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Welcome: Professor Paul Harnett
Director of Sydney West Translational Cancer Research Centre
Implementing change through Multi-
disciplinary teams (MDTs)
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Disclaimer
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Objectives today
How do we maximise the impact of Multidisciplinary
teams?
What is the scope of Multidisciplinary teams?
Four domains (thought provoking):
Using data to improve performance
Engaging with others in hospital such as QI teams
Cross talking between teams
Engaging with clinical trials
Improving governance and organisational change
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What’s in a name
MDT
Tumour boards
Tumour programs
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High Performing Tumour Program
‘SCOPE OF PRACTICE’
Clinical management
Defined training program
Defined Quality Assurance program
Linkages/driving T1, T2, T3.
Linkages to screening/population health
Business, research agenda/meetings
Fundraising
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What else can they help you solve
Area Cancer Networks via Tumour Programs are the people who should monitor care in the LHD
Why? – because who else can / will?
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What else can they help you solve?
Variations in care
Peers comparing data is the most effective way to optimise practice
Balancing demands for resources
Cultivating the benefits of the “next generation”
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If done well you are more likely to do
things we couldn’t do otherwise
Sequential Meeting Program
Quality of
care
+ to +++ + to ++ +++
Quality
assurance
+ to +++ + to +++ +++
Links to
research
+/- + +++
Training + ++ +++
Monitor
access
- - +++
Influence + + +++
Resources - - +++
Fund raise - - +++
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(Some of..) What is needed (at least
in the public)
LHD recognises the Clinical Lead as a specific and novel leadership task and challenge
Relationship between Clinical Leads and Dept Directors in the service
Formalised Position Description
Formalised KPIs for the Tumour Program
Formalised appointment and reporting process/lines
New way of thinking about how programs operate
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Professor Kwun Fong
Professor of Medicine at University of Queensland,
Director UQ Thoracic Research Centre at Prince Charles
Using data to inform rapid feedback
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KEY COMPONENTS
BENEFITS AND OPPORTUNITIES
Learning from what we do; opportunities for using existing information to improve processes and care
Opportunity to collect relevant data
analyse
available
improve care
Steps
Technical data processes ie tools
Action of producers and users of data ie people
Organisational context ie environment
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CASE STUDY:
Embedding data into daily practice
The Pulmonary Malignancy Conference
at The Prince Charles Hospital
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Symptoms
Signs
Smoking History
Basis of Diagnosis
Diagnosis & Histology
Comorbidities
Performance Status
Lung Function
Biochemical Prognostic Factors
Clinical & pathological stage
Planned treatment sequence
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Total cases submitted 100,869
Included in analyses 81,015
SCLC (and mixed SCLC/NSCLC) 13,290
NSCLC 67,725
Big data
Prince Charles
Hospital
1164
Peter MacCallum 203
QRI 5472
Australia St. Vincent's Hospital 28
University of Sydney 1784
Western Hospital 765
Total 9,416
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Small data
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Real time data
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Teeny data
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CHALLENGES IN APPLICATION
Poor data quality
Data ownership and relevance
Insufficient resources
Data Skills - Analysis, Interpretation and Use
Access to Data
Institutional Support for Data Collection and Use
Data lack value unless informs decisions or innovate changes
Efforts to require data and use are critical to improving MDT effectiveness
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Professor Tim Shaw
Director of the Research in Implementation Science and eHealth
group at the Faculty of Health Sciences, University of Sydney
Engaging with QI and redesign
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KEY COMPONENTS
BENEFITS AND OPPORTUNITIES
MDTs do not often engage with QI and redesign teams in
hospitals
Major lost opportunity to collaborate on combined
implementation programs
Facilitate rapid transfer of learning
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CASE STUDY
Westmead TCRC engaged with Upper GIT team on
combined QI/Implementation program
LHD led process mapping exercise
A number of key quality improvement and
implementation science questions identified
Four collaborative projects moving forward
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CHALLENGES IN APPLICATION
Lack of opportunities for engagement of
QI and redesign in MDTs
MDTs may not see CQI as there role
Mismatch between research and QI
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Associate Professor Alexander Engel
Chair for the Colorectal MDT at RNSH and NSLHD
Director, Sydney Vital TCRC
Cross talking teams
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GRADING OF EVIDENCE
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NHMRC CANCER GUIDELINES
N=68
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NHMRC CANCER GUIDELINES
N=68
0
20
40
60
Grade
2012 RECOMMENDATIONS
MANAGEMENT OF PATIENTS WITH
LUNG CANCER
(%)
A BC
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NHMRC CANCER GUIDELINES
N=68
0
10
20
30
40
50
60
Grade
2012 RECOMMENDATIONS MANAGEMENT OF
PATIENTS WITH LUNG CANCER
(%)
A B C
3 OF 4 RECOMMENDATIONS ARE BASED
ON MODERATE TO LOW QUALITY OF EVIDENCE
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DECISION MAKING
UNDER UNCERTAINTY
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WHY DO WE NEED CROSS TALK
BETWEEN MDTs
Identify gaps based on multi MDT snapshots
Share ideas on improving meeting processes
Improve existing guidelines
Incorporate new evidence in multiple sites
Identify questions for local multi MDT randomised trials
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CHALLENGES IN APPLICATION of
Cross Talk
Time (more unpaid time after hours!)
Particular workforce issues for pathology and imaging
who work with multiple teams
Concerns about comparison of outcomes between units
without due regard for variations in casemix
Lack of funding for improved guidelines and trials – all
talk and no action
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Professor Fran Boyle
Professor of Medical Oncology at University of Sydney
Sydney Vital Translational Cancer Research Centre
Engaging with T1-T2 trials
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Clinical Trials as a driver of change
Participation in Trials offers opportunities to
Learn new techniques under supervision
Learn how to manage side effects of new medications, with
clear protocol mandated actions and immediate assistance
Obtain feedback on quality of patient care processes
through monitoring
Improve communication within the team, and with patients
Improve clinician understanding of the quality and
relevance of other clinical trials, so as to gauge whether
they should be implemented
Better understand the importance of biospecimens
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Recent trials in Australia that have driven
practice change in Poche teams
Breast Cancer
Sentinel node biopsy
(SNAC 1 and 11)
Herceptin adjuvant studies led
to routine Her 2 testing and
drug approval (HERA)
Preventing menopause from
chemotherapy with Zoladex
(POEMS)
Preventing breast cancer with
Tamoxifen (IBIS 1 and 11), PBS
submission underway
Melanoma
Sentinel node biopsy (MSLT1
and 11)
BRAF / MEK inhibitor trials led
to routine mutation testing
(BRIM etc) and drug approval
Immunotherapy trials led to
multidisciplinary approach to
side effect management and
drug approval (Keynote etc)
Brain metastasis trials ongoing
with RT and drugs
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The front row…
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Engaging the back row
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CHALLENGES IN APPLICATION
Finding time on the MDT agenda to discuss research, and particularly to include basic or psychosocial researchers
Planning trials as an MDT to avoid overlap of patient populations and commitment to impractical studies
Employing research staff as an MDT / tumour stream rather than as discipline led Departments
Niche populations specified by mutations mean multiple trials with small recruitment numbers
Cost of doing trials in Australia, and inadequate payments from cooperative trials groups ?helped by NSWCI funding
Lengthy gap from trial publication to PBS funding, with loss of continuity and knowledge about the intervention
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Dr Peter Carswell
Organisational Psychologist and senior lecturer at the School of
Population Health, University of Auckland
Governance/organisational change
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KEY COMPONENTS
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CASE STUDY
Northern Cancer Clinical Network
Cross organisational membership
Agreement on regional budgets
Regular review of data
Team work with senior clinicians and managers
Incentives for achieving targets
Reduced time to access cancer services by 30%
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CHALLENGES IN APPLICATION
Organisational level commitment
Need good intelligence
Politics and turf protection
Low levels of trust