Multidisciplinary Team Meeting Breast Care (Improvement Project Work ) West Yorkshire and Harrogate Cancer Alliance) striving for excellence Striivng for Excellence

Introduction This project is following on from commissioned work by CRUK to improve the effectiveness of the MDTM. 5.51 (Achieving World Class Cancer Outcomes: A strategy for England 2015 - 2020) The High Quality Services (HQS) Project Group asked the Trusts to consider piloting a study from these initial discussion/ findings. Our team in Harrogate agreed to participate with the aim of reviewing and considering possible recommendations to implement change Aim to improve the effectiveness of MDT meetings in cancer. (CRUK). Commissioned work identified key themes:-not enough time, attendance not optimal, Right information often not used to inform discussion.In line with this the numbers of cases for discussion are increasing. This creates a longer MDT, which may have an impact on the length of time spent on each case, and the quality of discussion could be questioned. striving for excellence Striivng for Excellence

MDT Pilot Question Recommendation 1   Question Recommendation 1 Should pre-meetings be held to ensure only the correct patients are discussed at length in MDTs The Pre-Meeting MDT does not fit all MDT’s and therefore Trusts  need to identify which MDTs would benefit from holding a pre-meeting 2 Could some patients be streamlined or reviewed outside of the meeting, providing that this was undertaken to a strict protocol? There should be development of  specific MDT protocols for patients who could be streamlined outside of the full MDT meeting 3 Could the pre-MDT act to make recommendations for patients deemed straightforward and to ensure diagnostic information is ready by the full MDT discussion There should be development of  protocolised pathways for straightforward patients 4 Patients are regularly deferred for another MDT - how could this be improved? There should be an interim forum between MDTs to make decisions when results are available. MDTs should consider developing WhatsApp type groups/cohorts 5 How could patients with metastatic disease or more complex patients (co-morbidities, cardiorespiratory etc.) be better managed through the MDT? MDTs should  collate and standardise the required information needed to enable optimal MDT discussion making for complex and metastatic patients striving for excellence

The table below shows which Trusts and Tumour Sites have agreed to participate. Pilot Airedale Gynaecology Recommendation 3 Bradford Lung Considering recommendations 2, 3 and 5 Calderdale & Huddersfield Are planning to pilot the Red/green principles at a small team meeting on Monday/Wednesday/Friday to progress patients through their pathway Colorectal Recommendation 4 Harrogate Breast Recommendation 2 Mid Yorks Skin Upper GI Recommendation 1 Leeds York Are planning to develop a ‘mini-MDT’ and a daily board round of patients on the cancer pathway striving for excellence

MDT MDT working is deemed as the gold standard for patient management, bringing continuity of care and improving outcomes for patients. (2015 Cancer Strategy) MDT meetings (MDTM) provide a forum for health care professionals to discuss and make recommendations on their management of care. The core members of these teams are professionals such as consultants, medical and clinical oncologists, radiologists, pathologists, clinical nurse specialists and MDT co-ordinators. Each of these disciplines contributes his/her skills and knowledge to the discussions of the patients (Hall and Weaver, 2001). striving for excellence Striivng for Excellence

HDFT Referrals striving for excellence Striivng for Excellence

Projected new diagnoses UK Current striving for excellence Striivng for Excellence

More Patients, More Complex, More Therapies. MDT More Patients, More Complex, More Therapies. MDT need to adapt to new pressures and discussions should focus more on difficult cases. Processes should be put in place to enable swifter decisions on patients going through standard treatment pathways. Achieving World Class Cancer Outcomes: A strategy for England striving for excellence

Project Aim Review literature both national and local projects Retrospective analysis of MDT proformas over a 3 month period of patients discussed Look for traits/ patterns which may identify areas to possibly change practice Create a policy/ protocol (if appropriate), to consider change – present to the team Prospective analysis - for a month - present to the team Implement change striving for excellence

Ideal Results Streamline the number of cases/ relevance Allow more time for each case Maintain a full complement of team members during the meeting     striving for excellence

Analysis of data * 3 months data will not capture possible patients discussed out of this time scale ( snap shot). From the data it is evident that approximately quarter (24%) of the discussions were benign cases. 22% New Cancers – encompasses the triple assessment process/ discussion. 22% with imaging review - is separate imaging e.g. Staging CT ,MRI. 26% Histology (all malignant) – Post op WLE / MASTECTOMY/ CAVITY SHAVE 1% Complex refers to anything out of the ‘ routine’ breast pathway - e.g. Pathology requiring further work up and discussion at other MDTs 5% other – query re breast screening f/up 24% Benign striving for excellence Striivng for Excellence

Project Focus 86% of benign cases were reassured and discharged following discussion at MDT striving for excellence

Considerations 1. Should the benign cases be discussed within the MDT meeting with a full compliance of core member attendance?   ABC Best Practice Diagnostic Guidelines state: “The diagnostic MDM must include pathologist, radiologist or consultant radiographer in breast imaging, surgeon or breast clinician and breast care nurse.” 2. Is it an efficient use of clinical time to have the full quoracy for MDT in attendance throughout all discussions, including benign cases?  From previous discussion it has been suggested to increase the length of time of the MDT to an hour and a half. If it is deemed appropriate to increase the MDT time by 50%, what impact will this have on the core members; this will need: -Revision of job plans to allow time for attendance -Consideration of impact on patient clinical time (In terms of oncology clinic, this could possibly equate to 1.5 follow up appointments or almost 1 new patient per week.) -Cost implications -This will require full monitoring of MDT quoracy striving for excellence Striivng for Excellence

Considerations 3. Could the obviously benign cases be grouped together for discussion at the start of the meeting incorporating the appropriate attendance? Protocol/guidance – B3 or above to remain on main MDT, B2 or below to be discussed in benign section of MDT. 4. Would a pre-MDT triage be helpful in streamlining the MDT discussions more efficiently? E.G the obvious benign concordant cases not to be discussed at MDT Watch this space – 5. Should the team consider the MDT coordinator’s input/workload in collecting information for the comprehensive proformas – could the proformas be simplified (in accordance with guidance/data analysis)? Anecdotal evidence indicates that it takes an estimated 4-6 hours per week to compile proformas. New patient proformas often take longer to complete estimated as approximately 20 mins per proforma. When the majority (86% of benign cases) of these are being reassured and discharged we need to consider whether there is a more efficient way of documenting such cases. striving for excellence

Agreed plan going forward Start MDT at 12:30 pm, list benign cases at the beginning for discussion. Radiologist, pathologist, one breast surgeon (if on leave) needed for discussion of benign cases. Oncology presence not needed till 1 pm, till full MDT starts. Time taken to discuss each benign to be recorded. MDT to review MDT proforma to ensure reduction in time MDT coordinator spent on completing details. Review in one month Presentation of project and outcomes to be presented 28th March 1 – 4 pm Horizon, Leeds striving for excellence