Abstract

Background: In 1999, the National Representatives of European Society for Medical Oncology (ESMO) created a Palliative Care Working Group to improve the delivery of supportive and palliative care (S + PC) by oncologists, oncology departments and cancer centers. They have addressed this task through initiatives in policy, education, research and incentives. As an incentive program for oncology departments and centers, ESMO developed a program of Designated Centers (DCs) for programs meeting predetermined targets of service development and delivery of a high level of S + PC.

Method: The history, accreditation criteria and implementation of the DC incentive program is described.

Results: Since 2004, 75 centers have applied for designation and 48 have been accredited including 34 comprehensive cancer centers (CCCs) in general hospitals and seven freestanding CCCs. Perceived benefits accrued from the accreditation included the following: improved status and role identification of the center, positive impact on daily work, positive impact on business activity and positive impact on funding for projects.

Conclusions: The accreditation of DCs has been a central to the ESMO initiative to improve the palliative care provided by oncologists and oncology centers. It is likely that many other oncology departments and cancer centers already meet the criteria and ESMO strongly encourages them to apply for accreditation.

introduction

Over the past 30 years, there have been major developments in the standards of practice in palliative and supportive care for patients with advanced cancer [1–3]. Importantly, it is now widely acknowledged that a palliative and supportive care approach to care should utilized whenever needs are identified, irrespective of the stage of the disease, and not only at the end of life [2, 4–9]. By implication, many patients receiving active disease-modifying treatment will need palliative and supportive care as part of a comprehensive care plan. For patients with advanced and refractory cancer, when the risks outweigh the benefits of anticancer treatments, palliative care becomes the most important paradigm of good cancer care [4, 5].

Despite these developments, a parallel literature also indicated that many oncologists and cancer clinics have not integrated these evolving standards into training programs [10–13], routine practice [10, 14–19], research strategies [20, 21] or the resourcing of cancer departments and centers [10, 22]. The European Society for Medical Oncology (ESMO) recognizes that ensuring that patients with physical, psychological and social needs receive palliative and supportive care to address these issues is the responsibility of the medical oncology community. This does not imply that they must personally deliver all this care, but rather that they should ensure that these issues are being adequately addressed in cooperation with interdisciplinary professional team including home care services, nurses, social workers, physicians with expertise in palliative care, chaplains and mental healthcare professionals. Furthermore, ESMO recognizes that lack of uptake of standards in these aspects of cancer care is not only harming some patients and their families but also detrimental to the profession itself [9, 10].

In 1999, the National Representatives of ESMO created a Palliative Care Working Group (PCWG) to address this issue. The charter of the working group is to improve the delivery of supportive and palliative care (S + PC) by oncologists, oncology departments and cancer centers. The PCWG and ESMO have addressed this task through initiatives in policy, education, research and incentives. In 2003, ESMO issued a policy document including definitions of S + PC, defining the responsibilities of the oncologist in the provision of palliative and supportive care, outlining training requirements for oncologists in relation to these aspect of patient care and establishing minimal standards for provision of palliative care in cancer centers [10]. These policies oblige individual members, associated organizations and affiliated centers to aspire to these standards. The ESMO policies regarding S + PC have been widely cited and, in some countries, ratified as national policy.

The education initiatives of the PCWG program have included elucidation of the core elements of Palliative Care Education for Oncology trainees [10], the development of an ESMO Handbook of Advanced Cancer Care [23], incorporation of palliative and supportive care into ESMO conferences and sponsored educational activities and two incentive programs to further promote this endeavor. The first, and most novel, was to develop an incentive program for oncology departments and cancer centers by offering special recognition for meeting predetermined targets of service development and delivery of a high level of S + PC. This program is known as the ESMO Program for Designated Centers (DCs) in the Integration of Oncology and Palliative Care. It is commonly referred to by an abbreviated name: the DC Program.

ESMO Program for DCs in the Integration of Oncology and Palliative Care

conceptual development of the DC Program

In 1998, Catane and Cherny proposed the concept of an incentive program as part of the initial PCWG proposal that was presented to the National Representatives. The initial formulation had been to develop an accreditation program for centers of excellence for Integration of Oncology and Palliative Care, based on the model of the Comprehensive Cancer Center (CCC) designation by the National Cancer Institute [24, 25].

After the formation of the PCWG and at the request of the National Representatives, the concept of accrediting center of excellence was modified for two reasons; first, the identification and recognition of Centers of Excellence was considered too restrictive to be relevant to most oncology services or cancer centers, and secondly, it required a rigorous accreditation program in order to be credible. The concept was therefore modified to accredit centers which meet a challenging threshold for advanced program development. This threshold was considered to be medically substantial, readily achievable with due application and consistent with recognized international standards. This approach aimed for a threshold of service development that cancer centers could reasonably aim to attain even if they were starting from a low baseline of services, thus providing incentive to a wider range of institutions, not only those aiming for the pinnacle of excellence. This process was named the ESMO Program for DCs in the Integration of Oncology and Palliative Care.

development of the 13 criteria for accreditation

The criteria for accreditation were drafted based on recommendation from the World Health Organization guidelines on the provision of palliative care for patients with cancer [26]. An original list of 22 items was presented to a full meeting of the members of the PCWG and this was reduced to 13 core requirements by a process of consensus. The 13 criteria were ratified by the National Representatives in 2003 as face valid, fair, appropriate, reasonably comprehensive and adequately, but not excessively, challenging (Table 1).

Table 1.

Thirteen criteria for accreditation as a Designated Center in the Integration of Oncology and Palliative Care (valid 2004–2008)

1. The center provides closely integrated oncology and palliative care clinical services 
2. The center is committed to a philosophy of continuity of care and nonabandonment 
3. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 
4. The center incorporates programmatic support of family members 
5. The center provides routine patient assessment of physical and psychological symptoms and social supports and has an infrastructure that responds with appropriate interventions in a timely manner 
6. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 
7. The center incorporates expert care in the evaluation and relief of psychological and existential distress 
8. The center provides emergency care of inadequately relieved physical and psychological symptoms 
9. The center provides facilities and expert care for inpatient symptom stabilization 
10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 
11. The center provides facilities and expert care for inpatient end-of-life care and is committed to providing adequate relief of suffering for dying patients 
12. The center participates in basic or clinical research related to the quality of life of cancer patients 
13. The center is involved in clinician education to improve the Integration of Oncology And Palliative Care 
1. The center provides closely integrated oncology and palliative care clinical services 
2. The center is committed to a philosophy of continuity of care and nonabandonment 
3. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 
4. The center incorporates programmatic support of family members 
5. The center provides routine patient assessment of physical and psychological symptoms and social supports and has an infrastructure that responds with appropriate interventions in a timely manner 
6. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 
7. The center incorporates expert care in the evaluation and relief of psychological and existential distress 
8. The center provides emergency care of inadequately relieved physical and psychological symptoms 
9. The center provides facilities and expert care for inpatient symptom stabilization 
10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 
11. The center provides facilities and expert care for inpatient end-of-life care and is committed to providing adequate relief of suffering for dying patients 
12. The center participates in basic or clinical research related to the quality of life of cancer patients 
13. The center is involved in clinician education to improve the Integration of Oncology And Palliative Care 

application and accreditation

Description of the DC Program, the accreditation criteria and the application process were published on the ESMO Web site and in ESMO newsletters. Starting in 2004, application was invited from all cancer centers and oncology departments meeting the criteria.

The application, made by the head of the department or cancer center, is submitted to the ESMO education department. The application consists of two parts. The first is a checklist indicating compliance with each of the 13 criteria. The second part requires a narrative description as to how the center meets each of the 13 criteria. Compliance with each criterion is described on a separate page signed, for veracity, by the head of the department and head of institute.

Completed applications are blinded by the education office and distributed to three reviewers drawn from the PCWG. Accreditation is made on the basis of meeting all 13 criteria as determined by a review committee drawn up from the membership of the PCWG. If two to three of three reviewers agree that a criterion is not adequately met, this decision holds. If one of three reviewers assess a criterion as not adequately met, then this is reviewed by the accreditation chairperson for final adjudication. If five or less criteria are deemed to be inadequately met, the applicant is given the opportunity to elaborate further regarding the specific concerns. If the feedback is deemed adequate to the chair, then this is returned to the committee for reevaluation. If six or more criteria are deemed to be inadequately met, the application is deemed unsuccessful. Unsuccessful applicants receive feedback on the specific shortcomings and are encouraged to use this constructively in their service development and to reapply.

Accreditation is valid for 3 years and full reapplication is necessary for renewal. Certificates of accreditation are presented at the awards session of the ESMO or European Cancer Organization/ESMO congresses.

application history

Since the inception of the DC Program in 2004, 75 centers have applied for designation and 48 have been accredited (Table 2). After first review, 33 applications were successful and 15 centers were asked to clarify or elaborate on items of their submissions. The items most commonly requiring clarification were 3 (home care), 5 (patient assessment and timely response), 6 (staff credentials), 10 (respite care) and 12 (research). All applications requiring clarification were subsequently approved. Eight of the 24 centers whose applications were initially unsuccessful during 2004–2007 reapplied in subsequent years, six of them reapplied successfully. The two centers which were twice rejected did not reapply further. Thirteen of the 15 centers accredited in the 2004 and 2005 applied for reaccreditation and all were successful.

Table 2.

Application and accreditation history

Initial applications       
Year Applications new Approved at first review Rejected at first review Required clarification Clarifications successful Total accredited 
2004 18 10 
2005 13 
2006 13 
2007 
2008 25 10 19 
Initial applications       
Year Applications new Approved at first review Rejected at first review Required clarification Clarifications successful Total accredited 
2004 18 10 
2005 13 
2006 13 
2007 
2008 25 10 19 
Reaccreditation applications 
Cohort Reapplications Approved at first review Rejected at first review Number needing clarification Clarifications successful Total accredited 
From centers 2004 Seven reapplied in 2007 out of eight   
From centers 2005 Six reapplied in 2008 out of seven 
Reaccreditation applications 
Cohort Reapplications Approved at first review Rejected at first review Number needing clarification Clarifications successful Total accredited 
From centers 2004 Seven reapplied in 2007 out of eight   
From centers 2005 Six reapplied in 2008 out of seven 

Most of the 27 unsuccessful applications failed to meet 6–8 of the criteria listed in Table 1. The most common unmet criteria were items 2 (continuity of care), 5 (patients assessment and timely response), 6 (staff credentials), 9 (inpatient symptom stabilization), 10 (respite care), 12 (research) and 13 (education).

characteristics of the accredited centers

Thirty-four of the DCs are CCCs in general hospitals, 24 of which are university affiliated. Seven of the centers are freestanding CCCs (Table 3). Among these, are major centers such as Institut Jules Bordet in Belgium, Institut de Cancerologie Gustave Roussy in France, Institut Catala d'Oncologia in Spain and Charite University Hospital in Germany. Others are medical oncology departments in general (2) or university hospitals (1) and one is an oncology department in a dermatology hospital.

Table 3.

Designated Centers in the Integration of Oncology and Palliative Care

2004 Designated Centers Reaccredited 2007  
    AZ Middelheim, Antwerp Belgium 
    Kliniken Essen-Mitte, Essen Germany 
    Klinik Dr. Hancken GmbH, Stade Germany 
    Cork University Hospital, Wilton, Cork Ireland 
    O.D.O. AVAPO, div. Oncologia medica, osp. SS. Giovanni e Paolo, Venezia Italy 
    Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Switzerland 
    Velindre Cancer Center, Cardiff, Wales UK 
2005 Designated centers Reaccredited 2008  
    Shaare Zedek Medical Center, Department of Oncology and Palliative Medicine, Jerusalem Israel 
    Ramban Medical Center, Oncology Division, Haifa Israel 
    Ospedale S. Giovanni Calibita , Fatebenefratelli Oncology Department, Rome Italy 
    Ospedale San Salvatore, U.O. Oncologia Medica, l'Aquila Italy 
    Hospital General Universitario G. Maranon, Madrid Spain 
    Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen Switzerland 
2006 ESMO Designated Centers  
    SMBD Jewish General Hospital, Montreal Canada 
    The Complex Oncology Center, Prague Czech Republic 
    KTB Klinik for Tumorbiologie, Freiburg Germany 
    Cancer Center Beaumont Hospital, Dublin Ireland 
    Medical Oncology University Hospital of Parma, Parma Italy 
    Ospedali Riuniti di Bergamo, Oncologia medica, Bergamo Italy 
    Istituto Dermopatico dell'Immacolata, Divisione di Oncologia e Oncologia dermatologica, Rome Italy 
    Hospital Universitario Salamanca, Salamanca Spain 
    Alaw Unit, Bangor, North Wales UK 
2007 ESMO Designated Centers  
    Oncology Center Virga Jesseziekenhuis, Hasselt Belgium 
    Dr. Horst Schmidt Kliniken, Wiesbaden Germany 
    University Hospital of Lord's Transfiguration, Poznan Poland 
    Institut Catala d'Oncologia, Hospitalet, Barcelona Spain 
    Anadolu Medical Center Gebze, Kocaeli Turkey 
2008 ESMO Designated Centers  
    Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University Graz Austria 
    Royal Adelaide Hospital Cancer Center Australia 
    Institut Jules Bordet Belgium 
    Institut de Cancerologie Gustave Roussy France 
    Städtische Kliniken Frankfurt Höchst Germany 
    Klinikum Heidenheim Germany 
    Palliativstation 55 der Charité Germany 
    Department of Hematology and Medical Oncology University Hospital Regensburg Germany 
    St. Antonius-Hospital Germany 
    Department of Oncology, Hematology, Bone Marrow Transplantation with Section Pneumology (2. Medical Clinic), University Cancer Center Hamburg Germany 
    Klinikum Hanau GmbH Germany 
    Tuen Mun Hospital Hong Kong 
    Department of Clinical Oncology Pamela Youde Nethersole Eastern Hospital Hong Kong 
    S.M.S. Medical College & Attached Hospitals India 
    Bon Secours Cork Cancer Center Ireland 
    Medical Oncology Unit S. Orsola-Malpighi Hospital Italy 
    Oncology and Hematology Department, Hospital of Piacenza Italy 
    Maria Sklodowska-Curie Memorial Cancer Center—Institute of Oncology Poland 
    Chelsea and Westminster NHS Foundation Trust UK 
2004 Designated Centers Reaccredited 2007  
    AZ Middelheim, Antwerp Belgium 
    Kliniken Essen-Mitte, Essen Germany 
    Klinik Dr. Hancken GmbH, Stade Germany 
    Cork University Hospital, Wilton, Cork Ireland 
    O.D.O. AVAPO, div. Oncologia medica, osp. SS. Giovanni e Paolo, Venezia Italy 
    Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Switzerland 
    Velindre Cancer Center, Cardiff, Wales UK 
2005 Designated centers Reaccredited 2008  
    Shaare Zedek Medical Center, Department of Oncology and Palliative Medicine, Jerusalem Israel 
    Ramban Medical Center, Oncology Division, Haifa Israel 
    Ospedale S. Giovanni Calibita , Fatebenefratelli Oncology Department, Rome Italy 
    Ospedale San Salvatore, U.O. Oncologia Medica, l'Aquila Italy 
    Hospital General Universitario G. Maranon, Madrid Spain 
    Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen Switzerland 
2006 ESMO Designated Centers  
    SMBD Jewish General Hospital, Montreal Canada 
    The Complex Oncology Center, Prague Czech Republic 
    KTB Klinik for Tumorbiologie, Freiburg Germany 
    Cancer Center Beaumont Hospital, Dublin Ireland 
    Medical Oncology University Hospital of Parma, Parma Italy 
    Ospedali Riuniti di Bergamo, Oncologia medica, Bergamo Italy 
    Istituto Dermopatico dell'Immacolata, Divisione di Oncologia e Oncologia dermatologica, Rome Italy 
    Hospital Universitario Salamanca, Salamanca Spain 
    Alaw Unit, Bangor, North Wales UK 
2007 ESMO Designated Centers  
    Oncology Center Virga Jesseziekenhuis, Hasselt Belgium 
    Dr. Horst Schmidt Kliniken, Wiesbaden Germany 
    University Hospital of Lord's Transfiguration, Poznan Poland 
    Institut Catala d'Oncologia, Hospitalet, Barcelona Spain 
    Anadolu Medical Center Gebze, Kocaeli Turkey 
2008 ESMO Designated Centers  
    Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University Graz Austria 
    Royal Adelaide Hospital Cancer Center Australia 
    Institut Jules Bordet Belgium 
    Institut de Cancerologie Gustave Roussy France 
    Städtische Kliniken Frankfurt Höchst Germany 
    Klinikum Heidenheim Germany 
    Palliativstation 55 der Charité Germany 
    Department of Hematology and Medical Oncology University Hospital Regensburg Germany 
    St. Antonius-Hospital Germany 
    Department of Oncology, Hematology, Bone Marrow Transplantation with Section Pneumology (2. Medical Clinic), University Cancer Center Hamburg Germany 
    Klinikum Hanau GmbH Germany 
    Tuen Mun Hospital Hong Kong 
    Department of Clinical Oncology Pamela Youde Nethersole Eastern Hospital Hong Kong 
    S.M.S. Medical College & Attached Hospitals India 
    Bon Secours Cork Cancer Center Ireland 
    Medical Oncology Unit S. Orsola-Malpighi Hospital Italy 
    Oncology and Hematology Department, Hospital of Piacenza Italy 
    Maria Sklodowska-Curie Memorial Cancer Center—Institute of Oncology Poland 
    Chelsea and Westminster NHS Foundation Trust UK 

impact of ESMO accreditation on the DCs

In early 2008, the program directors of the 27 cancer centers that were accredited before that time were surveyed to evaluate the impact of the application process and the accreditation. Program directors were asked six questions inviting both closed (yes/no) and open answers: (i) In preparing your application did you need to develop new services to meet the 13 required criteria? (ii) Has the recognition as ESMO DC of Integrated Oncology and Palliative Care affected: The daily work in your department? The business activity in your hospital? The identification of your center in you country? (iii) Do you use the ESMO Designation on stationery or letterhead? (iv) Has the recognition as ESMO DC of Integrated Oncology and Palliative Care affected the funding for your projects? (v) Since the ESMO Designation have you developed any new services? (vi) Would you suggest adding or removing any of the criteria for accreditation as a DC of Integrated Oncology and Palliative Care?

Twenty-four responses were received. Four of the 24 centers had developed new services specifically to make themselves compliant with the 13 criteria. The perceived benefits accrued from the accreditation included improved status and role identification of the center (18 of 24), positive impact on daily work (12 of 24), positive impact on business activity (11 of 24) and positive impact on funding for projects (6 of 24). Eight of the centers have incorporated the designation as part of their official letterhead. Seven of the centers demonstrated further program development with the development of additional services beyond those described in their original applications.

identifying and recognizing leadership

In many countries, DCs have undertaken leadership roles in promoting palliative care for cancer patients. In 2009, the Italian Association of Medical Oncology invited the clinical leadership of the eight DCs in Italy to direct a new task force on palliative care in oncology. The charter for their working group is to promote the ESMO philosophy on simultaneous care model for oncology patients.

ESMO grantee visits to DCs

The second of the incentive programs of ESMO and the PCWG are the palliative care grants, awarded since 2006. These are special grants, of up to 5000 Euro, for oncologists or oncology fellows seeking additional experience in palliative care by spending 1–3 months of observation and/or research at one of the DCs. Candidates must be oncologists and ESMO members (or in process of application). The candidates must demonstrate approval of the project by their institutional director and have agreement from a host institution which is one of the DCs. In the 3 years 2006–2008, there were 11 applications, 10 of which were successful (Table 4). Upon return, grantees must make a presentation of their experience to their home institute including research outcomes and observations that could be incorporated into local practice. Grantees must submit a report to ESMO.

Table 4.

ESMO Palliative Care grantees for Observership or Research at a Designated Center

Year Grantee From Host Designated Center 
2006 Gazealeh Sh. Razavi Teheran, Iran Ospedale San SalvatoredEPT Medical Oncology, l'Aquila, Italy 
2006 Valeria Pesceddu Cagliari, Italy Velindre Cancer Center, Cardiff, Wales 
2007 Jan Wierecky Hamburg, Germany Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen 
2007 Shamsudeen Moideen Calicut, India Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen 
2007 Tamari Rukhadze Tbilisi, Georgia Shaare Zedek Medical Center, Jerusalem, Israel 
2008 Gabriella Morar-Bolba Cluj-Napoca, Romania Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona 
2008 Dana-Oana Donea Bucharest, Rumania Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona 
2008 Alexandu Grigorescu Bucharest, Romania Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen 
2008 Ioseb Abesadze Tbilisi, Georgia Institut Catala d'Oncologia, Hospitalet, Barcelona 
2008 Gadrun Pohl Vienna, Austria Velindre Cancer Center, Cardiff, Wales 
Year Grantee From Host Designated Center 
2006 Gazealeh Sh. Razavi Teheran, Iran Ospedale San SalvatoredEPT Medical Oncology, l'Aquila, Italy 
2006 Valeria Pesceddu Cagliari, Italy Velindre Cancer Center, Cardiff, Wales 
2007 Jan Wierecky Hamburg, Germany Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen 
2007 Shamsudeen Moideen Calicut, India Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen 
2007 Tamari Rukhadze Tbilisi, Georgia Shaare Zedek Medical Center, Jerusalem, Israel 
2008 Gabriella Morar-Bolba Cluj-Napoca, Romania Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona 
2008 Dana-Oana Donea Bucharest, Rumania Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona 
2008 Alexandu Grigorescu Bucharest, Romania Kantonsspital St Gallen, Department of Internal Medicine; Oncology/Hematology, St Gallen 
2008 Ioseb Abesadze Tbilisi, Georgia Institut Catala d'Oncologia, Hospitalet, Barcelona 
2008 Gadrun Pohl Vienna, Austria Velindre Cancer Center, Cardiff, Wales 

meeting of the DCs, June 2008

ESMO organized a meeting of the DCs in Lugano in June 2008 which was attended by representatives from 21 of the 27 DCs at that time. Each center presented a summary of their activities, projects, research interest and special programs. Challenges to integration were discussed including problems related to communication between oncology and palliative medicine clinicians, differing cultures of care between oncology and palliative medicine and issues related to timing of referral of patients for palliative care interventions. The meeting provided a rich opportunities for cross-fertilization of ideas, innovations, research plans and educational initiatives.

revision of the accreditation criteria

The DC Program has continually been under review by both the PCWG and the national representatives. Both groups expressed concern regarding difficulty in describing how centers meet each of the 13 criteria for accreditation. In 2007, the PCWG began a process to review the accreditation criteria and the manner in which submissions are made. Suggestions for amendments were solicited from the members of the PCWG in early 2008. They were edited, drafted and presented for critical discussion at the meeting of all the designed centers in June 2008. The criteria have been amended (Table 5) to better reflect the issues of integration (items 1 and 2), credentialing (items 3 and 4), service provision (items 5–11), research (item 12) and education (item 13). Furthermore, guidelines for describing each of the criteria are presented to help structure the applications and facilitate evaluation. These new criteria will apply from 2009.

Table 5.

Amended criteria for Designated Center accreditation with structured guidelines for criteria narratives

1. The center is a cancer center or oncology department which provides closely integrated oncology and palliative care clinical services 
    1.1. Please describe the oncology department or cancer center 
    1.2. Describe how oncologists and palliative medicine services interact 
    1.3. When complex needs are identified, describe how the oncologists and palliative medicine services share responsibilities for patient care 
    1.4. Describe the availability of oncological care and evaluation for palliative care patients 
2. The center is committed to a philosophy of continuity of care and nonabandonment 
    2.1. Please present an overview describing how the center provides continuity of care including, but not limited to, patients who are no longer benefiting of antitumor interventions 
3. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 
    3.1. Please provide details about the medical and nursing clinicians involved in the program including their professional training and credentials in palliative care 
4. The center incorporates expert care in the evaluation and relief of psychological and existential distress 
    4.1. Please provide details about the clinicians involved in psychooncologic care including their professional training and credentials in palliative care 
    4.2. Please provide details about the staff involved in chaplaincy, pastoral care or spiritual care including their professional training and credentials in palliative care 
5. The center provides routine patient assessment of physical and psychological symptoms and social support and has an infrastructure that responds with appropriate interventions in a timely manner 
    5.1. Describe how physical and psychological symptoms of patients with advanced cancer are evaluated in outpatient and inpatient settings 
        5.1.1. Describe how severity of symptoms is recorded 
        5.1.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 
    5.2. Describe how psychosocial problems or inadequate of patients with advanced cancer are evaluated in outpatient and inpatient settings 
        5.2.1. Describe how these problems are recorded 
        5.2.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 
6. The center provides emergency care of inadequately relieved physical and psychological symptoms 
    6.1. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems during office hours 
    6.2. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems outside office hours 
7. The center provides facilities and expert care for inpatient symptom stabilization 
    7.1. Describe the criteria for admission for inpatient care of patients with poorly controlled symptoms in need of symptom stabilization 
    7.2. Describe where they are physically cared for (oncology ward, medical ward, palliative care ward) 
    7.3. Describe who manages the care of patients needing symptom stabilization 
    7.4. Describe how these aspects of care are monitored with ward rounds, case conferences, etc. 
8. The center incorporates programmatic support of family members 
    8.1. Describe how the needs of the family members of patients with advanced cancer are routinely evaluated and managed 
    8.2. Describe the psychological and social supports to available to family members 
9. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 
    9.1. Describe the availability of home care services and the expertise of the care providers 
    9.2. In the case that care is delivered by other community services 
        9.2.1. Describe the services and their credentials 
        9.2.2. Describe the ongoing relationship to those services in the care of your patients 
10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 
    10.1. Please describe the centers approach in situations when the patient and/or family request admission because either the patient is unable to cope at home or in situations of severe family fatigue 
11. The center provides facilities and expert care for inpatient end-of-life (terminal) care and is committed to providing adequate relief of suffering for dying patients 
    11.1. Describe the management approach to dying patients who are unable to manage at home 
    11.2. When inpatients are dying, describe how adequacy of comfort is monitored and documented 
    11.3. Describe the management approach to refractory symptoms at the end of life 
    11.4. Describe the supports offered to comfort the patient and family 
12. The center participates in basic or clinical research related to palliative care and the quality of life of cancer patients and their families 
    12.1. Please describe, open studies, completed studies and list all publications and presentation 
        12.1.1. Research may be related to physical, psychological or social aspects of patient care 
        12.1.2. Research may be related to quality assurance or improvement including models of care delivery 
        12.1.3. Please note that quality-of-life evaluation as part of routine oncological studies ‘does not’ constitute palliative care research for purposes of recognition 
13. The center is involved in clinician education to improve the Integration of Oncology and Palliative Care 
    13.1. Please describe palliative cancer care teaching activities to: 
        13.1.1. Medical and nursing students 
        13.1.2. House staff 
        13.1.3. Oncology trainees 
        13.1.4. Others 
    13.2. Please describe any teaching publications 
    13.3. Pleases describe any conferences or symposia (past and planned) 
    13.4. Please describe any other teaching activities 
1. The center is a cancer center or oncology department which provides closely integrated oncology and palliative care clinical services 
    1.1. Please describe the oncology department or cancer center 
    1.2. Describe how oncologists and palliative medicine services interact 
    1.3. When complex needs are identified, describe how the oncologists and palliative medicine services share responsibilities for patient care 
    1.4. Describe the availability of oncological care and evaluation for palliative care patients 
2. The center is committed to a philosophy of continuity of care and nonabandonment 
    2.1. Please present an overview describing how the center provides continuity of care including, but not limited to, patients who are no longer benefiting of antitumor interventions 
3. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 
    3.1. Please provide details about the medical and nursing clinicians involved in the program including their professional training and credentials in palliative care 
4. The center incorporates expert care in the evaluation and relief of psychological and existential distress 
    4.1. Please provide details about the clinicians involved in psychooncologic care including their professional training and credentials in palliative care 
    4.2. Please provide details about the staff involved in chaplaincy, pastoral care or spiritual care including their professional training and credentials in palliative care 
5. The center provides routine patient assessment of physical and psychological symptoms and social support and has an infrastructure that responds with appropriate interventions in a timely manner 
    5.1. Describe how physical and psychological symptoms of patients with advanced cancer are evaluated in outpatient and inpatient settings 
        5.1.1. Describe how severity of symptoms is recorded 
        5.1.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 
    5.2. Describe how psychosocial problems or inadequate of patients with advanced cancer are evaluated in outpatient and inpatient settings 
        5.2.1. Describe how these problems are recorded 
        5.2.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 
6. The center provides emergency care of inadequately relieved physical and psychological symptoms 
    6.1. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems during office hours 
    6.2. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems outside office hours 
7. The center provides facilities and expert care for inpatient symptom stabilization 
    7.1. Describe the criteria for admission for inpatient care of patients with poorly controlled symptoms in need of symptom stabilization 
    7.2. Describe where they are physically cared for (oncology ward, medical ward, palliative care ward) 
    7.3. Describe who manages the care of patients needing symptom stabilization 
    7.4. Describe how these aspects of care are monitored with ward rounds, case conferences, etc. 
8. The center incorporates programmatic support of family members 
    8.1. Describe how the needs of the family members of patients with advanced cancer are routinely evaluated and managed 
    8.2. Describe the psychological and social supports to available to family members 
9. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 
    9.1. Describe the availability of home care services and the expertise of the care providers 
    9.2. In the case that care is delivered by other community services 
        9.2.1. Describe the services and their credentials 
        9.2.2. Describe the ongoing relationship to those services in the care of your patients 
10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 
    10.1. Please describe the centers approach in situations when the patient and/or family request admission because either the patient is unable to cope at home or in situations of severe family fatigue 
11. The center provides facilities and expert care for inpatient end-of-life (terminal) care and is committed to providing adequate relief of suffering for dying patients 
    11.1. Describe the management approach to dying patients who are unable to manage at home 
    11.2. When inpatients are dying, describe how adequacy of comfort is monitored and documented 
    11.3. Describe the management approach to refractory symptoms at the end of life 
    11.4. Describe the supports offered to comfort the patient and family 
12. The center participates in basic or clinical research related to palliative care and the quality of life of cancer patients and their families 
    12.1. Please describe, open studies, completed studies and list all publications and presentation 
        12.1.1. Research may be related to physical, psychological or social aspects of patient care 
        12.1.2. Research may be related to quality assurance or improvement including models of care delivery 
        12.1.3. Please note that quality-of-life evaluation as part of routine oncological studies ‘does not’ constitute palliative care research for purposes of recognition 
13. The center is involved in clinician education to improve the Integration of Oncology and Palliative Care 
    13.1. Please describe palliative cancer care teaching activities to: 
        13.1.1. Medical and nursing students 
        13.1.2. House staff 
        13.1.3. Oncology trainees 
        13.1.4. Others 
    13.2. Please describe any teaching publications 
    13.3. Pleases describe any conferences or symposia (past and planned) 
    13.4. Please describe any other teaching activities 

discussion

The ESMO initiatives to improve the Integration of Oncology and Palliative Care have achieved wide recognition as a major public health undertaking that endeavors to change the culture and logistics of care. The program has received heavy endorsement form allied organizations including the International Association for Hospice and Palliative Care, the Open Society Institute, the European Association for Palliative Care and the Multinational Association for Supportive Care in Cancer, all of whom have featured the ESMO initiative prominently in their meetings and in their communications. ESMO's efforts are now being emulated in North America by the American Society of Clinical Oncology [27].

The DC project is one of the more prominent elements of the ESMO initiative. In the world of oncology, it has sought to set a new standard for service development and delivery of integrated oncology and palliative care; a standard that is high enough to be worthy of special recognition, but not so high as to be beyond the reach of most centers.

There are several characteristics of the DC Program that deserve emphasis:

  • 1 Creating incentives: The DC initiative aims to improve the relative advantage of adopting high-quality palliative care by giving it status. In doing so, ESMO is trying to influence the culture of oncology to emphasize the commonality of purpose and goals between good cancer care and good supportive care and that they are an irreducible unity.

  • 2 Education with structure: Through the DC Program, ESMO has tried to reduce perceived complexity of developing integrated palliative care services by providing concrete guidelines and achievable targets and through the identification of hospitals and services that can serve as models and mentors for the development of new programs.

  • 3 Importance irrespective of scope: The recognition awarded is not dependent in the size of the institute or the number of patients treated. Both large cancer centers and relatively small oncology departments can be accredited as long as they clearly demonstrate that oncology and palliative care are well integrated as evidenced by meeting accreditation criteria.

  • 4 Quality of integration does not have implications for other aspects of care: Accreditation as a DC does not involve or imply any statement about the quality of oncological antitumor care. Standards of antitumor care are not evaluated in this process and accreditation does not imply that the center offers the best of cancer care. It implies only that oncological and palliative care are well integrated and that this itself is worthy of special recognition since is such an important aspect of cancer care delivery.

The DC Program has not been without its critics. Issues of concern have included perceived difficulty in describing how centers meet each of the accreditation criteria, the underrepresentation of major centers among those that have achieved accreditation and the validity of the accreditation process. The PCWG have attempted to address each of these concerns.

The PCWG acknowledged the difficulties in addressing the narrative requirement of the application process and have revised the accreditation process accordingly. The revised criteria are clearer and the application process more structured with the incorporation of directive subpoints to be addressed in the application narratives. Well-recognized major cancer centers have less marginal benefit in prestige accrued from accreditation as a DC in the Integration of Oncology and Palliative Care and this may be one of the reasons for the predominance of smaller centers to date. This situation appears to change, and the 2008 cohort of successful candidacies included Institute Jules Bordet in Belgium and Institute de Cancerologie Gustave Roussy in France. We believe that the participation of major centers is important; it enhances the role modeling effect of the initiative and emphasizes their leadership in clinical and service development. We anticipate the participation of other major centers in 2009. Although there have been few successful applications from centers in the Former Soviet Union or from developing countries, those that have been successful are particularly notable. The PCWG have received many expressions of interest from centers in these regions and we are aware of programs using the criteria as a model for ongoing program development.

The PCWG and the ESMO Executives considered the introduction of validation site visits. After weighing the matter, the ESMO Executives felt the organization should not undertake auditing responsibility. Given that the aim of the project was to reward threshold achievements rather than excellence, it was agreed that the current system of blinded evaluation of applications by multiple independent reviewers is sufficiently valid for this purpose. This process relies on the integrity of the program directors and medical directors who attest, by their signature, to the accuracy of the submitted description of each of the required criteria in the application process.

In 2008, the PCWG undertook a series of site visits to document the work being done at the DCs and to study the ways in which centers had developed successful integrative programs. Visits were undertaken by members of the PCWG and representatives of the ESMO education office. Centers were asked to deliver a verbal presentation of the care facility, the department structure including a description of the healthcare team members and the activities which fulfill the current ESMO requirements for accreditation in integrated oncology and palliative care. This was followed by a guided visit of the facilities, highlighting how the facility functions and meets the ESMO criteria and an interdisciplinary team discussion. The information gleaned from these visits supported the validity of the accreditation process. The centers all lived up to the expectations generated by their submissions for candidacy. These visits rendered useful information for purposes of modeling different ways to integrate oncology and palliative care services. Furthermore, the centers were offered constructive suggestions for program development in a formal report by the visiting representatives and this feedback was appreciated. Reports on these visits are available through the ESMO Web site.

Addressing these intrinsic factors, the ESMO’s initiative aims to improve the relative advantage of adopting high-quality palliative care by giving it a status and creating incentives. ESMO is trying to influence the culture of oncology to emphasize the commonality of purpose and goals between good cancer care and good supportive care and by emphasizing that they are an irreducible unity. Through its DC Program, ESMO has tried to reduce perceived complexity of developing integrated palliative care services by providing concrete guidelines and achievable targets and through the identification of hospitals and services that can serve as models and mentors for the development of new programs.

Conclusions

The accreditation of DCs in the Integration of Oncology and Palliative Care has been a key element in the ESMO initiative to improve the palliative care provided by oncologists and oncology centers. The DC initiative emphasized the priority of this endeavor. The 48 centers that have achieved accreditation serve as a valuable nucleus for education and role modeling. The modifications made to the program will improve the application and evaluation processes. It is likely that many other oncology departments and cancer centers already meet the criteria, and ESMO strongly encourages them to apply for accreditation. Furthermore, to improve quality of cancer care, ESMO urges oncology units and cancer centers which do not yet meet these standards, to develop programs in order to meet these pragmatic and clinically significant benchmarks and thus further improve cancer care in Europe and beyond.

The authors wish to acknowledge colleagues the ESMO National Representatives who supported this initiative, the members of the PCWG who have helped to develop and maintain this program and Reto Guelli, Doris Vola and Svetlana Jezdic of the ESMO office and the ESMO executive who continue to provide encouragement and support to this initiative.

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