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Hospital Tumor Board

Ospital ng Maynila Medical Center

 

Organizational Primer

 

Name of Committee or Board:

 

Hospital Tumor Board of Ospital ng Maynila Medical Center

(OMMC HTB)

 

Purpose:


A policy-making body on management of cancer patients and cancer program in a hospital (OMMC).

 

It is requirement set by the

1.      Department of Health for licensure of the hospital

2.      Philippine College of Surgeons and Philippine Society for General Surgeons for accreditation of training program in general surgery.

3.      Philippine Obstetrics and Gynecologic Society for accreditation of training program in obstetrics-gynecology.

 

Goal

            To promote quality services to patients with cancers.

 

Objectives:

 

1.      To formulate integrated, coordinated, and comprehensive hospital-wide policies on the management of patients with cancer in the hospital.

2.      To monitor and continually improve the quality of care to patients with cancers.

3.      To conduct educational and training programs for concerned staff so as to facilitate implementation of hospital policies on management of cancer patients.

4.      To promote research on oncology that will continually improve the quality of care for cancer patients.

 

 

Composition:

 

Executive Committee whose members are appointed by the Hospital

Director

            Members-at-large – representatives from clinical departments involved in

the management of cancer patients

 

 

            2002 Executive Committee:

Chair                           : Reynaldo Joson, MD

                        Vice-Chair                 : Eduardo Tan, MD

                        Secretary                   : Somia Comia, MD

                        Member                      : Edgardo Rodriquez, MD

                        Member                      : Josefina Valdez , MD

 

            2002 Members-at-large: Representatives from the Departments of

                        Anesthesia

                        Dermatology

                        Internal Medicine

                        Obstetrics-Gynecology

                        Ophthalmology

                        Otorhinolaryngology

                        Pathology

Pediatrics

                        Radiology

                        Radiotherapy

                        Surgery

 

                       

Nature of Appointment:

 

            Temporary without compensation

 

Term of Office:

 

            Members of the Executive Committee:     

                       

3 years unless sooner terminated by Hospital Director

 

Members-at-large:

 

Yearly unless sooner terminated by department chair

 

Schedule of Meetings:

 

            Every other month

            Third Thursday of the month

            8-10 am

            Department of Surgery, Conference Room

 

 

 

 

 

 

 

Duties and Responsibilities of Members:

 

Executive Committee

 

All Members:

                        Attend meeting

                        Contribute to the goal and objectives of the Hospital Tumor Board

 

            Secretary:

                        Makes minutes of meetings of the Hospital Tumor Board

                        Safekeeps records of Hospital Tumor Board

 

            Vice-Chair:

                        Assists chair

 

            Chair:

Leads Hospital Tumor Board in its accomplishment of shared

mission, goal, objectives and management action plans.

 

 

Data Needed:

 

            Cancer caseload 

                        Number of cancer patients

                        Distribution as to age and sex

                        Distribution as to type

                        Distribution as to clinical stage

            Quality of cancer care – through monitoring of

Treatment mortality and morbidity rates

                        Clients’ complaints

           

 

Flowchart of Procedures and Reporting:

 

            Meetings

Information dissemination

Reporting to Hospital Director

            Formulation of clinical practice guidelines

            Cancer Registry       

 

 

 

 

 

 

 

Meetings:

 

The chair will convene the Hospital Tumor Board.

            Formal notice of meeting will be given to members of the Hospital Tumor       

Board together with agenda.

           

The chair will preside and serve as the moderator.  He can delegate this task to another person.

 

Minutes of the meeting / proceedings will be done by the secretary and then approved by the chair.

 

Minutes of the meeting / proceedings will be disseminated to all members of the Hospital Tumor Board as well as to the Hospital Director.

 

The secretary will safekeep all minutes of the Hospital Tumor Board.

 

 

Information Dissemination

 

Information dissemination will be done through memos and during meetings of the Hospital Tumor Board.

 

Reporting to Hospital Director

 

            Mid-year Report

            Annual Report

 

            Based on Management Action Plan for the year

            Based on objectives of the Hospital Tumor Board

 

           

Formulation of Clinical Practice Guidelines

 

            Issues to formulate guidelines on: hospital-wide concern or concern of

majority of clinical departments

 

            A technical working group will be formed to gather data and then formulate

practice guidelines.

            Deliberation by members of the Hospital Tumor Board.

            Approval by members of the Hospital Tumor Board.

            Approval by the Hospital Director.

            Institutionalization of the clinical practice guidelines.

 

 

 

 

 

 

Cancer Registry

 

Objectives:

  1. To create a database for planning and development purpose in the cancer program of the hospital.
  2. To monitor the performance of the cancer program of the hospital in terms of number of cancer patients and types of cancer managed and the mortality and morbidity rates in cancer management.

 

Data needed and reasons:

 

  1. To determine the cancer caseload in the hospital and in departments involved in the management of cancers.

Data needed:

            Number of cancer patients seen per year

            Distribution of cancer patients seen as to type of cancer

            Distribution of cancer patients seen as to age and sex

 

Who will supply data:

Department of Pathology

Department of Surgery

Department of OB-GYN

Department of ENT

Department of Ophtha

Department of Medicine

Department of Pediatrics

Department of Dermatology

 

  1. To determine the clinical stage of cancer at time of treatment at OMMC (This information has impact on results of treatment.  Likewise, this information may be used for planning and development purpose in the cancer program of OMMC.)

Data needed:

            Clinical stage 

            Pathological stage

 

 

Who will supply data:

            Clinical stage – clinical departments except pathology

            Pathological stage – department of pathology

 

  1. To determine the mortality and morbidity rates in the management of cancer patients in OMMC.

Data needed:

            Mortality rates

            Morbidity rates

 

Who will supply data:

            Clinical departments

 

Database from Clinical Departments other than Pathology

 

Department of _____________________

 

Name (initials)

Age

Sex

Organ

Type of Cancer

Clinical stage

Mortality

Morbidity

Stage

T

N

M

Yes

NO

Yes

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of Information:

 

Department of _____________________

           

            Total no. of cases

            Age range; mean age

            Sex ratio

            Type of cancer by organ (frequency distribution)

            Clinical stage (frequency distribution)

            Overall mortality rate

            Overall morbidity rate

 

Database from Department of Pathology

 

Name (initials)

Age

Sex

Organ

Type of Cancer

Pathological stage

Stage

T

N

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of information:

 

            Department of Pathology

           

                        Total no. of cases

                        Age range; mean age

                        Sex ratio

                        Type of cancer by organ (frequency distribution)

                         Pathological stage (frequency distribution)

 

When to submit data and information:

            Semi-annual

                         

 

Performance Parameters and Standards

Hospital Tumor Board

 

Objectives

Parameters

Standards and Targets

To formulate integrated, coordinated, and comprehensive hospital-wide policies on the management of patients with cancer in the hospital.

Presence of written policies

Integrated, coordinated, and comprehensive hospital-wide

Continually updated

To monitor and continually improve the quality of care to patients with cancers.

Morbidity and mortality rates

Complaints of patients

Acceptable rates (<5%)

Acceptable no. of complaints (<5 / year)

To conduct educational and training programs for concerned staff so as to facilitate implementation of hospital policies on management of cancer patients.

Educational and training programs

Structured

Geared towards goal and objectives

To promote research on oncology that will continually improve the quality of care for cancer patients.

Research output

Number (4 a year)

Useful enough to be integrated into policies and procedures

 

Note: Acceptable morbidity and mortality rates – tentatively set, as indicated.