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Table 2 Facilitators to Optimal MCC Decision Making

From: Use of the theoretical domains framework and behaviour change wheel to develop a novel intervention to improve the quality of multidisciplinary cancer conference decision-making

TDF DOMAINTHEMESQUOTES
KnowledgeMCC provide opportunities for learning (from colleagues, other specialists, resident learning)“We learn way more in MCC than anything else now” – P14
“You learn things from the MCC, right, a trial might come up that you weren’t aware of, or a new drug approval might come that you didn’t know about, and you get that education at the tumour boards” – P1
 MCC allow for standardization of decision making and treatment plans“You get to stay up with what the rest of your colleagues are thinking, and we get some kind of standardization around treatment” –P4
SkillsAttending MCC allows specialists to better collaborate with their colleagues/ understand what others need“From my perspective as a pathologist, I have learned a lot over the years about what is relevant and what is not … what are the major parameters that radiation oncologists, medical oncologists or the surgeons look for in guiding their management” – P15
“I love getting to see how my other colleagues think, we don’t get an opportunity to do that outside of MCC, because right, it’s not like I go to my colleagues’ clinics, so right, it’s good to know how other people are thinking” –P1
Social InfluencesThe ability to work cohesively as a group positively impacts decision making and teamworking“You have to be able to practice as a group and to value people’s opinion” – P3
“Culture eats strategy for breakfast … in a big group inter-personal relationships are diluted but in a smaller group, inter-personal relationships are very important. And so all of that will probably overshadow any process [of decision making]” – P7
 MCC facilitate collegiality“There’s coffee and muffins there...and there’s, every one of the surgeons, they like to come and talk about their cases, like I think it’s a very positive social culture” – P10
Social/Professional Role and IdentityMany MCC participants feel a personal responsibility to discuss cases, beyond the scope of CCO instruction (e.g., use of email to circumvent time restraints)“I get emails all the time. They’ll email like ten experts...and we all weigh in on how we might look at a case” –P2
“Email is also quite good because for a lot of non-urgent things you can just send an email and get responded to later down the line” – P11
Beliefs about capabilitiesParticipation in MCC doesn’t limit physician autonomy to make decisions“I don’t think [autonomy is affected], because at the end of the day, we’re making recommendations, and it’s not like they have to follow through with them if they are uncomfortable or if they don’t agree” – P2
“I don’t feel that my autonomy has been taken away from me, because I probably would have been thinking about the problem differently” –P7
GoalsMCC groups have set goals to improve efficiency and ensure comprehensive discussion of cases
- Rotate attending specialists
- Set limits on number of cases to be discussed
- Triage cases based on urgency
MCC goals dictate what MCC participants define as an ‘optimal MCC’
“We rotate, so we send a medical oncologist to [rounds] every week” – P2
“We try to time the discussion as well with patient’s treatment urgency, kind of, sense of urgency, we triage the cases” – P3
IntentionsMotivation to discuss cases due to:
- Patient requests
- Intrinsic motivation
- Facilitating quality improvement
“There are people who bring cases to tumor board when they tell the patient up front we will discuss you at tumor board and then we will come up with a recommendation” – P12
“For the support and care of my patients. I’ve always gone [to MCC], I’ve been doing these for almost 20 years” – P9
OptimismGeneral positive attitudes towards MCC“They’re [MCC] absolutely vital. I can’t imagine having a centre where you were having any area where there’s multidisciplinary care of patients where you’re not getting together to discuss the difficult cases” – P14
Beliefs About ConsequencesPositive consequences of MCC decisions:
- streamlines decision making for complex cases
- saves patients from unnecessary consults/ results in more efficient care
- improves quality care
[If someone says] “well, actually they should probably see this specialist,” and then they [patient] wait for a consult to see that specialist, I mean that’s avoided, the waiting from one doctor to another, so I think that’s its primary benefit, is that you can narrow down what to do fairly quickly and were the patient should go next “– P16
ReinforcementCCO ability to withdraw funding is a major driver in bringing patients forward for MCC discussion“There’s a [CCO] score card, and one of them has to do with, um, participation in MCC, so, you know … you had to have five [MCCs] per quarter … there’s also pressure from the organization to make sure that the organization gets credit, because if they don’t, then there are funding implications” – P4
“CCO will say, ‘you did twenty radical prostatectomies last quarter, only four of those patients saw a radiation oncologist, can you explain why?’ And with the subtle hint that eventually, they’ll start to withdraw funding if the patient’s aren’t seen” –P14
“We have to meet this metric otherwise Cancer Care Ontario will take our money away” – P16
 Personal Incentives:
- Billing for MCC
- Obtaining continuing medical education credits
“I think people like going to rounds, I think it’s an enjoyable experience generally, I can’t see the financial being the driving force but I mean well you have that for sure” –P11