The Issue or Problem
Sarcomas of soft tissues and bones are comparatively rare, which leads to rather complicated management of the issue. In order to arrange optimal care for patients suffering from such sarcomas, multidisciplinary expertise is needed. According to Pan et al. (2016), the in-person tumor board in the Mercy Hospital in Miami, Florida is not practical. The reason for such a conclusion is that two out of three orthopedic oncologists from four counties of South Florida (namely, Miami-Dade, Munroe, Palm Beach, and Broward) are employed at the hospital. To perform their functions, these oncologists need to obtain referrals from private radiation and medical oncologists, as well as other institutions belonging to the Hospital Corporation of America (HCA).
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The Explanation of the Issue or Problem
Soft tissue and bone sarcomas have probably the highest level of need for the multidisciplinary approach (Biermann et al., 2013). The major rationale behind such a requirement is that sarcomas are very rare tumors, and they necessitate the advanced pathological diagnosis along with highly effective imaging interpretation. If the employed biopsy technique is not selected and implemented correctly, the outcomes of surgery or resection may be not beneficial for the patient. A common treatment of soft tissue and bone sarcomas involves surgery. However, the protean anatomic allocation of the disease frequently demands multidisciplinary input. The disciplines the contribution from which might be needed are general surgical oncology, orthopedic oncology, thoracic surgery, and other similar anatomically aimed areas.
The medical management of high-grade soft tissue sarcomas, as well as high-grade bone sarcomas, frequently involves complex multi-agent chemotherapy with a high level of toxicity. As a result, particular support and expertise are required for these procedures. Bagaria, Ashman, Daugherty, Gray, and Wasif (2014) mention that radiation therapy delivered to patients with soft tissue and bone sarcomas is selected either instead of surgery or as an additional measure.
In such cases, the administration of radiation therapy presupposes the doses far exceeding the ones assigned in cases of more common indications, such as bone metastasis (Bagaria et al., 2014). The combination of the mentioned aspects necessitates the tight cooperation and requires a multidisciplinary approach in order to enhance the treatment outcome.
The institution where I work performs the functions of coordinating sarcoma cancer conferences and navigating orthopedic oncology methods. Being the ones who combine these responsibilities, we realize the need for the multidisciplinary approach. To reach this requirement, the hospital employs an expert referee pathologist who investigates each soft tissue and bone sarcoma case. Additionally, there are two orthopedic oncologists in our team. However, not all of the necessary positions are covered in the hospital. As a result, radiation and medical management of some patients necessitate resorting to outside sources.
The investigation of the issue is primarily focused on the complexity of obtaining the outside radiation oncology and medical oncology specialists. Furthermore, these providers should personally engage in the analysis of the treatment of patients diagnosed with soft tissue or bone sarcoma. The major problem is that physicians providing subsequent care to the mentioned category of patients do not have the opportunity to observe the clinical scenario in its entity. Such reports are commonly presented and discussed before these specialists’ visits.
However, if medical oncology or radiation oncology specialists were present at all phases of the scenario, they would be able to comprehend it better and come up with more beneficial solutions. One of the most common negative outcomes of the situation is that the radiation or medical oncologist cannot review referrals within the team. Probably the most crucial drawback is the possibility of missing out on some treatment options, which may occur when some of the providers are not willing to share their knowledge. As a consequence, overlooking of some pathologic or radiologic findings may lead to a wrong direction of treatment.
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The Indication and Proof of the Issue or Problem
In order to resolve the existing problem, it is necessary to create a tumor board, the responsibility of which is arranging efficient management. The tumor board is a working conference, and each patient is represented at it in a streamlined approach. Patients’ examination findings, as well as clinically relevant history, are explained and considered there. Additionally, the images relevant to the discussion are available at hand.
Every fortnight, the Mercy Hospital holds the Multidisciplinary Musculoskeletal Oncology Tumor Conference, which is also known as Sarcoma Tumor Conference. The event takes place at 7 a.m. on Monday mornings. At the conference, orthopedic oncologists present lists of patients whose cases require reviewing. Also, the images most pertaining to the topic are demonstrated, along with pathology requests.
Primary lists are handed out within two or three days prior to the meeting so as to promote clerical processing that can improve the workflow for pathology and radiology providers. Usually, patients are presented within a fortnight of the latest intervention. Another indication for one’s case’s presentation is an urgent need for reviewing images and making important decisions regarding pathology.
Before the conference, all prospective attendees receive invitations in order to collect specialists from various areas. Thus, the list of participants includes faculty from medical oncology, orthopedic oncology, thoracic oncology, radiation oncology, surgical oncology, diagnostic radiology, and pathology. Representatives of other disciplines may be invited if they have some relevant cases. Therefore, sometimes, specialists in otolaryngology or other surgical disciplines, nurse practitioners, physician assistants, administrative personnel, fellows, residents, and medical students may be present at the conference.
A serious limitation of these meetings is that due to distance, radiation and medical oncologists from referring institutions are absent during case demonstrations. The major benefit is that every member of the faculty has a particular academic and clinical interest in sarcoma, which enables them to present a unique prospect to the team. In order to help referring physicians to understand the missed data better, the nurse navigator prepares one-page notes that serve as organizational guidelines for decision making, medical documentation, and subsequent care.
The investigation of data available from case presentations shows that the number of patients referred into the Mercy Hospital-based oncology providers is growing, and currently, it is estimated as 30%. At the same time, radiation and medical therapy for such patients are administered by the institutions referring them. Unfortunately, these institutions are situated very far from the Mercy Hospital, the distance sometimes reaching over a hundred miles. Radiation treatments and chemotherapy sessions may be performed every day for several weeks. Meanwhile, surgical intervention is made at the Mercy Hospital in Miami, Florida.
Therefore, there exists a problem of reaching other physicians who could help to improve the plan of treatment. Also, there is no opportunity to hold a substantial discussion of the case, which leads to the insufficient interchange of opinions and knowledge.
Factors Responsible for the Issue or Problem
The rate of people commuting to work in South Florida is very high (78%) compared to other areas. For instance, in San Francisco, it reaches 60%, in New York – 50%, and in Hong Kong – 13%. According to Mann (2017), the increasing level of traffic problems in South Florida is likely to restrict the region’s economic growth. The issue in question is closely related to this contributing factor since traffic difficulties hinder specialists’ direct attendance of the tumor board. Therefore, traffic is the factor that is largely responsible for the problem analyzed.
The Suggested Change or Solution
Upon analyzing the available data, it seems that one of the most promising methods of dealing with the problem of geographic constraints is the employment of videoconferencing technology. Still, there is not enough evidence of tumor boars programs using this technology that would facilitate real-time access of all participating specialists from various medical establishments. A few relatively dated studies on this topic were performed by Dickson-Witmer et al. (2008) and Gagliardi, Wright, Anderson, and Davis (2007). In their research, scholars emphasize the significance of the multidisciplinary approach to complicated cases.
The suggested Mercy Hospital Virtual Tumor Board (VTB) is a collective service offered chargeless to community-based physicians from various regions of the state who want to take part in the program irrespective of their or their patients’ affiliation with the Mercy Hospital or HCA. This interactive service also corresponds to the tumor board’s demand of the Commission on Cancer. This Commission expects from providers to review and discuss all new cases in order to come up with viable care delivery options even for the most complicated cases.
The Rationale for the Suggested Change or Solution
Generally, every patient admitted to the hospital spends approximately $30,000 during the first three inpatient days, without the inclusion of surgical cost. These statistics allow concluding that one additional patient can cover the expenditures on the necessary electronic equipment. Thus, the project will not require much financial support from the hospital itself while offering substantial progress for physicians and their patients.
The expected course of actions involves various presenters’ thorough preparation for the discussion. The preparation presupposes reviewing and synthesizing relevant scholarly literature on the topic. Evidently, some physicians might find such a requirement time-consuming and difficult. However, literature reviews may also be regarded as a beneficial outcome of the VTB work. Such a method may help community-based clinicians to gain expertise in the details and specifications of different cases.
The major rationale behind VTB is that it will allow arranging better services for patients with sarcoma cancer living in South Florida. Additionally, this approach will offer physicians and other healthcare professionals multidisciplinary consultative support and help. Furthermore, a well-organized VTB will increase the opportunities on the surgical market since other hospitals might want to use the program as a highly-established option and refer their patients to the surgical oncology practice.
The Cost-Benefit Analysis and Resources Needed
The cost of equipment is approximately $30,000, whereas the funding needed for treatment of a patient suffering from a sarcoma that has not been detected timely or has been maltreated reaches much higher numbers. Thus, the project is cost-efficient, and its implementation will not require much money. The resources required for the project’s implementation include software and IT technologies and some video and audio equipment.
The Timeline of the Project
The project’s timeline covers 16 weeks, and it is presented in the table below.
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|Phase||Time period||Activities to be performed|
|1||Week 1||Inspecting the hospital’s funds, locating the necessary resources|
|2||Week 2||Inviting and persuading providers; analyzing the equipment that is currently available, predicting additional equipment needs|
|3||Weeks 3-4||Setting up the equipment in the main center|
|4||Weeks 5-14||Checking the equipment, practicing for the main event|
|5||Weeks 15-16||Analyzing the obtained data, assessing the results|
The suggested timeline will be sufficient for settling the VTB’s direction and goals. Simultaneously, the time period is not too long, so in case of any unexpected obstacles, the hospital will not lose too much time or money. Due to the division into phases, the timeline will promote the efficiency of work and will enable the participants to have enough time for the accommodation. New working conditions may seem challenging at first, but it is expected that with the appropriate division into stages, the tasks will not cause much difficulty to the members of the team.
The Role of the Major Partners and Stakeholders
As well as in any similar project, it is rather important to determine what participants will be involved. The presence of the selected actors will make sure that the project is successful. As a result, the surgical hospital will obtain beneficial outcomes in the future. The main stakeholders in the suggested project are the director of oncology, the chief financial officer (CFO), and the IT director. In the course of the project, each of these three key participants will suggest their views on how the process of work should be arranged and how it could be enhanced. As a consequence, the continuance of market share and patient care will be considerably improved.
Each of the key participants will have specific roles and perform separate functions. In particular, the CFO will deal with allotting the budget and finding the necessary funding. The responsibilities of the director of oncology will include supervising the tasks that are performed by the team. Additionally, the director will cooperate with healthcare providers and collect their feedback on typical work tendencies as well as obstacles that they face. Finally, the director of oncology will analyze all the gathered data in order to find the most relevant resolutions to complicated issues. The third key stakeholder, the IT director, will have to perform the duties outlined by the program’s schedule. Also, he will discuss the obstacles with the management team and collaborate with them to find optimal ways of improving the work process.
The Cooperation Between the Major Partners and Stakeholders
The main stakeholders need to arrange successful collaboration in order for the project to gain the best results. Upon discussing the necessary stages with the director of oncology and the CFO, positive feedback was obtained from both of them. When the IT director was asked to express his apprehensions and expectations, he said that new equipment was needed. The CFO immediately agreed to fund the necessary supplies, which indicated successful cooperation between all the main partners. The director of oncology, the CFO, and the IT director all acknowledged that the suggested project could become a valuable option of expanding the currently working aspects of the oncology care plan. In particular, such units as radiology, pathology, surgical oncology, and others would be involved in the process of optimization.
The Project’s Success
The important part of any project is reaching a successful outcome and fulfilling its initial goals. For the present program to be successful, it is necessary to create an atmosphere of mutual encouragement and help. Also, it is crucial to arrange close cooperation between the key stakeholders and other participants.
The Implementation of the Solution
The primary step in implementing the approach will be observing the VTB cases. To do this, it is necessary to create the observation checklist which would contain the institutional affiliation of each presenter, the number of conference participants, the duration of discussions, and treatment suggestions. Also, the checklist will contain information on whether the agreement has been reached on each particular recommendation. Finally, structural observations will be pointed out, including the level of participants’ commitment to conferences and the prospects of arranging a follow-up discussion with the presenter.
The Nurse’s Role as a Scientist
Nurse’s role of a scientist is the most important in the current project. Commonly, this function is performed with the help of research and investigation of evidence-based practice. With the aim of analyzing the issue from various angles, several peer-reviewed articles have been consulted. The work by Shea et al. (2014) is particularly relevant since it offers the analysis of the feasibility of VTB programs. The study by Pan et al. (2016) is also valuable since the authors discuss the benefits of a system-based VTB. Pan et al. (2016) note that such a VTB can serve as an exemplary platform for enhancing care quality and increasing physicians’ confidence in finding solutions to managing soft tissue and bone sarcoma patients’ cases. Performing research and analysis helped me to carry out the role of the scientist.
The Nurse’s Role as a Detective
The role of the detective is demonstrated through one’s attention to detail when performing professional duties. While working on the project, every viable effort was taken to be scrupulous and mindful. Every opportunity to compare and contrast some details was effectively used in order to detect mistakes or misinterpretations. Furthermore, the detective’s role was manifested through arranging the timetable when every possible attempt was made to foresee the most appropriate conditions for the implementation of change. Finally, report analysis and discussions with participants were employed to collect an adequate amount of relevant data.
The Nurse’s Role as a Manager of the Healing Environment
The third nursing role was carried out through singling out the issues influencing patients most, as well as finding solutions to those issues. While this aspect is not closely associated with direct patient care, it is highly crucial in arranging a healing environment. The role of a nurse navigator was manifested through understanding the fact that all stakeholders had an important role in arranging a wholesome healing environment for every patient. As a manager of the healing environment, I also made sure that treatment was given timely and appropriately.
Bagaria, S. P., Ashman, J. B., Daugherty, L. C., Gray, R. J., & Wasif, N. (2014). Compliance with National Comprehensive Cancer Network guidelines in the use of radiation therapy for extremity and superficial trunk soft tissue sarcoma in the United States. Journal of Surgical Oncology, 109(7), 633-638.
Biermann, J. S., Adkins, D. R., Agulnik, M., Benjamin, R. S., Brigman, B., Butrynski, J. E., … Sundar, H. (2013). Bone cancer. Journal of the National Comprehensive Cancer Network, 11(6), 688-723.
Dickson-Witmer, D., Petrelli, N. J., Witmer, D. R., England, M., Witkin, G., Manzone, T., … Smith, D. (2008). A statewide community cancer center videoconferencing program. Annals of Surgical Oncology, 15(11), 3058-3064.
Gagliardi, A. R., Wright, F. C., Anderson, M. A. B., & Davis, S. (2007). The role of collegial interaction in continuing professional development. Journal of Continuing Education in the Health Professions, 27(4), 214-219.
Mann, J. A. (2017). Growing traffic congestion in South Florida threatens economic growth: ULI panel. The Real Deal. Web.
Pan, M., Fang, A., Kavanagh, M., Kim, B., Lee, J. D., McCormick, C., … Yu, J. C. (2016). Improving care quality for patients with soft tissue and bone sarcoma by establishing a national virtual tumor board and electronic consultation platform. Journal of Clinical Oncology, 34(7), 211.
Shea, C. M., Teal, R., Haynes-Maslow, L., McIntyre, M., Weiner, B. J., Wheeler, S. B., … Shea, T. C. (2014). Assessing the feasibility of a virtual tumor board program: A case study. Journal of Health Management, 59(3), 177-193.