We identified three models of development of multidisciplinary cancer care into which all teams could be classified (table
3). Their internal consistency means that they can be seen as
models of co-operation, and despite being general categories, any given team model may well contain elements of the other two. Moreover, the qualitative classification described here may even occur within the same hospital for different teams, with each of these assuming responsibility for a different tumour.
Table 3
Models of co-operation in multidisciplinary cancer care
Cases submitted (approx. %) | "Complex" cases or off-protocol: 10% - 50% | All "possible" cases: 50% - 80% | Initial source of clinical assessment: 90%-100% |
Patient access to team | Treatment (whether or not initiated) | Diagnosis or treatment | Suspect or diagnosis (early access)
|
Nature of agreements | Recommendations | Consensus decisions not always implemented | Binding decisions defended by the team |
Professional team roles | Negative perception | Chair, tumour board co-ordinator | Chair, co-ordinator, nurse case manager |
Impact on clinical process management | Minor changes | Some segments of care | Whole process (cross-boundary frequent) |
Specialist participation | No diagnostic specialisations | Absences due only to timetable problems | Professionals associated with a clinical committee |
Junior doctors and nursing role, in terms of attendance | Considered inappropriate | Open meeting, participation encouraged | Mandatory presence |
Hospital executive board role | Lack of interest | Acknowledgement without express support | Express support (room, clerk, etc.) |
Presence in health system | 40% | 50% | 10% |
Rather than targeting specific forms of organisation (tumour board, cancer unit), this approach focuses instead on team capabilities, based on each team's work method and the overall scope (breadth and depth) of the tasks performed, elements of analysis that emerged during the study and indicate the nature of interaction among professionals. While all cancer teams fulfilled the role of assessing patients and complying with and updating clinical protocols, obvious differences in their respective abilities to achieve quality of care were nevertheless observed.
Critical factors in multidisciplinary cancer team development
For many clinicians, development of multidisciplinary care has involved a cultural change, as can be seen from the pathway which resulted from recommendations that were proposed by cancer team members for clinical management of patients and have gradually become binding decisions. The key critical factors identified for this change are as follows:
Existence of different gateways for the same patient profile
Many clinicians acknowledged significant variability in clinical practice as a result of diagnosing and treating patients who, despite having similar symptoms and diagnoses, might receive different initial therapy because access to hospital took place through different departments. A typical example is provided by the different therapeutic approaches proposed to a prostate cancer patient depending on the initial hospital department responsible for his diagnosis. Although a shared clinical protocol on such patients for the whole hospital plus an agreement to submit the patient to the MDT meeting would limit this variability, it is the unification of hospital-access gateways into a single hospital department that would have the necessary transforming quality in terms of standardisation of clinical criteria and pathways. Indeed, a recurring example of this type of organisational change is afforded by unification of admission to radiology for breast cancer or to gastroenterology for colorectal cancer in the case of patients displaying symptoms with a high risk of cancer. The experience of agreeing upon a common gateway for suspects has three effects: it provides teams with early access to patients; it reduces the feeling of patients being the "property" of any given clinician or department; and it sets up a primary care reference catchment area, as it becomes easier and clearer to determine where and how subjects with high risk of cancer should be referred and who the specialists of reference are. Moreover, where the department taking on the gateway unification process of the clinical pathway is a diagnostic unit, this implies that it should have a more relevant role within the team.
"At the hospital, there is a breast cancer unit that is beset by a root problem, i.e., two treatment options depending on whether the patient has been admitted via gynaecology or surgery. These are internal battles waged by the respective competencies." (Breast surgeon)
"In this hospital there are two chairs of surgery: one comes to the meetings, the other doesn't. We know that they administer different forms of treatment. The percentage of cases in which this occurs is by no means inconsiderable." (Medical oncologist)
Variability in the development and use of clinical protocols and guidelines
Evidence-based decisions are a source of concern to professionals, and the updating of clinical protocols by the team reflects this concern. Many clinicians felt, however, that this goal was conditioned by the implementation and dissemination of cancer clinical guidelines in the Spanish Health System. They argued that the absence of common guidelines for the whole country and the lack of co-ordination strategies for implementing the few that did exist resulted in reduced use and a lack of systematic assessment of existing levels of adherence. Owing to this perceived situation, clinical protocols at a hospital level are very often based on foreign guidelines, and efforts made to produce Spanish ones are of little use. This in turn leads to three common situations which impact at a team level. Firstly, hospitals that refer cases (e.g., because of their clinical complexity) have protocols based on different guidelines that are not standardised across the health care system. Secondly, multidisciplinary cancer care displays different levels of development, so that patients in one hospital may be referred to a specific department, but not to the tumour board, in another, the point here being the absence of pre-specified criteria for referral among levels of care. Thus, some decisions are made without the scientific consensus of an MDT. Finally, a cancer team might change the original treatment plan for a patient referred from a lower level hospital. This was a concern voiced by several clinicians, since decisions sometimes tend to differ widely, causing confusion and lack of trust in the patient. This perception was not shared by health professionals who work for cancer networks.
"When a surgeon comes along saying that he has operated on a given patient without the consensus of the committee but -according to him- this course of action was 'in line with the evidence'... this is unacceptable. It's an issue to be addressed by the respective cancer plans. When guidelines are reviewed, this should be the starting point, i.e., the tumour committee report should be seen before the surgical report." (Radiation oncologist)
The role of the hospital executive board
Most health professionals believed that, while they had not been hampered by the hospital executive board, neither had they been specifically supported to better organise clinical pathways and MDT activity. In their view, the main problem was that MDT work time was not recognised as a health care activity (or "real work" to quote them). Half of those interviewed felt that hospital managers knew little about their tasks, goals, level of involvement and management problems. These professionals identified two clear priorities for hospital executive boards, namely: to protect multidisciplinary meetings and work time; and to promote new professional roles, such as nurse case-managers or administrative support. Those with management responsibilities stated that cancer teams were not reflected in the organisational chart but were very important in terms of quality of care, and more innovative and responsive insofar as health care organisation achievement was concerned.
"If you tell management that you have to attend a committee meeting, they view it as something that is all well and good but nevertheless ancillary, and so not meriting consideration as part of the daily work load. Yet such attendance should be accorded health care and scientific value, i.e., so many hours correspond to committee work, which is equal to time spent seeing patients in a medical practice." (Colorectal
s
urgeon)
"Your personal efforts are not appreciated, regardless of whether you've taken part in drawing up a protocol or whether you've devoted one day or three weeks to the job... And, as no stress is laid on the importance of teamwork, there are pockets of resistance that don't change". (Radiologist)
Outcome assessment
The main goal of any multidisciplinary cancer team is to enhance the effectiveness of diagnosis and treatment of a specific disease. Assessment of the MDTs that had been put in place revealed relevant differences among the views held by the professionals themselves. To most of them, the ultimate consequence of the efforts of some hospital units or specialised professionals that regularly collect clinical data was evaluation or a study aimed at assessing MDT outcomes. Others, in contrast, described process evaluation involving initial inter-departmental consensus on indicators, development of a specific data-collection methodology, and periodic analysis of results using a shared database. Above all, this situation defines different approaches to the possibility of taking clinical outcomes and process indicators, and linking these to actions aimed at improving cancer care. There were two recurring arguments associated with possible ways of achieving organisational change: the first centred on the key role to be played by the health care service in reaching a technical definition of and agreement on a minimum set of indicators for the entire hospital system and a proposed level of transparency vis-à-vis outcomes; the second addressed the pervasive "culture of efficiency" currently prevailing in hospital departments, insisting on the need to limit its influence and instead give increased relevance to clinical and process indicators. An experience that has had remarkable success in various health care regions and has served as the basis for the evaluation of each MDT, is the implementation of a fast-track, colorectal, breast and lung cancer diagnosis and treatment programme, a driving force in promoting integration among services and MDTs. Its implementation has shown the key role that health care policy could play in enhancing the organisation of cancer care.
"The problem is that each specialisation has developed its own indicators of toxicity, clinical results, etc. There should be at least one database in which the team's outcomes are reflected. This is something that the hospital ought to demand. We could then say in real time, 'this, or that, is what's happening in prostate cancer'." (Medical oncologist)
"Yesterday I saw 37 patients: I can't devote myself to recording that much information in the database without any support... It's difficult for everyone's survival to be ascertained under such conditions. We tend to move within a 'dead' database context, that's to say, we get together at the end of the year to see how things have gone..." (Colorectal surgeon)
Recording and documenting of clinical decisions in an MDT setting
The more formalised MDTs become, the more important easy access to and transparency of decisions and the rationale behind them are. The reason for this is that recording decisions reflects the outcome of consensus building and the value that professionals attribute to their work. Half of all clinicians interviewed stated that they noted their decisions on the electronic clinical record. Not only does such action clearly define the end-point of the decision-making process, it also renders it more transparent, something that, in turn, generates a positive perception of the entire hospital environment. In contrast, there are many cases where team decisions do not extend beyond the strict limits of the tumour board, as shown by the first comment in Excerpt 5. The major weaknesses in recording clinical decisions stem from the lack of standardisation achieved in tumour-board Minute-taking, due to absence of common forms, failure to identify clear recording responsibilities and, very often, lack of administrative support. What this tends to mean is that only the decisions affecting of-protocol patients are recorded, thus hindering the possibility of establishing a reference database for a specific cancer. One last very important aspect for any team is the recording of decisions made in those cases where there is no consensus. Though infrequent, this situation is thought to play a relevant role in terms of medico-legal implications.
"In one of the hospital teams, there are professionals who find it difficult to accept consensus-based decisions. Accordingly, we consider it appropriate that, in addition to the decision being recorded in the digital clinical history, a file should be circulated to all team members so that decisions taken with respect to all patients are 'known' to them..." (Medical oncologist)
"We keep a number of formal records, I mean to say that there are several specialists who record details of patients in their files... but there is no single overall record." (Nurse case manager)
"There is an element of administration (which should be the task of a secretary) entailed in the drafting and signing of Minutes. This is generally performed by a physician, but if he's absent for any reason, then no-one does it. It's always the same old story: it's all a matter of personal involvement." (Pathologist)