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Improving Midland Cancer Multidisciplinary Meetings Action Plan 2016 Table of Contents 1 Executive summary..................................................................................................... 3 2 Introduction ................................................................................................................. 5 3 Background ................................................................................................................. 6 4 Summary of progress against 2015 action plan ....................................................... 6 5 The Way Forward – Midland Cancer MDM Action Plan 2016.................................... 9 6 Summary proposed expenditure for July 2015 – June 2016 .................................. 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. In 2012-13 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. 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. In 2015-16 DHBs are required to report six monthly on the expenditure of these funds and progress against this regional action plan. Phase 2 of the national tumour standards work programme was to include the development of tumour stream data sets and prioritisation criteria for discussion of patients at cancer multidisciplinary meetings by December 2015. As at December 2015 the data sets have not been published and the MDM prioritisation criteria development has been put on hold. The NZ Cancer Health Information Strategy has been developed and under this programme there is a national MDM Project in 2016. The project team will work with the DHBs and Regional Cancer Networks (RCNs) to develop national data, business and system requirements and business processes. The development of standardised national MDM requirements and business processes will provide the framework to support the move to a national MDM model and improve functionality, information quality to support clinicians, patients and service delivery reporting. What we have achieved Waikato now has a room set-up specifically for video conferencing with Auckland MDMs (2 landscape monitors). Bay of Plenty lung cancer MDM commenced in September 2015 Bay of Plenty Urology MDM is now held on the first and third Tuesdays of the month with Waikato oncologists video conferencing in to participate in the discussion of Lakes patients from 1 March 2016 Lakes Breast Cancer MDM continues with 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, Melanoma (as required), LGI and UGI Oncology MDMs; Whakatane surgeons connect to the Bay of Plenty Breast and Surgery Pathology MDMs; Bay of Plenty clinicians connect to the regional Lymphoma MDM, Head and Neck MDM and Chest 3 Conference; Lakes clinicians connect to the LGI Oncology MDM, Chest Conference and as required Melanoma MDM. Midland clinicians have been connecting to the Auckland Gynaecological and CMDHB Sarcoma MDMs. 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 Waiora L2 at Waikato and more recently, the Kathleen Kilgour Centre. Enhanced regional lung cancer eMDM proforma and database aligned to the National Lung Cancer Standards and data set (draft). 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. What we need to focus on Information systems as an enabler for an MDM management system and an MDM data repository which allows data to be available for audit and clinical decision making. Budget Bid 2014 signalled the development of regional clinical data repositories but these have not eventuated. While there is a national MDM project commencing in 2016 there is little understanding of the implications for DHBs or financials. There are no current local or regional plans or capital for MDM-related IS development in Midland. At Waikato the Meade L4 meeting room hosts the regional Head and Neck MDM utilising equipment that was not designed for hosting a MDM via video conference. VC participants are not able to see pathology and at times there is difficulty with audio – an additional table microphone has been purchased. Consideration was given to upgrading equipment to same standard as the Radiology conference Room but room pillars create difficulty with this. In 2017-18 Waiora L4 meeting room may become available for MDMs and other users and with the addition of a microscope and camera and ceiling microphones would be an ideal venue for larger MDMs such as Head and Neck and Waikato Breast. However there will be demand from other non-cancer clinical meetings for this room at peak times. Completion/review of MDM terms of reference. 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 template being available in the MDM Guidance document. The diversity in source information systems in Midland DHBs means there is currently little opportunity for integration to support development and implementation of eProformas and associated databases or MDM management systems to reduce the administrative workload. Only two MDMs (Chest Conference and Head and Neck) have an associated database able to be populated by data download from the eProforma. The Neurosurgery MDM has an associated database. Waikato is implementing a Dendrite database for surgical clinical audit and this has been demonstrated to other Midland DHBs. It is yet to be determined whether this will collect a full data set for tumour streams such as colorectal, or utilised only for surgical audit. 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 some MDMs due to administrative burden. At Waikato a Breast proforma is now in use for oncology cases. Otherwise breast proformas are completed by hand at the Breast MDMs prior to uploading into clinical workstation. 4 There continues to be resource constraints include shortage of specialists to prepare for and participate in cancer MDMs especially pathologists and radiologists particularly at peak holiday and conference times. Ensuring patients from Hauora Tairawhiti have access to a Genito-urinary or Urology Oncology MDM. Currently there is only radiology and pathology support available for the fortnightly Genito-urinary MDM at Waikato. The focus of the 2016 Midland MDM Action Plan includes: audit of MDMs against the relevant tumour stream standard and/or the national Guidance requirement for all cancer MDMs to comply all aspects of the national guidance and with requirements in the recently published national tumour standards investigating information systems solutions for MDM database/data repository and meeting management requirements and keeping a watching brief on the outcomes of the NZ Cancer Information Strategy MDM project. review of audio-visual equipment in radiology conference rooms which has now been in place for 3 years; and video conferencing in place for nearly 3 years. DHBs are encouraged update technology/equipment that is no longer supported by manufacturers implementation of processes to ensure Tairawhiti patients are discussed at Waikato urology MDMs. 2 Introduction The Midland Cancer Network has updated the 2014-15 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/guidanceimplementing-high-quality-multidisciplinary-meetings. Phase 2 of the national tumour standards work programme was to have included the development of tumour stream data sets and prioritisation criteria for discussion of patients at cancer multidisciplinary meetings (December 2015). However these have not been progressed nationally. The Midland Cancer Network has updated the 2015 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. 5 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 supra-regional 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. Sustainable funding from 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 was 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. As in previous years Midland Cancer Network has facilitated the implementation of regional priorities outlined in the annual Midland MDM action plans. PP24 reporting is six monthly in 2015-16. 4 Summary of progress against 2015 action plan The table below outlines progress on achievement of the actions as outlined in the plan. Action When Who leads Progress 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 project manager/Clinical Director Completed. All MDMs have a designated Chair Partially completed. Waikato Gynae-Oncology MDM and Upper Gastrointestinal MDM, Bay of Plenty Surgery Pathology and Urology Oncology MDMs, Waikato Urology Oncology and Genitourinary MDMs now have terms of reference. See table 2 for 6 Action When Who leads 3. Implement MDM recommendations from regional lung cancer review including revision of terms of reference to incorporate provisional prioritisation criteria 4. Implement MDM recommendations from regional bowel cancer review including: Terms of reference Proforma changes March 2015 Chest Conference Chair Midland Cancer Network project manager Assistant GM Internal Medicine MDM Chair Midland Cancer Network project manager 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. 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 June 2015 11. Identify appropriate facilities for Urology and Colorectal Pathology MDMs March 2015 June 2015 January 2015 June 2015 March 2015 Progress MDM Chair Midland Cancer Network project manager Waikato Clinical Director Midland Cancer Network Project Manager MDM Coordinators MDM Chair Midland Cancer Network project manager Midland Cancer Network Project Manager MDM Chairs MDM Coordinators Midland Cancer Network Project Manager MDM Coordinators further information. Completed. Partially completed. Bay of Plenty: Number of patients referred/registered to MDM is recorded – ongoing Tairawhiti: Referral system in place. Waikato: Separation of Upper and Lower GI MDMs – Lower GI terms of reference to be updated. Completed. Waikato: Terms of Reference completed; Chair confirmed. Completed. Completed. Proforma in use for oncology cases. Completed at Waikato. BOPDHB has developed an intranet resource and a schedule of MDMs is included. MDM Guidance now on Waikato intranet as part of FCT resources. December 2015 MDM Chairs Midland Network Manager Midland Network Manager Cancer Project Cancer Project In progress - aligned with tumour standard reviews. Completed 7 Action When Who leads To be determined Midland Network Manager Cancer Project 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 Ongoing Midland Network Manager Cancer Project Ongoing Midland Cancer Network Manager and Project Manager MDM Chairs and specialists Database in place for lung cancer and implemented June 2015 for Head and Neck MDM. On hold nationally. 16 Ensure all MDMs have appropriate representation from all required disciplines including medical and radiation oncologists 17. Continue development of MDM proformas and eProformas Ongoing Midland Cancer Network Manager, Midland clinical work group chairs MDM Chairs DHBs and MDM Chairs Ongoing Midland Cancer Network Project Manager MDM coordinators 18. Appoint MDM Coordinator at Tairawhiti 19. Implement process for Tairawhiti breast pathology slides to be shown at MDM TLab (Medlab Central) March 2015 Clinical Nurse Manager Midland Cancer Network Project Manager MDM coordinators Tairawhiti 20. Planning and Funding to work with urology providers to ensure future MDM data To be determined Partially completed. Word-based Breast proforma now in use at Waikato. Bay of Plenty has developed some MDM proformas but not all in use at meetings given lack of resource to complete. Bay of Plenty lung cancer MDM using regional Chest Conference proforma. Bay of Plenty Urology Oncology MDM using electronic proforma. Completed. In place until 30 June 2015. Partially completed. Discussion with TDH and Medlab. PN pathologist unable to VC into MDM. Tairawhiti surgeons to discuss any queries with pathologist concerned Meeting at end of March following Midland Cancer Network Executive Group to at Waikato and implement 12. Investigate options to ensure Lakes and Tairawhiti patients have access to a Genito-urinary MDM When developed March 2015 P&F Progress Partially completed. Bay of Plenty Urology Oncology MDM now held fortnightly rather than monthly. Lakes patients to be discussed at the BOP MDM with participation from Waikato oncologists from 1 March. Waikato Urology Oncology and Genito-urinary MDMs held alternate weeks. Ongoing. Tumour stream data sets not yet available. Completed. 8 Action When Who leads requirements are included in contracts. Progress discuss additional clauses for urology contracts. Venturo contract completed. Urology Services Limited negotiations continue. Additional In early 2015 Midland Cancer Network worked with KKC and their video conferencing provider to enable their participation in Midland MDMs. 5 The Way Forward – Midland Cancer MDM Action Plan 2016 Assumptions There is no additional oncology, radiology or pathology resource available. Hauora Tairawhiti cancer patients are to be included in all Waikato or regional MDMs. Action Plan 2016 Action When Who leads 1. Participate in national MDM project which is part of the NZ Cancer Health Information Strategy programme of work 2. Audit of MDMs in 2016 against MDM cluster in each of the tumour standards. For those MDMs where there is no tumour standard, audit will be against the 2012 MDM Guidance document.. 3. Each MDM must have a terms of reference agreed and signed off 2016 Ministry of Health June 2016 Midland Cancer Network March 2015 4. Tairawhiti - $14, 900 to support additional administration FTE of 0.4 FTE for 12 months. This additional FTE will complete a piece of work around current practices and then support alignment and standardisation of processes from referral through to MDM and ensuring feedback from MDMs is received and acknowledged by clinicians. 5. Maintain watching brief on data required for MDM in National Patient Flow 6. Waikato – additional infrastructure required in Waiora L4 meeting room if Breast and Head and Neck MDMs move there from 2017-18 (microscope and ceiling microphones) 7. Waikato Breast MDM to review implementation of MDM proforma for oncology cases. Consider use of same proforma in Lakes and Bay of Plenty 8. Investigate options to ensure Tairawhiti patients have access to a Urology Oncology or Genito-urinary MDM including June 2016 MDM Chair Midland Cancer Network project manager/Clinical Director Debbie Barrow, Hauora Tairawhiti Ongoing Midland Cancer Network December 2016 Waikato DHB June 2016 MDM Chair Midland Cancer project manager December 2016 Midland Cancer Project Manager Network Network 9 Action When Who leads increased radiology and pathology availability at Waikato. Tairawhiti urologist not always available to present cases 9. Investigate options for collation of MDM data for clinical audit and clinical decision making 10. Continue review and development of MDM proformas and eProformas Ongoing Midland Cancer Network Manager and Project Manager Midland Cancer Network Project Manager MDM coordinators Midland Cancer Network and Sarcoma MDM 11. Ensure there are clear pathways and guidance for clinicians referring patients to the national Sarcoma MDM at CMDHB. 12. Stocktake of palliative care participation in cancer MDMs Ongoing June 2016 June 2016 Midland Cancer Network 6 Summary proposed expenditure for July 2015 – June 2016 Allocation of funding for cancer MDMs across Midland Cancer Network DHBs in 2015-16 MDM required spend Audiovisual support contract Datacom VC support MDM Coordinator Spark MDM VC endpoint Corporate overheads (20%) Depreciation Support for MDMs Proforma development Maintenance Upgrades to MDM room equipment Total Data entry lung cancer database 0.2FTE @$50k Contingency for unplanned maintenance Total Underspend/overspend Bay of Plenty Lakes 110,207.51 50,748.68 9,780 6,180.00 7,420.59 2,635.00 26,293 21,249.50 18,482.52 5,684.18 13,782.00 15,000.00 15,761.40 7,877.55 10,810.45 110,207.51 50,748.68 Tairawhiti Waikato 25,592.46 173,617.82 7,320 9,705.84 14,900 50,000 5,580 5,118 34,723.56 30,418.28 167.50 4,896.36 25,598.00 137,231.54 10,000 110,207.51 50,748.68 0.00 - 25,598 147,232 -5.54 26,386.28 7 Conclusion While an increasing number of cancer MDMs almost meet the new Guidance requirements there are some gaps and issues to be addressed to ensure all cancer MDMs in Midland comply. 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. Please note that the funding will not meet all MDM service requirements in particular, workforce gaps. 10 Appendix 1: Current cancer multidisciplinary meetings DHB Regional or Local Bay of Plenty DHB Breast (weekly) Surgical Pathology meeting includes colorectal (weekly) Endocrine (monthly) LGI Oncology (weekly) UGI Oncology Gynae-oncology (weekly) Head and Neck (weekly) Lymphoma (weekly) Melanoma (fortnightly) Neurosurgery Genito-urinary Urology Oncology (Alternate weeks) Myeloma (Fortnightly) Terms of reference √ Screening √ Those to be considered for surgery discussed with Chest Conference √ √ Tuesday 12.30 √ √ √ √ Local Wednesday 13.30 √ √ √ Handwritten Screening √ Waikato and Tairawhiti Regional Wednesday 08.30 Wednesday 10.00 Friday 12.30 Wednesday 08.00 √ √ √ √ (oncology) Screening √ √ √ Tuesday 08.00 BOP & Lakes Regional Waikato Lakes Tairawhiti Waikato Lakes Tairawhiti Local Regional Regional Local Regional Local Regional Tuesday 13.30 Thursday 08.00 Wednesday 09.00 Monday 08.30 Thursday 10.00 Wednesday 10.00 Wednesday 15.00 √ Database √ Urology Oncology (first and third Tuesdays) Lakes DHB Breast (weekly) √ Proforma Wednesday 11.00 Local Local Chest Conference (weekly) Full MDT Agenda membership √ Lung Waikato DHB Breast (weekly) VC available Wednesday 07.40 Wednesday 08.30 Local – Day/time Handwritten √ √ √ √ Draft Not in use at MDM √ √ √ Hand written √ √ √ √ √ √ √ √ √ √ √ (Draft) √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ 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 Waikato DHB Hamilton MCC L1 MDM Radiology Cisco C90 Waikato DHB Hamilton MCC L4 meeting room 1 Cisco SX20 1 landscape + 1 portrait Waiora L2 Waikato DHB Waiora L2 MDM Waikato DHB Thames MDM Cisco SX20 Cisco SX20 2 landscape BOPDHB.TGA.MDM_RAD Cisco C90 2 landscape + 2 portrait BOPDHB.WHK.MDM_RAD Cisco C60 2 landscape + 2 portrait Kathleen Kilgour Centre Polycom Group 500 Cisco C60 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 Thames Seminar Room Tauranga RCR Whakatane RCR 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 Comments New tablet installed to replace previous touch panel for AV/VC November 2015 Room was not setup to host regional MDMs by VC but for Waikato oncologists to participate in Lakes/BOP MDMs. Now hosts regional MDMs but room not fit for purpose. Set up with2 landscape monitors for linking into Auckland MDMs 2 landscape + 1 portrait New tablet installed to replace previous touch panel for AV/VC February 2016 New tablet installed to replace previous touch panel for AV/VC February 2016 Codec does not have same functionality as Cisco AV touch panel and software no longer supported by manufacturer 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 are presented in the bowel cancer MDM 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 surgeons, a medical and radiation oncologist, a radiologist, a pathologist, an 13 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. Standard 12 The MDM discussion takes place within 14 days of referral (provided referral criteria are 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: 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 14 met). 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. 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 Head and neck Standard 5.1 Patients diagnosed with head and neck 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. 15 Lung Standard 9 All patients with lung cancer should be discussed at a multidisciplinary meeting. (Expert opinion) (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 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 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. Melanoma Standard 5.1 Patients with the following are discussed at an MDM: stage III and IV cutaneous melanoma desmoplastic melanoma 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. 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, 17 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 in the patient’s medical records and communicated to the patient, the treating clinician and the patient’s GP within one week. 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 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 18 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. 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 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. 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. 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 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, 20 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 treatment options and plans offering all Māori patients and their family/whānau access to Whānau Ora assessments and cultural support services. 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. 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. 21