Hamilton-Niagara Haldimand Brant
On October 21, twenty-three surgeons practicing colorectal caner surgery in LHIN 4 met for a workshop titled "Sticks, Carrots or Total Quality Management." The Southern Ontario Surgical Society, researchers from McMaster University and the Juravinski Cancer Centre, and physician leaders from teaching and community hospitals in LHIN 4 initiated and led the workshop. Participants reviewed the strengths and weaknesses of quality improvement initiatives in jurisdictions around the world. The principles and techniques of Total Quality Management were then introduced including the need for participatory and non-confrontational engagement with all stakeholders, the use of the continuous quality improvement cycle which runs from problem hypothesis to evaluation of intervention, and dependence on rigorous statistical analyses of data.
Small group sessions and a consensus discussion were used to select three measures for quality improvement including rates of peri-operative imaging of the abdomen for colon cancer, rates of pre-operative cross-sectional imaging for rectal cancer, rates of pathology reporting for tumour-radial margin distance for rectal cancer. A similar approach was used to select quality improvement interventions. Selections included audit and feedback, standardized presentations for surgeon-pathology and surgeon-radiology meetings, and point-of-care reminders. The group has set an ambitious target of completing the first continuous quality improvement cycle within six months.
Central West and Mississauga/Halton
A multi-disciplinary hepatobiliary/pancreatic carcinoma team has been assembled and multi-disciplinary clinics established to treat both primary and secondary patients with this disease. As well, two regional hospitals have the skills and technology to provide percutaneous Radio Frequency Ablation (RFA) and the HPB surgeons are adept at interoperative RFA.
As an initial step toward the establishment of a Regional Thoracic Surgical Oncology Program, the region has developed a regional thoracic surgical on-call schedule. A number of discussions with William Osler Health Centre have occurred as their new site is set to open in the summer/fall 2007. Further discussions are ongoing and it is hoped that the necessary cooperation and agreements will be in place to open what will probably be a Level 1 and a Level 2 Thoracic Surgical Oncology unit in this region.
The establishment of a Breast Diagnostic Centre (BDC) at the Credit Valley Hospital is well under way in combination with the OBSP, the Peel Regional Cancer Centre, regional radiologists and general surgeons. It is hoped that this patient-centered BDC facility will provide timely access for patients with breast disease and appropriate consultation and treatment within clearly defined and appropriate timeframes.
The South Eastern Regional Cancer Centre has been experiencing significant shortages in operating room availability over the past months due to construction. Soon, two new Minimal Invasive Surgical rooms will be completed; the first in November and the second in January. This will bring the centre back to its previous capacity, and relieve some of the current cancer surgery wait time pressures. The additional resources dedicated to laparoscopic surgery in thoracic, urology and colorectal will also benefit the cancer patient population.
The Centre has been using an online OR booking tool at two sites which has been modified to include CCO's wait time definitions, allowing real time data analysis and availability. This will permit ongoing wait time surveillance and provide opportunity for timely action, reporting, and intervention, if required. The region has also confirmed its participation in the provincial liver PET scan study and has local surgical Principle Investigators for new trials in breast, colon, and liver oncology.
In June, a Regional Surgical Oncology Retreat was held that discussed colon surgery, breast sentinel node biopsy and thoracic surgery. This regional collaboration helps to ensure a consistent approach to surgical oncology issues in the area, and improve communication and understanding between our centres.
The region is undertaking implementation of the CCO Thoracic Cancer Surgery Standards. It will require a significant change to patient referral patterns, and location and allocation of hospital resources. In order to facilitate implementation, the region has brought together stakeholders to discuss the planning and preparation. In addition, an external reviewer from out-of-province has been asked for input into the strategy.
Lakeridge Health has been designated the first hospital-based Ontario Breast Screening Program (OBSP) affiliate in Durham. With two new state-of-the-art digital mammography machines, the program will be available at the Lakeridge Health-Oshawa site and eventually at the Bowmanville site. This program expects to perform over 5,500 scans in the first year of operation.
North Simcoe Muskoka
The program continues to develop, albeit slowly. Outcome assessment is regarded as essential to the future of the program. The region is engaged in a post operative mortality review for colon cancer at the request of CCO and will build on this to develop a regional group for ongoing quality indicators, which will include annual review and the introduction of timely case conferences when needed. It is essential that this process is non-threatening or regarded as punitive. Mentorship is encountering delays due to lack of funding, though help is hopefully imminent. Self mentoring in the region is having limited success; financial and non-financial ways of making it more attractive are being explored. The inaugural meeting of the Georgian Bay Oncology Group will be held December 4th. It will include all specialties and aim to meet four times per year to discuss clinical and administrative issues. It is intended to bring together all cancer treating physicians, pharmacists etc. The group is supported at arms length by industry.
Toronto Central - South
Five surgeons have recently been recruited to the University Health Network including:
Donations-Fellowship Education Support:
- Dr. Alexandre Zlotta to the Division of Urologic Oncology at PMH and Mount Sinai. Dr. Zlotta joins us from Brussels, Belgium.
- Dr. Sarah Ferguson to Gynaecology Oncology. She received her fellowship from Sloan Kettering.
- Dr. David Goldstein is an ENT- head and neck surgeon specializing in microvascular reconstruction, he received his fellowship training from the University of Iowa and the University of Toronto.
- Dr. Erin Kennedy to the General Surgery Department specializing in colorectal surgery. Erin adds to an already significant group of surgical oncologists working in the areas of health policy and clinical epidemiology.
- Dr. Ben Beheshi to the Division of Orthopedic Oncology who will be working at Mount Sinai Hospital and the Princess Margaret Hospital.
UHN has been very honoured to receive generous donations that will have a substantial impact on education and research initiatives. The department has directed that one of the major priority areas for funding is fellowship education. Dr. Irish has worked actively with the Princess Margaret Hospital Foundation, the Toronto General and the Western Hospital Foundation to make this a high priority for fundraising.
The surgical oncology fellowship education program will be supported by a $1M donation from Joey and Toby Tanenbaum over 10 years with $100,000 per annum to support surgical oncology fellowship education. Dr. Gerald Hatch has contributed $300,000 for Surgical Oncology research support and fellowship education from the Gerald and Shelia Hatch Surgical Oncology Fellowship Education Fund. The Rachel Higgins Memorial Fund (“THE RACH Fund”) has provided $40,000-50,000 per year to research skull base malignancies.
The Princess Margaret Hospital recently honoured Dr. Patrick Gullane with a Tribute Dinner sponsored by the Princess Margaret Hospital Foundation. Dr. Gullane has been President of the American Head and Neck Society and President of the North American Skull Base Society and is a recognized world leader in the surgical treatment of head and neck cancer. All proceeds will be used to establish the Dr. Patrick Gullane Fellowship in Surgical Oncology. It is expected when all of the contributions have been accrued this will raise between $300,000-400,000 for fellowship education. On going operational support (computers, phones, printers, space) for the Surgical Oncology Fellowship Education Centre has been secured for $38,000. Lastly, a further $1M contribution has been made to start fundraising towards the establishment of a Chair in Surgical Oncology.
The Guided Therapeutic Program (GTX) is under the direction of the Surgical Oncology department led by Dr. Jonathan Irish, Dr. David Jaffray and Dr. Jeff Siewerdsen. The GTX laboratory will develop new imaging modalities, physical therapy delivery systems and robotic techniques for cancer surgery. This will create Translational Research Image Guided Operating Rooms (TRIGORs) at the Toronto General, Toronto Western and Princess Margaret hospitals where real time image guided cancer surgery is merged with intraoperative laser, photodynamic therapy, HIFU and robotics. Fundraising for this initiative has been led by the Dr. Irish and is currently $3.4M with a further Spotlight Fundraising Dinner being planned for February 15, 2006.
Last year Toronto Central met its surgery volume obligations. This year, however, poses a more difficult challenge in meeting the volumes due to OR nursing shortages, high occupancy rates and an anesthesiologist shortage. Various problem solving initiatives are being considered to rectify this shortage issue.
Toronto Central - North
Two surgeons and one scientist have recently been recruited by Sunnybrook Health Sciences Centre (SHSC):
- Dr. Natalie Coburn was recruited to the Division of General Surgery. She is a specialist in HPB surgery and upper GI surgical oncology and is cross-appointed as an adjunct scientist at the Institute of Clinical Evaluative Sciences.
- Dr. Kal Ansari was recruited to the Department of Otolaryngology. He is a head and neck oncologic surgeon specializing in microvascular reconstruction. He received his fellowship training at the Mayo Clinic.
- Dr. Anna Gagliardi was recruited as a Research Scientist in knowledge transfer.
Fundraising to establish a Chair in Surgical Oncology Research is ongoing and more than $1.5 million of the $3 million dollar goal has been raised to date. Our team of translation researchers, including Drs. A. Smith, C. Law, N. Coburn, C. Holloway, F. Wright, M.L. Quan and A. Gagliardi, has been extremely productive academically.
On October 27, 2006, the U of T “Update in Surgical Oncology” course was held at the Granite Club, under the leadership of Dr. Andy Smith of Sunnybrook, Toronto. The course was a great success and was attended by over 200 surgeons, including community surgeons from all over Ontario.
Although last year the region was slightly below our targets for incremental surgery volumes, this year is proving an even greater challenge because of frequent O.R. cancellations due to bed shortages. Numerous initiatives are currently underway in an attempt to resolve this issue.
CCO – Thoracic Standards:
Following the retirement of one thoracic surgeon at SHSC in July 2005, a regional partnership with Toronto East General Hospital (TEGH) was established to transfer thoracic surgery cases. Thus far, this partnership has worked very well for both institutions over the past year.
CCO – HPB Standards:
In order to meet and potentially exceed the CCO standards in HPB surgery, the SHSC recruited a third HPB surgeon in addition to establishing a formal HPB multidisciplinary tumour board; this is in addition to the GI Oncology multidisciplinary tumour board. This area is recognized as an area of growth as the HPB surgery volumes are projected to increase due to changes in practice, eligibility criteria, and new referral patterns. Preliminary discussions with regional partners are taking place to centralize HPB surgery for the northeast sector of Toronto at SHSC.
The SHSC, along with regional partners, has been involved in CCO's provincial Stage Capture Project aimed at increasing cancer staging to 90% of all cases included in the 2007/08 cancer surgery agreement. Staging leads for this initiative at Sunnybrook are Rosemary Walo, head of Health Data Resources, and Sherif Hanna.