Structuring a Hospital Tumor Board – OMMC Experience

Janix M. De Guzman, M.D.

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Department of Surgery

Ospital ng Maynila Medical Center

Reprint requests: Janix M. De Guzman, MD, Department of Surgery, Ospital ng Maynila Medical Center, Quirino Avenue, Malate, Manila, Philippines.

Email: ommcsurgery@ yahoo.com

Abstract:

Introduction: A structured Hospital Tumor Board is needed to be effective, efficient, and sustainable.

Objective: To describe how a structured Hospital Tumor Board (HTB) was established and institutionalized in the Ospital ng Maynila Medical Center (OMMC), a tertiary city government hospital.

Methods: An action research methodology was utilized.

Results: A situational analysis of OMMC HTB done in August, 2002 showed absence of clear operational system. Reorganization started with a primer which spelled out the objectives, evaluation parameters, and definite strategies to achieve objectives. Using the primer as a guide together with a definite action plan and an active participation from the different clinical departments, the OMMC HTB was able to accomplish all its objectives effectively and efficiently after one year of re-engineering. Some milestones consisted of a simplified cancer registry; unified concept statements on cancer causes, prevention, cure, and palliation; clinical practice guidelines on cancer palliation and cancer pain control program for the entire hospital; and cancer researches.

Conclusion: A structured program as reflected in an organizational primer is an essential requirement for an effective, efficient, and sustainable Hospital Tumor Board.

Introduction

In the United States, tumor boards have been an integral part of oncology management since the early 1940’s. Scholnik, et al., defines tumor boards as “multidisciplinary conferences convened for the discussion of cancer patients.” (1) A Hospital Tumor Board (HTB) includes access to multidisciplinary consultation; wherein a group of physicians meet on a regular basis, to improve the quality of cancer care, provideeducational opportunities for participants, and become an asset to thehospital and to the community. (2) Tumor boards now provide a forum for the discussion of treatment strategies, through continual updates of standard approaches from the point of view of all modalities. Medical experts regard tumor boards as an essential component of quality control in both community hospitals and medical centers.

In the Philippines, however, Hospital Tumor Board is quite new. It was formulated as one of the components of the Administrative Order No. 89 - A S. 1990, the Department of Health - Philippine Cancer Control Program (DOH-PCCP) issued on April 10, 1990 by then Secretary of Health Alfredo R. Bengzon. Hospital Tumor Board together with Hospital Cancer Registries, are viewed as the major implementing and monitoring structures of the PCCP with regards to hospital services. It is required by the Department of Health for licensure of all DOH regional hospital and medical center; the Philippine College of Surgeons for accreditation of training program in general surgery; and the Philippine Obstetrics and Gynecologic Society for accreditation of training program in OB-GYN.(3)

With the implementation of Administrative Order No. 89 – A S. 1990, every training hospital is supposed to have a tumor board. Unfortunately, there are only a few hospitals with active tumor board, active in the sense that it has meetings and conducts cancer-related activities; others are either non-existent or existent in name only. This may due to problems in establishing and sustaining a hospital tumor board. This arises primarily because most of hospital tumor boards are not structured. Other common problems include the following: hospital administrators, appointed chairs, and oncologists do not have a clear idea on the goal and objectives of a Hospital Tumor Board; appointed chairs do not have sufficient leadership and managerial skills; turfing and insecurity among oncologists; and inadequate logistic support.

In July 2002, the OMMC Hospital Tumor Board (OMMC-HTB) was reorganized under a new leadership.

The objective of this paper is to describe how the OMMC-HTB was re-organized to make it structured, effective, efficient, and sustainable.

Methods

An action research methodology was utilized consisting of the following steps: situational analysis, identification of problems, formulation of solutions followed by implementation and evaluation of results.

The records of OMMC-HTB were retrieved, reviewed, and analyzed focusing on the processes of establishing and evaluating a Hospital Tumor Board.

Results

In July 2002, under a new leadership, a situational analysis of the OMMC-HTB was made. The findings showed that prior to Aug 2002, OMMC had no structured hospital tumor board. However, cancer case presentations in the Department of Surgery were being conducted and moderated by a radiation oncologist. These conferences were not attended by other departments. There were no specified goals and objectives for the HTB; no proper recording of performance outputs; hence, no means of monitoring and evaluating these outputs.

The situational analysis was immediately followed by a formulation of an organizational primer for the OMMC-HTB. The organizational primer contains information on the following: purpose, goal, objectives, composition, schedule of meetings, expected activities and accomplishments, and performance parameters and standards (See Appendix 1).

After the organizational primer was approved by all involved clinical departments, a specific management action plan was formulated, implemented, and monitored every 2 months, mid-year and at year end. (See Appendix 2).

Table 1 shows the performance parameters and standards. Table 2 shows the 2002 year-end and Table 3, the 2003 mid-year reports of accomplishment based on the management action plan. All the specified performance objectives were accomplished.

Table 4 shows the specific accomplishments of the OMMC-HTB as reflected in each meeting.

At least 5 clinical departments with heavy load of cancer patients and cases had been actively involved in the bi-montly activiites of the OMMC-HTB. These departments included pathology, surgery, internal medicine, obstetrics and gynecology, otorhinolaryngology.

Table 5 shows a list of unified concept statements on certain issues in cancer. These were intended to serve as the philosophy and foundation in the decision-making in the cancer patient management in the hospital.

A simplified cancer registry was formulated to facilitate reporting of cancer load in each department and in the entire hospital (see Appendices 1 and 2).

Discussion

Before August, 2002, OMMC-HTB was probably like most hospital tumor boards in the country, not active; if in existent, not structured, no clear goal and objectives, no specific action plan, poor leadership and managerial skills on the part of the chairperson, with problems of turfing and disharmony among the oncologists resulting in poor multi-departmental cooperation and collaboration, and inadequate logistic support, just to cite of few of the problems.

The Department of Health, the Philippine College of Surgeons, and the Philippine Obstetrics and Gynecologic Society have made HTB as a requirement for accreditation. However, these organizations have not formulated any primer to guide the hospitals in establishing and running a HTB.

The newly reorganized OMMC-HTB formulated its own organizational primer which contained clear and specific statements on purpose, goal, objectives, composition, schedule of meetings, expected activities and accomplishments, and performance parameters and standards. Briefly, the OMMC-HTB is envisioned to be a policy-making body on management of cancer patients and the hospital cancer program. The goal of OMMC-HTB is to promote quality service to patients with cancers with the following objectives: to formulate integrated, coordinated, and comprehensive hospital-wide policies on the management of patients with cancer in the hospital; to monitor and continually improve the quality of care to patients with cancers; to conduct educational and training programs for concerned staff so as to facilitate implementation of hospital policies on management of cancer patients; and to promote research on oncology that will continually improve the quality of care for cancer patients.

After one year of operation, the OMMC-HTB can be said to be successful in that it has accomplished all the performance objectives that it set out to do at the start of the reorganization and at the start of the year. What contributed to the success were the following: systematic planning for the reorganization; an organizational primer that clearly spelled out the management system which made the HTB very structured; a specific management action plan cascaded from the goal and objectives and performance parameters and standards and being monitored every two months, which made the HTB, effective and efficient; multi-departmental cooperation and collaboration promoted by a chairperson with leadership and managerial skills, which made the HTB effective and efficient; unified concepts of basic and key issues in cancer management, which made the HTB effective, efficient, and sustainable; and implementation of doable, simple and relevant activities and targets, which made the HTB sustainable.

The OMMC-HTB can become a model hospital tumor board in the country because it has clear, definite, and specific direction, task prescription, and performance evaluation as provided in its organizational primer and it is performing satisfactorily in just a year and in 7 meetings. It is a hospital tumor board that all hospital tumor boards in the country can emulate and ask assistance from, in terms of the organizational primer (the only one in the country), a practical cancer registry that is easy to accomplish and useful, and innovative approaches such as unifying the concepts of different oncologists which often times contribute to slowing if not breakdown of tumor boards. The OMMC-HTB will keep on improving and innovating within the framework of its organizational primer.

References:

Scholnik, A. P., et al. A New Mechanism for Physician Participation in a Tumor Board. Adv Ca Con: 1986. 337–43.
Gross GE. The role of the tumor board in a community hospital. Ca J Clin. 1987(37). 88-92.
Philippine College of Surgeons Scientific Publication No. 6, Manila 1994.

Table 2. Performance parameters and standards.

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	For nonhospice cancer 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

Table 4. Accomplishments of Hospital Tumor Board as reflected in each meeting.

Meeting	Accomplishments
August 23, 2002	Organizational Primer
October 17, 2002	Cancer Registry, Jan to June 2002
December 19, 2002	Unified concept on certain cancer issues -
February 24, 2003	Annual Cancer registry, 2002 Unified concept on Cancer Palliative Treatment
April 10, 2003	Unified concept on OMMC’s cancer pain control program
June 19, 2003	Update on Cancer research – 4 ongoing
August 19, 2003	Mid-Year Cancer Registry, 2003

Appendix C

Cancer Registry

Database from Clinical Departments other than Pathology

Department of ______________________

NAME

AGE

SEX

ORGAN

CANCER TYPE

CLINICAL STAGE

MORTALITY

MORBIDITY

(Initials)

(yrs)

M/F

STAGE

YES

Summary of Information:

Department of ___________________________

Total number 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

Appendix D