QUATRO audit procedures
• Auditors: RO, MP, RTT• Typically 5 days per RT centre• Entrance briefing• Assessment: tour of facility, staff
interviews, review & evaluation of procedures and documentation, measurements, tests, observation of practical work
• Exit briefing: feedback to the department, preliminary recommendations, questions, discussion.
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Radiotherapy Program Quality: QUATRO
QUATRO missions
lower middle incomeupper middle incomehigh income
• Training of auditors and regional QUATRO workshops in all regions • 70 QUATRO missions to date: Africa – 6; Asia – 18; Europe – 30 + 3 re-audits;
Latin America – 13
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Radiotherapy Program Quality: QUATRO
QUATRO audit procedures
84
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Radiotherapy Program Quality: QUATRO
QUATRO: selected preliminary results
• 30 audits – mainly Eastern Europe• 742 recommendations (7-83)Frequent recommendations• more or replacement machines• education, training, development• quality management• documentation
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Accreditation
QUATRO
APEx
SPA
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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87
Radiotherapy Program Quality: APEx
RT Program Quality: APEx
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Radiotherapy Program Quality: APEx
RT Program Quality: APEx
Standard 12: Quality Management of Treatment Procedures and Modalities
The radiation oncology practice (ROP) operates a comprehensive quality management program and safe practices for each treatment procedure and modality.
The ROP's comprehensive quality management program for each treatment procedure and modality:
12.1 Is consistent with American Association of Physicists in Medicine (AAPM) or equivalent body standards of practice for:
12.1.1 External beam radiation therapy dosimetry, mechanical, safety and respiratory management checks. 12.1.2 Brachytherapy dosimetry, mechanical and safety checks. 12.1.3 Quality assurance of measurement equipment.12.1.4 Acceptance testing, clinical commissioning and clinical release.12.1.5 End to end dosimetric system testing.12.1.6 Simulation dosimetry, mechanical, safety and respiratory management checks.
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Radiotherapy Program Quality: APEx
At the Miami Meeting, Dr. Tripuraneni reported that• Since 1986 only 240 out of 2000 US Radiation
Therapy facilities were accredited.
• Only two States actually require accreditation with a third one thinking about it.
• A major cause of failing to satisfy accreditation criteria was inadequate QA on the treatment planning system.
• This system has now been discontinued.
89
ACR/ASTRO Audits
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Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Accreditation
QUATRO
APEx
SPA
Spring Clinical Meeting, March 2015
Quality in Medical Physics and Beyond
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91
Radiotherapy Program Quality: SPA
Safety Profile Assessment
SPA is a Safety Profile self Assessment Tool developed by the AAPM’s Work Group on the Prevention of Errors in Radiation Oncology.
91
spa.aapm.org
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Radiotherapy Program Quality: SPA
Safety Profile Assessment
4 topic areas92 questions
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93
Radiotherapy Program Quality: SPA
Safety Profile Assessment
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Radiotherapy Program Quality: SPA
View results by questionCompare to others
Safety Profile Assessment
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Radiotherapy Program Quality: SPA
Tracking improvement over time
Year 1Year 2
Safety Profile Assessment
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Radiotherapy Program Quality: SPA
SPA results
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16APEX Primary Standard
SPA and APEX
APEX
SPA
1. Patient evaluation, care coordination, follow-up2. Treatment planning3. Patient specific safety interventions7. Culture of safety12. Quality management
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Radiotherapy Program Quality: SPA
SPA results
Highest compliance from 114 Safety Profile Assessment surveys
1.Strongly Agree 2. Agree 3. Neutral 4. Disagree 5. Strongly Disagreeê
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Radiotherapy Program Quality: SPA
SPA results
Lowest compliance from 114 Safety Profile Assessment surveys
1.Strongly Agree 2. Agree 3. Neutral 4. Disagree 5. Strongly Disagreeê
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Quality in Medical Physics and Beyond
Quality
Donabedian
Medical Physics Quality
Radiotherapy Program Quality
Bottom Lines
Spring Clinical Meeting, March 2015
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Radiotherapy Program Quality: SPA
Bottom Lines: Structure
✔Nationally, no shortage of machines.✔Opportunities exist to ensure calibration accuracy.
Independent validation at commissioning✔Nationally, no shortage of medical physicists.✔Opportunities to upgrade education and skills.? More effort required on documentation (SOPs)
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Radiotherapy Program Quality: SPA
Bottom Lines: Process
✔TG-100 will help focus on process.✔Medical Physics Practice Guidelines should help standardize processes.
Less craftsman and more equivalent actor.(More emphasis on following SOPs.)? More research on the relationship between QA/QC and patient outcome.
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Radiotherapy Program Quality: SPA
Bottom Lines: Outcome
✔APEx provides an independent assessment of some dimensions of quality.✔AAPM’s Safety Profile Assessment is an accessible, low resource QI tool.
More emphasis on physics peer review.? Medical Physicists need to get more involved in developing and promoting the quality agenda.
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Acknowledgements
• Noémie Defourney (HERO)• David Followill (IROC)• Eric Ford for SPA (UW)• Cai Grau (HERO)• Joanna Izweska (IAEA)• Yolande Lievens (HERO)• Steve Sutlief (UCSD)• Attila Veres (Equal-Estro)• Eduardo Zubizarreta (IAEA)