 OK, good morning, everyone. Introduce myself a little bit. My original name is Sun Ming-Tang. But usually people call me Sam, or Samuel Tang. I originally from Taiwan. And then I went to the United States, got a master degree, and then I started working. And after working at a relatively small hospital, I went down to Texas. That's the UTMD Anderson Cancer Center. And there I started working there in 1989. Ever since then, I have been in the United States in Texas for almost 30 years, 30 years. Right now, I'm the section chief for the head and neck section. We also cover, OK, Eminence Center, we have different services according to an anatomical site. So I'm the section chief for medical physics for the head and neck, melanoma, lymphoma, and the sarcoma services. We have the most things I've been doing is like do the treatment plan for the head and neck services. And sometimes by request, I do the plan for lymphoma. Most of the plan is actually done by what we call the dosimetrist. They will run the treatment plan. And then we basically just check, review what the treatment plan can be improved or we approve before the treatment begins. At Eminence, it's a little bit different. The setup is a little bit different because we have a different specialty. So we just do whatever you ask to do. So most of the things, because we have set up this comprehensive quality assurance program so everyone can do their own part and will be respect by the management team so that they know you'll spend the time, spend the effort, meaning the hospital spend money for this effort. They think this is worth the while. They would like to spend the money. So this is very important. Continue from the last talk. You have to get respect for what you are doing so that people know what you are doing. In order to get the respect, you have to make sure you do a good job. You need to somehow convince the management team. Convince this we call the CFO or CEO or your department chairman, this team leader, so that they know what you are doing is very important since for your department, for your treatment, for your services. Otherwise, most of the time, medical physicists doing the things, we call the behind the scenes. People will think nothing to do with the patient because when patients complain, they complain to a nurse, complain to radiation, we call the therapist. But here I know it's called a technician or they complain to the radiation oncologist. Here maybe we call the therapist so that they have this patient interaction, which is very important. However, most of the time, medical physicists never have a chance to interact with patients. And this top layer, people think, oh, this is wasting money. Unfortunately, most of the time when you are medical physicists, in this management team, you really is called a quality officer. This quality officer, just like we said, sometimes you become a police. Do you like the police? And even if everything is fine, it's OK. But when you have a speeding, you give your ticket, is that right? You have something wrong, people say, oh, I got you wrong. Sometimes medical physicists work as a quality officer just like the police. Nobody wants to get a ticket. But the point is, when you have an external audit, people come over here. People will say, you didn't do a job. Then the external audit gives you the hospital problem. See what I'm saying? Say, your hospital never has a quality program, so you cannot treat certain amount of patients or give your lower, we call that rate investment rate, give your lower money. So maybe even close down your hospital. And then who's going to plan? The top management team said, you didn't do a good job. But then you say, I keep talking to you. You need to do this. You need to do that. You write me a ticket. I don't want to do anything. I don't want to listen to you. See what I'm saying? You are in this between. You are in trouble. So most important thing is, you need to develop this from the top layer down to the lower level. OK, the talk I'm going to give is actually, you are doing this every day. You need to do this. You need to do a good job. You need to convince the teams that you can do the good job and do a reasonable job so that you will be the part of this whole team. And then people respect you. And the people like to do what you do. And you think what you do is important for the hospital. If you just focus doing what I'm going to talk, nobody knows what you are doing. And when something right, you say, oh, you need to do this. And then you are not going to be successful. You're going to have a more problem. Maybe it's going to have a long time before you can reach this step. But you need to pay attention. You need to keep the focus of this whole program. This is the foundation for what I'm going to talk. I'm just trying to respond. Depends on how your foundation, how solid your foundation, how broad or how deep your foundation before you can build up the program. So this we call the quality control program. Meaning this is what you're going to do every day. But this quality control program has to be under this we call comprehensive quality assurance program that you get the support to do these things. Because you're going to spend your time and effort to do this. But this is what you're going to do every day, OK? People have to respect and to know what you're doing. This is just quickly said. So this is what I'm going to do is to, I'm going to use a lot of talk from Dr. Harmon too also. Because for this continuity, I realize, I think he probably gave the talk for the last time or something. He has a very good comprehensive program. You can go yourself and to get from him. I basically just summarize this, OK? So that you will know how to generate this program based on this talk, OK? Some procedure. And most likely, you're going to develop your own procedures in your own department, OK? Depends on what you have to develop your own. This just give you example, OK? OK, a lot of the reference he's talking about already, OK? The new reference, we call the Task Group 142. I'm talking about the United States program, OK? By the way, this all keep changing. Keep getting more. See, for our first practice, I used Task Group 40. Now we use Task 1.42. I'm going to have a new one, a new one. You need to, this just give the introduction. And when you practice, you're going to have all new protocol or new material come out. You have to keep update for that, OK? Not just this solution. Like, first of all, do the absolute calibration. We use the grad protocol. And then we have the TG20, and then we have the TG41. Even this calibration protocol keep changing. You need to keep update yourself, OK? Same thing for the quality assurance program. A lot of things I'm going to do is come from this book based on the talk by Dr. Harmon, OK? So this is the continuity of the book. OK, so I'm going to talk about four parts, OK? For this setup, this kind of quality control, quality assurance program, this includes this many four parts. We are starting talking about when you get like a linear oscillator. When you get a linear, what are you going to do? OK, this is important, or maybe when you get a copper 60 unit, or you get also voltage. This is a new unit. How are you going to do? OK, what are you going to do? So you need to check what you're going to set up, the program to get what kind of a test. We call it quality control test. And then it's something, other things you need to do. And this is the four part, OK? And then some PM. We call it preventive maintenance. So I'm going to talk about these four things, OK? These four subject. OK, first, I'm talking about the initial specification, acceptance testing, and commissioning. Meaning when you buy a machine, usually the people who pay the money, usually the hospital, or institution, or CFO, we call the chief financial officer, or maybe the doctors, the radiation oncologist, they have some relationship with some company, manufacturer, they just buy this machine, OK? But before they get this, we call the purchase order. We sort of have this, we call the initial specification to do, OK? We sort of do some site visit. Meaning we need to go to the manufacturer site when they fabric this NINEC. You need to make sure this NINEC is somehow meet your spec before they ship out to your institution, unless this has been established, the model. If it is like a new model, for any understanding, they always get some new type of the machine so that we often go to the site to make sure this is manufactured based on what we specify. But if you just buy a commercially available standard model, you don't have to go to site visit, OK? But it is recommended, OK? Also, when the machine shipped to your institution, they're going to install the machine. Right after installation, they usually have this we call the cookbook, meaning they have this acceptance procedure. You need to check one at a time, one at a time, one at a time. Make sure the machine that you received you have is follow this procedure so that you can accept this machine. Sometimes, if you have specialized the machine, then you have to write your own acceptance procedure, how to accept this machine, OK? And then after you accept this machine, meaning they meet your spec, and then you need to commission it. Commissioning meaning you make this machine available, ready for clinical use, OK? You need to generate more table, more information for the people to use this machine safely and then effectively, OK? So I'm going to say a little bit, OK? So when we're talking about the equipment, we need to do this equipment selection, meaning you need to specify what kind of equipment, what kind of this machine you want to perform, OK? Just like if you buy a car, you want the red one, or blue one, or white one, you need to specify. It's not going to the car shop and say, OK, whatever you have, give to me, OK? You need to buy something that you need for your clinic, OK? So that's why you need to use this concept to generate this multi-disciplinary team so that everyone get involved, OK? This we're talking about the equipment operation, your facility, your performance, your service. This is what get everybody involved so that this is what we want to buy. Of course, many decisions are made by the hospital, many decisions made by the radiation oncologists. But as medical physicists, you need to give your voice to say, what's the good part for this machine? What's the bad part for this machine? So that before you buy it, they need to know what's the difference between different machines. See what I'm saying? Whether you want to buy, I don't know how we call it. Electra, or variant, or you want to do like a cyber knife, or you want to do gamma knife, or you want to do like a stereotype of different treatment. What's the best? What's the good? So that they will make the right decision for the department. And you need to provide professional opinion for them. So this is very important. You should be the part of this team. Medical physicists should be the part of this team to select which machine to buy. So you need to make a connection. You need to build up this relationship with your management team. You need to be a team player. This is all the question you need to ask. How to select the machine. Like how to use the new technology. How many treatment you're going to provide. All this you need to answer. This is all relevant to select a proper, appropriate machine for your department. This is part of the quality assurance program. It's not after the machine come over here. After this, people say, oh, this is not good. OK, recently, MD Anderson purchased an electric version machine after we got it. And the physician complained, this portal image quality is not as good as before. And then we go back to manufacture. Manufacture, this is the best I can get. And guess what? Everybody has to suffer because we accept, we commission, we buy this machine already. You see what I'm saying? The physician say, oh, we have this good part. So I want to buy a version machine. But then when we actually use it, and they realize there's some important things. Even though at the beginning, we don't think that important, but later on it becomes very important. A lot of these small things, because we are in this learning curve. OK, this is like a brand new machine for us. So we have to make a lot of things. Sometimes we always get these ratings. During the treatment, we call it optical distance indicator. We need to get this part of our treatment quality assurance. We have to get this rating once every week. But then for version machine, for the treatment technologies to rate this number, they are having hard time. They cannot get this rating. Everybody say, what are we going to do? So eventually, we made a device for the people. They can make this measurement every day. But before we buy this machine, we didn't know we have this problem, see what I'm saying? So we spent a lot of effort to solve this kind of problem. So we're still in the learning curve, because this is like a brand new machine. But this is a problem. Some I can solve, but some things we cannot solve. Just like image quality, the manufacturer say, this is the best I can get. And this is what we specify in our specification. And this is what we buy according to your specification. And what do you complain for? No reason to complain. Just like you buy a blue card, and your complainer says, I want to buy the red card at the beginning. But you say you want blue card. It's too late. OK, it's too late. Anyway, that's what I'm going to talk about. Then we need to basically discuss all this to get all this information. And then we compare with the manufacturer specification. You need to compare with the manufacturer. And you need to compare what's the best you can do from the public. You need to discuss with all other users. We did discuss this with the machine with other users, went to another state, went to Louisiana. And the people talk to me, they have this problem, how to solve this problem. They have this new problem, usually related to a multi-leaf calameter, MLCs. So we decided we don't buy that one, we buy the new one. Anyway, so we buy the Versa. But still, so you get some information from other users. So before you buy, you can talk to other people. So you know other people from different countries, from different institutions. You can ask around. See what kind of the problem you have, what's going on for this. OK, so you can get this. To generate this, we call the spec, OK, specification. And then this specification has to be righted down in a number, not just say, oh, you have a high quality. You need to say, what kind of this quantity you can measure to reflect this quality. So this has to be measurable, OK, write down some numbers. You need to generate this. This usually, you can get from what we call this manufacturer specification, what we call the salespeople. They give you brochures. See this is how you can do. Usually, whatever is specified in the brochure is the manufacturer. They are comfortable to achieve the goal. Like if they think they can make this 1 millimeter. In the brochure, they will say 2 millimeter. But if you want to buy a good one, some of you need to just specify 1 millimeter. Make sure they do a good job. Because when they feel comfortable, they may make me a little bit deterioration, or maybe not quite good. So instead of 1 millimeter, they do like 1.5 millimeter. But since the brochure is specified 2 millimeter, you get a machine 1.5 millimeter, you still have to accept it. Normally, OK, if the manufacturer can make this accountable, to meet the specification, they just double the number. So if you want to, for this, that if you do sales tactic or some machine, if you want to make sure you have a good one, they need to write your own number in there. You understand? And then after the decision makes this, then this has to be made by all the person. So for the virtual machine, a lot of the physician, a lot of people complain after we buy, after we clinical use. So the management team has to write an email, write a memo to everyone saying, OK, originally, this machine has been decided by these people. Meaning you have this engineer, you have a medical physicist, you have a physician. If everyone agrees, this one we're going to buy. And before we buy, we went to Louisiana. We checked the machine. So the management team said, we did this according to our list. Now it's too late to change. But basically, everybody has been involved. So management team tried to, I don't know. But this is important, OK? So before you get a machine. And then when you receive the machine, after the machine is stored in your department, then you do a certain testing. A certain test, equipment is a process which supplier needs to demonstrate the baseline performance of equipment is to the satisfaction of you, OK? You are the customer, OK? So you satisfy with this machine, OK? So usually they have this, what we call a cookbook. This is like a standardized test. You need to go through with the installation team, OK? So you do this. And sometimes, so after this new equipment is stored, OK, are you right? The equipment must be tested in order to ensure that it meets the specification. That's why you specify that the environment free of resistance and then all this safety issue, OK? Are you right? So the real quick, essential improvements you quite expect from the machines to be agreed upon before a certain test of equipment, OK? Meaning if this doesn't meet your spec, you are in trouble, OK? They hold maybe 10% of the money, OK? So also important is all this sometimes for this particular machine doesn't really meet the spec. Then you have this waiver, we call it waiver. Then everybody has to agree. So this is where we're going to agree. This is why we're going to accept. If this is the case, then you need to write it down, OK? You need to write it down so that everybody agrees. Sometimes you can have this, like we call it a supplement. Sometimes we say, OK, because if you cannot meet the spec, because this is the reason, the hospital can hold manufacturing, maybe 5% of the money. They don't pay them. Usually when they install, they don't have the full amount. They can hold 10% to 5% of the money. So then this form has to be accepted by both parties, by the installation pin and by you or someone, OK? Then after you accept the machine, you do commissioning. Commissioning is the process to prepare this equipment. I'm talking about the NINAC for clinical use, OK? So usually there's a full restriction of the performance. You need to make the measurement. Make sure you kind of expect what kind of the machine, what kind of the treatment, what kind of usage for this particular machine that you make a different measurement. Make sure the system is going to use. Like for Amy Anderson, who I first went down there, I was part of an electron dosimeter team. We are responsible for commissioning. And we make the measurement all the way for the electron cut out the field size all the way down to 2 by 2. Field size is very small. I was asking why we need to make this measurement. We are never using this 2 by 2. Small field for the electron. But for Amy Anderson, they do expect sometimes they do 2 by 5. They still need the 2 by 2 for the output calculation. So we need to make all this insert all the way down to 2 by 2 for all the cone. For 10 by 10, for 15 by 15, for 25 by 25, all this cone, we have to make a cut out of the 2 by 2 to make the measurement, to make sure they are consistent for the commissioning, which is a very long process. Depends on what most hospitals, though, for the electron, they don't expect that kind of measurement. That kind of treatment, not often. You don't have to make that kind of measurement. Basically, you make a measurement on 5. Meaning, if there is a particular patient, you want to treat this particular cut out, you just measure for this particular patient. Because you don't have that many patients. You only have to treat this kind of patient maybe one or two times during this machine lifetime. So you don't have to do it at the beginning. You just do during the treatment. That's it. See what I'm saying? Yeah. So save your time. OK. So commissioning also includes this preparation to prepare all this, how to use this machine, this protocol, this instruction, all this data book. All these have to make this available and ready for clinical use. This is called the commissioning process. Also, including the training of this stuff, OK? Give you an example. This is the COBOL unit I received a long time ago. This we call a COBOL-A. This is a COBOL-A machine. After we do the source replacement, OK? And then this is a concise table. After we commission, this is what we give to them. This is called a decay table for them. This is a table for the therapist. We call it a therapist. Here it's called a technician. Technicians, they do this monthly or weekly or daily check. They have to some form to follow, OK? This is for them to double check. This is also for the physicists on the machine to do real quick treatment time. We have a program to run treatment time. But then physicists, when they sign off, they have to do quicker. We call the manual check. And this is concise table for the physicists to do the check. Basically, you specify most important things, how these those three are measured so that people after left or whoever left, they can do the same measurement according to this specification. And then you do that on the first day. And then you generate this decay table. This decay table has to be generated based on what we call this half-life, correct? You use different half-lives. You have a different decay table. So you need to say where this comes from so people can double check. If something's wrong, if you have a new number of, because this decay table could be, this half-life could be changed during the process. Right now, everybody know Cobalt-60 is very, very, the half-life is very accurate. But sometimes during my practice, the half-life has been changed once. Same thing, OK. So this is what the information, also this time correction. So basically, this is just kind of a table you generate for the commission. It's not for that, same test. Same test is just measure the output to meet the spec. On the first date, the manufacturer doesn't provide this to you. You have to do this yourself, OK? This is the commission report. We just said we received this last year. We just received last year. So after we received last year, this is the commission report. This is the first one we received for the vessel machine. So we generally say this is a table of content. This is our team, my team member over here. This is the team member. I'm the section chief, this is Dr. Gidding, he's our section, the clinical chief. He's responsible for all section, OK? Then we generate this table. This is the section. This is called the commission report, OK? This is the table of content. It's too small to read, I know. But the point I want to make is you need to generate this comprehensive report, comprehensive data sheet for people to use this machine correctly, OK? So you need to, this is one of your important job during your practice. Usually you receive machine once every 10 to 15 years. You need to do this. If you are fortunately involved, you can do this really quick so you can learn, OK? A lot of people, when they do this medical physicist, they don't know how to do this, OK? You need someone for you to do the first time. If you are only a physicist, you need to get information, you need to get help from some other people. If you are the junior physicist, you need to quickly learn this from senior physicists. You need to learn this. OK, talking about the external audit, even though we are in the Anderson, we have a physicist. One of my team members checked the TG51, the absolute calibration, and then Dr. Gidding, my clinical chief, asked me to double check. So I make another measurement. We agreed. Still, we, the Dr. Gidding asked for all the new machine, not just for us, OK? We have this outside audit. Actually, MDSN has an outside data we call it, outreach program, OK? This is also MDSN. But this is called this new name. These people are, OK, from Iraq. We call it Iraq. It's not TOD now, how do you call it? Or it's the new detector, OK? So we measure the output to make sure what we specify is what we're going to measure. For this particular, they measure 0.99. Can you see this 0.99? 0.99, OK? We spent this 300 centigrade. They used their equipment, they used their reference, using their standard. The output, the absolute calibration they have agreed with what we have within 1%. We needed this measurement done by other institution. We called out. This is part of the QA program, OK? By outside audit, kind of outside people to determine. This is the form that give to me. For each bin, we have a different machine. I mean, different bin modality. They have a full-time electron. We have a different energy. We have a 6 and 15. Each bin has at least one report from the beginning. And then every year, every year, we also have this. And then we keep the track. I didn't really show you. For each machine, we do TG51, meaning the absolute calibration during the annual, this part of the QA program during our annual calibration, our annual check. We do TLDs every year. This is kind of redundant, is it right? Kind of waste a lot of time, waste a lot of money because you need to get money to do this. So you have to convince the department chairman. You have to convince the hospital to say this is important. What is important? If the radiation technician, the technologist, they make a mistake. What happened? For today's treatment, they make a mistake. So patient treatment today, quality is not good. Suffered, maybe under-dose or over-dose or treat the wrong side, see what I'm saying? But that's for one treatment, correct? If the radiation therapist or the radiation cause the physician make a mistake, it's supposed to give a 70 grade for this whole treatment course. But this physician is not quite qualified. They specify 50 grade or 60 grade, not a 70 grade. Who is suffering? The patient, throughout all courses, no matter how good you are, no matter how careful, the radiation technician set up the patient, give treatment every day. But this patient is not going to have good treatment. Quality is suffered. But for this particular patient, correct? But the physicists, if we do the absolute calibration, TG 51, if we do wrong, your calibration of by 5%, who is suffering? All the patients going to suffer all your treatment. No matter how good your physician give the prescription, 70 grade, no good. No matter how careful the radiation therapist set up every day, poor thing, check every day, no good, because your output is way up. So your job is very important. Our job is very important. That's why we double check output and double check. We do this. This is supposed to be part of your comprehensive quality assurance program. Now we do this daily dirty job. We call it the things you do every day. You need to set up this quality control program. But again, let me re-emphasize. All these programs, you spend a lot of time. You spend a lot of effort. But the management team has to know, has to understand, or convinced, that the time you spend, the money they spend for this is important so that your job is important so that they know. But then you have to do this in a timely, like a qualification. You need to do your job correct too. This is all permitted. What kind of permitted you want to set up, what kind of things to do. This you can find a lot of reference, like a TG-40 or TG-142 or this European machine, or you want to go back to your governments, your regulations, to set up this, your own procedure. This quality control program usually set up for different frequency. We have this called a daily or weekly check. We have this monthly check. We have this annual check. This is different checks. This is your program. So I'm talking about this daily check now. I need to go fast. Usually it's done by RTT. We call it a therapist. But here I think we call it a technician, is that right? Or technologist. Different concept, different way to say. Usually this just check in the safety, the warm up procedure. That's a simple output check and the safety check. And then, but this check has to be verified by medical physics, okay? And all regulations in the United States, this has to be reviewed within five days of treatment. You don't have to be there, but you establish this program. You establish baseline. They just do this every day, but then you have to review, at least within five treatments, okay, five days. And then you have a monthly check. This monthly check usually done by physics people. When I say physics staff could be, we call the physics assistant to help you. But I think when you go by this, probably mostly done by yourself, okay? Or your physics team, okay? Then you use a different type of equipment. Different type of setup. What's the difference different from daily or different from weekly? So this kind of like a double check, okay? So that you check the system that, maybe one system failure, you can double check. And then we do annual check. But when I say annual check, usually we like to say annual calibration because no matter how you do monthly or how you do weekly, this could be related to, we call the TG51 calibration. This absolute dose calibration. But in your annual check, you have to do exactly follow this absolute calibration to do the checks during your annual check. So we usually call annual calibration. And this annual calibration, since we need going to do this, we call the absolute dose calibration. So this has to be done by qualified medical physics. Okay, qualified medical physics here, qualified medicals. So we usually call this annual calibration. Okay, you need to set up this program for people to follow. Okay, give you maybe. Okay, the most important is why we set up this program? We did at the beginning, at the symptom testing, is that right? Everything has been checked. But we want to make sure this at beginning, we check this has to be consistent throughout, throughout this machine life. Okay, during all the treatment. That's usually sometime we call it, that's why we call it a consistency check, consistent check, okay? Make sure this has been consistent. That's why even for the COBO 60, you accept at the beginning, you generate the decay table, you need to verify. It is COBO 60, it is decayed as like a 5.26 years, okay? So you double check, it's not like oh, this is COBO. So it should follow this, but maybe they have impurity in there, some say they may have some long life or short life. Maybe not quite pure COBO 60. So you need to double check, we do this monthly. And sometime this may be mechanical mechanism, it's not quite good, not quite to the position. So the output may be not quite good. So you do this monthly, okay? Okay, this is quite also, so right after your commissioning, before you start the treatment, you need to do this. That's why we call, you need to do this prior to clinical use. So this program is not say oh, after we treatment, or this new machine, the first year, that's the first year new car, sometimes they don't do test, is that right? This is a new car, it certainly have no problem. No, for your treatment, once you start the treatment, before the first treatment, you need to set up this, okay? And then sometime you have a change, sometime you add a new equipment, sometime you add a new the capability, and sometimes maybe you need to replace the part. Some important part, maybe like an un-chamber, you're broken, you need to do the scanning all things again. So sometime you have a major repairman, you have something that you expect, or you anticipate maybe something's going wrong, then you need to do check again, okay? This is including this. Okay, give you example, right? This is a new machine, version machine for us. So after we come a second test, did on this day, we start doing this, we set up this program, we do this consistent check. We wanna make sure this machine is, according to whatever the performers is what we want to do, okay? So we do this consistent check for the opto, including both photon and the electron opt, we did almost a month already before give the machine for daily treatment. Make sure this is consistent. You still can see it's kind of drift a little bit, see it? If you care for it. So we set up the new baseline for them to start. See what I'm saying? Can you see it? You're not getting get a straight line. You are getting this every day. It's, we call the drifting. See what I'm saying? Is it dynamic wedge? This is including the wedge. See, this is the wedge, it's not quite stable. We kind of, what we call monitor this, we are not, we not really use this machine because it's not good, okay? But this one, we decided to use then, okay? So by the way, we decided to use then, but we give the new baseline. We not quite satisfied with the machine, but for some reason this is not up to our spec, okay? But we have to use it like I said from the beginning. So the measurement here has to explain this. Anyway, but you need to do this, you need to check this part of your team. So right after we accept the machine, hopefully your management team has been convinced that they allow you to do another week or even a month without treating any patient. That's wasting money, see what I'm saying? Love, lot of you, when you go back, you may have this. Right, I say, oh, they say we have the machine, we can treat the patient tomorrow. So no, no, no, I want one month to do commissioning. One month? No, you have only one week or maybe one day to do your commissioning. When you go back, this is probably the face. So you need to sample how before you buy the machine, before you're doing this, you need to have to talk to your management team. You need one month to do commissioning, to generate all this table for you and to make sure this is consistent. This has been one month for us. But we set up this program, okay? I don't really have time, we have to quick, okay? So you set up this, you can see this kind of drifting, okay? I talk about you have to have the radiation therapist or radiation technology to do this every day. Then you have this statistic, you have this random arrow, you have this set up arrow. You have to generate like a 95% lost lecture we're talking about, I don't know if you have time to really do this very quick. Okay, basically this is what the measurement this may be the standardized measurement but you are not gonna measure this number every time, okay? You're usually, you measure in this one standard deviation which is very normal. But when you generate this daily check for people to do it, it's not, usually it's not yourself, someone else. So you have to give this two standard deviation inside that window, you can accept this machine kind of temporarily, okay? You don't want to trigger this alarm all the time, something the same. So only like outside this 95% window you trigger the alarm, okay? So usually this is the window we accept machine. That's why the physics has to be responsible to check machine within five days. If you do see this outside this one standard deviation it's like between one and two all the time. That means your output may be drift, maybe you need to reduce your calibration, make sure you bring this back, see what I'm saying? But if for this particular day, if you're outside this four standard deviation which is impossible, then for that particular day this particular machine is not allowed to trigger the patient until physics check, see what I'm saying? Okay, so you need to set out this window, first action window. So this is called the action level, okay? What is accepted, what is you need to take action? And this is the machine we use for M-Denters and we're still using also voltage, okay? This is a very old machine, maybe 30 years. It was there when I first went there. It's still working, so that's a good thing for the also voltage, 30 years still using. Need that, usually 12, 15 years you have to get a new one, this, okay? So this is also very machine, we're still using it. There's a one time this machine left on after the treatment because we don't do it very often. Sometimes they leave us, oh, this patient may become for treatment they leave on, but then after physician talk to the patient, patient refuse the treatment, then they leave on, nobody turn off. By the time when the physics do it, the check that the machine is on, he was kind of upset, so he leave this note over there, okay? This is the console, console, okay? So we're still using this for the treatment and he, this doing all the treatment, this is the way, this will be replaced actually by the end of this year. We're still going to buy, they've been back and forth, okay, back and forth, because there's no spare part for this machine. So there's a lot of people don't want to use, but some physicians still like to use this. So eventually, just last year, the management they decide we're going to buy new also virtual machines. So our team is going to commission this next year, okay? In order to make sure this check, we call the monthly check done by that the physicist, he is very careful, he make this, we call the jig, this like a fixed gas fixture, okay? To attach the machine. So his chamber will be at the same location every time. He make the measurement quickly and easily, okay? He make this, and he make sure we do this. And then this is double the check we monitored, okay? So this is for the bin, and then it's very consistent, very consistent for the different energy for the different filter, okay? And this is a part of the important thing, your quality assurance program is not just for the measurement, is to monitor the trend, okay? Monitor the trend. See whether there's a system functioning, okay? This is where the one standard activation window, I'm showing you, this is still very consistent. I'm sorry, this is two standard activation window. And then there's the one thing he showed me, he asked me whether we sort of changed the output, okay? This is starting to, we'll have this like a fluctuation, like a statistical, but he suspect that machine maybe have an output drifting because he use some regression analysis, whatever, okay? To find out they may have like a straight line. He think there's something after 10 years, something going on. Oh, too fast. It's hard to say. He believed because we are using so long, there's maybe the target, there's some metal fall off inside the tube, so make the system, make the bin a little bit harder. Maybe he gets some literature. So anyway, we decided, we decided just still using the same output, okay? We think this is really not important. At least a lot of copper machine, it's very old machine also. We are not using for patient treatment now, okay? All copper treatment has been replaced by six MV and four MV, but this machine still use for experimental therapy for the research purpose. We're still using it, okay? At least the copper, I just talk about. I'll give you that, the decay table. That's for this machine. Okay, now the things I'm going to talk to you is this cobalt 60. Usually for the NINEC, we do daily check, okay? For the cobalt because after a while, we think it's very stable. So we are doing weekly, we ask them to do weekly check. And this is the number, this is the window based on the first sheet I show you, is that right? And so we do weekly. So you need to base on your machine. Like a wiring machine, that's the one time we do weekly check because it's very consistent, okay? And then this is the cobalt unit I developed. Why I do the monthly check, okay? This is where based on your literature review, this is what you're going to do. You need to generate this table. This worksheet for you to do your work every day, not every day, every month or something. This is where you summarize based on whatever the leisure you have. As you can see, when I first described, I was asking for three millimeter for the ODI, for the light field. For my, this maybe 15, 10 years ago, this is required. But I did write down, I measured for this particular day, for this particular day I measured at two millimeter, two millimeter. This still meet the most current regulation or the recommendation, okay? But you need to generate this form, this is your form to do, okay? And this is the output, do the output check. Make sure the ratio here is good within certain window limit, okay? Since this is my machine, I know what's the windows and I never measure something different from 1%, okay? And then this is for the cobalt, that's the monthly check, you know the weekly monthly and the annual check. You can get all this information, all this specification, all this action level I talk about from literature. And you need to keep update to you. Just like the form I have, I have a three millimeter. But right now, since the new regulation comes out, it's a new quadriceps program that everybody accepted. I need to change my form from three millimeter to two millimeter. Remember, you know what I'm talking about, okay? So all this has to be, you can get this information. All this you can get for the annual test. And this is now called the NINEC now. This is the NINEC done every day. I'm using APM task group. That's what we are following, this task group report. This is what the requirement for different technique, for different type of the machine that you're going to use. So it depends on whether you have a multi machine or not, I'm a multi machine. That you need to set up this. I have to do real quick. So this is monthly check by the physics. You need the base on this requirement, base on this, what we call recommendation or regulation. Then you need to set up your own program. This is your worksheet, okay? You need to set up. You cannot just, every time you do, you go back to this literature, okay? You need to set up this. What are you going to do? Each item, deep blank, this yellow, is how you're going to make the measurement. This is the output measurement. We, you need to set up how you do the different build up. What is the most time efficient manner to do all this measurement for the full time machine, for the edge machine, for the range. And then you put this action level for yourself to double check, and this is the setup. All this form, you need to establish for you or for someone to do this monthly check, okay? If you are the first person, okay? And then when we have the new machine, this origin is no OBI, add a new OBI, then you need to add a new test. This is just part of the test. I don't really have time to very show you. Then you do additional requirements. This is just, if the machine running smoothly, no problem, no repair, no changing, and you just use that form. But sometimes you have this significant repair. Sometimes you have like part replacement. You have to make some significant adjustment or you add some new procedure. Then you still need to add on, keep add on. Okay, keep add on. So this is add on for me to do, we call the total skin irradiation. This machine will add a new procedure for the total skin, electron irradiation. Then we set up this new table to do total skin, okay? Check, before treatment. Then we do preventive. Okay, then this is for the cobalt, give you some example. This kind of, you check yourself. Whether you follow this quality assurance program. Say this is, you check, why do the monthly check? I need to sign up here. Whether the service check every month, every week. It's this week measurement within the action window, okay? And then we do this with just sound, sound. And there's one thing, if here is regulation require us to do five year inspection from outside. There's some people that are qualified to do this five year inspection. This is required by regulation. You do this every five years. Do you think you can remember? No, you're going to forget, okay? If you want to use more than five years. Usually after five years, you need to do the source replacement. But if you still want to use it, I don't know your country, then for us, you need to do this. So this comes just like a reminder for us what you need to do so you don't forget. This is just to give you an example, okay? I don't think I have time to do this, my time is up. So basically, the take home message is this. You need to set up a program. You need to do this every day, lot of dirty work. But important, you need to get everybody involved. Not just yourself. The person knows how to do this, do it correctly. You need to let the top level know what you're doing is good for the treatment. Even though you do all these things, behind the scenes, after patient treatment, okay?