'Beyond Bricks and Mortar - Building Quality Clinical Cancer Services' Symposium 2011

Quality Standards in Australian Radiation Oncology: Time to put on the "Yellow Jersey" - Associate Professor Christopher Milross

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Chair of the Tripartite Committee; Dean of the Faculty of Radiation Oncology, RANZCR; Director of Radiation Oncology, Royal Prince Alfred Hospital

Download presentation by Associate Professor Christopher Milross (PDF 569 KB)

Norman Swan:

So when I heard that we were going to launch the radiation oncology practice standards, I thought, you know, we’re gonna have to introduce some weight lifting to get the brick up on the table, but the good news is that it will hold open all your doors. Then look what you get, it’s not a brick, it’s fantastic. To launch this is Chris Milross, who runs radiation oncology at the Sydney Cancer Centre at Royal Prince Alfred Hospital, he is Dean of the Faculty of Radiation Oncology at the College and chair of the Tripartite Committee which puts this together, Please welcome Chris Milross to launch the Standards.

Assoc. Prof. Chris Milross:

Thank you very much. What a pleasure it is for me to be here today to launch these Standards. Fourth speaker before lunch is a difficult position to be in, but what a hard act I have got to follow this morning after David, Jeremy and Ian. Thank you Ian, we are a very technical specialty, but you remind us this morning that we are working in an area which is very, very real.

So, as I say, it is my pleasure to officially launch the Radiation Oncology Practice Standards and it is my conviction this morning, that these Standards hold promise to deliver the needs of each of the groups represented by the three preceding speakers this morning. The service planners, the service providers and those that challenge us to be better at what we do, and most importantly, to deliver according to the needs of our patients. What I am not going to do this morning, is provide a detailed discourse on the individual Standards themselves. What I am going to do is tell a long story rather briefly, and offer a challenge.

So, with apologies to team B and C, and seeking special forgiveness from Cadel Evans himself, I begin today with the suggestion that the quality race in Australian radiation oncology got off to a great start a long, long time ago. We need to recognise that we come from a tradition of high quality radiotherapy. The pioneers in radiation oncology the world over, and in Australia, also recognised very early on the promise of radiation as an anti-cancer treatment, and also the potential problems that came with the use of that, no doubt. And we developed, from the very beginning, a culture of quality assurance, continuous review of what we were doing, and of effort to improve the outcome, the results of our treatment. It is a time for self-congratulation. We need to remember that we invented multi-disciplinary care. It came from cancer centres, led by radiation. We, as a discipline, function as a multi-disciplinary team. None of us can do our work on our own.

So, in 2002, the report “A Vision for Radiotherapy”, also known as the Baume report, identified a number of national safety and quality issues for radiotherapy. In fact, it was the Tripartite Committee, a multi disciplinary group representing the radiation oncology sector, that prompted the Baume report. And, there are key words in the title of Baume’s report. And in my opinion, they are vision and change.

In 2005, the Department of Health and Aging funded the College to develop a suite of practice standards, and this initiative was enthusiastically welcomed by the Tripartite Committee, and by the radiation oncology sector at large, and together, we undertook to develop and refine the standards that will be launched this morning. The Department was very proactive in its support. The Tripartite Committee was very positive in its response to that initiative, and the sector welcomed the development with excitement, with enthusiasm, and with quite a number of brilliant individual efforts. A long period of consultation followed between 2005 and 2008. Developing and refining the Standards involved writing, re-writing, meeting, discussion, argument, re-writing, and it all took time and inevitably, there was some doubt, and even perhaps some conflict that arose as a result of that iterative process of developing the Standards. And we got to a point where we needed perhaps, a little prompt to get the job completely completed, and to continue the team analogy, I think our team was extended at the time.

The Department counselled us as to the use of an independent third party to run an industry trial of the Standards, and to use that step to finally refine them and develop them to a point where we were happy to publish them, and to abide by them. And this leads us then to the NATA pilot of the draft Standards. So, the National Association of Testing Authorities successfully tendered to run that pilot for us, and it was conducted across 14 Australian radiation oncology facilities, 16 sites, and it covered a really neatly balanced mix of public and private services, of metropolitan and regional sites, large and small radiotherapy centres, and of single and multiple site services. This was an important phase, a phase filled with optimism, but also a phase that provided us with a reality check on this last important step, finalising the Standards.

I love the word that was used in planning for the pilot, which was to test their implementability. I’ve checked. I’m not sure it’s an actual word, but I think it’s a perfectly good word, because it very, very adequately describes what the effort was all about. Were these Standards implementable in our business. Publication of the Standards puts radiation oncology into a very commanding position.

To continue the Tour analogy, publication of the Standards represents a stage win of sorts. These published Standards provide us with an unarguably commanding position from which to continue to achieve our goal. But you can see Cadel there, stuck between the Schleck brothers, it’s not over yet. The Standards will be available for all of you, and I think delegates at this meeting get an opportunity over the next two days, to think about the implementation of the Standards. Their use as a quality measure, to be reported so that everybody knows that we meet the Standards, or to what level we meet the Standards. To be used as a tool to facilitate quality improvement, and also to think about related issues that are associated with the Standards, including accreditation and certification. Recently, the Tripartite Committee has committed to ongoing review of the Standards themselves, an effort that will endeavour to keep the Standards current and relevant.

So, success is close, but not guaranteed. It is appropriate to consider the scope of the Standards, the resources that will be required to report against the standards, the cost of doing so, and to also think strategically about what that means, and what the data ought to be used for. So, today, I think, provides us with an opportunity to focus one more time on the goal. Do we really want these Standards? What do we really want? And, what do our patients expect from us? What do they demand from us, and how will we deliver that for them?

So, the next stage challenges us to contemplate seriously, what the end game is. It is an opportunity to refocus on our original goal, and to re-ask the basic questions that we began to ask back in 2005 in response to the challenges issued by the Baume report. As I said, the program for the next two days, provides us with a wonderfully broad range of inputs that I think will counsel and stimulate us as we consider where we’re going to next. So, my thesis this morning is that we can rely on the strength from which we began, to carry us forward. We began on a very solid foundation in providing a quality service, delivered through a multi-disciplinary approach, and a common commitment across the professions to providing excellence in patient care. The implementation phase of an agreed set of Standards provides radiotherapy with an opportunity to define who we are and what we want to be known for. High standards and excellent patient care.

So, it is time to wear the yellow jersey. Having done the work, having developed the Standards, having refined them, having tested them, and reading the NATA report on all the issues associated with the draft implementation trial, it is actually not hard to identify what the challenges are, what the barriers might be, what the obstacles are, and what the other potential impediments to progress might be. I want you to remember that the NATA pilot found that facilities already have 75% of the documentary evidence prescribed by the Standards. Glass half full, glass half empty. It is actually a good number, 75%. I mean, if we had met the Standards, then I am not quite sure where we would be. I think the fact that we did not have all of the evidence, tells us that the Standards actually represent a stretch goal for us, the realisation of which will make us all better at what we do, and deliver better care for those patients that we are privileged to care for.

Having come this far, it is my conviction that the do nothing option is really not an option at all, and at the risk of mixing sporting metaphors, I like the byeline from Nike, which is “Just do it”.

Having said that, today is an opportunity to celebrate success. I think congratulations are deserved by many who have been involved in the process along the way. Special thanks to those here who have been involved from the beginning, who have shared the vision, and have done the hard work. And, there are too many people to name individually, and I hope you will forgive me for not naming people individually. I would also like to thank the jurisdictional Health Departments, the hospitals and the radiation oncology practices that have supported the development of these Standards, and the conduct of the pilot of the draft Standards. We could not have done it without the support and co operation of all of those groups.

Finally, last, but by no means least, thanks to the Department of Health and Ageing, in particular the members of the radiation oncology section in the Health, Technology and Medical Services Group. Your support, and your great and genuine interest in what we do, is hugely appreciated by all of us and time will prove it to be have been enormously beneficial to our patients.

So, in launching the Standards today, I am thinking about the talk that David gave, and my conviction is that high quality radiation oncology by definition, helps us to achieve best possible outcomes for our patients, both in terms of palliation and disease control or cure.

David spoke of the inverse relationship between volume and outcome with respect to 30 and 90 day mortality for a major surgical procedure. Jeremy reminded us that Lester Peters has written about a similar relationship between radiotherapy case number and outcomes for radiotherapy treatment of head and neck cancer. There is one important, extra little detail with respect to that story, and that is that it is worth noting that the Head Start trial data demonstrated that outcomes were good when the treatment plans were modified according to the protocols that had been prescribed by the trial itself. And, I think that speaks to the value of standards and performance against a defined set of standards. And these Standards are our standards: Radiation Oncology Practice Standards, a Tripartite Initiative, and the Radiation Oncology Practice Standards Supplementary Guide. The Supplementary Guide provides a fully fleshed out supplementary commentary of each of the criterion, and gives extra options for collecting even more data against those Standards if we wish to.

So, I would like to pick up on a key phrase from Ian’s talk, and he used the word “transition”, the transition that our patients are going through when their diagnosis is made, and their treatment is delivered, and I am going to suggest today, although with not quite the same meaning, that this is our time of transition as an industry, in providing radiation therapy to cancer patients in Australia. And, so without any further ado, it is my pleasure to officially launch the Standards.
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Norman Swan:

I don’t want to spoil the warm glow Chris. What is your view about gaining maximum implementation of these Standards? Compulsion, voluntary, financial incentives? What is the story here?

Ass. Prof. Chris Milross:

If my mother was here, she ….

Norman Swan:

She always is Chris.

Ass. Prof. Chris Milross:

...“Chris, keep your options open”. And, by that, I mean I think we have to realise the reality of the situation that we are in. I talked in the draft about the range of centres, big and small, and public and private, and single and multiple. I think the reality of that is that it may be unlikely that one size will fit all. I think, as an industry, we’re going to have to be smart about how we roll this out. But, I don’t see any reason or any impediment to doing that if we have a will to do so.

Prof. Gill Duchesne:

I wanted to look at it in a slightly different regard. I don’t know whether you realise Norman, quite the enthusiasm which all the professions involved embraced this project, and the support that it has been given all the way through. It has been absolutely astounding to have everybody involved. And, I see it also not just as a stick, it’s also a carrot. It gives us a framework, again to use that word, with which to set up our quality programs, with which to deliver our care, so we may be measured against it, but it’s also very helpful to us to be able to put these things into practice.

Ass. Prof. Chris Milross:

The point that Gill has just made is a resounding conclusion in the NATA document, that everybody, even people who were not in a position to provide evidence about the Standard, were invariably enthusiastic about the Standard itself. And the industry wants to do the best job it can.

Norman Swan:

Congratulations to everybody involved, and thanks for launching it Chris.

Ass. Prof. Chris Milross:

Thank you very much.

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