mdt improvement project - uclh internet · •mdt improvement workshop – july 2016 •mdt visits...

21
MDT IMPROVEMENT PROJECT Professor Muntzer Mughal, UCLH

Upload: vothuan

Post on 25-Sep-2018

236 views

Category:

Documents


0 download

TRANSCRIPT

MDT IMPROVEMENT PROJECT

Professor Muntzer Mughal, UCLH

1995 “..assessment and management of rare cancers in multi-

disciplinary teams..”

2000 “…the care of all patients with cancer should be

formally reviewed by a specialist team…”

More patients, more complex, more therapies

0

50

100

150

200

2011-12 2012-13 2013-14 2014-15

Cost in million £s

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

2011-12 2012-13 2013-14 2014-15

Activity (patient discussions)

Challenges for cancer MDTs

• Time - increasing case-load & complex case-mix

• Increasing treatment options

• Demands on time of MDT Lead & members

• Preparation and attendance of MDMs

• Annual review meetings

• Leadership

• IT support

• Video links

• Data

5

1995 assessment and management of rare cancers in multi-

disciplinary teams

2000 the care of all patients with cancer should be

formally reviewed by a specialist team

2015 2017

Streamlining & more effective

working

• MDT discussions should focus more on difficult cases and processes should be put in place to enable swifter decisions on patients going through standard treatment pathways.

• Recommendation 38: NHS England should encourage providers to streamline MDT processes such that specialist time is focused on those cancer cases that don’t follow well-established clinical pathways, with other patients being discussed more briefly.

• Identify protocolised treatment pathways.

• ‘pre-MDT triage meeting’ to apply protocolised

pathways.

• Minimum attendance based on quoracy. NHS England

to run pilots to determine optimal attendance

requirements.

• Develop referral proforma template to include

minimum dataset including HNA, patient preferences,

suitability for trials

• Real-time documentation of outcomes.

• Ensure regular morbidity & mortality meetings and

quarterly operational meetings – time in job plans

8

UCLH Cancer Collaborative MDT Improvement project

• MDT Improvement workshop – July 2016

• MDT visits (5 local, 8 specialist) – Nov 2016 to March 2017

• Questionnaires to MDT leads and co-ordinators

• Develop JD for MDT lead & co-ordinator

• Report published – April 2017

Differences in MDTs

Content Number of cases in the time available

Information about the patient & preferences

Stratification of cases

Combination of benign & malignant

Infrastructure Room, seating, screens, video-conferencing

Process – preparation and who does what • Presentation of cases

• Recording of outcomes

• Consideration of cases for trials

Chairing • Involving team members

• Summarising discussion & outcomes

Evidence of operational/review meetings 10

11

0

20

40

60

80

100

120

140

160

180

1 2 3 4 5 6 7 8 9 10 11 12 13

Length of meeting and number of cases

Dur (mins)

21 Recommendations

• Leadership, infrastructure and attendance

• MDT lead & MDT co-ordinator JDs • Quoracy

• Process • Information about patient – performance

status & wishes • Protocolised pathways • Clear outcomes

• Governance & Improvement • Morbidity & mortality – SACT data • Operational meetings

• Support • Mentorship, support & development 12

Do MDT chairs have the time to prepare & lead?

13

0%10%20%30%40%50%60%70%80%

No Partly Yes Preperation isminimal due to theuse of proformas

Does your job plan allow time for MDT preparation?

0%

10%

20%

30%

40%

50%

60%

70%

80%

Yes no It would havebeen useful

when I started

JD would bebeneficial butrecruitment

process wouldnot

We alreadyhave one

(PAH)

Do you feel your role as MDT lead would benefit from a structured job description and recruitment

process?

15

0%

20%

40%

60%

80%

100%

120%

Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17

% cases submitted with complete dataset

RLH BHRUT WXH HUH PAH Other/Private Total

Protocolised management

Tumour Site

Percentage in favour

What percentage of patients do you feel could be resolved outside of the meeting - for example,

through clearly defined treatment protocols and review by a smaller group?

Overall 74% 31.00% Skin 89% 37.80% Urology 87% 35.30% Other (please specify) 81% 28.50% Children and Young People 79% 31.40% Lung 78% 26.90% Gynaecology 78% 28.20% Upper GI 75% 30.70% Breast 75% 33.70% Haematology 75% 32.90% Brain 74% 26.70% Sarcoma 73% 21.10% Palliative Care 67% 42.90% Colorectal 63% 27.90% Head and Neck 50% 25.00% CUP 43% 12.20%

Analysis of single OG Cancer sMDT meeting

18

Clinical details Question for MDT MDT outcome Suitable for pre-MDT triage

Next step after pre-MDT

Metastatic gastric adenoca, CT scan Treatment options Palliative care Yes Palliative care

Adenoca oesoph, neoadjuvant chemo Review CT Liver lesion - for MRI ? Adenoca stomach, CT - T3N1, staging lap Results of staging lap Cytology - positive, for palliative chemo Yes Refer to oncology OPC

Perforated adenoca oesoph, CT & PET Case review For neoadjuvant chemo-rad No

Metastatic SCC oesoph treated with chemorad CT to determine disease progression Disease progression Yes Oncology review

SCC oesoph treated with chemorad, OGD ? Recurrence Review histology Recurrent disease, discuss salvage surgery No

Perforated adenoca oesoph, SCLN biopsy Review histology Benign, consider oesophagectomy No

Metastatic SCC oesoph treated with chemorad, interval CT CT to determine disease progression Stable disease Yes Oncology review

SCC oesoph treated with chemorad, surveillance PET CTExclude recurrence No recurrence Yes Continue surveillance

SCC oesoph, CT - T3N2M0 Next step PET scan Yes PET scan

Referral from sarcoma MDT - oesophageal nodules biopsied Histology Repeat OGD with mapping biopsies No

Adenoca oesoph, CT- T3N1M0, PET - staging lap clear Next step Neoadjuvant chemo Yes Refer to oncology OPC

Adenoca oesoph, CT - R adrenal mass & suspicious liver lesions Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC

Adenoca oesoph, CT/PET - T3N2M0, co-morbidities Case discussion Review in surgical clinic to discuss optiona No

Resected gastric cancer Review histology For adjuvant chemotherapy No

High grade dysphasia on surveillance OGD for Barretts Review histology Repeat biopsy but patient not keen for further invx No

Adenoca stomach, CT - T3N1M1, bleeding Review case & imaging For palliative DXT No

Adenoca oesoph, CT - T3N2M0 Review CT For PET scan Yes PET scan

Adenoca oesoph, CT - T2N1M0 Review CT For PET scan Yes PET scan

Adenoca stomach, CT - TxN1M1 Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC

Elderly patient with gastric outlet obstruction from gastric ca Review CT T3N2M1 disease - stenting ? Elderly patient with early adeno oesoph, EMR Review histology Complete resection, for surveillance OGD No

Resected gastric cancer Review histology ypT3N2R1, for adjuvant chemo No

Cases suitable for protocolised pathway

19

Clinical details Question for MDT MDT outcome

Suitable for pre-MDT triage Next step after pre-MDT

Metastatic gastric adenoca, CT scan Treatment options Palliative care Yes Palliative care

Adenoca stomach, CT - T3N1, staging lap Results of staging lap Cytology - positive, for palliative chemo Yes Refer to oncology OPC

Metastatic SCC oesoph treated with chemorad CT to determine disease progression Disease progression Yes Oncology review

Metastatic SCC oesoph treated with chemorad, interval CT CT to determine disease progression Stable disease Yes Oncology review

SCC oesoph treated with chemorad, surveillance PET CT Exclude recurrence No recurrence Yes Continue surveillance

SCC oesoph, CT - T3N2M0 Next step PET scan Yes PET scan

Adenoca oesoph, CT- T3N1M0, PET - staging lap clear Next step Neoadjuvant chemo Yes Refer to oncology OPC

Adenoca oesoph, CT - R adrenal mass & suspicious liver lesions Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC

Adenoca oesoph, CT - T3N2M0 Review CT For PET scan Yes PET scan

Adenoca oesoph, CT - T2N1M0 Review CT For PET scan Yes PET scan

Adenoca stomach, CT - TxN1M1 Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC

20

12 cases for discussion

7 patients for oncology review

1 patient for palliative care

3 patients for PET scan

Pre-MDT meeting

7 patients for oncology review

1 patient for palliative care

3 patients for PET scan

AT LEAST – 2 DAYS IN TIMED PATHWAY FEWER CASES FOR DISCUSSION

Introducing protocolised management

• Develop pathways with MDTs & Pathway Boards

• Each MDT to determine who will triage? • E.g. MDT lead, MDT co-ordinator, radiologist

• Ensure ’direct to next step’ patients listed on MDT agenda

• Systematic study & audit

Implementation of recommendations

22

JD & time for MDT leads & co-ordinators

Make patient information mandatory

Develop & pilot protocolised management pathways

QI programme to support MDTs

Develop datasets to report patient outcomes regularly to the MDT

Consider setting up MDT leads

forum