The aim of this article is to describe the accreditation process of the Veneto Institute of Oncology (IOV-IRCCS) according to the Organisation of European Cancer Institutes (OECI) model, with particular reference to the standards for the multidisciplinary approach. Through the analysis of the process and the activities of each multidisciplinary team (MDT) and the development, at a regional level, of diagnostic, therapeutic, and care pathways (PDTA), all the necessary steps to meet the OECI standards have been determined. Adjustment is ongoing. We are working on the inclusion of the MDT registration forms in the electronic medical records and on the possibility to extend the OECI model to the MDT not based at IOV, but participated in by IOV professionals. The sarcoma MDT has achieved results demonstrating that the OECI framework has allowed the professionals involved in the multidisciplinary meeting to systematically share the clinical information of the patient, who can benefit from better continuity of care. The model has also provided greater clarity in the management of patients who are enrolled in clinical trials and deviate from Guide Lines (GL)/PDTA. The accreditation process according to the OECI model has added value to the IOV’s already well-developed multidisciplinary activities.
Tumori 2015; 101(Suppl. 1): 38 - 41
Article Type: REVIEW
AuthorsDaniela Chiusole, Piero Cioffredi, Umberto Basso, Alberto Bortolami, Gino Crivellari, Gisella Gennaro, Romina Spina, Giuseppe Opocher
- • Accepted on 02/12/2015
- • Available online on 30/12/2015
- • Published in print on 31/12/2015
This article is available as full text PDF.
The Veneto Institute of Oncology (IOV-IRCCS) has participated, together with the other Italian oncology IRCCS, in the targeted research project “Tailored Accreditation Model for Comprehensive Cancer Centers: Validation Through the Applicability of the Experimental OECI-Based Model to the Network of Cancer IRCCS of the Alliance Against Cancer.”
The IOV has been certified as a Comprehensive Cancer Center (CCC) (the highest recognition awarded by the Organisation of European Cancer Institutes [OECI]). This result was the Institute’s objective and demonstrates that the OECI model is applicable in Italy with good results. The IOV has adequately met most of the standards (scoring “mostly” and “yes”). Many others have been met during the self-assessment phase, owing to the contribution of the professionals involved and to the strength of the corporate quality management system (certified International Organization for Standardization [ISO] 9001). The development and wide application of the latter were crucial in determining a working method that proved to be useful and effective also for OECI accreditation.
Great was the satisfaction of everyone involved when, at the end of the peer review, the team leader said (and subsequently repeated in the report): “If there was one overarching impression, it was modesty, as noted by the frequent use of the word ‘mostly’ […] in the scoring sheets. The Board on several occasions upgraded these opinions to ‘yes.’ We felt that the work within the Institute was a well-kept secret of which staff and patients could feel very proud, but it might be fruitful to broadcast its excellence more widely.”
The development of patient empowerment oriented to marketing and fundraising was one of the opportunities for improvement indicated by the auditors. Other opportunities included initiatives for specific academic training for oncology nurses (lacking in Italy); the development of a tech-transfer service in order to exploit the commercial potential of the results of research; and the extension of the Institute’s information system to every division and member of the Regional Oncology Network.
Among the strengths of the cancer center with regard to the OECI quality standards worth mentioning are the continuity of care; the leadership of the institute as the regional oncology hub; the excellence of research at basic, translational, and clinical levels; and the quality of the units visited during the peer review.
Strengths and opportunities for improvement have been pointed out with regard to the multidisciplinary activity. In the OECI model, multidisciplinarity is identified as a key issue at all stages of patient management.
“Multidisciplinarity…percolated through the entire Institute. It was observed that working together in teams was in its DNA” is written in the report. This confirms the high regard in which IOV holds multidisciplinarity. The presence of a strong base is therefore recognized—a mentality and an inclination favorable to the involvement of specialists from different disciplines throughout the diagnostic, therapeutic, and care pathways of patients. With OECI, the Institute has moved a step ahead in a more structured organization of multidisciplinary teams (MDTs).
The opportunities suggested in the report include reporting and analysis of deviations from GL/PDTA, annual review and systematic evaluation of each MDT activity, and consolidation, according to the OECI model, of the MDTs not based at IOV.
Organization at the beginning of the accreditation
The IOV has long been engaged in the development of multidisciplinarity: 6 weekly discussion groups, 1 biweekly discussion group, and 10 weekly clinics are held at IOV; 9 weekly discussion groups and 2 weekly clinics are held within the Azienda Ospedaliera di Padova attended by IOV professionals.
From the organizational point of view, the activity of multidisciplinary clinics is structured with the following:
Computerized appointment scheduling
Data recording using the proper e-tools and in the electronic medical record
Medical report for the patient and his or her family doctor, written in an appropriate format, specific for the multidisciplinary clinics, and signed by the specialists involved in the consultation
As for the activities of the MDTs, there is a weekly meeting to discuss clinical cases. The MDTs discuss a higher number of cases than the clinics, yet in terms of organization and management, their activity is not as structured. The meeting minutes and the recording of the activities are not uniform across all groups.
The OECI standards
The OECI standards for multidisciplinary include about 20 out of the 264 standards, including the following:
Identification of the key figures for the patient (case manager, physician)
Definition of the criteria for the selection of patients to be discussed in the MDT meetings
Availability of the necessary facilities to show diagnostic and examination results
Definition of standard communication criteria among team members about the cases
Methods to inform patients about conclusions and advice from the MDT meetings
Registration of the MDT conclusions and the possible deviations from GL/PDTA in the electronic medical record
Availability of reports on each MDT activity and annual reviews
The Veneto Oncology Network (ROV) and diagnostic, therapeutic, and care pathways (PDTA)
The Veneto Region entrusted the IOV with the coordination of the ROV with Decree 7/2014. Over the years, the institute had gained specific expertise in the development of PDTA for most common cancers in collaboration with other oncology units in the region.
The PDTA working groups established by the ROV aim to determine oncology pathways in order to improve the efficiency of all structures by defining objectives, roles, times, and areas of operation.
The complexity of the health care system can create conditions that favor the variability of care in terms of continuity and patient management, facilitating inappropriate behaviors and/or errors. Health needs also become more complex, to the point where they can hardly be met by a single health provider or in the healthcare system alone. In this scenario, PDTAs allow the outlining, with respect to a disease or clinical problem, of the most viable path within the single organization and the network.
Therefore, a PDTA is an organizational health pathway, distinct for specific pathology, identifiable in the system of the services related to the diagnosis and treatment process. Its goal is to codify the responsibility at every stage of the process.
In drafting of PDTAs, the main objective was to ensure timely patient management, adequate levels and continuity of care, equity in terms of access and use, and control of appropriateness in prescription and supply.
The ROV has planned the following 15 PDTAs: breast, colorectal, lung, prostate, sarcoma and gist, melanoma, kidney, hepatobiliary, esophagus, hereditary breast and ovarian cancers, stomach, head and neck, gynecologic, endocrine, and neuroendocrine.
Improvements during the accreditation
The specialists participating in MDTs have been asked to help meet the OECI standards. After analysis of the process, a specific procedure was obtained. It introduced the required elements of uniformity and traceability, with a precise registration of the activities in order to ensure that information flows are always documented.
One of the main problems to be addressed was the inadequacy of the e-tools (medical and clinical records) for the needs of a multidisciplinary approach; for this aspect, an improvement plan (still in progress) has been drafted.
The procedure, properly documented and shared within the MDTs, introduces all the requirements of the OECI model; thus they are now applied in daily activities. The procedure has gradually been applied by IOV-based MDTs, which are participated in by professionals from other hospitals.
The ROV plays a central role in the qualitative development of the multidisciplinary activities. Within the ROV, PDTAs are developed, shared, and adopted; they facilitate the organizational development of the activities according to the OECI standards.
The PDTAs are elaborated by groups within the ROV whose aim is to produce homogeneous documents in which diagnostic and therapeutic decisions are based on national and international GLs.
In any PDTA, the multidisciplinary meeting is the key moment for sharing personalized options of treatment and care and for ensuring appropriate timing and integration of the different operators’ activities. The MDTs use a format for sharing patient information prior to the meeting and the subsequent decisions. This forms the database of all discussed patients and includes the number of patients proposed for the discussion, the unit caring for the patient, the assessment of patient characteristics, the conclusions of the MDT, and possible deviation during the treatment. The results of the multidisciplinary discussion are recorded in the patient’s medical record by his or her referring physician or case manager, and communicated to the patient and the family doctor.
The overall development and implementation of PDTAs has been shown to be in line with the OECI standards.
The ongoing digitization of clinical documentation must necessarily include the activities of MDTs. The software must have dedicated spaces for recording the discussed cases, the deviations from the PDTA, and all the diagnostic and clinical information about the examined cases. Such digital recording facilitates the production of reports containing the relevant data for the annual review of each team’s activity.
The software package used at the IOV to manage clinical records, OncoSys, includes 2 types of MDT activities: MDT patient examinations and MDT discussions. For the latter, it was decided to implement a summary sheet within OncoSys to record the results of breast MDT discussions.
An improvement plan was drafted, in the context of which the following actions have been carried out.
The paper form used by the breast MDT team to record decisions about patients was presented to the IT team. An electronic version was developed within OncoSys and activated on the test server. Clinicians were asked to test the e-form and evaluate its usability. A posteriori analysis was performed to summarize the critical issues and propose improvements. The electronic form developed within OncoSys was judged appropriate and easy to use by the breast MDT team.
The current major limitation is that the OncoSys software is used by oncologists and radiotherapists, but not by surgeons. Nevertheless, patient cases discussed in the weekly breast MDT team are mostly proposed by surgeons. The development of a surgery record (now ongoing) is mandatory to make the breast MDT e-form effective.
The digitalization of records is ongoing and, once fully operational, will simplify the related activities preparatory and subsequent to the multidisciplinary discussion.
Adapting to the OECI model: the sarcoma MDT
Modern protocols for the diagnosis and treatment of sarcomas require the joint efforts of numerous specialists, such as surgeons, oncologists, radiologists, nuclear physicians, orthopedists, radiotherapists, pathologists, biologists, and psychologists. The difficulty in coordinating this multidisciplinary activity, in order to establish and optimize the diagnostic and treatment pathways of patients with sarcoma by the Surgical Oncology Unit (regional center of reference for cutaneous melanoma), has resulted in the need for a stronger structure and organization. The new model involves the identification of clinical cases to be discussed; particular attention is devoted to the analysis of diagnostic imaging and pathology findings.
The multidisciplinary discussion plays a key role in defining the most appropriate and effective diagnostic procedures (with a rational and efficient use of the available diagnostics tools) and in formulating a shared, and at times complex, treatment plan, according to the principles of personalization, with strong adhesion to the latest GL. The results of treatments, the care program, and the subsequent follow-up of the patient are also discussed and shared.
In line with the OECI model and beginning in 2014, the sarcoma MDT applies a standard organizational methodology for recording activities. The team meets weekly and discusses an average of 15 cases.
The decisions taken collectively are recorded both in the specific form for the minutes and in the patient’s medical record.
An annual team meeting is devoted to the discussion of the results produced during the year, in particular the following:
Number of cases discussed
Verification of the patients’ actual pathways compared to the pathways defined by the team
Evaluation of deviations from the decisions of the team
Recommendations for the management of the institute for the improvement of care
The meeting is crucial to analyze the work done during the year, identify possible problems, and make improvements.
This framework has allowed the professionals involved in the meeting to systematically share clinical information on patients, who can benefit from better continuity of care.
The OECI model has also provided greater clarity in the management of patients who are enrolled in clinical trials and deviate from GL/PDTA; in fact, during the meetings, the trials, the mode of recruitment, and the inclusion/exclusion criteria are described.
Challenges in the organization of multidisciplinary activities in genitourinary oncology at IOV
Multidisciplinary care in genitourinary oncology is relatively young compared to other solid tumors such as breast or colorectal cancer. While chemotherapy and radiotherapy are routinely applied after surgery in testicular cancer, the use of neoadjuvant chemotherapy as well as of chemoradiotherapy protocols in bladder cancer is limited, and controversy hampers widespread use of combined prostate cancer treatments in Italy.
A formal call to action toward the implementation of multidisciplinary strategies in the treatment of prostate cancer, and genitourinary tumors in general, has been made by several scientific societies at the European level (ESMO and Europa Uomo), as well as in Italy (AIOM consensus statement for multidisciplinary care in uro-oncology, PERSTEP project sponsored by SIURO and CIPOMO for multidisciplinary care of prostate cancer). A recent article (1) has updated the requirements for the ideal model of integrated care within a formal prostate unit.
At IOV, several activities of the radiotherapy and oncology unit are devoted to multidisciplinary management of genital-urinary tumors, in cooperation with the urology units of 3 different associated hospitals (Azienda Ospedaliera-Universitaria, ULSS 16, and Policlinico of Abano Terme) and the corresponding radiology units.
Every Monday, urologists of the Azienda Ospedaliera-Universitaria meet with oncologists and nuclear physicians of IOV to discuss the most challenging cases seen during the previous week. A detailed document for the constitution of a Padova Prostate Cancer Unit has been prepared and shared by IOV and Azienda Ospedaliera-Universitaria, but formal approval by the general directors of IOV and Azienda Ospedaliera is pending.
Every Wednesday, a multidisciplinary clinic for prostate cancer is active at the radiotherapy unit, where oncologists and radiotherapists share a room and the patient is able to discuss treatment options with both specialists. All clinical data and shared therapeutic decisions are registered in the IOV electronic patient record (OncoSys). Logistic and time limitations hamper the participation of urologists in this multispecialty clinic.
Once a month, radiotherapists meet with the urologists of ULSS 16 to discuss the most complex cases of genitourinary tumors together with oncologists of ULSS 16.
Psycho-oncology consultation is available for selected patients, as well as consultation with andrologists, physiatrists, pain management, and nutrition specialists.
Patients with bone metastases to the spine may have access to a multidisciplinary clinic specifically devoted to osteo-oncology in order to offer all types of local (orthopedic surgery, interventional radiology, and radiotherapy) and systemic (bisphosphonate and denosumab) treatments for the prevention and treatment of skeletal-related events.
This fragmentation of activities is due to the fact that several units of 3 different hospitals are involved in the care of genitourinary tumors and, therefore, a unique tumor board meeting is not feasible due to logistic and time constraints. Yet cooperation of IOV with Azienda Ospedaliera-University and ULSS 16 expands the number of patients that are being cared for, allows specialists of IOV to share their knowledge and expertise with a broader number of specialists, and increases the number of patients who can be enrolled in experimental trials at IOV.
A plan is being developed to create a new oncology interinstitutional department, which could help to harmonize and better integrate the multidisciplinary activities for prostate and genitourinary cancers in general. These processes, aimed at optimal patient management, would be facilitated if the department implements OECI standards for the management and organization of multidisciplinary activities.
The IOV-IRCCS has obtained OECI designation as a Comprehensive Cancer Center, owing to the institute’s staff and the collaboration and sharing of the process with the other IRCCS that took part in the project. The goal of the project, to accredit Italian oncology IRCCS in accordance with a qualifying and prestigious European model, was largely achieved.
The project has allowed all the involved oncology IRCCS to test the model in the national context, ensuring added value for patients and the application of high uniform standards in care provision and scientific research.
The OECI certification is a necessary and sufficient condition to meet the requirements of current legislation (Legislative Decree No. 288/2003, Art. 13, H: “quality certification of the services according to internationally recognized procedures”) for granting and maintaining the status of IRCCS, yet the accreditation process has shown that our institute cannot do without a corporate quality management system, which, in our case, is certified ISO 9001.
- Chiusole, Daniela [PubMed] [Google Scholar] 1
- Cioffredi, Piero [PubMed] [Google Scholar] 1, * Corresponding Author (firstname.lastname@example.org)
- Basso, Umberto [PubMed] [Google Scholar] 2
- Bortolami, Alberto [PubMed] [Google Scholar] 3
- Crivellari, Gino [PubMed] [Google Scholar] 2
- Gennaro, Gisella [PubMed] [Google Scholar] 4
- Spina, Romina [PubMed] [Google Scholar] 5
- Opocher, Giuseppe [PubMed] [Google Scholar] 6
Quality and Accreditation Office, Veneto Institute of Oncology IOV - IRCCS, Padua - Italy
Clinical and Experimental Oncology Department, Veneto Institute of Oncology IOV - IRCCS, Padua - Italy
Veneto Oncology Network, Veneto Institute of Oncology IOV - IRCCS, Padua - Italy
Radiology and medical physics Department, Veneto Institute of Oncology IOV - IRCCS, Padua - Italy
Surgical Oncology Department, Veneto Institute of Oncology IOV - IRCCS, Padua - Italy
Scientific Directorate, Veneto Institute of Oncology IOV - IRCCS, Padua - Italy