Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS is a public-private partnership among 3 public sector bodies and 6 private nonprofit organizations and represents the hub of the Oncology Network of Romagna, which provides a wide range of services for the population ranging from primary prevention to palliative care. In 2012, IRST took part in the ministerial research project of the Organisation of European Cancer Institutes (OECI) accreditation program for Comprehensive Cancer Centers. The self-assessment period lasted 6 months and was coordinated by a multidisciplinary project team headed by a project leader. Each project team member coordinated a subgroup whose task was to analyze specific standards from qualitative and quantitative questionnaires. During the self-assessment period for the areas in which IRST did not meet OECI requirements, the project team outlined several improvement plans. At the end of the self-assessment period, the OECI Accreditation & Designation Board approved the documentation presented by IRST and a peer review visit was scheduled. The OECI report suggested establishing a more specific and stronger centralized management and leadership of all the oncologic activities carried out in other centers. In accordance with these suggestions, IRST and the Local Health Authority of Romagna laid the foundations for a new management model for the Oncology Network of Romagna: the Comprehensive Cancer Care Network (CCCN). The CCCN is a territory-oriented model (population approach) based on a principle of cooperation and collaboration among the network nodes.
Tumori 2015; 101(Suppl. 1): 55 - 59
Article Type: REVIEW
AuthorsValentina Ancarani, Marna Bernabini, Chiara Zani, Mattia Altini, Dino Amadori
- • 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.
Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, one of the 2 cancer research hospitals in the Emilia Romagna region, is located within the wide catchment area of Romagna (AVR), which has a population of 1,124,866 inhabitants, 546,111 male and 578,755 female. The average age of the population is 45 years. The AVR consists of 3 provinces (Forlì-Cesena, Rimini, and Ravenna) extending over a total of 5,098 km2 and with 75 boroughs. A total of 23% of the AVR population live in boroughs of fewer than 10,000 inhabitants. IRST operates within a social context characterized by a good quality of life and by an overall population that is older than the national average, homogeneously distributed throughout the territory.
IRST is a public-private partnership among 3 public sector bodies (the Local Health Authority of Romagna, the Emilia Romagna region, and the Borough of Meldola) and 6 private nonprofit organizations (Oncology Institute of Romagna and 5 banking foundations). With regard to administrative status, IRST is a limited liability company (Srl in Italy), where 69.62% of stocks are held by public members and used for the betterment of the healthcare services offered and for nonprofit activities.
IRST represents the hub of the Oncology Network of Romagna, which provides a wide range of services for the population ranging from primary prevention to palliative care.
The Oncology Network of Romagna was founded in accordance with the Network Plan agreement (Piano di Rete), approved in 2005 by the Emilia Romagna region. Regional programming provided for the adoption of a specific network model, i.e., the hub and spoke model, to organize highly specialized hospital care. This model is based on the link between the hub (highly specialized center) and spokes (local hospitals or facilities), the latter sending their patients to the hub when their medical condition renders this necessary. Such planning has been extended to the regional level and operates alongside local programming, thus guaranteeing regional self-sufficiency.
In this context, IRST, as the hub of the Oncology Network of Romagna, organizes and coordinates the following activities: research and clinical experimentation; promotion, execution, and evaluation of cancer research and healthcare; use of innovative technologies for patient treatment; and continuous training in the field of oncology. IRST, which has 4 main sites (Meldola, Forlì, Cesena, and Ravenna), operates in the following areas: oncology, radiotherapy, nuclear and radiometabolic medicine, radiology, oncohematology, biosciences laboratory, somatic cell therapy laboratory, biostatistics and clinical trials, ethics committee, cancer registry, palliative care, psycho-oncology, medical physics, clinical genetics, and biobank. The Meldola site offers all of the above services. The Forlì site is located in Morgagni-Pierantoni Hospital (Forlì) at a distance of 12 km from Meldola and provides an oncology day hospital service. The Cesena branch of IRST is situated in Bufalini Hospital (Cesena) 25 km from Meldola and provides an oncohematology day hospital service. The Ravenna site of the institute is located inside Santa Maria delle Croci Hospital (Ravenna) 40 km from Meldola and provides a radiotherapy service. The IRST is fully responsible for the management of these sites and for the services offered.
For the services that IRST does not provide directly, supply contracts have been stipulated with the Romagna Local Health Authority (RLHA). These services comprise pathology, clinical laboratory, blood transfusion, anesthesia, gastroenterology, and other specialist areas. The services that are not included in the supply contracts, e.g., general practice, rehabilitation medicine, cancer prevention, and palliative care, fall under the management of the Italian National Health Service and Regional Health Service.
In 2012, IRST took part in the ministerial 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” (1). IRST’s objectives were to promote cooperation between the Cancer IRCCSs within the Italian network and to validate, in accordance with European standards, a Comprehensive Cancer Network model. Other aims were to improve adherence to quality and safety standards in the institute, instruments of communication and information for patients, and clinical outcomes.
Thanks to the OECI accreditation program (2), IRST redefined its role within the Oncology Network of Romagna and forged new connections with the Local Health Authority of Romagna to promote a shared governance of a future Comprehensive Cancer Care Network of Romagna (CCCN). A CCCN is an advanced network model based on the integration of entities without a defined hierarchy and a central governance that manages all the services offered and defines the role of the components of the network (3-4-5).
IRST and Oncology Network of Romagna: milestones and legislation
In accordance with Regional Law no. 29/2004 of October 24, 2005, the Social and Healthcare Territorial Conferences and General Directors of the 4 ex–Local Health Authorities of Romagna (now RLHA) approved the network planning agreement, a document for the strategic planning of the Oncology Network of Romagna. Under the same law, IRST was recognized as a partner of the future Oncology Network of Romagna, with specific functions with regard to research, innovation, and care.
In 2007, the institute was opened in Meldola and the Oncology Unit of Forlì was encompassed by IRST. The Regional Law No. 4 of February 19, 2008, confirmed that IRST could be considered a candidate for recognition as a research hospital. In 2011, IRST took over the running of the Oncohematology Day Hospital of Cesena, followed in 2014 by the Radiotherapy and Medical Physic Units of Ravenna.
On April 13, 2012, the Official Gazette of the Italian Republic (No. 87, 2012) published the news that IRST had been formally recognized by the Italian Ministry of Health as a research hospital (IRCCS). Regional Law No. 22 of November 21, 2013, established the creation of the RLHA, a regional heathcare body formed by the unification of the 4 Local Health Authorities of Romagna (Forlì, Cesena, Ravenna, and Rimini).
In 2014, the Italian Regions Committee, together with the Italian Ministry of Heath, cosigned the Guide for the Constitution of Regional Oncological Networks (Rep. No. 144/CSR of October 30, 2014), which outlines the regulations, objectives, and organizational models of networks within the National Health System.
The OECI accreditation program
The OECI accreditation program started in IRST on February 1, 2013. As stipulated in the accreditation manual, the self-assessment period (step 4 of the program) lasted 6 months, from March to September 2013, and was coordinated by a multidisciplinary project team headed by a project leader. Each project team member coordinated a subgroup whose task was to analyze specific standards from qualitative and quantitative questionnaires (
Composition of the project team
|Composition of the project team||Main questionnaire areas|
|OECI = Organisation of European Cancer Institutes.|
|Project leader||Project team coordinator/OECI contact person|
|Subgroup A||Education and training/research, innovation, and development|
|Subgroup B||Research, innovation, and development|
|Subgroup C||Research, innovation, and development and quality system|
|Subgroup D||General management and patient pathways|
|Subgroup E||Nursing management|
|Subgroup F||Patient-related processes|
|Subgroup G||Quality system|
|Subgroup H||Quantitative data|
The items of the qualitative questionnaire were assigned to each subgroup on the basis of competencies (
Items from the Organisation of European Cancer Institutes (OECI) qualitative questionnaire assigned to each subgroup.
Accreditation program: self-assessment
During the self-assessment period, the subgroup members recruited the help of many other professionals from the institute (e.g., oncologists, nurses, pharmacists, technicians, psycho-oncologists, IT technicians) to analyze the qualitative and quantitative standards and to provide the necessary supporting documents. The multidisciplinary project team organized 4 meetings with colleagues from other IRCCS in northern Italy (Milan [IEO], Aviano [CRO], and Reggio Emilia), 2 internal meetings involving all institute personnel, 10 meetings with various professionals (i.e., physicians, nurses, researchers) to share the results of the self-assessment phase, and 7 internal simulations of the peer review visit.
For the areas in which IRST did not meet OECI requirements, the project team outlined the following improvement plans:
A group of representatives chosen from each unit of the institute was created to provide support for quality system management.
Procedures were written describing the work modalities of the monodisciplinary and multidisciplinary groups and taking into consideration the identification, use, and sharing of international guidelines.
Improvements were made in internal methods for the detection and management of pain and in the transfer of patients to an external palliative care service (specific operating procedures were also written). The Hospital Without Pain Committee was founded, with regional resolution.
A research project focusing on psychological distress was planned.
Several instruments for internal and external communication were implemented and a “Hospital Information Booklet for Patients and Carers” was produced.
The Mixed Consultation Committee, a body composed of citizens and patients, was set up to evaluate the quality of care provided by IRST.
A project was created to provide support for patients, carers, and IRST employees who want to stop smoking.
With the collaboration of an external agency, a training project for IRST personnel was designed to develop expertise in the areas of intellectual property and innovation strategies.
Informatics tools were designed for the cost-reporting of each research project undertaken at the institute. An internal procedure was also drawn up to facilitate financial monitoring of all research activities and projects.
Accreditation program: pre-audit
At the end of the self-assessment period, the OECI Accreditation & Designation Board approved the documentation presented by IRST (Go decision) and a peer review visit was scheduled. However, OECI requested a preliminary visit (pre-audit) before the planned site visit to evaluate a number of aspects regarding the governance of IRST within the Oncology Network of Romagna. During the pre-audit held in January 2014, OECI representatives found some issues relating to the fact that IRST did not coordinate the network’s activities pertaining to cancer prevention, surgery, pathology, medical physics, and rehabilitation, and that there was no shared network database. The subsequent report produced by OECI stated that there was a lack of clarity regarding the responsibilities of the network in terms of the responsibility of each partner, the composition of the multidisciplinary teams, the responsibility for decision-making with respect to guidelines and procedures, and the way in which information was shared between the network nodes.
The OECI report also underlined that an important criterion for designation as a Comprehensive Cancer Center was a sufficient volume of patients treated for different types of cancer, with a defined clinical governance and quality control that extended throughout all the care pathways, including surgery, radiation therapy, and medical oncology.
These were the main reasons for not proceeding with the accreditation process. It was also stated that, if steps were taken to formally extend the governance to the other network nodes, the potential for accreditation would improve considerably. To that purpose, OECI suggested establishing a more specific and stronger centralized management and leadership of all the oncologic activities carried out in the other centers.
In accordance with these suggestions, IRST and the Local Health Authority of Romagna laid the foundations for a new management model for the Oncology Network of Romagna: the CCCN. This is a system based on a principle of cooperation and collaboration between the network nodes and is in contrast to a Monad model that focuses on competitiveness between entities in the same catchment area and where technical-professional competencies are concentrated in a single site (
Monad model vs network model. IRCCS = Istituti di Ricovero e Cura a Carattere Scientifico.
The CCCN is a territory-oriented model (population approach) (6) with the following advantages for IRST, the Local Health Authority of Romagna, and the general population: increased value of scientific production; higher accessibility to research funding, availability of hospital logistics platforms for high-complexity treatments, higher number of scientific collaborations, attractiveness for nonresidents, mutual exchange of information on clinical startup activities for high-complexity care in hospitals, mutual exchange of scientific information, more complete approach to the care of the cancer patient through the integration of different disciplines from diagnosis to treatment and from follow-up to the management of critical phases, reduction in patient migration, innovative treatments available through the network, and proximity to care.
The network model proposed, comprising both major (oncology, radiotherapy, nuclear medicine, hematology, early diagnosis) and complementary (primary medicine, surgery, pathology, radiology, and palliative care) oncologic disciplines, would be under the direct responsibility of IRST. The institute would coordinate all activities using common guidelines defined for the network that would help to centralize policy and monitoring and evaluation processes and to merge clinical healthcare with research and training, as suggested by OECI. The instrument identified for the CCCN shared management is a board composed of directors from both entities (
Comprehensive Cancer Care Network shared management: composition of the network board. GP = general practitioner; IRCCS = Istituti di Ricovero e Cura a Carattere Scientifico; IRST = Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori.
The experience of the accreditation process has enabled IRST to bring about numerous improvements in several areas, e.g., research, quality system, and patient pathways, and has also led to a project aimed at strengthening the management of the network. Furthermore, OECI has undertaken to create a series of standards for network models.
OECI accreditation represents a unique opportunity to improve the quality of care and research. The establishment of several European Cancer Networks and their subsequent interconnection through common standards would help to enhance integration between healthcare and research in oncology; improve performance; standardize and guarantee the quality of the services provided; improve adherence to quality management, safety criteria, and guidelines within the various units/department of the network nodes and within single and multidisciplinary teams; improve the means of communication and consequently the information given to patients; and monitor and improve clinical outcomes. This would enhance the bench-to-bedside process through the development of new diagnostics, treatments, and technologies focusing on prevention and rehabilitation.
In conclusion, IRST, following the recommendations made in the pre-audit report, is now ready to start the OECI accreditation process to be recognized as a Clinical Cancer Center, which would represent an important step towards becoming the Comprehensive Clinical Cancer Network of Romagna.
- Ancarani, Valentina [PubMed] [Google Scholar]
- Bernabini, Marna [PubMed] [Google Scholar]
- Zani, Chiara [PubMed] [Google Scholar]
- Altini, Mattia [PubMed] [Google Scholar] , * Corresponding Author (firstname.lastname@example.org)
- Amadori, Dino [PubMed] [Google Scholar]
Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (Forlì-Cesena) - Italy