Research Article

Process management and safety culture in radiotherapy services: impacts on quality patient care and safety

José Carlos de Toledo; Livia Silveira Almeida; Fabiane Letícia Lizarelli

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Paper aims: Analyzes the use of process management and safety culture practices in Radiotherapy Services and impacts on quality of patient care and safety.

Originality: Radiotherapy processes require controls and must be developed in an environment with safety. However, despite necessary practices, there are few studies that analyze their implementation and impacts.

Research method: Was conducted a survey and the data were analyzed using descriptive statistics and SEM-PLS.

Main findings: Process management practices and safety culture have been used in response to competitive environment and regulatory guidelines. The study confirmed the positive impact of using safety culture and process management practices.

Implications for theory and practice: Managerial support promoting management and improvement practices and safety culture, along use of process maps, feedback in response to incident reports, patient satisfaction surveys and teamwork contributes to the quality of care and safety. These practices can be prioritized to be deployed by managers and in theoretical models.


Process management, Safety culture, Radiotherapy services, Care quality, Patient safety


Advisory Committee on the Safety of Nuclear Installations - ACSNI, Study Group on Human Factor. (1993). Organizing for Safety: third report of the Advisory Committee on the Safety of Nuclear Installations, HSE Books: Sudbury. London.

Agency for Healthcare Research and Quality - AHRQ. (2016). Hospital survey on patient safety culture. Retrieved in 2022, July 19, from

American Society for Radiation Oncology - ASRO. (2019). Safety is no accident: a framework for quality radiation oncology care. Retrieved in 2022, July 19, from

Baume, P. (2002). Report of the radiation oncology inquiry: a vision for radiotherapy. Canberra: Commonwealth of Australia.

Campione, J., & Famolaro, T. (2017). Promising Practices for Improving Hospital Patient Safety Culture. Joint Commission Journal on Quality and Patient Safety, 44(1), 23-32. PMid:29290243.

Chandrasekaran, A., Senot, C., & Boyer, K. K. (2012). Process Management Impact on Clinical and Experiential Quality: managing tensions between safe and patient-centered healthcare. Manufacturing & Service Operations Management, 14(4), 548-566.

Chang, S., Chen, W., Teng, T., Yeh, C. Y., & Yen, H. C. (2019). Fall risk program for oncology inpatients: addition of the “traffic light” fall risk assessment tool. Journal of Nursing Care Quality, 34(2), 139-144. PMid:30198946.

Chen, E., Arnone, A., Sillanpaa, J., Yu, Y., & Mills, M. D. (2015). A special report of current state of the medical physicist workforce - results of the 2012 ASTRO Comprehensive Workforce Study. Journal of Applied Clinical Medical Physics, 16(3), 5232. PMid:26103483.

Chera, B. S., Mazur, L., Buchanan, I., Kim, H. J., Rockwell, J., Milowsky, M. I., & Marks, L. B. (2015). Improving patient safety in clinical oncology applying lessons from normal accident theory. JAMA Oncology, 1(7), 958-964. PMid:26182183.

Chiew, K., Sundaresan, P., Jalaludin, B., & Vinod, S. K. (2018). A narrative synthesis of the quality of cancer care and development of an integrated conceptual framework. European Journal of Cancer Care, 27(6), e12881. PMid:30028054.

Cionini, L., Gardani, G., Gabriele, P., Magri, S., Morosini, P. L., Rosi, A., & Viti, V. (2007). Quality indicators in radiotherapy. Radiotherapy and Oncology: Journal of the European Society for Therapeutic Radiology and Oncology, 82(2), 191-200. PMid:17267059.

Deufel, C. L., McLemore, L. B., Fong de Los Santos , L. E., Classic, K. L., Park, S. S., & Furutani, K. M. (2017). Patient safety is improved with an incident learning system—Clinical evidence in brachytherapy. Radiotherapy and Oncology: Journal of the European Society for Therapeutic Radiology and Oncology, 125(1), 94-100. PMid:28823406.

Emanuel, L., Berwick, D., Conway, J., Combes, J., Hatlie, M., Leape, L., Reason, J., Schyve, P., Vincent, C., & Walton, M. (2009). What exactly is patient safety? Journal of Medical Licensure Discipline, 95(1), 13-24.

Fong de Los Santos, L. E., Evans, S., Ford, E. C., Gaiser, J. E., Hayden, S. E., Huffman, K. E., Johnson, J. L., Mechalakos, J. G., Stern, R. L., Terezakis, S., Thomadsen, B. R., Pronovost, P. J., & Fairobent, L. A. (2015). Medical physics practice guideline: development, implementation, use and maintenance of safety checklists. Journal of Applied Clinical Medical Physics, 16(3), 5431. PMid:26103502.

Gabriele, P., Malinverni, G., Bona, C., Manfredi, M., Delmastro, E., Gatti, M., Penduzzu, G., Baiotto, B., & Stasi, M. (2006). Are quality indicators for radiotherapy useful in the evaluation of service efficacy in a new-based radiotherapy institution? Tumori, 92(6), 496-502. PMid:17260490.

Gouvêa, C., & Travassos, C. (2010). Indicadores de segurança do paciente para hospitais de pacientes agudos: revisão sistemática. Cadernos de Saúde Pública, 26(6), 1061-1078. PMid:20657973.

Hair, J. F., Risher, J. J., Sarstedt, M., & Ringle, C. M. (2019). When to use and how to report the results of PLS-SEM. European Business Review, 31(1), 2-24.

Hair, J. F., Tomas, G., Hult, M., Ringle, C. M., & Sarstedt, M. (2017). A primer on partial least squares structural equation modeling (PLS-SEM). Thousand Oaks: Sage.

Halligan, M., & Zecevic, A. (2011). Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ Quality & Safety, 20(4), 338-343. PMid:21303770.

Heinrich Heine Universität - HHU. (2022). G*Power: statistical power analyses for Mac and Windows. Düsseldorf. Retrieved in 2022, July 19, from

Hendee, W., & Herman, M. (2011). Improving patient safety in radiation oncology. Medical Physics, 38(1), 78-82. PMid:21361177.

Huq, M. S., Fraass, B. A., Dunscombe, P. B., Gibbons Junior, J. P., Ibbott, G. S., Mundt, A. J., Mutic, S., Palta, J. R., Rath, F., Thomadsen, B. R., Williamson, J. F., & Yorke, E. D. (2016). The report of Task Group 100 of the AAPM: application of risk analysis methods to radiation therapy quality management. Medical Physics, 43(7), 4209-4262. PMid:27370140.

Institute of Medicine - IM, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academic Press.

Institute of Medicine - IM. (2000). To err is human: building a safer health system. Washington, DC: National Academies Press.

International Atomic Energy Agency - IAEA. (1991). Safety culture (Safety-Series, No. 75-INSAG-4). Vienna: International Safety Advisory Group.

International Atomic Energy Agency - IAEA. (2007). Comprehensive audits of radiotherapy practices: a tool for quality improvement. Vienna: Quality Assurance Team for Radiation Oncology (QUATRO).

International Atomic Energy Agency - IAEA. (2008). Setting up a radiotherapy programme STI/PUP 1296. Vienna.

International Atomic Energy Agency - IAEA. (2016). A newsletter on patient safety in radiotherapy. Retrieved in 2022, July 19, from

International Atomic Energy Agency - IAEA. (2019). Updates on patient safety in radiotherapy. Retrieved in 2022, July 19, from

Kapur, A., & Potters, L. (2012). Six sigma tools for a patient safety-oriented, quality-checklist driven radiation medicine department. Practical Radiation Oncology, 2(2), 86-96. PMid:24674084.

Klein, E., Drzymala, R., Purdy, J., & Michalski, J. (2005). Errors in radiation oncology: a study in pathways and dosimetric impact. Journal of Applied Clinical Medical Physics, 6(3), 81-94. PMid:16143793.

Kohlbacher, M. (2010). The effects of process orientation: a literature review. Business Process Management Journal, 6(1), 135-152.

Kolybaba, M., Kron, T., Harris, J., O’Brien, P., & Kenny, L. (2009). Survey of radiation oncology centers in Australia: report of the Radiation Oncology Treatment Quality Program. Journal of Medical Imaging and Radiation Oncology, 53(4), 382-395. PMid:19695046.

Kron, T., Dwyer, M., Smith, L., MacDonald, A., Pawsey, M., Raik, E., Arnold, A., Hill, B., & Duchesne, G. M. (2015). The development of practice standards for radiation oncology in Australia: a tripartite approach. Clinical Oncology, 27(6), 325-329. PMid:25669589.

Kusano, A., Nyflot, M., Zeng, J., Sponseller, P. A., Ermoian, R., Jordan, L., Carlson, J., Novak, A., Kane, G., & Ford, E. C. (2015). Measurable improvement in patient safety culture: a departmental experience with incident learning. Practical Radiation Oncology, 5(3), e229-e237. PMid:25413404.

Leonard, S., & O’Donovan, A. (2018). Measuring safety culture: application of the hospital survey on patient safety culture to radiotherapy departments worldwide. Practical Radiation Oncology, 8(1), e17-e26. PMid:28967578.

Lindberg, D., Prosperi, M., Bjarnadottir, R., Thomas, J., Crane, M., Chen, Z., Shear, K., Solberg, L. M., Snigurska, U. A., Wu, Y., Xia, Y., & Lucero, R. J. (2020). Identification of important factors in an inpatient fall risk prediction model to improve the quality of care using EHR and electronic administrative data. International Journal of Medical Informatics, 143, 104272. PMid:32980667.

Liu, S., Bush, K. K., Bertini, J., Fu, Y., Lewis, J. M., Pham, D. J., Yang, Y., Niedermayr, T. R., Skinner, L., Xing, L., Beadle, B. M., Hsu, A., & Kovalchuk, N. (2019). Optimizing efficiency and safety in external beam radiotherapy using automated plan check (APC) tool and six sigma methodology. Journal of Applied Clinical Medical Physics, 20(8), 56-64. PMid:31423729.

Lohr, K., & Schroeder, S. (1990). A strategy for quality assurance in Medicare. The New England Journal of Medicine, 322(10), 707-712. PMid:2406600.

López Torrecilla, J., Marín I Borràs, S., Ruiz-Alonso, A., Jaen Olasolo, J., Vázquez de la Torre, M. L., Bóveda Carro, E., Rodríguez, A., Ignacio García, E., Caballero Martínez, F., Campos Lucas, F. J., Lara Jiménez, P. C., Martínez, J. C., & Ferrer Albiach, C. (2019). Quality indicators in radiation oncology: proposal of the Spanish Society of Radiation Oncology for a continuous improvement of the quality of care in oncology. Clinical & Translational Oncology, 21(4), 519-533. PMid:30311145.

Mancosu, P., Nicolini, G., Goretti, G., De Rose, F., Franceschini, D., Ferrari, C., Reggiori, G., Tomatis, S., & Scorsetti, M. (2018). Applying Lean-Six-Sigma Methodology in radiotherapy: Lessons learned by the breast daily repositioning case. Radiotherapy and Oncology : Journal of the European Society for Therapeutic Radiology and Oncology, 127(2), 326-331. PMid:29523411.

Mancosu, P., Signori, C., Clerici, E., Comito, T., D’Agostino, G. R., Franceschini, D., Franzese, C., Lobefalo, F., Navarria, P., Paganini, L., Reggiori, G., Tomatis, S., & Scorsetti, M. (2021). Critical re-evaluation of a failure mode effect analysis in a radiation therapy department after ten years. Practical Radiation Oncology, 11(3), e329-e338. PMid:33197646.

Marks, L., Jackson, M., Xie, L., Chang, S. X., Burkhardt, K. D., Mazur, L., Jones, E. L., Saponaro, P., Lachapelle, D., Baynes, D. C., & Adams, R. D. (2011). The challenge of maximizing safety in radiation oncology. Practical Radiation Oncology, 1(1), 2-14. PMid:24673862.

Martin, L., Nelson, E., Lloyd, R., & Nolan, T. (2007). Whole system measures (IHI Innovation Series White Paper). Massachusetts: Institute for Healthcare Improvement. Retrieved in 2022, July 19, from

National Patient Safety Foundation - NPSF. (2008). Retrieved in 2022, July 19, from

Norsa’adah, B., Rampal, K., & Mohd Amin, R. (2021). Time taken for symptom recognition, first consultation, diagnosis and first definitive treatment and its associated factors among women with breast cancer. Asian Pacific Journal of Cancer Prevention, 22(11), 3623-3631. PMid:34837921.

Podsakoff, P., Mackenzie, S., Lee, J. Y., & Podsakoff, N. P. (2003). Common methods biases in behavioral research: A critical review of the literature and recommended remedies. The Journal of Applied Psychology, 88(5), 879-903. PMid:14516251.

Radicchi, L. A., Toledo, J. C., & Alliprandini, D. H. (2020). Critical success factors for implementation of an incident learning system in radiation oncology department. Reports of Practical Oncology and Radiotherapy : Journal of Greatpoland Cancer Center in Poznan and Polish Society of Radiation Oncology, 25(6), 994-1000. PMid:33132764.

Richard, M., Parmar, M., Calestagne, P., & McVey, L. (2010). Seeking patient feedback an important dimension of quality in cancer Care. Journal of Nursing Care Quality, 25(4), 344-351. PMid:20164806.

Royal College of Radiologists - RCR. (2008). Towards safer radiotherapy. Retrieved in 2022, July 19, from saferRT final.pdf

Schubert, L., Liu, A., Gan, G., Amini, A., Hutchison, R., Ernest, J., Thornton, D., Stoehr, S., Hinman, B., Stuhr, K., Westerly, D., Schefter, T., & Fisher, C. (2016). Practical implementation of quality improvement for high-dose-rate brachytherapy. Practical Radiation Oncology, 6(1), 34-43. PMid:26577008.

Simons, P., Backes, H., Bergs, J., Emans, D., Johannesma, M., Jacobs, M., Marneffe, W., & Vandijck, D. (2017). The effects of a lean transition on process times, patients and employees. International Journal of Health Care Quality Assurance, 30(2), 103-118. PMid:28256930.

Simons, P., Houben, R., Vlayen, A., Hellings, J., Pijls-Johannesma, M., Marneffe, W., & Vandijck, D. (2014). Does Lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute. European Journal of Oncology, 19(1), 29-37. PMid:25266845.

Stock, G., Mcfadden, K., & Gowen 3rd, C. (2010). Organizational culture, knowledge management, and patient safety in U.S. hospitals. The Quality Management Journal, 17(2), 7-26.

van Lent, W., de Beer, R., van Triest, B., & van Harten, W. H. (2013). Selecting indicators for international benchmarking of radiotherapy centers. Journal of Radiotherapy in Practice, 12(1), 26-38.

Vissers, J., & Beech, R. (2005). Health operations management: patient flow logistics in health care. In J. Vissers & R. Beech (Eds.), Health operations management: basic concepts and approaches (pp. 39-51). New York: Routledge.

Williamson, F., & Thomadsen, B. (2008). Foreword - Symposium quality assurance of radiation therapy: The challenges of advanced technologies. International Journal of Radiation Oncology, Biology, Physics, 71(1, Suppl.), S1. PMid:18406904.

World Health Organization - WHO. (1988). Quality assurance in radiotherapy. Geneva: WHO.

World Health Organization - WHO. (2008). Radiotherapy risk profile. Geneva: WHO.

Yan, H., Hu, Z., Huang, P., Men, K., Zhang, Y., Wang, L.-H., Li, Y.-X., Dai, J.-R., & Hu, Y.-M. (2021). The status of medical physics in radiotherapy in China. Physica Medica, 85, 147-157. PMid:34010803.

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