Welcome: Professor Paul Harnett

Director of Sydney West Translational Cancer Research Centre

Implementing change through Multi-

disciplinary teams (MDTs)

Disclaimer

Objectives today

How do we maximise the impact of Multidisciplinary

teams?

What is the scope of Multidisciplinary teams?

Four domains (thought provoking):

Using data to improve performance

Engaging with others in hospital such as QI teams

Cross talking between teams

Engaging with clinical trials

Improving governance and organisational change

What’s in a name

MDT

Tumour boards

Tumour programs

High Performing Tumour Program

‘SCOPE OF PRACTICE’

Clinical management

Defined training program

Defined Quality Assurance program

Linkages/driving T1, T2, T3.

Linkages to screening/population health

Business, research agenda/meetings

Fundraising

What else can they help you solve

Area Cancer Networks via Tumour Programs are the people who should monitor care in the LHD

Why? – because who else can / will?

What else can they help you solve?

Variations in care

Peers comparing data is the most effective way to optimise practice

Balancing demands for resources

Cultivating the benefits of the “next generation”

If done well you are more likely to do

things we couldn’t do otherwise

Sequential Meeting Program

Quality of

care

+ to +++ + to ++ +++

Quality

assurance

+ to +++ + to +++ +++

Links to

research

+/- + +++

Training + ++ +++

Monitor

access

- - +++

Influence + + +++

Resources - - +++

Fund raise - - +++

(Some of..) What is needed (at least

in the public)

LHD recognises the Clinical Lead as a specific and novel leadership task and challenge

Relationship between Clinical Leads and Dept Directors in the service

Formalised Position Description

Formalised KPIs for the Tumour Program

Formalised appointment and reporting process/lines

New way of thinking about how programs operate

Professor Kwun Fong

Professor of Medicine at University of Queensland,

Director UQ Thoracic Research Centre at Prince Charles

Using data to inform rapid feedback

KEY COMPONENTS

BENEFITS AND OPPORTUNITIES

Learning from what we do; opportunities for using existing information to improve processes and care

Opportunity to collect relevant data

analyse

available

improve care

Steps

Technical data processes ie tools

Action of producers and users of data ie people

Organisational context ie environment

CASE STUDY:

Embedding data into daily practice

The Pulmonary Malignancy Conference

at The Prince Charles Hospital

Symptoms

Signs

Smoking History

Basis of Diagnosis

Diagnosis & Histology

Comorbidities

Performance Status

Lung Function

Biochemical Prognostic Factors

Clinical & pathological stage

Planned treatment sequence

Total cases submitted 100,869

Included in analyses 81,015

SCLC (and mixed SCLC/NSCLC) 13,290

NSCLC 67,725

Big data

Prince Charles

Hospital

1164

Peter MacCallum 203

QRI 5472

Australia St. Vincent's Hospital 28

University of Sydney 1784

Western Hospital 765

Total 9,416

Small data

Real time data

Teeny data

CHALLENGES IN APPLICATION

Poor data quality

Data ownership and relevance

Insufficient resources

Data Skills - Analysis, Interpretation and Use

Access to Data

Institutional Support for Data Collection and Use

Data lack value unless informs decisions or innovate changes

Efforts to require data and use are critical to improving MDT effectiveness

Professor Tim Shaw

Director of the Research in Implementation Science and eHealth

group at the Faculty of Health Sciences, University of Sydney

Engaging with QI and redesign

KEY COMPONENTS

BENEFITS AND OPPORTUNITIES

MDTs do not often engage with QI and redesign teams in

hospitals

Major lost opportunity to collaborate on combined

implementation programs

Facilitate rapid transfer of learning

CASE STUDY

Westmead TCRC engaged with Upper GIT team on

combined QI/Implementation program

LHD led process mapping exercise

A number of key quality improvement and

implementation science questions identified

Four collaborative projects moving forward

CHALLENGES IN APPLICATION

Lack of opportunities for engagement of

QI and redesign in MDTs

MDTs may not see CQI as there role

Mismatch between research and QI

Associate Professor Alexander Engel

Chair for the Colorectal MDT at RNSH and NSLHD

Director, Sydney Vital TCRC

Cross talking teams

GRADING OF EVIDENCE

NHMRC CANCER GUIDELINES

N=68

NHMRC CANCER GUIDELINES

N=68

0

20

40

60

Grade

2012 RECOMMENDATIONS

MANAGEMENT OF PATIENTS WITH

LUNG CANCER

(%)

A BC

NHMRC CANCER GUIDELINES

N=68

0

10

20

30

40

50

60

Grade

2012 RECOMMENDATIONS MANAGEMENT OF

PATIENTS WITH LUNG CANCER

(%)

A B C

3 OF 4 RECOMMENDATIONS ARE BASED

ON MODERATE TO LOW QUALITY OF EVIDENCE

DECISION MAKING

UNDER UNCERTAINTY

WHY DO WE NEED CROSS TALK

BETWEEN MDTs

Identify gaps based on multi MDT snapshots

Share ideas on improving meeting processes

Improve existing guidelines

Incorporate new evidence in multiple sites

Identify questions for local multi MDT randomised trials

CHALLENGES IN APPLICATION of

Cross Talk

Time (more unpaid time after hours!)

Particular workforce issues for pathology and imaging

who work with multiple teams

Concerns about comparison of outcomes between units

without due regard for variations in casemix

Lack of funding for improved guidelines and trials – all

talk and no action

Professor Fran Boyle

Professor of Medical Oncology at University of Sydney

Sydney Vital Translational Cancer Research Centre

Engaging with T1-T2 trials

Clinical Trials as a driver of change

Participation in Trials offers opportunities to

Learn new techniques under supervision

Learn how to manage side effects of new medications, with

clear protocol mandated actions and immediate assistance

Obtain feedback on quality of patient care processes

through monitoring

Improve communication within the team, and with patients

Improve clinician understanding of the quality and

relevance of other clinical trials, so as to gauge whether

they should be implemented

Better understand the importance of biospecimens

Recent trials in Australia that have driven

practice change in Poche teams

Breast Cancer

Sentinel node biopsy

(SNAC 1 and 11)

Herceptin adjuvant studies led

to routine Her 2 testing and

drug approval (HERA)

Preventing menopause from

chemotherapy with Zoladex

(POEMS)

Preventing breast cancer with

Tamoxifen (IBIS 1 and 11), PBS

submission underway

Melanoma

Sentinel node biopsy (MSLT1

and 11)

BRAF / MEK inhibitor trials led

to routine mutation testing

(BRIM etc) and drug approval

Immunotherapy trials led to

multidisciplinary approach to

side effect management and

drug approval (Keynote etc)

Brain metastasis trials ongoing

with RT and drugs

The front row…

Engaging the back row

CHALLENGES IN APPLICATION

Finding time on the MDT agenda to discuss research, and particularly to include basic or psychosocial researchers

Planning trials as an MDT to avoid overlap of patient populations and commitment to impractical studies

Employing research staff as an MDT / tumour stream rather than as discipline led Departments

Niche populations specified by mutations mean multiple trials with small recruitment numbers

Cost of doing trials in Australia, and inadequate payments from cooperative trials groups ?helped by NSWCI funding

Lengthy gap from trial publication to PBS funding, with loss of continuity and knowledge about the intervention

Dr Peter Carswell

Organisational Psychologist and senior lecturer at the School of

Population Health, University of Auckland

Governance/organisational change

KEY COMPONENTS

CASE STUDY

Northern Cancer Clinical Network

Cross organisational membership

Agreement on regional budgets

Regular review of data

Team work with senior clinicians and managers

Incentives for achieving targets

Reduced time to access cancer services by 30%

CHALLENGES IN APPLICATION

Organisational level commitment

Need good intelligence

Politics and turf protection

Low levels of trust