Background: ROTP extends from simulation (SIM) through the start of treatment and constitutes a sequence of processes. Accurate implementation of each of these is essential for proper treatment. Prior guidelines had been proposed in our department for conformal treatment and intensity modulated radiation therapy (IMRT) or Volumetric Modulated Arc Therapy (VMAT); these were often not met leading to dissatisfaction by staff and patients. To improve this we evaluated the current steps in ROTP in an effort to improve our process. Methods: We analyzed the records of 157 eligible patients who underwent CT simulation from 1/1/12 through 3/30/12, excluding patients treated for benign disease, brachytherapy, or patients who never started treatment. The departmental standard was for urgent cases to start within 4 days (d), non-IMRT cases to start in 5d and IMRT/VMAT/SBRT cases to start in 10d. We defined three intervals, from SIM to start of treatment, SIM to approval of the plan by the physician, and approval to treatment start. Results: The median interval between planning landmarks in work-days and the % exceeding planning standards plus 2 days are shown below. Almost half of cases exceeded departmental standards for timeliness of ROTP. Much of the variability occurred after the physician had approved the plan. Conclusions: To improve timeliness of ROTP we have introduced changes in our planning process: 1. Strict definition of urgent cases. 2. Assigning a start date at the time of simulation. 3. Case planning review by the Radiation Oncologist, dosimetrist (+/- Physicist) at SIM. 4. Daily review of task list by Chief of Physics and Department Chair. These changes have been implemented in our department and results of the first two months of their use will be presented.

Treatment type	SIM-START (days)	SIM-APP (days)	APP-START (days)	Allowed time (days)	% Exceeding departmental standard >2 days
Urgent	2	2	1	4d	2/30
3D	9	5	4	7d	48/70
IMRT/VMAT	11	6	7	12d	15/43
SBRT	14	6	8	12d	10/14
All patients	9	4	5		75/157