Download Appendix 1: Current cancer multidisciplinary meetings

D
Improving Midland Cancer
Multidisciplinary Meetings
Action Plan
2015
1
Table of Contents
1 Executive summary ............................................................................................ 3
2 Introduction ........................................................................................................ 5
3 Background ........................................................................................................ 5
4 Summary of progress in 2013-14 ....................................................................... 6
5 The Way Forward – Midland Cancer MDM Action Plan 2015 ............................. 8
6 Summary proposed expenditure for July 2014 – June 2015 ............................. 10
7 Conclusion ....................................................................................................... 10
Appendix 1: Current cancer multidisciplinary meetings............................................ 11
Appendix 2: VC connectivity .................................................................................... 12
Appendix 3: National tumour standards – summary of MDM requirements ............. 13
2
1 Executive summary
Cancer MDMs are a deliberate, regular, face-to-face (or videoconference) meeting to facilitate
prospective multidisciplinary discussion of options for patients’ treatment and care.
Prospective treatment and care planning refers to making recommendations in real time, with
an initial focus on the patient’s primary treatment. These recommendations can only be as
good as the information available to the range of specialists (surgeons, radiologists,
pathologists, medical and radiation oncologists etc.) at the meeting. The final decision on the
treatment is made by the patient in discussion with their lead clinician.
Improving cancer multidisciplinary meetings is a national priority contributing to the
achievement of the faster cancer treatment health target, faster cancer treatment wait times,
achievement of national tumour standards and improved patient outcomes. The Ministry of
Health published the national guidance document Achieving best practice cancer care:
Guidance for implementing quality multidisciplinary meetings (MDM Guidance) in 2012 to
inform DHB best practice related to MDMs.
The Ministry of Health has directed that pharmacy savings ($2m by PBFF to DHBs) be
utilised for the establishment of MDMs for all cancer types and increasing the number of
cases discussed at MDMs.
Midland funding allocation
Bay of Plenty: $110,207.51
Lakes: $50,301.28
Total: $359,719.07pa
Waikato: $173,617.82
Tairawhiti: $25,592.46
This funding builds on prior investment by the Ministry of Health and regional cancer
networks. DHBs are required to report quarterly on the expenditure of these funds and
progress against this regional action plan.
Phase 2 of the national tumour standards work programme will include the development of
tumour stream data sets and prioritisation criteria for discussion of patients at cancer
multidisciplinary meetings (December 2015). More information will be available in April 2015
about Budget Bid 2014 and tools for data capture to support clinical decision making that will
be associated with data available at MDMs.
What we have achieved

Established new regional myeloma MDM which is held fortnightly.

Lakes Breast Cancer MDM now has participation by Waikato-based oncologists and
surgeon via video conferencing.

Implementation of video conferencing for clinicians to participate in regional cancer
MDMs and for Waikato specialists to participate in local MDMs; Tairawhiti surgeons
connect into the Waikato Breast and GI Oncology MDMs; Whakatane surgeons
connect to the Bay of Plenty Breast and Surgery Pathology MDMs; Bay of Plenty
clinicians connect to the regional Head and Neck and Chest Conference; Lakes
clinicians connect to the GI Oncology MDM, Chest Conference and as required
Melanoma MDM. Waikato clinicians have been connecting to the CMDHB Sarcoma
MDM.

Video conference connectivity with associated audio visual equipment is located in
the Waikato, Tauranga, Rotorua and Whakatane radiology conference rooms,
Thames, L4 Meade Clinical Centre and more recently, Kathleen Kilgour Centre.

Enhanced regional lung cancer eMDM proforma and database aligned to the National
Lung Cancer Standards and data set (draft).
3

Employment of MDM coordinators at Waikato, Lakes and Bay of Plenty DHBs to
support the administration of cancer MDMs.

Development of agenda, proformas and terms of reference for an increasing number
of MDMs to comply with the national guidance.

Improved data capture related to MDMs.

Discussion regionally and with Auckland DHB gynae-oncology surgical services on
MDM service improvements (work in progress).
What we need to focus on

Current scheduling of MDMs regionally means that there are no fit for purpose video
conference facilities to enable clinicians to participate in supra-regional MDMs held at
the same time as Midland MDMs e.g. Auckland Gynae-Oncology MDM on
Wednesday and CMDHB Sarcoma MDM on Thursday at Waikato with the only option
being the CEO Meeting room VC which has only one monitor (two required).

Development of MDM terms of reference. Only the Breast MDMs, Chest Conference,
and Melanoma MDMs have finalised terms of reference and the GI Onology MDM
one is in draft. Responsibility was assigned to MDM Chairs, MDM Coordinators and
clinical nurse specialists. Most have experienced competing priorities and terms of
reference were not considered a high priority despite a generic draft being available
in the MDM Guidance document.

Little integration of DHB source information systems or implementation of MDM
management systems to enable the auto-population of eProformas (once developed)
to reduce the administrative workload in the preparation for MDMs and associated
data entry into tumour stream databases for audit and clinical decision making.

Only one MDM (Chest Conference) has an associated database able to be populated
by data download from the eProforma. The Head and Neck eProforma is in
development with an associated database. The Neurosurgery MDM has an
associated database.

Development of proformas and eProformas. While work has occurred at Bay of
Plenty to develop these for Breast and Surgery Pathology MDMs, there is reluctance
to use them at MDMs. At Waikato work was halted on further development of
proformas due to the imminent implementation of Orion Clinical Portal. A decision
was later made not to proceed and work has not yet resumed in HealthViews.
Proformas are completed by hand at the Breast MDMs.

Not all MDMs have a designated Chair and deputy.

Bay of Plenty Breast and Urology MDMs do not have medical oncology participation.

Waikato Genito-urinary and Urology Oncology MDMs meet in facilities that are not fit
for purpose, as does the Colorectal Pathology MDM.

resource constraints include shortage of specialists to prepare for and participate in
cancer MDMs especially pathologists and radiologists; oncologists at Bay of Plenty.
The focus of the 2015 Midland MDM Action Plan includes:

requirement for all cancer MDMs to comply all aspects of the national guidance and
with requirements in the recently published national tumour standards

all MDMs to have a designated Chair, deputy and terms of reference to ensure an
efficient and effective use of staff time

investigating MDM database requirements and keeping a watching brief on
development of National Cancer Information Strategy, tumour stream data sets and
Budget Bid 2014 for improving quality clinical decision making
4

FTE for data entry to comply with recommendations from regional tumour standards
reviews for lung and bowel cancers

regional agreement for Midland clinicians including oncologists to connect to
Auckland Gynae-Oncology MDM

additional VC endpoint at Waikato with 2 landscape monitors for connection to supraregional MDMs

establishment of a regional Genito-urinary MDM or sub-regional MDM to enable
patients from Lakes and Tairawhiti to be discussed at an MDM.
2 Introduction
The Midland Cancer Network has updated the 2013-14 gap analysis for cancer
multidisciplinary meetings and is continuing a regional approach to the improvement of these
meetings on behalf of Midland Cancer Network DHBs. Regional oversight and leadership is
critical for the implementation of consistent best practice cancer MDMs across Midland
supporting the Faster Cancer Treatment work programme and ensuring better outcomes for
those diagnosed with cancer.
Cancer MDMs are a deliberate, regular, face-to-face (or videoconference) meeting to facilitate
prospective multidisciplinary discussion of options for patients’ treatment and care.
Prospective treatment and care planning refers to making recommendations in real time, with
an initial focus on the patient’s primary treatment. These recommendations can only be as
good as the information available to the range of specialists (surgeons, radiologists,
pathologists, medical and radiation oncologists etc) at the meeting. The final decision on the
treatment is made by the patient in discussion with their lead clinician.
Implementing quality cancer MDMs supports the faster cancer treatment programme. In
October 2012 an updated guidance document Achieving best practice cancer care: Guidance
for implementing quality multidisciplinary meetings (MDM Guidance) was released by the
Ministry
of
Health
to
inform
DHB
best
practice
related
to
MDMs
http://www.health.govt.nz/publication/guidance-implementing-high-quality-multidisciplinarymeetings.
Phase 2 of the national tumour standards work programme will include the development of
tumour stream data sets and prioritisation criteria for discussion of patients at cancer
multidisciplinary meetings (December 2015). More information will be available in April 2015
about Budget Bid 2014 and tools for data capture to support clinical decision making that will
be associated with data captured at MDMs.
3 Background
Midland Cancer Network priority 2011-12
The network has had improving cancer MDMs as a priority since 2009-10. In 2011-12 the
network prioritised one-off Ministry of Health funding ($200,000) for improving cancer MDMs
with agreement for upgrading audiovisual equipment to high definition (HD) in radiology
conference rooms at Rotorua, Tauranga and Waikato hospitals. This was to enable best
practice local meetings where radiology, pathology, summary of clinical information for each
patient (proforma) could be viewed simultaneously providing high quality information for
discussion by clinicians. It was also preparation for connecting the three rooms by video
conferencing which would allow clinicians to participate in regional meetings and supraregional meetings as well as for Waikato oncologists to participate in Bay of Plenty and Lakes
MDMs. All audiovisual upgrades were completed by 1 September 2012. The Tauranga
Hospital upgrade was completed in December 2011. At that time Tairawhiti DHB participated
in the Central Cancer Network MDM project.
5
DHB new sustainable funding 2012-13
To support achievement of Faster Cancer Treatment indicators the Ministry of Health directed
that pharmacy savings ($2m by PBFF to DHBs) be utilised for the establishment of MDMs for
all cancer types and increasing the number of cases discussed at MDMs. MDMs are an
essential component of care pathways supporting DHBs to meet the Faster Cancer
Treatment wait time indicators.
Midland funding allocation
Bay of Plenty: $110,207.51
Lakes: $50,301.28
Total: $359,719.07pa
Waikato: $173,617.82
Tairawhiti: $25,592.46
The Ministry of Health advised that the funding is to be used for additional MDM activity
including:
 MDM coordination roles
 increasing MDM connectivity
 reviewing existing MDMs and streamlining processes so more cases are discussed
 implementing MDMs across all main tumour types
 implementing electronic clinical agendas and forms across all MDMs
 implementing information system and data collection for MDM monitoring and audit
across all MDMs.
The action plan within this document outlines the priorities for cancer MDM development
across the region for this funding. Some DHBs have stated that after two years of specified
funding, this is now included in national oncology prices and have not included it as a
separate stream in their provider arm price volume schedules. The network approached the
Ministry of Health for clarification and they responded “The expectation is that the funding be
applied on going, at the same rate to support MDM improvements, and that this continues to
be reported on quarterly” (email communication 7 May 2014). This will continue in 2015-16.
4 Summary of progress in 2013-14
The table below outlines progress on achievement of the actions as outlined in the plan.
Action
Progress
1. Support and enhance clinical leadership
for cancer MDMs in each DHB
2. Tairawhiti DHB to facilitate identification
of alternate venue for VC for MDMs –
current room unsuitable.
Additional
monitor and larger monitors recommended
and to be fixed on wall.
3. Complete technical changes to Lakes
Radiology Conference Room to enable
Lakes Breast MDM to have Waikato
oncologists and surgeons participate via
VC.
4. Explore web-based MDM meeting
management software for use across the
region – national initiative
5. Ensure processes for Tairawhiti
clinicians to refer to cancer MDMs are
clearly defined
Partially achieved.
Andy Simpson and Clare Possenniskie (MoH)
attended MDMs at Bay of Plenty DHB on 12
November. Feedback provided to DHB.
Achieved
New room identified and VC equipment
upgraded September 2014.
Achieved
VC connectivity to Lakes Breast MDM
established. Meeting time changed to 1330
Wednesdays. Commenced 5 February 2014.
Completed September 2014. Midland Cancer
Network project manager participated on
steering group for CCN/SCN Orion Clinical
Portal proof of concept.
Awaiting NHB
decision.
Achieved
MDM Group email established. Policy and
processes implemented.
TDH clinicians
6
Action
Progress
6. Ensure there are agreed secure
processes for MDM Coordinators to
communicate/send agendas and proformas
across Midland DHBs
regularly VC into Waikato Breast and GI
Oncology MDMs.
Partially achieved
Secure email confirmed between Auckland,
Waikato, Bay of Plenty and Lakes DHBs. Yet
to be confirmed for Tairawhiti. Generic emails
set-up for MDMs at each DHB.
Completed
7. Develop processes for completed MDM
proformas to be sent back to the DHB of
domicile for loading into the electronic
patient record and to be sent to patient’s
GP
8. Ensure all proformas clearly state who
will communicate the recommendation to
the patient and by what method
9. MCN project manager and MDM
coordinators work with MDM Chairs to
streamline MDM processes and ensure
each has
 Agenda
 Electronic proforma
 Terms of reference
 Attendance register
Working towards full implementation of the
MoH Guidance for MDMs
10. MDM Coordinators at Lakes and
Waikato DHBs enter record of those
discussed at MDMs into the patient
management system
11. Develop intranet resource for cancer
MDMs to outline schedule at each DHB:
day, time, agenda cut-off, MDM coordinator
contact details, cancer nurse specialist
contact details, referral process, proformas
and/or registration process.
12.
Negotiate
any
necessary
venue/schedule
changes
to
more
appropriate venues including:
Waikato Head & Neck MDM to Meade L4
for 2014
Waikato Melanoma MDM to Meade L4 for
2014
13. Work with Radiology Managers to
progress use of video conferencing for
cancer MDMs particularly regarding
scheduling of meetings in conference
rooms
14. Identify training needs for successful
use of video conferencing for MDMs
15. Review MDM database requirements
for audit and implement recommendations.
Support development of national tumour
stream data sets and implement once
In progress.
Serious incident at Waikato
related to patient referred to an MDM but action
assigned to clinician not related to the MDM.
Audit June 2015.
Ongoing
See Appendix 2 for progress. At Waikato
further proforma development was halted with
planned move to Orion Clinical Portal.
Waikato – Record of those discussed at most
MDMs and outcome entered into iPM at
Waikato. Yet to be implemented for Breast
MDM.
Lakes – data entry ceased with resignation of
initial MDM Coordinator.
Some progress but not yet complete.
Venue changes implemented for Head and
Neck, Melanoma, Myeloma.
Urgent venue change required for Genitourinary, Urology Oncology and Colorectal
Pathology MDMs.
Ongoing.
Training needs to be identified for Waikato with
recent transfer of endpoints from Bay of Plenty.
Lakes completed.
Ongoing
Tumour stream data sets yet to be completed.
Budget 2014 announcement for clinical
decision making yet to be clarified.
7
Action
approved
16. Investigate access to national and/or
supra-regional
MDMs
and
facilitate
appropriate referrals particularly Auckland
Gynae-Oncology MDMs
17. Work with Regional IS to progress VC
into production for MDMs
18. Implement specific tumour standards
requirements for MDMs – see Appendix 1
19. Support development of prioritisation
criteria for tumour stream MDMs and once
developed and agreed nationally
20. Ensure all MDMs have appropriate
representation from all required disciplines
including medical and radiation oncologists
21. Ensure annual leave approved at peak
holiday times does not compromise the
ability to hold regional MDMs
22.
Streamline
meeting
preparation
processes ensuring MDM agenda cut-off
times allow appropriate time for preparation
– radiology and pathology
23. Keep watching brief on NZ Cancer
Registry initiative to collect staging data
from MDMs (Cancer Control NZ lead this
work)
Progress
Ongoing
Access to Auckland MDMs now available and
tested through Connected Health VMRs.
Access to Sarcoma MDM from CEO Meeting
Room VC at Waikato.
Completed
Waikato endpoints transferred to Waikato
infrastructure in November/December with
associated
software
upgrade.
Lakes
transferred to HealthShare domain.
Ongoing
MDM Chairs
Midland Cancer Network Project Manager
Lung cancer MDM prioritisation criteria
developed. Other tumour streams in progress
nationally.
No medical oncology attendance at Bay of
Plenty Breast and Urology MDMs.
Schedule of MDMs for December/January
communicated to referrers in November.
Waikato cut-offs for radiology and pathology
changed to earlier times.
Watching brief maintained.
Now being
considered as part of the National Cancer
Information Strategy and National Patient Flow.
5 The Way Forward – Midland Cancer MDM Action
Plan 2015
Assumptions
 There is no additional oncology, radiology or pathology resource available.
 Most medical oncologists and all radiation oncologists are based at the Regional
Cancer Centre. There are three medical oncologists based at Bay of Plenty DHB
 The implementation of the Kathleen Kilgour Centre may affect MDM configuration in
Bay of Plenty
 Tairawhiti cancer patients are to be included in Waikato MDMs
 Provisional agreement for Midland gynae-oncology clinicians to VC into Auckland
MDM 0830-0900 in 2015.
Action Plan 2015
Action
When
Who leads
1. Each MDM must have a designated
Chair and deputy
June 2015
2. Each MDM must have a terms of
reference agreed and signed off
March 2015
MDM Chair
Midland Cancer Network
project
manager/Clinical
Director
MDM Chair
Midland Cancer Network
8
Action
When
3. Implement MDM recommendations from
regional lung cancer review including
revision of terms of reference to
incorporate provisional prioritisation criteria
March 2015
4. Implement MDM recommendations from
regional bowel cancer review including:
 Terms of reference
 Proforma changes
5. Implement MDM recommendations from
regional gynaecological cancer review and
Midland Gynae-oncology model of service
improvement project
6. Midland DHBs connect to Auckland
Gynae-Oncology MDM:
 Agree time for all including
oncologists
 Identify VC endpoints
7. Waikato Breast MDM to implement MDM
proforma for oncology cases
June 2015
8. Ensure all proformas clearly state who
will communicate the recommendation to
the patient and how.
June 2015
9. Develop intranet resource for cancer
MDMs to outline schedule at each DHB:
day, time, agenda cut-off, MDM coordinator
contact details, cancer nurse specialist
contact details, referral process, proformas
and/or registration process.
10. Implement tumour standard guidance
for MDMs – See Appendix 3
March 2015
11. Identify appropriate facilities for Urology
and Colorectal Pathology MDMs at
Waikato and implement
12. Investigate options to ensure Lakes
and Tairawhiti patients have access to a
Genito-urinary MDM
13. Identify training needs for successful
use of video conferencing for MDMs
including VC etiquette
14. Review MDM database requirements
for audit and implement recommendations.
Support development of national tumour
stream data sets and implement once
approved
15. Support development of prioritisation
criteria for tumour stream MDMs and
implement
March 2015
16 Ensure all MDMs have appropriate
representation from all required disciplines
including medical and radiation oncologists
Ongoing
Who leads
project
manager/Clinical
Director
Chest Conference Chair
Midland Cancer Network
project manager
Assistant
GM
Internal
Medicine
MDM Chair
Midland Cancer Network
project manager
June 2015
MDM Chair
Midland Cancer Network
project manager
Waikato Clinical Director
Midland Cancer Network
Project Manager
MDM Coordinators
January 2015
June 2015
MDM Chair
Midland Cancer Network
project manager
Midland Cancer Network
Project Manager
MDM Chairs
MDM Coordinators
Midland Cancer Network
Project Manager
MDM Coordinators
December 2015
To
determined
be
MDM Chairs
Midland Cancer
Project Manager
Midland Cancer
Project Manager
Network
Network
Midland Cancer
Project Manager
Network
Ongoing
Midland Cancer
Project Manager
Network
Ongoing
Midland Cancer Network
Manager
and
Project
Manager
MDM Chairs and specialists
When
developed
Midland Cancer Network
Manager, Midland clinical
work group chairs
MDM Chairs
DHBs and MDM Chairs
9
Action
17. Continue development
proformas and eProformas
of
MDM
When
Who leads
Ongoing
Midland Cancer Network
Project Manager
MDM coordinators
Clinical Nurse Manager
Midland Cancer Network
Project Manager
MDM coordinators
Tairawhiti
P&F
18. Appoint MDM Coordinator at Tairawhiti
19. Implement process for Tairawhiti breast
pathology slides to be shown at MDM TLab (Medlab Central)
March 2015
March 2015
20. Planning and Funding to work with
urology providers to ensure future MDM
data requirements are
To
determined
be
6 Summary proposed expenditure for July 2014 –
June 2015
Allocation of funding for cancer MDMs across Midland Cancer Network DHBs in 201415
Ongoing operational funding
Audiovisual support contract
Cisco SmartNet
MDM Coordinator
Spark MDM VC endpoint
Corporate overheads (20%)
Depreciation
Support for MDMs
Proforma development
Updates TGA and WHK
Transfer MDM AV and VC equipment to new room
Total
Bay of Plenty
Lakes
110,207.51 50,301.28
9,780 6,180.00
7,054.04 2,679.00
25,981 21,963.00
18,482.52 10,060.00
13,782.00 10,900.00
15,761.40
15,000.00
4,000.00
109,840.96 51,782.00
Tairawhiti Waikato
25,592.46 173,617.82
7,320
5,584.00
14,900
50,000
5,580
5,118 34,723.56
30,418.28
25,598
For consideration
Data entry lung cancer database 0.2FTE @$50k
Data entry/data capture all tumour streams 0.4 FTE @ $50k
Additional MDM endpoint
Cisco Smartnet for above endpoint (1 yr)
Contingency for unplanned maintenance
MDM database/s
Total
Underspend/overspend
4,988.00
133,034
10,000
17,000
5,000 *
1,870 *
10,000 **
109,840.96 51,782.00
25,598
176,904
366.55 - 1,480.72
-5.54
-3,286.02
*Provision for VC endpoint Capex $15k depreciated at 33%
**Provision for Database Capex $50k depreciated 20%
7 Conclusion
While an increasing number of cancer MDMs almost meet the new Guidance requirements
there are a number of gaps and issues to be addressed to ensure all cancer MDMs in
Midland comply. This is complex, will take time and it is envisaged that changes may take
more than one year. The action plan signals the way forward utilising the MDM funding to
support both one-off and ongoing initiatives ensuring the infrastructure is in place to support
best practice cancer MDMs. A key focus in 2015 is the development of tumour stream data
sets and data capture for clinical decision making with cancer MDMs being a key component.
Please note that the funding will not meet all MDM service requirements in particular,
workforce gaps.
10
Appendix 1: Current cancer multidisciplinary meetings
Bay of Plenty DHB
Regional
or Local
Breast (weekly)
Local
Surgical Pathology meeting
includes colorectal (weekly)
Urology (monthly)
Lakes DHB
Breast (weekly)
Urology (To be established)
Tairawhiti DHB
No cancer-related MDMs on site
Waikato DHB
Breast (weekly)
Chest Conference (weekly)
Endocrine (monthly)
GI Oncology (weekly)
Colorectal Pathology (fortnightly)
Gynae-oncology (weekly)
Head and Neck (weekly)
Lymphoma (weekly)
Melanoma (fortnightly)
Neurosurgery
Genito-urinary
Urology Oncology
(Alternate weeks)
Myeloma (Fortnightly)
–
Local
VC available
√
√
Full
MDT Agenda
membership
No
medical oncology
√
√
√
Proforma
Database
√
Terms of
reference
√
Not in use at
MDM
√
Not in use at
MDM
No
medical oncology
√
√
√
√
N/A
N/A
N/A
N/A
N/A
√
√
√
Hand written
Screening
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
BOP and
Lakes
Local
Local
Waikato and
Tairawhiti
Regional
Regional
Waikato
Lakes
Tairawhiti
Local
Local
Regional
Regional
Local
Regional
Local
Regional
√
√
√
√ (Draft)
√
√
√
11
Appendix 2: VC connectivity
Video conferencing equipment at each site for Midland cancer MDMs
DHB
Room
Directory name
Codec
Waikato
Radiology
Conference
Room (RCR)
Meade L4
meeting room
1
Thames
Seminar
Room
Tauranga
RCR
Whakatane
RCR
Waikato DHB Hamilton
MCC L1 MDM Radiology
Cisco C90
Waikato DHB Hamilton
MCC L4 meeting room 1
Cisco
SX20
1 landscape + 1
portrait
Waikato DHB Thames
MDM
Cisco
SX20
2 landscape + 1
portrait
BOPDHB.TGA.MDM_RAD
Cisco C90
BOPDHB.WHK.MDM_RAD
Cisco C60
Kathleen Kilgour Centre
Polycom
Group 500
Cisco C60
2 landscape + 2
portrait
2 landscape + 2
portrait
1 large landscape +
46” portrait
3 landscape + 1
portrait
1 landscape and 1
monitor able to be
rotated – both 50”
3 landscape monitors
in host room
Bay of
Plenty
Lakes
Rotorua RCR
Lakes DHB MDM
Tairawhiti
(Spark
Digital)
Northern
DHB VMRs
(Vivid)
Tui Te Ora
Tairawhiti DHB MDM
Cisco
SX20
Various
Gynae-Oncology MDM
Sarcoma MDM
Polycom
Monitor
configuration
(all 55” unless
specified)
2 landscape + 2
portrait
12
Appendix 3: National tumour standards – summary of MDM requirements
Tumour type
Standard
Good practice point
Breast
Standard 5.1
All women with a confirmed breast cancer
have their treatment plan discussed at an
MDM, and the outcomes of this are clearly
documented in the woman’s medical
records and communicated to the woman
and her GP.
Bowel
Standard 11
Patients with non-metastatic colon cancer
5.1 Every specialist involved in breast cancer care regularly participates in a
breast MDM. For further information on expected frequency of attendance,
refer to the professional requirements section of the BreastScreen Aotearoa
National Policy & Quality Standards (NSU 2008).
5.2 The breast cancer MDT should meet weekly or at least fortnightly (NSU
2008).
5.3 The breast MDM membership should include at least the following: a
radiologist, a pathologist, oncologists – radiation and medical, breast
surgeons, a breast cancer or cancer nurse coordinator, a breast
radiographer and psychosocial service representation (as appropriate) (NHS
Quality Improvement Scotland 2008). Core members are present for the
discussion of all cases where their input is needed.
5.4 Locally agreed referral pathways clearly establish who can refer, how to
refer and the timeframes within which referrals are expected (along with
processes for late referrals) (Ministry of Health 2012d).
5.5 Treatment recommendations should be available as an electronic record
and accessible to other members of a woman’s health care team, including
her GP (expert opinion).
5.6 The MDM identifies women at high risk for inequitable care so that a
special effort can be made to avoid this outcome.
5.7 The MDM report may be used as a basis of referral to a treatment
provider, to reduce referral to treatment waiting times.
5.8 Breast cancer core data are collected prior to and during MDMs. Data
sets are consistently and routinely captured for use in clinical audit and
pathway monitoring for ongoing quality improvement.
5.9 Women are informed about the MDM’s recommendations and, in
consultation with members of the treating team, make final decisions about
their own treatment and care plan.
MDM membership
4.1 Minimum core membership of a bowel cancer MDM consists of two
13
are presented in the bowel cancer MDM
within three weeks after surgery for
consideration of adjuvant therapy.
Standard 12
All patients with non-metastatic rectal
cancer or a new diagnosis of metastatic
colorectal cancer have their treatment plan
discussed at a bowel cancer MDM;
recommendations are clearly documented
in the patient’s medical records and
communicated to the patient and their GP.
Standard 13
MDMs identify patients at high risk of
receiving inequitable care, and auditable
data on these patients is collected from
them along their cancer journey.
Gynaecological
Standard 11
All women with gynaecological cancer,
borderline ovarian tumours or gestational
trophoblastic neoplasia have their treatment
plan discussed at an MDM;
recommendations are clearly documented
in the woman’s medical records and
communicated to the woman and her GP.
surgeons, a medical and radiation oncologist, a radiologist, a pathologist, an
expert colonoscopist, a colorectal clinical nurse specialist, an appropriate
allied health professional and an MDM coordinator. A palliative care team
member (specialist or nurse) should be included where appropriate.
4.2 Each MDM keeps an attendance register and reviews core membership
annually to ensure members have sufficient scope in their job to adequately
contribute to their roles.
4.3 MDM outcome forms record which members of the team were present
for each case the MDM discussed.
4.4 If a core member is the sole representative of a specialty and is unable
to attend an MDM, a deputy attends in their place.
Case discussion
4.5 A patient’s MDM notes document whether the patient is potentially
eligible for clinical trials.
4.6 MDMs review patients with apparently isolated colorectal metastases to
determine their eligibility for further surgery by an MDM with the relevant
expertise (e.g. hepatobilary or thoracic).
4.7 MDMs consider preoperative or post-operative adjuvant radiotherapy for
all patients with rectal cancer (NZGG 2011b).
4.8 MDMs document distance to the circumferential margin in all cases of
rectal cancer. Post-operatively, the same rectal cancer MDM that determined
the preoperative therapy discusses those patients with a histologically
involved (<2 mm) circumferential margin.
4.9 For patients in whom rectal cancer recurs locally, the same MDM that
determined the preoperative therapy discusses the case post-operatively.
4.10 MDMs discuss and record comorbidities.
4.11 MDMs record family history of bowel cancer.
4.12 Public hospital MDMs may discuss private and public patients.
4.1 A comprehensively staffed gynaecological MDM includes, at minimum: a
gynaecological oncologist, a medical oncologist, a radiation oncologist, a
radiologist, a clinical nurse specialist or care coordinator and a pathologist,
all of whom regularly attend gynaecological cancer MDMs. The referring
clinician or delegated deputy is also present, and there is an adequately
resourced dedicated MDM coordinator/data manager.
4.2 Discussion at the MDM includes:
14
Standard 12
The MDM discussion takes place within 14
days of referral (provided referral criteria are
met).
Head and neck
Standard 5.1
Patients diagnosed with head and neck

review of pathology by a pathologist with a special interest in
gynaecological pathology, who regularly attends the gynaecological
oncology MDM
 documentation of treatment recommendations agreed by the MDM
participants
 formal allocation and documentation of staging, as per the FIGO
system
 Documentation of MDM proceedings is collected and made available
as part of a woman’s medical record.
4.3 Criteria and information requirements for referral to regional MDMs are
developed and agreed nationally.
4.4 For women with gynaecological cancer or a high clinical suspicion of
ovarian cancer, MDM review occurs prior to definitive management (unless
acute illness requires immediate intervention) and after surgery, to plan postoperative treatment.
4.5 Women are informed about MDM recommendations by an identified
clinical team member. Following consultation with members of the treating
team, women make the final decision about their treatment and care plan.
4.6 Review at MDM is considered for women with gynaecological cancer
who have recurrent disease.
4.7 Options for fertility preservation are discussed with all women of
childbearing age prior to definitive management.
4.8 Discussion between paediatric and gynaecological oncology MDMs is
appropriate for women under the age of 20 with gynaecological tumours.
4.9 Discussion between MDMs is appropriate in cases of gynaecological
melanoma, sarcoma and haematological tumours.
4.10 To ensure sustainability and contingency for absence, multiple team
members from single specialty groups attend the MDM regularly.
4.11 The MDM takes a regional team approach to use and foster regional
expertise in gynaecological pathology and radiology services.
4.12 Protocols for expedited MDM review are agreed nationally.
4.13 MDM protocols are consistent with Ministry of Health guidance for
implementing quality MDMs (Ministry of Health 2012c).
5.1 Ideally, MDMs are held weekly, or at least fortnightly, to minimise delays
in initiation of patient treatment and patient anxiety.
15
cancer (excluding T1, 2 N0 cutaneous) are
assessed at an MDM for staging and
treatment planning; recommendations are
clearly documented in the patient’s medical
records.
Lung
Standard 9
All patients with lung cancer should be
discussed at a
multidisciplinary meeting. (Expert opinion)
5.2 Treatment plans are agreed and documented prior to the initiation of
treatment, noting the reasons for any variation from standard practice. Plans
are available electronically, and are accessible to other members of the
health care team.
5.3 All referrals to a MDM include demographic data; provisional staging
information; and data on clinical factors such as current symptoms,
performance status, weight loss, medical co-morbidity and clinical findings
(including through endoscopy, relevant imaging and pathological diagnosis)
to maximise the chance of making appropriate clinical decisions.
5.4 Treating clinicians record reasons for not following a treatment plan
recommended by the MDT.
5.5 Patients undergoing treatment for cancers of the oral
cavity/pharynx/larynx are assessed by a speech-language therapist and
dietitian prior to treatment.
5.6 Malnutrition screening is undertaken with a validated tool.
5.7 In order to meet Māori needs and reduce inequalities, cancer care
services are focused on Māori priorities. This may involve the reorientation of
existing services or the development of new services or initiatives, as well as
strengthening the role of effective service delivery models. Some specific
areas of good practice include:
 involving Māori expertise and the range of relevant Māori services
and providers in MDTs and networks
 prioritising Māori in the piloting of developments or initiatives in
service delivery
 developing tools (such as Whānau Ora assessments) to meet the
needs of Māori, which can be used to inform patient treatment plans
and care coordination
 involving Māori patients and their family/whānau in MDMs to discuss
treatment options and plans.
5.8 All Māori patients and their family/whānau are offered access to Whānau
Ora assessments and cultural support services.
5.1 All referrals to a multidisciplinary meeting should include demographic
data, provisional staging, and clinical factors such as: current symptoms,
performance status, weight loss, medical co-morbidity, bronchoscopy,
relevant imaging, pathological diagnosis (if available) and lung function to
16
Lymphoma
Standard 4.1
All patients with confirmed lymphoma have
their treatment plan discussed at an MDM;
recommendations are clearly documented
in the patient’s medical records and
communicated to the patient, the treating
clinician and the patient’s GP within one
week.
maximise the chance of making appropriate clinical decisions. (Expert
opinion)
5.2 The multidisciplinary team should record information in a database that
can be collated and analysed locally, regionally and nationally. (Expert
opinion)
5.3 The multidisciplinary discussion report should include treatment
recommendations and intent, where possible, as well as reasons for any
variation from standard practice. (Expert opinion)
5.4 The treating clinician should record the reason for not following the
treatment plan recommended by the multidisciplinary team. (Expert opinion)
5.5 Patients and their GP should be informed of the recommendations of the
multidisciplinary discussion within two working days of the meeting. (Expert
opinion)
5.6 The recommendations of the multidisciplinary discussion should be
available as an electronic record and accessible to other members of the
health care team. (Expert opinion)
4.1 MDMs are governed by agreed terms of reference, and written protocols
describe the organisation and content of the meeting.
4.2 A chair is appointed according to the terms of reference. Core members
(see Ministry of Health 2012b) are present for the discussion of all cases
where their input is needed.
4.3 Locally agreed referral pathways are established with clear information
as to who can refer, how to refer and the timeframes within which referrals
will be expected (along with processes for late referrals). Agreed criteria
determine which patients should be discussed at the MDM.
4.4 A role representing a single point of coordination for MDMs is
established, to supports clinicians participating. Treatment recommendations
agreed by participants are documented during the meeting and recorded in
patients’ medical records.
4.5 Lymphoma-specific core data is collected prior to and during the MDM.
Data sets for use in clinical audit and pathway monitoring are consistently
and routinely captured, for ongoing quality improvement.
4.6 Patients are informed about the MDM prior to the presentation of their
case. They are then informed about the MDM’s recommendations and, in
consultation with members of the treating team, make their own final
decisions about their treatment and care plan.
17
Melanoma
Standard 5.1
Patients with the following are discussed at
an MDM:
 stage III and IV cutaneous
melanoma
 desmoplastic melanoma
 melanoma under 18 years of age
 non-cutaneous melanoma
The outcome of the MDM is documented
and communicated to the treating clinician,
GP and patient within one week.
Myeloma
Standard 4.1
All patients diagnosed with myeloma have
their treatment plan discussed at an MDM;
recommendations are clearly documented
4.7 Established processes govern communication of recommendations to
patients, GPs and clinical teams within locally agreed timeframes. The MDM
identifies a lead clinical team member to discuss the MDM’s
recommendations with the patient.
5.1 Minimum core membership of a melanoma MDM consists of a general
surgeon and/or plastic surgeon, a pathologist, a radiation oncologist, a
medical oncologist, a radiologist and a clinical nurse specialist. Other MDT
members may be involved, including dermatologists, GPs, adolescent and
young adult key workers and palliative care team members.
5.2 The melanoma MDM process within each hospital and region is
documented, including: appointment of MDM members, referral pathways,
meeting frequency and videoconferencing links between regional and
provincial hospitals, where appropriate.
5.3 Details of patients discussed at the MDM are recorded on a standardised
MDM template.
5.4 A dedicated clinical nurse specialist or other health professional is
appointed to coordinate written and verbal communication (including use of
a dedicated melanoma MDM referral proforma).
5.5 Adequate support staff and resources are available to the MDM. Smaller
provincial MDTs or treating clinicians present patients to regional MDMs in
person or via teleconferencing.
5.6 The MDM records and discusses patients with stage Ib melanoma and
above if required.
5.7 The MDM records information in a database that can be collated and
analysed locally, regionally and nationally.
5.8 Treating clinicians record reasons for not following treatment plans
recommended by the MDM.
5.9 Recommendations from MDM discussions are available as an electronic
record and accessible to other members of a patient’s health care team.
5.10 All Māori patients and their family/whānau are offered an opportunity to
access Whānau Ora assessments and cultural support services.
4.1 MDMs are governed by agreed terms of reference, and written protocols
describe the organisation and content of the meeting.
4.2 A chair is appointed according to the terms of reference. Core members
(see Ministry of Health 2012a) are present for the discussion of all cases
18
in the patient’s medical records and
communicated to the patient, the treating
clinician and the patient’s GP within one
week.
Sarcoma
Standard 4.1
All patients with the following confirmed
sarcomas are presented at a sarcoma
MDM:
 bone sarcoma
 soft tissue sarcoma of extremities,
trunk and retroperitoneum.
where their input is needed.
4.3 Locally agreed referral pathways are established with clear information
as to who can refer, how to refer and the timeframes within which referrals
will be expected (along with processes for late referrals). Agreed criteria
determine which patients are discussed at the MDM.
4.4 A role representing a single point of coordination for MDMs is
established, to support clinicians participating. Treatment recommendations
agreed by participants are documented during the meeting and recorded in
patients’ medical records.
4.5 Myeloma-specific core data are collected prior to and during the MDM.
Data sets for use in clinical audit and pathway monitoring are consistently
and routinely captured, for ongoing quality improvement.
4.6 Patients are informed about the MDM prior to the presentation of their
case. They are then informed about the MDM’s recommendations and, in
consultation with members of the treating team, make their own final
decisions about their treatment and care plan.
4.10 Established processes govern communication of recommendations to
patients, GPs and clinical teams within locally agreed timeframes. The MDM
identifies a lead clinical team member to discuss the MDM’s
recommendations with the patient.
4.1 Core membership of a sarcoma MDT ideally includes the following: a
specialist sarcoma radiologist, a specialist sarcoma pathologist, a specialist
sarcoma surgeon, a radiation oncologist, a medical oncologist, a palliative
care specialist and a clinical nurse specialist/cancer nurse. Paediatric
oncologists, AYA key workers and allied health practitioners such as a
physiotherapists, orthotists, psychologists and occupational therapists may
also be involved.
4.2 The agreed terms of reference governing the MDM are based on Ministry
of Health guidance (2012a), and include written protocols that describe the
organisation and content of the meeting, including agreed criteria outlining
which patients should and should not be discussed.
4.3 Hospitals support members of the MDT to attend MDMs either virtually or
physically.
4.4 The MDT records information in a database that can be collated and
analysed locally, regionally and nationally.
4.5 One national sarcoma MDM is held every week, with core members of
19
Thyroid
Standard 5.1
Patients with the following are discussed at
an MDM:
 differentiated thyroid cancer greater
than a micro carcinoma (>1 cm in
diameter) or any size cancer with
adverse histology (e.g., medullary,
anaplastic)
 a preoperative diagnosis of thyroid
cancer with suspicion of
extrathyroidal invasion or
lymphadenopathy
 recurrent thyroid cancer
 metastatic thyroid cancer.
the sarcoma MDT present either in person or via videoconferencing facilities
where their input is required (expert opinion).
4.6 Patients and their GPs receive the MDT’s recommendations on
diagnosis, treatment options and treatment care plans in writing within two
working days of the MDM.
4.7 Final decisions on treatment and care plans are made by patients and
their family/whānau, in consultation with members of the treating team
(expert opinion).
4.8 Treating clinicians record reasons for not following a treatment plan
recommended by the MDT (expert opinion).
4.9 A clear pathway exists for patients with a sarcoma who require
management under a site-specific MDT (such as those for head and neck,
gastrointestinal stromal, gynaecological or skin cancers) or paediatric
services (NCCN 2012a).
4.10 Specific cultural services and expertise are involved through the MDT
where appropriate.
4.11 Multidisciplinary meetings formally audit their operations and review
complications outside the routine MDM at regular intervals, as deemed
appropriate by the members of the group.
5.1 Most patients with thyroid cancer are discussed at an MDM.
5.2 One clearly identified lead clinician is responsible for coordinating patient
care.
5.3 The core membership of a thyroid MDM includes:
 an endocrinologist
 a thyroid surgeon
 a radiologist
 specialist pathologists (histopathology and cytopathology)
 a clinical nurse specialist or team care coordinator/data clerk
 at least one team member trained and licensed to give radioactive
iodine (a nuclear medicine physician, a radiation oncologist or a
radiologist).
5.4 The MDT has contact with and appropriate access to the following
support services:
 FNA cytology
 flexible laryngoscopy
20
 radiation oncology
 medical oncology
 clinical genetics
 clinical biochemistry
 adolescent and young adult services
 psychology/social work.
5.5 Smaller provincial MDTs or treating clinicians from smaller centres aim to
present patients to their regional MDT in person, via teleconferencing or via
email discussion (i.e., to attend a ‘virtual MDM’).
5.6 Meeting frequency is dictated by patient numbers.
5.7 The multidisciplinary discussion report includes treatment
recommendations and intent where possible, as well as reasons for any
variation from standard practice.
5.8 Treating clinicians record reasons for not following treatment plans
recommended by the MDM.
5.9 Patients and their GPs are informed of the MDM’s recommendations
within seven days of the meeting.
5.10 Recommendations of the MDM are available as an electronic record,
and accessible to other members of the health care team.
5.11 The MDT records information in a database that can be collated and
analysed locally, regionally and nationally.
5.12 An electronic MDM reporting system is developed and available online,
for uniform recording of information at a national level.
5.13 In order to meet Māori needs and reduce inequalities, cancer care
services are focused on Māori priorities. This may involve the reorientation of
existing services or the development of new services or initiatives. Some
specific areas of good practice include:
 involving Māori expertise and the range of relevant Māori services
and providers in MDTs and networks
 prioritising Māori in the piloting of developments or initiatives in
service delivery
 developing tools (such as Whānau Ora assessments) to meet the
needs of Māori, which can be used to inform patient treatment plans
and care coordination
 involving Māori patients and their family/whānau in MDMs to discuss
21

Upper gastrointestinal
Standard 5.1
All patients with the following are presented
at an MDM:
 a confirmed diagnosis of HBP/upper
GI cancer
 a high suspicion of HBP/upper GI
cancer.
treatment options and plans
offering all Māori patients and their family/whānau access to
Whānau Ora assessments and cultural support services.
5.1 Agreed terms of reference govern MDMs, based on Ministry of Health
guidelines (Ministry of Health 2012b); these include written protocols that
describe the conduct and content of the meeting, including criteria outlining
which patients should be discussed.
5.2 A designated chairperson guides discussion and encourages consensus
within the MDM.
5.3 Each case is presented by the referring doctor or designee, unless the
patient has already been seen by a specialist.
5.4 An optimal number of cases is discussed at each MDM.
5.5 The MDM meets weekly, and not less frequently than bimonthly.
5.6 The MDM discusses patients prior to their first cancer treatment, to
ensure they are staged appropriately and can be offered neo-adjuvant
therapy if appropriate.
22