Optimal Care Pathways Implementation

Optimal Cancer Care Pathways aim to improve patient outcomes by facilitating consistent, safe, high quality and evidence-based care.  They can be used by health services and professionals as a tool to identify gaps in current cancer services and inform quality improvement initiatives across all aspects of the care pathway.

To date we have done OCP implementation work in:

Aboriginal and Torres Strait Islander Project:

A co-planned, co-designed and co-delivered approach to identify barriers and develop strategies to improve the quality of cancer services for Aboriginal and Torres Strait Islander people with cancer in southern Melbourne.  Development of an educational program for cancer services and Aboriginal health workers to support the workforce to deliver culturally competent cancer services.

Project Lead: Jenny Thresher

Pancreatic Resectability Project:

SMICS in partnership with North Eastern Melbourne Integrated Cancer Service (NEMICS) engaged key stakeholders to adopt the ‘International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017.’ A newly developed synoptic report is currently being piloted by MDTs at Alfred and Austin Health.

Project Lead: Anna Maciejewska

Brain Project:

Based on the recommendations from the Victorian Brain Tumour Summit, areas of investigation for SMICS include:

  • improving coordination of care between metro/regional services for patients repatriated for post-surgery treatment and care. SMICS is working with Gippsland ICS to explore referral pathways.

  • access to early palliative care planning.

Project Lead: Anna Maciejewska & Tracey Bucki

Patient Information Brochure for Bowel Surgery Preparation:

An easy English patient information brochure has been developed and translated into six additional languages to support the introduction of the Monash Health Enhanced Recovery After Surgery (ERAS) Colorectal Pathway at Dandenong Hospital. The resource will provide surgical preparation information to approximately 190 patients treated for bowel cancer per year.

Project Lead: Tracey Bucki

Prostate Project:

In alignment with the principles of the Optimal care pathway for men with prostate cancer, SMICS is exploring access for patients to appropriate information and support at diagnosis; identifying and addressing supportive care needs of men with prostate cancer and reducing variations in access to MDM meetings. 

Project Lead: Tracey Bucki & Anna Maciejewska

Improving Equity
MDM Quality: QOOL VIC Implementation at Peninsula Health:


SMICS has assisted Peninsula Health in implementing the Queensland Oncology On-Line-Victoria (QOOL-VIC) application for all oncology multi-disciplinary meetings.


QOOL-VIC assists meeting preparation, and documentation and communication of essential clinical information such as diagnosis, cancer stage and recommended treatment plans.

Project Lead:

Anna Maciejewska & Jenny Thresher

MDM Quality: Establishment of MDM Governance Group:

MDM Governance structures are being established and supported at Monash Health, Peninsula Health, and Alfred Health to monitor and improve MDM quality.

Project Lead:

Geraldine Largey (Monash Health)

Anna Maciejewska (Peninsula Health)

Jenny Thresher (Alfred Health)

Wellbeing & Support
Supportive Care: Living with Cancer Education Program (Mandarin):

Cancer Council Victoria, Monash Health and SMICS collaborated to adapt the Living with Cancer Education Program (LWCEP) to encompass Chinese culture and the Mandarin language. Interpreters from Monash Health and consumers assisted and informed the development of the Mandarin LWCEP. Delivery of the program is on hold until COVID restrictions allow.

Project Lead: Linda Marshall (Monash Health)

Supportive Care Refresh Project:

The aim of the Supportive Care Refresh project is to ensure people affected by cancer have equitable access to timely and appropriate supportive care throughout the care pathway by supporting health services to: build workforce capacity to identify and address supportive care needs; integrate supportive care screening, assessment and referral into routine practice; strengthen referral pathways and linkages to services; and assist people to self-manage supportive care needs using the WeCan.org.au resources.

Project Lead: Jessica Delaney

Advance Care Planning at Alfred Health and Peninsula Health:

SMICS is supporting the development and pilot of evidenced based E health interventions to support patients and their medical oncologists, radiation oncologists and haematologists initiate more timely discussion and documentation of patients advanced care planning preferences.

Project Lead: Geraldine Largey

Palliative Care Project at Monash Health:

The Monash Health Palliative Care Unit has established a virtual clinic to provide palliative care support to oncology outpatients and clinicians. Timed to coincide with outpatient clinics for tumour streams which would benefit from greater palliative care engagement, the clinic aims to offer consultations at the time of, or within one week of the outpatient appointment.

Project Lead: Geraldine Largey

Monash Health Virtual Nurse-led Clinic:

A dedicated, patient centred, Telehealth Cancer Support Nurse Review Clinic (TCSN-RC) has been established at Monash Health to support patients who experience symptoms from their cancer or cancer therapy.

Project Lead: Geraldine Largey

SMICS Funding Program

The SMICS funding program provides time limited funding for projects that support improvements in cancer patient care.  The focus areas of the program align with the statewide priorities of the Victorian Integrated Cancer Services and the Victorian Cancer Plan.

Quality and Service Improvement


     Applications are now closed

Health organisations have submitted expressions of interest for funding up to $100,000 for innovative quality and service improvement projects.


Submissions are currently being reviewed.

Project Lead: Nell Sproule

Service or Process Redesign


     Applications are now closed


Health organisations interested in undertaking service and/or process redesign submitted expressions of interest for up to $30,000 per project.

Submissions are currently being reviewed.

Project Lead: Nell Sproule

Symptom Urgent Review Clinics

A number of Symptom Urgent Review Clinics (SURCs) have been implemented across Victoria to support patients experiencing systemic anti-cancer therapy (SACT) side effects.

In 2020, SMICS provided over $300,000 in grant funding to establish SURCs at Alfred Health, Peninsula Health and Cabrini Health.

Project Lead: Nell Sproule

Workforce Development
Metastatic Breast Care Nurse Project:

Together with Monash Health, Monash University and the McGrath Foundation, SMICS is working to develop an online training package and clinical placement program at Monash Health for nurses to develop the knowledge and skills to provide high quality care to patients with metastatic breast cancer.  Up to 30 nurses will be upskilled over a four year period, with the first clinical placement scheduled for November - December 2020.

Project Lead: Jessica Delaney

Cancer Nurse Coordinator Community of Practice:


Following identification of the professional and supportive needs of Monash Health cancer nurse coordinators, a community of practice was developed and implemented incorporating an education and well-being program. The impact of participation on stress, burnout, resilience, job satisfaction and mindfulness was measured and documented via an evidenced based research methodology.

Project Lead: Jenny Thresher

COVID-19 Response
Telehealth Support:

To reduce the risk of exposing vulnerable patients and healthcare workers to COVID-19, SMICS supported oncology outpatient clinics to implement a telehealth service delivery model using the Health Direct platform. The level and type of support varied between health services, but included process mapping, documenting procedures, developing scripts to support telehealth bookings, rescheduling appointments and helping patients who required additional support accessing telehealth services. Rapid uptake of telehealth ensured continuity of care for people affected by cancer throughout the pandemic.

Project Lead:

Jessica Delaney (Monash & Alfred Health)

Jenny Thresher (Peninsula & Alfred Health)


VCCN COVID- 19 Cancer Network Support:

SMICS staff provide significant program management support to the Victorian COVID-19 Cancer Network (VCCN) Taskforce and expert working groups.

The VCCN was established in March 2020 by the VCCC alliance and Monash Partners Comprehensive Cancer Consortium (MPCCC) in response to the challenges involved with managing cancer care amid the COVID-19 global health crisis. It aims to provide support and advice to clinicians and health care services treating patients with cancer during the COVID-19 pandemic.


The Victorian Integrated Cancer Services are supported by the Victorian Government 

© 2022 Southern Melbourne Integrated Cancer Service

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The Victorian Government acknowledges Aboriginal and Torres Strait Islander people as the Traditional Custodians of the land and acknowledges and pays respect to their Elders, past, present and emerging.

We are committed to safe and inclusive work places, policies and services for people of LGBTIQ+ communities and their families.