Everything I needed to know about medical management I learned in acting school

Some people are doctors. Some people play them on TV. Brian Meltzer could probably do both. A physician executive at Memorial Sloan-Kettering Cancer Center, Meltzer relies on skills he learned in acting school to help manage business decisions. In the first of several essays for The Physician Executive, Meltzer explains how acting can help you become a better leader.

The development of a telemedical cancer center within the Veterans Affairs Health Care System: a report of preliminary clinical results

In order to optimize the delivery of multidisciplinary cancer care to veterans, our institution has developed a regional cancer center with a telemedical outreach program. The objectives of this report are to describe the organization and function of the telemedical cancer center and to report our early clinical results. The Veterans Affairs Health Care System is organized into a series of integrated service networks that serve veterans within different areas throughout the United States. Within Veterans Integrated Service Network 20 (Washington, Alaska, Idaho, Oregon) we have developed a regional cancer center with telemedicine links to four outlying facilities within the service area. The telemedical outreach effort functions through the use of a multidisciplinary telemedicine tumor board. The tumor board serves patients in outlying facilities by providing comprehensive, multidisciplinary consultation for the complete range of malignancies. For individuals who do require referral to the cancer center, the tumor board serves to coordinate the logistical and clinical details of the referral process. This program has been in existence for 1 year. During that time 85 patients have been evaluated in the telemedicine tumor board. Sixty-two percent of the patients were treated at their closest facility; 38% were referred to the cancer center for treatment and/or additional diagnostic studies. The patients' diagnoses included the entire clinical spectrum of malignant disease. Preliminary clinical results demonstrate the program is feasible and it improves access to multidisciplinary cancer care. Potential benefits include improved referral coordination and minimization of patient travel and treatment delays.

Architectural programming for the workplace and the careplace

Sensitive planning and architectural design will impact long-term costs and daily operations. At the same time, the quality of the total environment has a direct impact on the patient, the family and the staff. These needs should be carefully balanced with the emotions of the patient, the care partner (parent, husband, wife or guardian) and those of the clinical team (physicians, nurses and staff). This article addresses the first step in the process; the master plan and then focuses in detail on one aspect of the architectural work referred to as architectural programming. The key to the process is selecting the best team of consultants, following the steps carefully, involving the client at every appropriate milestone along the way and asking the right questions. With this experienced team on board; following the proper steps, listening carefully to the answers and observing the daily process one can expect a successful product.

Building a dream: creating an oncology day/evening hospital

The demand for inpatient beds has reached and often exceeds capacity producing waiting lists for cancer care. There is a need to explore alternative approaches to oncology treatment. The Oncology Day/Evening Hospital (ODEH), originally envisioned in 1995 as a joint project between an ambulatory cancer centre and a large teaching hospital, is an important cancer treatment initiative offering extended hours of ambulatory oncology treatment on days, evenings, weekends and statutory holidays. A review of current inpatient treatment modalities revealed that many patients receiving inpatient therapy could be safely and effectively managed in the ambulatory setting if treatment regimens were modified and if ambulatory hours of operation were extended. Healthcare improvements expected were: appropriate movement of inpatient activity to the ambulatory setting; more opportunities for patient choice in treatment time thereby allowing for maintenance of normal living; better quality of life for patients through prevention of hospitalization; decrease in treatment waiting times; consolidation of patients into an ambulatory oncology treatment setting as opposed to utilization of adult medicine units; and more rational inpatient bed utilization with reduction of admissions and intra-treatment transfers. This article describes our experience in building a dream, the challenges and lessons learned in implementing a better way to deliver oncology care in an environment of rapid change and staff shortages.

Ensuring a good death

PURPOSE

The purpose of this article is to describe how the commitment of the Dana-Farber Cancer Institute to pain management, quality of life, and optimal end-of-life care is operationalized through a comprehensive pain and palliative-care program.

OVERVIEW

Institutional standards for pain management often address only the physical aspects of pain. Effective pain management requires assessment and interventions that address the multidimensional nature of pain, suffering, and quality of life throughout the cancer continuum. This approach seeks to lay the foundation of comfort and peace associated with a good death.

CLINICAL IMPLICATIONS

Institutional pain management standards need to reflect the complexity of pain, especially cancer-related pain, by emphasizing comprehensive, holistic assessment and multimodality approaches to pain control and quality-of-life issues.

[Necessary prerequisites for the function of an oncological competence center. Information technology, documentation of findings and telecommunication]

INTRODUCTION

The organisation of an interdisciplinary cancer center, especially the establishment of a daily tumorboard requires adequate hardware and intelligent software, which is not available in most hospitals and described here with concepts, realisation and first clinical results.

MATERIALS AND METHODS

Based on a TCP/IP network and several inhomogeneous department subsystems we developed an intranet-based oncological documentation- and conference software (oncofile), which can be easily operated and administered in a web browser. Common digital media can be imported and the concept allows for paperless organisation of the daily tumor board. The expert decisions are documented online during tumor board runtime together with selected clinical images and the consensus of the decisionmakers. Local therapeutic guidelines as well as trial information can be accessed over the intranet, and interfaces for internet- and telecommunication are used for second opinion and integration of external expertise.

RESULTS

Between 10/99 and 2/2002 3298 presentations of 2438 cases were made in the daily tumor board. 74% of the patients had a curative oncological treatment concept, and 24% of the patients received neoadjuvant treatment. 49% of the patients were scheduled for primary resection. Six patients can be effectively handled in a 30 minute tumorboard.

CONCLUSION

The establishment of a daily tumorboard is possible by help of intranet-technology, a central database with web clients and moderate hardware investments. The composition of the patient cohort as well as all decisions ever made to a particular patient are transparent at all times. Prospective quality control studies are under way.

[Quality management and experiences with the "cancer center"]

BACKGROUND

The goal of quality management in oncology is to achieve the best possible therapeutic outcome. Improved diagnostic methods, more sophisticated therapies in various fields of specialisation and the increased implementation of multimodal therapies have led to considerable advances in the treatment of certain tumors in recent years. However, these advances depend on an interdisciplinary approach necessitating an increased division of labour. These in turn, because of the more complex organizational requirements within hospitals, make greater demands on quality management.

METHODS

In October 1999 first steps were taken in the Klinikum rechts der Isar der TU München to organisationally integrate the various institutions involved in the treatment of patients with gastro-intestinal tumors. All the oncologic competence available was bundled in a Cancer Center thus creating the structural prerequisites for interdisciplinary quality management. A daily multidisciplinary Tumor Board, a computer-supported interdisciplinary information and communications system, an interdisciplinary Disease Management Team, an outpatients department and a study centre were all called into life.

RESULTS

By the time the outpatients department went into service in November 2001 all the other structural innovations underlying interdisciplinary quality management had already been implemented. Since October 1999 2438 patients had been presented to the Tumor Board, 74% of them with primarily curative intent.

CONCLUSIONS

The disease-oriented structure of the Cancer Center has proved worthwhile. The impact of the structure on the quality of processes and results, however, has yet to be evaluated.

Renovate or replace?

The Cross Cancer Institute completed final facility is locked in on all sides with minimal room for future growth. Would a new facility in a new location have been a better option? From an engineering perspective, it would have been less complicated and frustrating to build new with a new stand-alone plant sized for future expansion capability. From a medical/research perspective, the location adjacent to the university was and still remains invaluable.

New millennium hospital management information system: experience of the National Cancer Institute--Cairo University

The National Cancer Institute-Cairo University (NCI) is a leading cancer center in the Middle East and Africa. It serves more than 15,000 new cases and more than 250,000 patient visit every year. The implementation of its Hospital Management Information System was completed and the system was operational in 1992. Although different modules were added to the HMIS, the core of the system has never been changed or updated. NCI evaluated its current system. NCI also evaluated the modern tools in databases and programming. NCI came to the conclusion that a new HMIS need to be installed. The needs of NCI staff were analyzed with consideration to budget issues and the limitations of a developing country. Different hardware, networking and software issues had to be considered in the updating. Arabization and customization were main factors in decision making.

Out-of-hours palliative care in the UK: perspectives from general practice and specialist services

Palliative care within the community requires well coordinated multidisciplinary teamworking, involving both primary and secondary care practitioners. 'Out-of-hours' periods are a potentially problematic time for delivery of high quality care. We report on two national surveys-one of medical directors of out-of-hours general practitioner cooperatives, the other of medical directors of specialist palliative care units. The aim was to describe general practitioners' and specialists' perspectives on the availability and scope of community nursing and specialist palliative care services. The results point to wide variation in service provision within the community. The two groups differed strikingly in their perceptions, the general practitioners being much less positive than the specialists about the availability of specialist advice and admission to specialist units out of hours. Equitable out-of-hours palliative care services of high quality are unlikely to be achieved without dialogue between primary and secondary care based providers, local needs assessment and adequate resourcing.

Mandatory patient safety training, from the board room to linen room

Here is a list of counter-intuitive statements about patient safety, a list of required reading on the subject, and an excerpt of a tool that can help you analyze your organizations patient safety strengths and weaknesses.

Evaluation of Norwegian cancer hospitals web sites and explorative survey among cancer patients on their use of the internet

BACKGROUND

Hospital homepages should provide comprehensive information on the hospital's services, such as departments and treatments available, prices, waiting time, leisure facilities, and other information important for patients and their relatives. Norway, with its population of approximately 4.3 million, ranks among the top countries globally for its ability to absorb and use technology. It is unclear to what degree Norwegian hospitals and patients use the Internet for information about health services.

OBJECTIVES

This study was undertaken to evaluate the quality of the biggest Norwegian cancer hospitals Web sites and to gather some preliminary data on patients use of the Internet.

METHODS

In January 2001, we analyzed Web sites of 5 of the 7 biggest Norwegian hospitals treating cancer patients using a scoring system. The scoring instrument was based on recommendations developed by the Norwegian Central Information Service for Web sites and reflects the scope and depth of service information offered on hospital Web pages. In addition, 31 cancer patients visiting one hospital-based medical oncologist were surveyed about their use of the Internet.

RESULTS

Of the 7 hospitals, 5 had a Web site. The Web sites differed markedly in quality. Types of information included - and number of Web sites that included each type of information - were, for example: search option, 1; interpreter service, 2; date of last update, 2; postal address, phone number, and e-mail service, 3; information in English, 2. None of the Web sites included information on waiting time or prices. Of the 31 patients surveyed, 12 had personal experience using the Internet and 4 had searched for medical information. The Internet users were significantly younger (mean age 47.8 years, range 28.4-66.8 years) than the nonusers (mean age 61.8 years, range 33.1-90.0 years) (P = 0.007).

CONCLUSIONS

The hospitals Web sites offer cancer patients and relatives useful information, but the Web sites were not impressive.

Multidisciplinary team working in urological cancer: one CNS's role

The 'cancer journey' for a patient with urological cancer can be complicated, with many different specialists involved and many treatment options. The uro-oncology clinical nurse specialist's role in one multidisciplinary team is to provide support, information and a link between all the staff involved in the patient's care.

Implementation of a blood irradiation program at a community cancer center

BACKGROUND

Blood component irradiation is an accepted method of preventing transfusion-associated GVHD. Previous publications have largely focused on the technical aspects of the irradiation process itself, but relatively little attention has been paid to the details associated with the implementation of a blood irradiation program at the level of a community cancer center.

STUDY DESIGN AND METHODS

An observational study was performed, detailing the specific operational, documentation, and quality assurance measures employed in providing a blood component-irradiation service within the institutional context of a community cancer center.

RESULTS

The Montgomery Cancer Center irradiated 589 units of blood components in 1998 and 1999 to provide a local blood bank with an alternative for procurement of irradiated blood components while complying with applicable quality assurance and regulatory requirements.

CONCLUSION

Blood component irradiation is within the scope of most well-equipped and adequately staffed community cancer centers. Establishment of a blood component irradiation program requires scrupulous physics and dosimetry support, both to ensure the quality of the irradiated component and to satisfy governmental agency regulatory requirements.

Comprehensive cancer centres and the war on cancer

Comprehensive Cancer Centres are now recognized as an important weapon in the war on cancer, but they had to fight a very different battle to become accepted by the academic community. Why were these centres developed? How do they contribute to cancer research? Have they achieved the aims for which they were set up? And how should they be improved? It is important to answer these questions because we believe that cancer centres, though in need of improvement, are vital parts of our anticancer strategy.