Quality improvement for cancer multidisciplinary teams: lessons learned from the Anglian Germ Cell Cancer Collaborative Group

Summary Shamash and colleagues describe how their supra-regional germ cell tumour multidisciplinary team achieved standardisation of treatment and improved survival. We discuss some of the insights the study provides into prioritising complex patients, streamlining processes, the use of telemedicine, and the centrality of good data collection to continuous quality improvement.

the suggestions set out in the Gore report 1 years ahead of publication.
Taking each of these individually: Focussing on complex cases The greatest benefit of MDT working is seen in complex cases, e.g. unusual subtype of disease, failure of previous treatment, significant comorbidities, and social or psychological problems. 2 These patients often do not fit guidelines, are not eligible for clinical trials, and can be challenging to engage in healthcare services. Shamash et al. 2 highlight patients with learning difficulties or mental health problems and those with late relapses each present problem that are less commonly addressed and require tailored individualised treatment plans. These findings are in line with the recent study on what constitute a complex case for MDT discussion, mirroring those found to be indicators of complexity across a range of tumour types. 3 Although they represent a small portion of cases, considerable amount of additional support is needed before and after diagnosis and treatment. 2 Shamash and colleagues 2 set out criteria for cases that may not need full discussion in the MDT meeting. It may be desirable to go further and identify cases that are truly 'complex' and those that are 'simple'. Recently, Soukup and colleagues 3 published work on the development and validation of a tool for stratifying cases by complexity, which might allow teams to streamline their caseload in a scientific manner. Further research is needed to assess its impact on patient care and the efficiency of MDT processes.
The inclusion of information on patients' comorbidities and psychological and social factors that may impact care are persistently, poorly represented in MDT meetings. 4 Such information, as well as that which focusses on the disease in question, is necessary for comprehensive clinical management planning. 5 These findings support the conclusions by Shamash and colleagues, 2 that patients with complicating features require holistic discussion in order to develop tailored treatment plans.
Using chair's action to facilitate urgent treatment The time between meetings can present a significant period for patients with rapidly progressing disease waiting for MDT review and recommendations. 2 In such cases, the MDT chair is well placed to endorse management proposals of clinicians out with www.nature.com/bjc the MDT meeting in order to avoid delays. 2 Such cases should still be registered with the MDT and could be reviewed post hoc. The responsiveness of an MDT to clinical or organisational pressures is an area fertile for improvement.
The use of videoconferencing to improve collaborative decisionmaking Videoconferencing has been controversial in MDT meetings, and Shamash and colleagues 2 discuss some of its advantages and challenges. Regular SMDT meetings are not feasible without some form of remote contact. 2 Technology failure and differences in communication styles can present challenges to the quality of MDT decision-making. 6 Perhaps a lasting legacy of COVID-19 will be the dramatic shift towards telemedicine, replacing many faceto-face interactions. Interestingly, Shamash and colleagues 2 note the benefits of a yearly meeting at which members of the SMDT can interact and discuss matters of importance. Many MDTs now manage to operate remotely via video link. It may be desirable to supplement this with periodic face-to-face interaction that permit more nuanced communication regarding performance, operational policy, challenges, and future directions.

Data collection and audit
The careful, planned collection of clinical and process data was crucial for assessing complex areas of healthcare, such as care pathways and organisational changes. 2 Recent NHS England and NHS Improvement report 7 has highlighted that data collection and regular audit must accompany MDT transformation. As Shamash and colleagues 2 showed, the collection and analysis of such data might provide a resource to benchmark processes and outcomes, thereby driving standardisation and convergence towards best practice. Well-designed data collection supports quality improvement and clinical research, driving the development of new and better standards of care. Ultimately, this will provide high-quality information to patients and their doctors, enabling shared decision-making of the highest quality.

ADDITIONAL INFORMATION
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Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Tayana Soukup 1 , Nick Sevdalis 1 , James S. A. Green 1,2 and Benjamin W. Lamb 3