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Participation of Italian Cancer Centres of the Alleanza Contro Il Cancro (ACC) in the Organisation of European Cancer Institutes (OECI) Accreditation and Designation program: a successful first national initiative

Abstract

The Organisation of European Cancer Institutes (OECI) launched a program for accreditation and designation (A&D) of cancer centers in Europe based on voluntary participation in 2008. In 2012, the Italian Ministry of Health decided to fund cancer centers in Italy, members of the Alleanza Contro il Cancro (ACC), to go through the OECI accreditation program. Ten centers participated in the program and 10 completed the full cycle of the OECI A&D process in consecutive series over a 2-year period. The process was successfully completed within the planned timeline and the overall findings were presented to the Italian Ministry of Health and representatives of all the participating centers in November 2015. The program had a considerable team-building effect, which will likely continue as the improvement plans are implemented. Centers fed back to OECI that the A&D program had led to better formal organization of multidisciplinary teams (MDTs) and cancer care pathways, and had helped them to harmonize the integration of research into clinical practice. Centers also concluded that they benefited from recognition through an international accreditation system, and that it had led to them developing better patient information and involvement. The importance of the improvement plans that each center had to produce following the audit reviews cannot be underestimated. The OECI concludes that implementation of the A&D program at the national level is feasible despite national peculiarities related to health planning and organization in each member state. This is a good example of an EU project working well, with member states helping each other and learning from best practice, to improve the overall quality of cancer care and research and to establish consistency. The initial accreditation is the first part of an ongoing process of improving comprehensive cancer care, integrating bench to bedside.

Tumori 2015; 101(Suppl. 1): 6 - 9

Article Type: REVIEW

DOI:10.5301/tj.5000464

Authors

Simon Oberst, Femke Boomsma, Claudio Lombardo, Marjet Docter, Harriët Blaauwgeers, Paolo De Paoli, Dominique de Valeriola, Angelo Paradiso, Mahasti Saghatchian

Article History

Disclosures

Financial support: No funding was received.
Conflict of interest: the authors declare no conflict of interest.

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Introduction

Cancer is a worldwide health burden affecting both the survival and quality of life of human beings. At the European level, efforts are being made for better coordination and ­overall ­improvement of research and care in the cancer field. However, health care planning in the cancer field is crucially and urgently needed in order to better integrate these efforts and foster existing initiatives.

Important funds are dedicated to research and actions are taken to promote the translation of knowledge and innovation into care. Still, information on quality of care standards and criteria and access to knowledge and information are unequally shared throughout Europe.

A common initiative of consensual definition of quality criteria and standards, their dissemination, and evaluation of the adequacy of local practices against the standards should help harmonize and improve care quality, both at the clinical level and at the organizational and management level. This will help ensure not only minimal safety conditions of cancer care, but also improve access to high-quality health care and potentially stimulate optimal provision of care integrating the best of knowledge.

The Organisation of European Cancer Institutes (OECI) is a network of cancer institutes in Europe. In order to fulfill its mission of improving quality of cancer care and reducing inequalities between cancer patients throughout Europe, the OECI initiated the accreditation and designation (A&D) program in 2002 with 3 objectives:

To develop a comprehensive accreditation program for oncology care, taking into account prevention, care, research, education, and networking as well as the involvement of patients

To set an updated database of cancer centers in Europe, with exhaustive information on their resources and activities

To develop a designation tool dedicated to the various types of cancer center organizations (1)

In 2012, the Italian Ministry of Health decided to fund cancer centers in Italy, members of the Alleanza Contro il Cancro (ACC), to go through the OECI A&D program (2) over a 2-year period. This was a major breakthrough, in that a member state selected a European accreditation program for national purposes.

This article brings together the overall findings of the OECI concerning the implementation of the A&D program at the national level in the frame of the Italian Ministry’s initiative, together with the feedback received by OECI from the centers themselves.

Methods

Participating centers and dates of peer review visits

IEO Milan: Peer review visit December 2 and 3, 2013

IRCCS Reggio Emilia: Peer review visit February 10 and 11, 2014

CRO Aviano: Peer review visit February 13 and 14, 2014

Fondazione IRCCS Instituo Nazionale dei Tumori Milan: Peer review visit June 18 and 19, 2014

Istituto Oncologico Veneto, Padova: Peer review visit September 25 and 26, 2014

IRCCS Istituto Tumori Giovanni Paolo II Bari: Peer review visit October 6 and 7, 2014

IRCCS Azienda Ospedaliera Universitaria San Martino-IST-Istituto Nazionale per la Ricerca sul Cancro Genua: Peer review visit November 25 and 26, 2014

Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione ‘G. Pascale,’ Naples: Peer review visit January 26 and 27, 2015

IRCCS CROB Centro di Riferimento Oncologico di Basilicata, Rionero in Vulture: Peer review visit February 16 and 17, 2015

Istituto Oncologico Regina Elena, Rome: Peer review visit April 13 and 14, 2015 

Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS Meldola 

Accreditation process

All centers went through the mandatory steps of the OECI A&D program, including the following:

Application of the cancer institute to the program

Explanatory visit and preliminary designation result

Self-assessment

Go/no-go decision

Peer review visit and designation check

Reporting

Formulating improvement plan

OECI A&D certificate awarded during the OECI general assembly

Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) at Meldola initially entered the accreditation process and had a preliminary site visit, owing to the unique character of its network. The OECI Accreditation and Designation Board looked carefully at the application of its principles and policies around cancer networks, and recommended establishing stronger centralized management and governance at the core of the IRST network to satisfy the OECI standards. Since then, IRST has changed its operating model, and OECI will continue to liaise with them about future accreditation.

Results

Strengths and successes of the Italian program from the OECI viewpoint

General remarks

This national program involving 11 cancer centers was successful in that all reviews were completed and accredited on time and on budget. Also notable was the engagement by all disciplines and all levels of staff in the centers (3). At the closing meeting of a 2-day center review, it was not uncommon to see around 100 members of staff attending the feedback. Thus there was a considerable team-building effect of the program, which is expected to continue as the improvement plans are worked upon. The peer review visits were well-organized, and the audit team invariably found great cooperation and pride among the staff members.

It was clear from working together prior to the audit visits that the challenge to gather quality data and examine quality systems for external review is a benefit in itself. Although all centers had existing quality management systems, some were fragmented or shared with general hospital systems and it was clear that the OECI required some data in forms that were unfamiliar, but nonetheless reflect best European practice.

The OECI A&D Committee and Board were impressed by the high quality of the Italian improvement plans. In each, there was a clear identification of opportunities to improve, a plan to fix the issues, and a reasonable timescale and individual accountable for delivery. These plans were sometimes ambitious, but they form the heart of what the OECI continuous quality improvement process is all about.

A number of Italian auditors from participating centers were trained at the beginning of the national project. A majority of them were involved in the Italian program reviews and in the same period in other centers across Europe. They will continue to be available in OECI audits in other member states, thus cementing the links between centers in Italy and throughout Europe, and bringing back to their own centers knowledge of other centers and good practice.

Findings common to all European centers

Many of the OECI findings at the accredited Italian cancer centers are common to other European centers. Cancer incidence is on the rise and survival rates are improving, and therefore there is more emphasis on the survivorship agenda in all centers. There is more evidence of an emphasis on putting the patient at the center of care, and more effort being put into information and support for patients, including good-quality written materials.

The OECI has always emphasized the importance of MDTs working in cancer, and in every center we found that there were MDTs for most cancer sites, although some were comparatively young in formation. We also found an increasing integration of science and patient treatment; MDTs often contained translational scientists, and eligibility for patients to go on clinical trials was discussed.

The OECI generally finds that integrated quality systems are difficult to establish and can often become overcomplicated. Sometimes managers are deluged by so much data that it is difficult to give a meaningful review and prioritize key areas for improvement. As always, the quality of data and IT integration are key, and all centers are evolving in this area. Most have electronic patient records, but in many centers it is difficult to extract key data across patients to monitor outcomes, for instance stratified by different therapeutic protocols.

Throughout Europe, many centers accredited by OECI are cancer specialist institutions, but increasingly centers are part of general (often university) hospitals. We find that getting directorial engagement is more difficult in a general university hospital, where the directors see cancer as only one of many priorities. It can be harder to leverage resources, specific quality requirements, and staff in such circumstances.

Finally, OECI finds that the quality of strategic plans and implementation plans is often not strong. They are often too vague, too long, not properly timed or costed, and not assigned to appropriate accountable people for implementation. There is room for better management discipline.

Distinctive findings in the accredited Italian centers

In the accredited Italian centers, one of the distinctive features that often recurred was the strength of supportive and palliative care services, often stronger than in other countries; there were multidisciplinary teams providing a continuity of care within and beyond the hospital walls, and this function is to be commended.

The OECI found on average in the Italian centers that nurses had less input into the patient pathway than in other European countries. In Italy, there is no specific oncology qualification for nursing staff, who learn by experience. The OECI recommended to centers with strong university links to begin to design such courses that have the potential over time to increase the role of nurses in oncology and MDTs.

As for information and support for cancer patients, generally, the OECI findings were that information-giving to patients was informal and less in written form in Italy than in other EU member states, although we commend the work of AIMaC ­(Associazione Italiana Malati di Cancro, parenti e amici - Italian Association of Cancer patients, relatives and friends) in publishing helpful booklets for patients for many aspects of cancer information and support. Best practice in Europe would also suggest that information and support centers close to outpatient units should be staffed by information professionals and volunteers who could also help in general matters of support for patients and carers, for instance, financial or welfare benefits advice.

In some Italian centers, the findings were that patient and public engagement could be strengthened. There were often patient liaison groups that helped deal with complaints, but it was rare to find patient groups consulted on cancer services or patient pathways, and the depth of patient satisfaction surveys could be improved.

Those who know the Italian system well will recognize the OECI observation that many budgets are controlled by regional government and therefore it is difficult to obtain a strategy for growth, both in the core resources required for translational science and for new developments in patient services.

Regarding clinical trials, OECI concluded that—money and research staff resources permitting—the number of clinical trials and number of patients included in them could be increased. Even for some comparatively large comprehensive cancer centers, the number of patients accrued to trials was fairly modest compared with many other European countries. There seems to be scope also for building more international collaborations in translational research.

Some of OECI’s standards concern centers’ monitoring of patient waiting times, which is crucial to timely diagnosis and treatment. Generally the Italian findings were that patient waiting times were better than in other EU countries, but sometimes there was also some doubt as to how closely each delay was monitored. This point again comes back to the quality of data and IT function (4).

Issues related to designation

At accreditation comes also the issue of which designation is to be given to the center. Among the 10 Italian centers, 4 were designated as a Clinical Cancer Center and 6 as a Comprehensive Cancer Center. This is determined by OECI independently through a combination of mostly quantitative factors but also with a degree of qualitative judgement based on the peer review visit. In fact, the OECI found a correlation between the scores in the quality standards by the audit team and the final designation decision.

Factors that were noted in this decision process included the number of high-impact scientific articles. These were often not as high as in other European centers; however, OECI interpreted these thresholds liberally. Another factor that impinged on comprehensiveness was the number of patients in the center in clinical trials; in some cases, these numbers often only just reached the minimum OECI requirement. The essence of comprehensive status is the degree of integration of science and clinical care which is translated by the 2 different types of OECI designation as a clinical or a comprehensive cancer center, and this was met by most of the centers, which accordingly were designated as Comprehensive Cancer Centers. In other cases, centers are on a path toward comprehensive status.

Feedback to OECI from centers

Half of the centers accredited by OECI provided formal feedback on the process, which we summarize below.

Some of the centers found it difficult to collect and analyze particular data due to the IT system of their center, and some would like the definitions of the data required to be clearer. A couple would like the OECI e-tool to be more user-friendly.

In some cases, there was a question concerning the applicability or relevance of the OECI standards, for instance around screening programs. The OECI has recently revised its standards to take user feedback into account, but has to design standards for general use across all member states with a variety of health systems.

Some centers believed that a pre-visit to center would facilitate OECI understanding the context and organizational issues of the center. This was in fact done where there were exceptional issues but the OECI audit teams are experienced in visiting a variety of different centers, each with distinctive governance, management, financing, health care systems, or service features.

Some centers believed that the audit visit could have been longer to visit more departments and observe the center more fully. The audit teams would generally have been willing to do this, but controlling costs and treating all centers equally dictates that (as in all audits) interviews and visits have to be based on a representative sample of cancer services and research.

Every center was satisfied with the support from OECI head office during self-assessment and peer review preparation. Most centers were “very satisfied” or “satisfied” with the final report of OECI, although one center expressed reservations concerning its final designation.

Centers’ feedback: how did the process benefit?

Most centers fed back to OECI that the accreditation process had led to better formal organization of the MDTs and Cancer Care Pathways. This is a welcome result, since these aspects sit at the heart of the OECI (and worldwide) standards of care for cancer. Centers also commented that the process provided motivation for quality improvement at both a strategic and operational level.

Centers commented that the process (and the improvement plans) led to them developing better patient information and involvement.

Some centers noted that the OECI process helped them to harmonize the integration of research into clinical practice. This is also a good result, since some recent studies (5) show how research-active and research-integrated institutions provide better outcomes for their patients.

Many centers mentioned increased awareness of quality issues among their staff, and the team-building effect that involved dozens of people at all levels of their center, as noted above. Some said that, as a consequence of the process, improvement projects were born spontaneously.

Finally, centers said that they benefited from recognition through an international accreditation system, which brings pride to their staff and assurance to their patients.

Discussion

Drawing upon OECI’s collective experience, and the feedback from the Italian centers involved in the A&D process, this was a good example of an EU project working well—member states helping each other and learning from best practice—to improve the overall quality of cancer care and research. The Italian centers and OECI both benefitted. At every touchpoint, the centers and OECI accreditation teams and committees obtain ideas and examples of best practice from other sources, and are able to revise the standards and assist in the rolling out of best practice across Europe and beyond.

The importance of the improvement plans and their careful implementation cannot be underestimated. The initial accreditation is only the first part of an ongoing process of improving comprehensive cancer care—integrating bench to bedside. At each subsequent stage, processes and outcomes are reviewed and improved, and patient experience is surveyed and tracked, which ensures that the quality of experience and patient outcomes are continuously improving across rare and common cancers throughout Europe.

We will strive towards replicating this successful national initiative in other European countries.

Disclosures

Financial support: No funding was received.
Conflict of interest: the authors declare no conflict of interest.
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Authors

Affiliations

  • Cambridge Cancer Centre, Cambridge - UK
  • The Netherlands Comprehensive Cancer Organisation (IKNL) - The Netherlands
  • Organization of European Cancer Institutes, Bruxelles - Belgium
  • SOS Europe Srl, Genova - Italy
  • Scientific Directorate, Centro di Riferimento Oncologico (CRO), IRCCS, National Cancer Institute, Aviano (Pordenone) - Italy
  • Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles - Belgium
  • Experimental Medical Oncology, Istituto Tumori G. Paolo II, IRCCS, National Cancer Institute, Bari - Italy
  • Medical Oncology Department, Institut Gustave Roussy, Villejuif - France

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