By Thomas J. Petrone

Safety has to be a top priority for hospitals and health systems if they want to protect their employees and patients. Failing to comply with safety training regulations opens them up to citations, penalties, litigation, and reputational damage as well. Yet safety training is not one-size-fits-all. The types of risks faced by employees in different positions, from custodial staff to cardiologists, vary widely. Both to minimize risks and to reduce liability, hospitals must provide tailored, diversified safety training to their various employees.

This is easier said than done.

In safety training in general and in radiation safety in particular, the knowledge is there — many experts understand in fine detail the medical physics and engineering aspects of the equipment and its optimal calibration and operation. But effective safety training requires not only mastery of the content but mastery of instruction. Fewer experts are able to convey their knowledge in a way that appeals to the entire required audience. (Standing up and reading through a PowerPoint to a sprawling lecture hall may indeed allow a hospital to check the “compliance” box, but it is not how physicians, technologists, nurses, and other staff learn best.)

Instead of one massive radiation safety lecture delivered to whichever hospital employees can attend that year, safety lectures and training should take advantage of educational technologies and existing pedagogical insights. The information should be: 1) conveyed in an engaging and succinct manner, 2) pitched to the specific audience, 3) made available via different formats (think Cheryl Turner’s excellent “RadCast” continuing education podcasts), and 4) offered asynchronously to increase access. To achieve this balance and manage their risks, hospitals have started outsourcing certain aspects of their safety training.

New regulatory pressures
Starting in 2015, the Joint Commission issued increased regulatory requirements around safety in computed tomography (CT) dose optimization. Shortly after, strong requirements were introduced for fluoroscopy. Disturbing exposés about injuries from excess doses partly explain the increased regulation around CT. With fluoroscopy, over the past 10 to 15 years there’s been a non-negligible number of reports of skin burns from sophisticated fluoroscopic procedures — some of them serious enough to require skin grafts or other additional surgeries. Those reports are being acted on now, with more stringent fluoroscopy training being required in local jurisdictions in states including Texas, Massachusetts, and New York as well as the Joint Commission. For example, New York City now demands an 8-hour training for anyone who is going to do fluoroscopically guided interventional procedures. The training is fairly technical and is meant for physicians and assisting technologists who perform cardiac catheterization, cardiac ablations, and other types of therapeutic procedures that need long fluoroscopy times from machines with high output. Finding those hours is not easy.

And as the compliance requirements ramp up, so do the risks of noncompliance.

The most acute set of risks falls on the hospital or health system: the organization can face a citation if it fails to comply with the Joint Commission’s requirements. And while it usually takes more than one citation to threaten any of the hospital’s approvals, even a single citation is embarrassing. Along with the potential for bad press and impact on patient volume, a citation also triggers the need for a corrective action plan, which ties up personnel and time.

Beyond the Joint Commission, though, there’s another world of risk. If a patient sustains a medical radiation-based skin injury — no matter how complicated the procedure — and there's a lawsuit, it’s certain that their lawyer will use the discovery process to learn whether or not the individual who performed the service had the appropriate training. Depending on how widespread those gaps in training are, too, they might be used as evidence of a pattern of negligence. The financial liability here would be significant, with likely secondary impacts to the organization’s reputation and referrals.

A “stick without a carrot”
Even those hospitals and health systems that recognize the urgency of safety training compliance face a dilemma: how to motivate their physicians and staff, especially if they already have substantial experience performing the procedure they’re being trained on. Some physicians have a massive clinical case load as well as accompanying administration, and find it hard to carve out a single hour in their day. Taking an entire work day to sit in a lecture hall is impractical if not unfeasible. Perversely enough, the only real tool the hospital can use to address this impasse is to threaten to withhold clinical privileges or hold back credentials. In other words, what they have is a stick — and no carrot to speak of.

If confidence is one threat to motivation and a busy, full schedule another, a third has to be the clinicians’ own bad past experiences with deadly dull or poorly organized trainings. This is where hospitals can either put in the time and energy to refine their approach to safety training or partner with an entity that’s already done that legwork.

Features of a modern safety training program
If synchronous, undifferentiated, lengthy training sessions are the past, what does the present of radiation safety look like? And beyond its effectiveness as education, how does this type of program help hospitals manage risk?

1. It works with HR to curate personnel lists and determine who needs what training.
If a custodian disposes of a gauze pad used with radiation incorrectly, he or she may open the hospital up to a fine for improper waste handling. That employee should understand what should be done and the consequences for not doing so — but may not need a fully structured half-day on the science and mathematics behind the radiopharmaceutical trace found on the gauze. Interventional cardiologists and radiologists, on the other hand, must receive in-depth training about the effects of radiation on tissue, and they should be instructed by experts who can answer their questions.

Some radiation safety partners are now working proactively with a hospital’s human resources department to identify and assign staff to the appropriate level training. Armed with the contact information for each of these employees, the partner will also do the legwork associated with scheduling and tracking completion of the training.

2. It creates educational materials, adapts them to various formats and audiences, and capitalizes on technology to make them as accessible as possible.

Curating personnel lists according to varying levels of training is a waste of time unless you have different trainings on offer. Some partners have the radiation safety expertise and the technological sophistication to create variable content and to break larger chunks of training into shorter, accessible modules. The strongest of these will arrange shorter lectures along a progressive pathway that can be started and stopped at will.

In all cases, the more flexible the platform, the better.

3. It takes on the responsibility to monitor and document who has undergone the required training.
This feature is critical to the risk management aspect of safety training: some partners are now setting up and executing a consistent protocol to get hospital personnel up to speed on safety training. While they won’t have the same ability of the hospital’s oncology or surgery departments to pull physicians into a training, they will, at a minimum, provide the statistics to those departments and the hospitals so they know who needs to be pulled. They can also fulfill the risk management piece by showing, even in the event of an injury, that honest, consistent attempts have been made to educate that clinician about radiation safety.

An example from outside the medical realm shows how the system to ensure that all personnel get trained is as important as the training itself. Body scanners are used in some non-medical environments across the country to detect contraband, such as drugs and weapons. In one instance, a person who received radiation safety training allowed an untrained individual to operate the equipment — a breach of safety protocol that led an advocacy group to force a shutdown of the program. In this case the actual training was robust; it was a failure of certification and monitoring that caused the program to grind to a halt.

Conclusion
While hospital risk managers are dedicated to getting 100% compliance for vital safety training, the first step is to establish a programmatic approach to the training. When that programmatic approach proves difficult to do in-house, outside entities are developing the educational, technological, and reporting systems to fill that need. Acquisition of a platform can also work, provided there is an in-house individual or department that will use it to its fullest capacity. However, a platform and content alone will never serve as true risk management. An organization needs ongoing monitoring — a dynamic and continual process — if it seeks to minimize safety risks and their associated consequences. Contractually engaging an outside entity to ensure execution of a comprehensive training program in radiation safety, with measurable metrics, is a viable alternative to running the program in-house.