We have developed a novel, observational measure for assessing quality in cancer MDT meetings. The quality criteria are calibrated against ‘effectiveness’ as defined by consensus from over 2000 MDT members, and measure quality in relation to 15 aspects of observable activity in MDT meetings. Our preliminary study has shown that independent observation of MDT meetings is acceptable to teams and feasible to conduct. Whilst only a small number of teams participated in this pilot study, the application of the measure highlighted wide diversity in the quality of teamworking across the range of characteristics measured.
Teams typically performed well in terms of the administrative preparation for meetings and having the appropriate team members in attendance. They performed less well in relation to spending adequate time discussing cases (requiring case prioritisation on the agenda), and having patient-centred case discussions. Both of these aspects of MDT function require additional preparation time, either in relation to compiling and assessing case information to determine their complexity, and/or additional time with patients to comprehensively assess their history, needs and wishes. The importance of undertaking regular assessment of patients' needs and preferences (now referred to as holistic needs assessment [21
]) was highlighted in the NICE guidance for improving supportive and palliative care [22
] and generally it is expected Clinical Nurse Specialists (CNS) should lead this. Ensuring patient-led decision making is fostered in the MDT meetings, where patients are not present, is challenging due to the time pressures of meetings and requires further attention. Nevertheless if the opportunity is not grasped for information to be obtained and shared with the wider team at the earliest opportunity it may fail to impact on decision making, or may cause avoidable delays to treatment [9
]. In this study, few nurses contributed to case discussions which may at least in part explain the lack of patient-based information discussed. Similar findings have been reported elsewhere [23
]. Although responsibility for ensuring that recommendations are patient-centred rests with the whole team, training and support to enhance nurses’ involvement in MDT discussions may be warranted.
This pilot study was aimed at determining ‘proof of concept’ and has demonstrated that it is acceptable and feasible to measure complex aspects of team behaviour and activities such as leadership, teamworking and decision-making. The calibration of quality criteria against characteristics of effectiveness agreed by a large sample of MDT members, in addition to using available evidence and expert input, ensured content validity. Furthermore, most characteristics were measured reliably in the hands of different observers. There was low agreement in ratings for the presence of tension/conflict and the clarity of treatment recommendations which may be related to level of clinical experience. The quality criteria require refinement to increase their reliability or it may be necessary for observers to have relevant clinical experience for the ratings of these aspects of teamworking to be valid.
Further testing is required with more teams and other tumour types. Only one meeting was assessed per team which may not have adequately represented their teamworking. Team members confirmed that the filmed meetings were typical of their usual meetings in all cases, but some aspects of teamworking may have been more reliably rated longitudinally. This may be particularly important where behaviour or performance receives a poor rating. Furthermore, the teams volunteered through their participation in another study. It is necessary to test this method of observational assessment with other teams to further confirm its acceptability. Validation of ratings against other subjective and objective outcomes (such as team member assessments of their own performance, clinical outcomes, peer review data & national patient experience data) will be important to further define the characteristics of effective teamworking. The current design of the tool, based upon rating case-by-case, enhanced objectivity of ratings but was time consuming and is likely to require simplification to have clinical as well as research utility. Together with further validation, it may be desirable to develop quality criteria for other characteristics of MDM effectiveness. In particular this could include other aspects of case discussions such as presentation of nationally agreed minimum datasets for radiology, pathology and clinical data; and adherence to relevant nationally and locally agreed protocols. Such assessment may require observers with clinical expertise, at least for assessment of these aspects of team functioning.
The variation in quality of teamworking we report reinforces the need to provide teams with appropriate assessment tools, resources and training to optimise their performance. Indeed 85% of MDT members that responded to the UK national survey agreed MDTs need performance measures [18