Core Services

Cancer care is complex and requires skilled and accountable leadership and management at all levels. Generally, hospitals with better management have better clinical outcomes, and good management practices help to preserve or enhance the quality of care (Carter, Dorgan, and Layton 2011). Useful frameworks exist to help guide the development and ongoing excellence of administration and management. For example, the United States–based Baldrige Performance Excellence Program focuses on performance excellence in leadership, strategic planning, customer focus, workforce focus, operations focus, results and measurement, and analysis and knowledge management (Baldrige Performance Excellence Program, National Institute of Standards and Technology, and U.S. Department of Commerce 2011); the program has a self-assessment tool.

Cancer centers require appropriately trained and licensed clinicians and administrative and support staff. Centers need to recruit and retain staff and provide professional and career development opportunities to maintain competence and develop new skills. Core human resource services include identifying the roles and responsibilities of the range of positions within the center, setting compensation and benefit levels, developing performance evaluations, setting up management and supervisory structures, and providing conflict resolution services.

Making the best use of human resources means maximizing their impact. Human resources can be increased in LMICs and remote areas by using nonspecialists or general medical professionals working under specific conditions. This practice promotes taskshifting and optimizes the use of sparse, highly skilled personnel. For example, the use of community health workers, expert patients, and clinical officers (Knaul, Bhadelia, and others 2012) and, in some countries, traditional healers who play an important role in influencing people’s health care decisions (Price and others 2012) will enhance the capacity for health care delivery. Teleservices, such as telepathology, teleradiology, and virtual consultation can offer support and guidance in
cancer to nonspecialists by tapping large international networks of highly trained professionals.

Information technology (IT) refers to systems and their applications, for example, computer hardware and software and telecommunications that collect, store, use, and share information. Information management refers to organizing, linking, analyzing, and presenting data to guide decisions.

In cancer centers, IT includes health records; operational systems, such as human resources, pharmacy, supplies, and equipment; financing; and other systems. IT also includes telemedicine and mobile information
and communication technologies, such as cell phones (mHealth), which improve access to services. Telemedicine initiatives have the potential to decrease disparities in cancer care between resource-poor and
resource-rich institutions by developing resources— human capital and telecommunication infrastructure—
that link institutions with different levels of funding and expertise (Hazin and Qaddoumi 2010).

Although IT requires funding for capital, training, ongoing maintenance, and technical backup, cancer centers need reliable electronic systems to manage the high volumes of information; inform safe, efficient, and effective care; and improve access. The systems can be especially important in LMICs for linking comprehensive centers to more remote areas and less specialized centers, as well as for linking to international expertise and networks (Knaul, Bhadelia, and others 2012; Shekelle, Morton, and Keeler 2006).

Pharmacy services focus on safe and effective medication use and include managing practice; adhering to policies
on medication use; optimizing medication therapy; procuring drug products and managing inventory; preparing, packaging, and labeling medications; delivering medications; monitoring medication use; evaluating the effectiveness of the medication-use system; and conducting research (American Society of Health-System
Pharmacists 2013).

Cancer pharmacy services reflect specialized knowledge about the medications used for cancer, management
of cancer complications, treatment side effects, and drug toxicities. The complexity of caring for patients with cancer; the costs of chemotherapy; the potential for severe drug toxicity and medication errors; and the requirements for safe preparation, administration, and disposal of cytotoxic drugs highlight the important role
of pharmacies in cancer centers, regardless of a country’s resource level (Wiernikowski 2013). The International Society of Oncology Pharmacy Practitioners has developed Standards of Oncology Pharmacy Practice that take into account realities from resource-rich and resourcepoor
settings.

Infection control is a core service that focuses on preventing and controlling infections in cancer patients,
including advice on the care of patients with infections, especially those acquired in the cancer center. 202 Cancer Main infection prevention and control tactics include complying with hand hygiene, disinfecting and sterilizing surfaces and equipment, investigating and monitoring suspected infections, managing difficult cases and outbreaks, wearing personal protective equipment, and vaccinating and educating health care providers. For centers, this includes introducing prevention bundles,9 improving compliance with hand hygiene, making prudent use of antimicrobials, translating research results into practice, and upgrading the capabilities of the microbiology laboratory (Raka 2010).

Cancer care has many potential risks. Complex clinical management using multiple treatment paths and multiple health care providers highlights the importance of a centerwide commitment to a quality and safety agenda and ongoing performance improvement.

Centers need to select appropriate indicators to monitor and assess the quality and effectiveness of their structures (for example, setting and facilities), processes (range of care), and outcomes (patients’ recovery,
restoration of function, and survival) (Donabedian 1966). Information systems should capture baseline performance measures for each indicator and track changes over time. Cancer centers should regularly monitor performance, identify problem areas, and focus improvement efforts in these areas.

All cancer centers need competent financial systems to monitor revenues and expenses. Sources of funding vary
widely and can include national and subnational government funding; private user payments, either through
health insurance or out of pocket; revenue-generating practices, for example, retail and parking; and philanthropic support from external donors. Available finances dictate the services that can be provided. Centers need systems that allow effective and efficient operations and ensure appropriate quality services to optimize the use of funds.

Additional key supports required in the cancer center include the following: equipment and technology support services, supplies and materials management, supply chain processes, patient transport, fire safety and radiation protection, occupational health and safety, and security. In areas of violence or conflict, security services may be especially important for patients and their families, as well as for guaranteeing the safety of health inputs and avoiding robbery. National and regional bodies generally set policies and standards for areas such as fire safety and radiation protection, occupational health and safety, and infection prevention and control. Organizations and providers usually determine how the other ancillary services will be provided, depending on local circumstances and resources.