at present , radiotherapy is an interdisciplinary field employing an advanced therapeutic and imaging apparatus and computerized therapy planning and simulation systems . this means that both the patient - related aspects ( diagnosis , selection , treatment indication , justification , referral , planning , therapy , follow - up ) and the control and measurement procedures , forming the technical part of the treatment process , should be subject to regular planning , verification and , most importantly , constant improvement . while as of late , quality assurance in radiotherapy has been believed to play a key role in ensuring safe and effective treatment in the physical and technical context ( efficient equipment , in vivo dosimetry , portal imaging ) , now a more systemic approach to quality is beginning to prevail [ 24 ] . this , however , calls for designing , implementing , maintaining and improving formalized quality systems or , in other words , implementing versatile quality management systems to cover all areas of activity ( administrative , organizational , physical , technical and clinical ) of a health care institution applying ionizing radiation for medical purposes . the aim of this study is to present clinical quality standards for radiotherapy as developed by the author . based on applicable eu directives [ 57 ] and polish legal acts published in the period of 2002 - 2006 [ 823 ] , guidelines for quality assurance in radiotherapy published by the world health organization in 1988 , recommendations for a quality assurance programme in external radiotherapy published by the european society for radiotherapy & oncology ( 1995 ) , american association of physics in medicine report no 13 . on physical aspects of quality assurance in radiation therapy ( 1994 ) , requirements of iso 9001:2000 and 9001:2008 for quality management systems [ 27 , 28 ] , international basic safety standards for protection against ionizing radiation developed by the international atomic energy agency ( 1996 ) , guidelines for comprehensive audit of radiotherapy practice developed by the international atomic energy agency ( 2005 ) , clinical assessment guide developed by the organization of european cancer institutes ( 2003 ) , and relevant literature review [ 3285 ] , a model of quality management system in radiotherapy was designed , including a detailed list of organizational , physical , technical and clinical standards . the analysis of reference material resulted in the development of 352 quality standards which were categorised into the three following groups : a ) organisational standards ; b ) physics and technical standards ; c ) clinical standards . the clinical standards were divided into the following categories : 
 referral for treatment / decision to treat / treatment prescription.therapeutic ( treatment ) protocol.interdisciplinary approach.communication.treatment planning.verification of treatment plan , irradiation time , radiotherapy form.treatment delivery.verification of treatment delivery.termination or withdrawal of treatment.medical accidents and radiological events.treatment quality control.radiation dose reference levels.documentation and records.follow-up.clinical audits . referral for treatment / decision to treat / treatment prescription.therapeutic ( treatment ) protocol.interdisciplinary approach.communication.treatment planning.verification of treatment plan , irradiation time , radiotherapy form.treatment delivery.verification of treatment delivery.termination or withdrawal of treatment.medical accidents and radiological events.treatment quality control.radiation dose reference levels.documentation and records.follow-up.clinical audits . verification of treatment delivery . termination or withdrawal of treatment . medical accidents and radiological events . patients hospitalised in the institution shall be subjected to medical exposure for diagnostic or therapeutic purposes , only when so prescribed by a medical practitioner . examination or treatment involving ionizing radiation require a written referral issued by a practitioner authorised to prescribe examination or treatment involving ionising radiation . examinations involving ionizing radiation without doctor 's referral may only be made under screening projects . decision to apply radiotherapy shall be based on patient interview , assessment of patient 's health and psychosocial status , physical and pathology examination results , cancer staging , and patient 's medical documentation . results of diagnostic tests shall form an integral part of patient 's medical documentation and remain available before , during and after treatment . the institution shall evaluate patient 's psychosocial condition and accordingly adjust its health care and treatment options . referral for radiotherapy shall be made in writing and duly authenticated ( by signature , stamp and date ) by a radiation oncologist . prescription for radiotherapy shall include planning target volume , gross tumour volume and clinical target volume ( ptv , gtv , ctv ) according to the rules provided by icru 50 , icru 62 , and icru 38 reports , total dose , method of fractioning , total duration of therapy , planned intervals , and description of treatment techniques pursuant to applicable therapeutic protocols . prescription for radiotherapy shall be forwarded to the team responsible for treatment planning ( medical physicist , dosimetrist , radiologic technologist ) who do necessary calculations and planning . the institution has established , implemented and documented a therapeutic protocol describing a treatment pattern for each type of therapy , tumour location and disease . the therapeutic protocol is consistent with the national model clinical procedures and based on confirmed results of clinical , radiological or physical tests . the institution has indicated sources of the clinical standards it applies ( own guidelines , national or international guidelines , etc . ) . patients are treated in accordance with an established therapeutic protocol ; any exemptions need to be accounted for and reasons recorded in patient 's medical documentation ( e.g. irradiation sheet ) . each therapeutic protocol provides for lowest possible exposure of healthy tissues ( alara ) and protection of healthy tissues where practicable and justified . the institution has implemented and documented a therapeutic protocol for radiotherapy of pregnant women pursuant to national regulations . therapeutic protocols are systematically reviewed and updated to keep in pace with the progress in medical and clinical knowledge . the institution has put in place an interdisciplinary radiotherapy team ( e.g. consultation committee in order to discuss all cases or difficult individual cases , cancer types , new treatment protocols , etc . ) . the role and tasks of the interdisciplinary radiotherapy team the team shall make annual statements indicating the ratio of the number of discussed and reviewed cases ( patients ) to the total number of patients treated in a given year . the team decisions concerning treatment of individual cases shall be minuted , and the minutes enclosed to patient 's medical documentation . patients shall have an easy access to complete , updated and legible information concerning the institution , scope and type of services provided , type of examination and therapy , methods and stages of treatment delivery , detailed prescription ( e.g. information brochures , website ) . prior to the beginning of therapy , patients shall be informed of the type of therapy to be delivered , course of treatment , possible complications and side effects and alternative treatment options , as well as procedures to be used before , during and after treatment ( oral communication , audiovisual means [ cd , dvd , vhs ] , brochures ) . responsible physicians shall make sure that information provided to patients and their families is well understood . patients shall give their written and informed consent to each examination and treatment ( application of contrast agent , mri , radiotherapy ) . patients shall give their written and informed consent to radiotherapy , before it is begun and after getting acquainted with information provided by the physician ( in oral , written , audiovisual or other form ) on the stage of the disease , prognosis , course of treatment , possible severe and late complications and side effects , and alternative treatment options , as well as procedures to be used before , during and after treatment . before providing information to the patient patients shall confirm their consent to treatment by a legible signature in a radiotherapy consent form . patients shall be informed of their rights and duties in the institution ( orally or in writing ) . patient 's rights and duties within the institution are communicated at that institution and available to both patients and staff ( e.g. information boards ) . patients shall be informed of any non - conformities during treatment ( e.g. under - exposure , over - exposure ) . patients shall be informed of their right to make complaints , grievances or comments about the work of the institution , services provided and treatment delivered . radiation therapists shall , upon completion of radiotherapy , inform the referring physicians of the course of treatment . the institution has developed and put in place a procedure for information flow between the institution and its patients and feedback from patients , in particular with regard to complaints and grievances . treatment planning shall be performed in consultation with a radiation oncologist , medical physicist , and , if possible , a radiologic technologist . the planning treatment process should , to the extent possible , take into account patient 's expectations ( e.g. preferred time of procedure ) . therapy involving ionizing radiation shall be preceded by the development of a treatment plan including data necessary for proper delivery of radiation and simulation of planned radiation beams . the simulation shall be recorded as an x - ray image or in a digital form . each decision to give up simulation for medical reasons only , shall be recorded in patient 's medical documentation . the simulations shall be made in the presence of a radiation oncologist , radiologic technologist and , if necessary , medical physicist . 3d treatment planning shall include : a series of ct images at intervals of no more than 10 mm,3d representation of the target volume and critical organs , treatment plan documentation in the form of dose volume histograms ( dvhs ) in the target volume and critical organs . 
  a series of ct images at intervals of no more than 10 mm , 3d representation of the target volume and critical organs , treatment plan documentation in the form of dose volume histograms ( dvhs ) in the target volume and critical organs . the institution has set rules for maximum and minimum dose in ptv and margins between ctv and ptv . treatment plan shall include information on radiation field , as well as accessories and compensators to be used . radiation oncologist shall be responsible for marking the radiation field on patient 's body and keeping the markings legible throughout the therapy . all treatment plans and difficult cases shall be consulted at regular ( weekly ) consultation meetings . . electronic transfer of data ( treatment parameters ) from the spl to a therapy machine shall be double checked . controls of radiation duration and dose shall be performed no later than before the second therapy session , except for treatments planned to take less than six days . in that case , controls shall be performed before radiation is started . the institution has implemented and documented the procedure for assessment of errors and non - conformities found during the verification of treatment plans and during the radiation process , including sources of such errors / non - conformities , time ( stage ) of detection and their impact on radiation dose : the institution has defined error / non - conformity source categories , e.g. documentation , dose calibration , treatment plan , patient position / immobilisation ( epid ) , medical documentation/ patient data management system , equipment breakdown , accidental error;the institution has established stages for possible error / non - conformity detection , e.g. stage 1  before treatment ( fraction ) , stage 2  during radiation , stage 3  after radiation;the institution shall analyse the impact of identified errors / non - conformities on potential and actual deviation of dose distribution . the institution has defined error / non - conformity source categories , e.g. documentation , dose calibration , treatment plan , patient position / immobilisation ( epid ) , medical documentation/ patient data management system , equipment breakdown , accidental error ; the institution has established stages for possible error / non - conformity detection , e.g. stage 1  before treatment ( fraction ) , stage 2  during radiation , stage 3  after radiation ; the institution shall analyse the impact of identified errors / non - conformities on potential and actual deviation of dose distribution . the institution has implemented and documented a procedure for double independent check of calculated time of irradiation or number of monitor units per radiation field . any changes in treatment plans shall be validated by a radiation oncologist and , where procedurally required , medical physicist . the following shall be checked before a treatment onset : correctness and durability of tattoos , correctness of recorded treatment physical parameters , reproducibility of patient 's positioning , method of patient 's immobilisation ( to ensure reproducibility),functional and mechanical stability , unambiguous patient identification , including documentation and individual accessories used in the process of treatment ( masks , shields ) . correctness and durability of tattoos , correctness of recorded treatment physical parameters , reproducibility of patient 's positioning , method of patient 's immobilisation ( to ensure reproducibility ) , functional and mechanical stability , unambiguous patient identification , including documentation and individual accessories used in the process of treatment ( masks , shields ) . all treatment procedures and related diagnosis shall be performed or supervised by radiation oncologists ( if performed by doctors being trained in this speciality or radiologic technologists ) . radiotherapy procedures shall be planned and performed in such a way as to allow for outage of therapeutic apparatus causing deviation from accepted treatment standards . the institution shall ensure that enough time is given for therapeutic session to be performed appropriately . one therapeutic apparatus shall accommodate the maximum of five radical treatment patients within one hour . each irradiation fraction shall be preceded by patient identification , including the check - up of name , personal identification number ( pesel ) or other identification numbers , date of birth , patient 's photo , irradiation technique , irradiation parameters , irradiated area , tumor location , accessories used , etc . at each stage of treatment , patient 's radiotherapy form shall be available at a given apparatus during each irradiation fraction . first irradiation fraction in radical treatment patients and  in justified cases  in palliative treatment patients shall be attended by a radiation oncologist to verify patient 's positioning and immobilisation , beam centring , correctness of radiation parameters and to provide patients with psychological support . medical physicist shall participate in radiation procedures at a radiation oncologist 's or technologist 's request . patients shall be positioned and immobilised as accurately , repetitively and comfortably as possible ( in each machine used in the treatment process , according to instructions contained in treatment plan ( as a text or diagram ) . in the case of radical and palliative treatment , a radiation therapist shall participate in the first irradiation session performed according to a pre - set treatment plan . during radiotherapy radiologic technologist shall confirm the consistency of physical parameters entered into the radiotherapy form with those actually delivered , in particular monitor units ( exposure time ) . during the first fraction , a radiation oncologist shall : instruct a radiologic technologist to take a portal image and verify patient 's position in relation to the beam ( whether the beam is well aimed at the target volume and whether oars are outside the radiation field ) , according to a simulator or ct plan , verify patient 's positioning and immobilisation , control the positioning ( centring ) of beams to ensure that all treatment parameters are consistent with the plan , check if all beam modifiers and accessories are suited for the patient being treated and properly positioned in relation to the patient and the therapeutic machine , instruct a radiologic technologist to perform in vivo dosimetry in order to check whether the dose administered is consistent with the planned one 5% ( according to icru report 24 ) . instruct a radiologic technologist to take a portal image and verify patient 's position in relation to the beam ( whether the beam is well aimed at the target volume and whether oars are outside the radiation field ) , according to a simulator or ct plan , verify patient 's positioning and immobilisation , control the positioning ( centring ) of beams to ensure that all treatment parameters are consistent with the plan , check if all beam modifiers and accessories are suited for the patient being treated and properly positioned in relation to the patient and the therapeutic machine , instruct a radiologic technologist to perform in vivo dosimetry in order to check whether the dose administered is consistent with the planned one 5% ( according to icru report 24 ) . any changes in treatment plans shall be authenticated by a radiation oncologist and , where procedurally required , medical physicist . the institution has established a code of practice in case of any changes in a treatment plan made during therapy . during treatment , a radiation oncologist shall , at least once a week , perform a control and review of : entries in the radiotherapy form and medical documentation , patient 's physical status ( tolerance to therapy and radiation response),correctness of treatment delivery ( in vivo dosimetry , portal imaging),deviation from a set radiological procedure shall each time be explained in medical documentation . entries in the radiotherapy form and medical documentation , patient 's physical status ( tolerance to therapy and radiation response ) , correctness of treatment delivery ( in vivo dosimetry , portal imaging ) , deviation from a set radiological procedure shall each time be explained in medical documentation . the institution has established a code of practice in case of therapy being interrupted or abandoned . treatment may be interrupted or abandoned by an attending or supervising physician , subject to prior consultation with a consultation committee , in cases of : wrong qualification for treatment , error in physical or technical radiation parameters found during treatment , patient 's intolerance to treatment or threat to patient 's life posed by continuing therapy . wrong qualification for treatment , error in physical or technical radiation parameters found during treatment , patient 's intolerance to treatment or threat to patient 's life posed by continuing therapy . the institution shall have immediate access to a defibrillator set in case of a threat to patient 's life and health . the institution has established a code of practice in case of acute conditions occurring during therapy . the institution has defined the concepts of radiological incident and accident in accordance with national legal regulations ( class a or b accidents ) . the institution has put in place and documented a code of practice for incidents or accidents related to the use of ionizing radiation in radiotherapy and detailed rules for prevention of such accidents . the institution shall document all radiation incidents or accidents and any corrective and protective measures taken in response to such events . the institution has established rules for informing victims of radiological incidents and accidents of such events , their side effects and possible complications . patients who are victims of radiation incidents or accidents shall , if necessary , be subjected to appropriate examination or treatment . treatment quality control shall include the verification of : treatment physical parameters ( dose , dose distribution , irradiation time),reproducibility of patient 's positioning , method of patient 's immobilisation ( to ensure reproducibility),functional and mechanical stability , unambiguous patient identification , including documentation and individual accessories used in the process of treatment ( masks , shields),correctness of treatment plan delivery ( in vivo dosimetry , portal imaging),correctness of records made in the course of the treatment process ( patient data),correctness of the recording and transfer of data and instructions between various stages , such as treatment planning ( spl ) , simulation , irradiation , and entries in medical documentation ( medication log , radiotherapy form),patient 's health status ( tolerance to therapy , radiation response , therapy side effects ) . treatment physical parameters ( dose , dose distribution , irradiation time ) , reproducibility of patient 's positioning , method of patient 's immobilisation ( to ensure reproducibility ) , functional and mechanical stability , unambiguous patient identification , including documentation and individual accessories used in the process of treatment ( masks , shields ) , correctness of treatment plan delivery ( in vivo dosimetry , portal imaging ) , correctness of records made in the course of the treatment process ( patient data ) , correctness of the recording and transfer of data and instructions between various stages , such as treatment planning ( spl ) , simulation , irradiation , and entries in medical documentation ( medication log , radiotherapy form ) , patient 's health status ( tolerance to therapy , radiation response , therapy side effects ) . all stages of control shall be performed by independent professionals with no direct involvement in the activity controlled ( e.g. treatment plans should be verified by a medical physicist not being a member of the planning team ) . the institution shall periodically and systematically analyse results of in - vivo dosimetry and portal imaging . all activities , from patient 's admission to discharge , including follow - up , shall be clearly defined , described and recorded in patient 's medical documentation . the institution has implemented and documented a procedure for supervising medical records , specifying , among other things , how they should be made ( electronically , on paper , plates , films , etc . ) and stored , as well as period and place of storage . the institution shall register : patient 's medical history , identified risk factors , patient 's general health status , results of physical examination , clinical stage of disease in line with adopted classification system ( e.g. uicc ) or staging method ( e.g. figo),for patients treated previously , description of techniques used , direct outcome and evaluation of effects ( e.g. leukopenia , impotence , nerve paralysis , etc.),diagnostic examination results , histopathology results . if treatment is delivered without histopathologic confirmation , the institution shall document rationale for treatment ( e.g. certain lesions in the brain unattainable for biopsy),purpose of treatment ( e.g. curative , adjuvant , palliative , alleviating pain),referral for treatment containing : patient 's name and date of birth , aim and reasons for examination or treatment , preliminary clinical diagnosis , information necessary for proper performance of radiological procedure , 
 patient 's treatment plan ( patient measurements , radiation parameters , anatomical description of the target volume ( as defined by icru 38 or icru 50 and 62),treatment summary . patient 's medical history , identified risk factors , patient 's general health status , results of physical examination , clinical stage of disease in line with adopted classification system ( e.g. uicc ) or staging method ( e.g. figo ) , for patients treated previously , description of techniques used , direct outcome and evaluation of effects ( e.g. leukopenia , impotence , nerve paralysis , etc . ) , diagnostic examination results , histopathology results . if treatment is delivered without histopathologic confirmation , the institution shall document rationale for treatment ( e.g. certain lesions in the brain unattainable for biopsy ) , purpose of treatment ( e.g. curative , adjuvant , palliative , alleviating pain ) , referral for treatment containing : patient 's name and date of birth , aim and reasons for examination or treatment , preliminary clinical diagnosis , information necessary for proper performance of radiological procedure , 
  patient 's name and date of birth , aim and reasons for examination or treatment , preliminary clinical diagnosis , information necessary for proper performance of radiological procedure , patient 's treatment plan ( patient measurements , radiation parameters , anatomical description of the target volume ( as defined by icru 38 or icru 50 and 62 ) , a radiotherapy form shall include : unambiguous patient identification and diagnosis , name of an attending doctor and , in his or her temporary absence , name of a substitute doctor , and a supervising doctor ( should the attending doctor be not a radiation oncologist),readable , unambiguous and duly signed doctor 's prescription to deliver radiation including : 
 patient 's medical exposure physical parameters and information enabling reproduction of patient 's position on the treatment couch , fractionated doses to the target volume for each radiation field ( or total dose to all radiation fields),time interval between successive fractions , total dose and method used to record the cumulative dose , for each radiation sensitive organ with dose histogram calculated , dose value shall be set , based on which , according to the therapeutic procedure used , the risk of late post - radiation damage is assessed ; organs with no histogram calculated shall be assigned a maximum dose , beam modifiers used ( shields , filters , compensators ) and their corresponding radiation fields , including methods of use . 


  unambiguous patient identification and diagnosis , name of an attending doctor and , in his or her temporary absence , name of a substitute doctor , and a supervising doctor ( should the attending doctor be not a radiation oncologist ) , readable , unambiguous and duly signed doctor 's prescription to deliver radiation including : 
 patient 's medical exposure physical parameters and information enabling reproduction of patient 's position on the treatment couch , fractionated doses to the target volume for each radiation field ( or total dose to all radiation fields),time interval between successive fractions , total dose and method used to record the cumulative dose , for each radiation sensitive organ with dose histogram calculated , dose value shall be set , based on which , according to the therapeutic procedure used , the risk of late post - radiation damage is assessed ; organs with no histogram calculated shall be assigned a maximum dose , beam modifiers used ( shields , filters , compensators ) and their corresponding radiation fields , including methods of use . patient 's medical exposure physical parameters and information enabling reproduction of patient 's position on the treatment couch , fractionated doses to the target volume for each radiation field ( or total dose to all radiation fields),time interval between successive fractions , total dose and method used to record the cumulative dose , for each radiation sensitive organ with dose histogram calculated , dose value shall be set , based on which , according to the therapeutic procedure used , the risk of late post - radiation damage is assessed ; organs with no histogram calculated shall be assigned a maximum dose , beam modifiers used ( shields , filters , compensators ) and their corresponding radiation fields , including methods of use . patient 's medical exposure physical parameters and information enabling reproduction of patient 's position on the treatment couch , fractionated doses to the target volume for each radiation field ( or total dose to all radiation fields ) , time interval between successive fractions , total dose and method used to record the cumulative dose , for each radiation sensitive organ with dose histogram calculated , dose value shall be set , based on which , according to the therapeutic procedure used , the risk of late post - radiation damage is assessed ; organs with no histogram calculated shall be assigned a maximum dose , beam modifiers used ( shields , filters , compensators ) and their corresponding radiation fields , including methods of use . at the end of treatment , patients shall receive discharge information including prescription for further conduct , care , diet , etc . on patient 's written request , the institution shall provide the patient with copies of his or her medical records . all medical records and documents produced during treatment make it possible to reconstruct and track down complete datasets on patients , clinical information and treatment modalities . medical documentation ( all records made  referral , medication log , treatment plan , etc . ) shall be authenticated by a signature and stamp of persons responsible for entering particular data . medical documentation ( radiotherapy form , treatment plan ) shall be subject to periodical and systematic review at least : before the start of treatment , after one fraction at the latest , daily , by a radiologic technologist , weekly , by a radiation oncologist and medical physicist ( radiation parameters),at each modification of a treatment plan or new radiation field , upon completion of treatment . 
  before the start of treatment , after one fraction at the latest , daily , by a radiologic technologist , weekly , by a radiation oncologist and medical physicist ( radiation parameters ) , at each modification of a treatment plan or new radiation field , upon completion of treatment . radiotherapy form shall be checked no less than once a week throughout the treatment period for correctness of doses administered to patients . the following shall be subject to detailed control : total doses absorbed by patients , compliance of radiotherapy form entries with treatment plan , including with regard to radiation regularity . total doses absorbed by patients , compliance of radiotherapy form entries with treatment plan , including with regard to radiation regularity . data included in radiotherapy forms shall be controlled by authorised persons , their competences specified in the quality management system in radiotherapy . committee for qms in radiotherapy has established and put in place a procedure for review of medical documentation , including : scope of review , responsibility , frequency , definitions for low - risk errors , definitions for high - risk errors , stages of conduct in case of identified errors or non - conformities , periodical and systematic review of identified errors or non - conformities by the committee for qms in radiotherapy , periodical and systematic review of corrective and preventive measures taken . definitions for low - risk errors , definitions for high - risk errors , stages of conduct in case of identified errors or non - conformities , periodical and systematic review of identified errors or non - conformities by the committee for qms in radiotherapy , periodical and systematic review of corrective and preventive measures taken . each documentation check shall be authenticated ( controller 's signature and date ) . the institution shall fix the mean duration for particular treatment stages ( e.g. imaging , treatment planning , simulation , irradiation , making of standard and customised masks , etc . ) and maximum permissible waiting time . the institution has established and implemented working and radiological procedures according to the national model procedures for all teleradiotherapy techniques applied , in particular for conformal teletherapy , radical teletherapy with 3d planning , radical teletherapy with 2d planning , palliative , and stereotactic teletherapy . the institution has implemented and documented : a procedure for treatment involving ionizing radiation specifying : 
 methods for qualifying patients for treatment , planning and simulation , course of radiotherapy , course of follow - up , rules for replacing a therapeutic apparatus , in case of technical failure during radiotherapy , including conversion and check of treatment parameters , 

 procedure for referring patients for treatment , procedure for priority admissions ( decision to admit patients out of turn shall be taken on a collegial basis by two specialist physicians and recorded in patient registration documents),report checking dose by measurement of in vivo dosimetry , verification report of correct patient positioning in relation to the beam by a portal image . a procedure for treatment involving ionizing radiation specifying : 
 methods for qualifying patients for treatment , planning and simulation , course of radiotherapy , course of follow - up , rules for replacing a therapeutic apparatus , in case of technical failure during radiotherapy , including conversion and check of treatment parameters , 

 
 methods for qualifying patients for treatment , planning and simulation , course of radiotherapy , course of follow - up , rules for replacing a therapeutic apparatus , in case of technical failure during radiotherapy , including conversion and check of treatment parameters , 
  methods for qualifying patients for treatment , planning and simulation , course of radiotherapy , rules for replacing a therapeutic apparatus , in case of technical failure during radiotherapy , including conversion and check of treatment parameters , procedure for referring patients for treatment , procedure for priority admissions ( decision to admit patients out of turn shall be taken on a collegial basis by two specialist physicians and recorded in patient registration documents ) , report checking dose by measurement of in vivo dosimetry , verification report of correct patient positioning in relation to the beam by a portal image . all procedures , instructions and records shall be periodically and systematically reviewed ( at least once a year ) and updated if necessary . the institution has put in place a detailed code of practice for persons who , on a free and voluntary basis , provide support and take care of patients subjected to medical exposure . the institution has implemented and documented a code of practice in case of patient medical documentation being lost . after completion of therapy , all patients shall be covered with regular follow - up performed by radiation oncologists . the institution shall set the frequency of follow - up examinations for patients treated radically and palliatively , and if recommended for particular cases . side effects ( radiation response ) shall be recorded using scoring systems for particular organs and tissues . treatment outcomes shall be regularly evaluated by physicians , radiotherapy team and internal clinical auditors . the institution shall carry out , on a written request from the head of the institution , annual internal clinical audits . head of the institution shall appoint an auditing team to perform the internal clinical audit consisting of a radiation therapist , medical physicist and , if necessary , a medical engineer . internal and external clinical audits shall focus on patients and their treatment process from diagnosis , through decision to treat , referral for treatment , prescription , planning , therapy preparation and delivery , to follow - up . the proposed clinical quality standards can be used in any institution employing ionizing radiation for medical purposes . however , quality standards are of value only if implemented , regularly reviewed and improved through a quality management system functioning in the institution concerned to enable verification whether the pre - set standards are complied with . therefore , it is also very important that a quality management system is developed and implemented to contribute to : improvement of work organization , quality of service provided , reduction of activity costs owing to rational material management , patient - orientation , reduction in the number of non - conformities and failures , and costs of their removal , increased patient and staff safety through on - going control of equipment and work place ; application of uniform procedures and documentation , creation of a clear organisational structure with regard to the responsibility for assigned work , strengthening of teamwork and cooperation between staff members and organisational units , increased commitment of the staff in continuous improvement of the institution and its qms . improvement of work organization , quality of service provided , reduction of activity costs owing to rational material management , reduction in the number of non - conformities and failures , and costs of their removal , increased patient and staff safety through on - going control of equipment and work place ; application of uniform procedures and documentation , creation of a clear organisational structure with regard to the responsibility for assigned work , strengthening of teamwork and cooperation between staff members and organisational units , increased commitment of the staff in continuous improvement of the institution and its qms .
aim of the studythe technological progress that is currently being witnessed in the areas of diagnostic imaging , treatment planning systems and therapeutic equipment has caused radiotherapy to become a high - tech and interdisciplinary domain involving staff of various backgrounds . 
 this allows steady improvement in therapy results , but at the same time makes the diagnostic , imaging and therapeutic processes more complex and complicated , requiring every stage of those processes to be planned , organized , controlled and improved so as to assure high quality of services provided . 
 the aim of this paper is to present clinical quality standards for radiotherapy as developed by the author.material and methodsin order to develop the quality standards , a comparative analysis was performed between european and polish legal acts adopted in the period of 1980 - 2006 and the universal industrial iso 9001:2008 standard , defining requirements for quality management systems , and relevant articles published in 1984 - 2009 were reviewed , including applicable guidelines and recommendations of american , international , european and polish bodies , such as the american association of physicists in medicine ( aapm ) , the european society for radiotherapy & oncology ( estro ) , the international atomic energy agency ( iaea ) , and the organisation of european cancer institutes ( oeci ) on quality assurance and management in radiotherapy.resultsas a result , 352 quality standards for radiotherapy were developed and categorized into the following three groups : 1  organizational standards ; 2  physico - technical standards and 3  clinical standards.conclusionproposed clinical quality standards for radiotherapy can be used by any institution using ionizing radiation for medical purposes . 
 however , standards are of value only if they are implemented , reviewed , audited and improved , and if there is a clear mechanism in place to monitor and address failure to meet agreed standards .