Over the last few decades, the landscape of hepatocellular carcinoma management and treatment has witnessed a rise in both case numbers and therapeutic complexity, with projections indicating a continued increase. In Italy, estimates suggest that new cases and deaths from HCC will rise by more than 55% by 2040 [2]. Moreover, the evolving HCC scenario and the expansion of therapeutic options across various stages of the disease indicate that HCC is in a state of constant change [4, 5, 25].

HCC primarily arises in cirrhotic livers [26], where progressive hepatic deterioration significantly impacts outcomes, irrespective of tumor burden. The liver functional status plays a central role in therapeutic decisions [14], influencing both curative and palliative treatments [9, 27]. Notably, liver decompensation is a leading cause of mortality in both early-stage HCC [28] and advanced disease treated with systemic agents [29, 30].

All these conditions emphasize the complex nature of HCC, which is fundamentally characterized by the intricate interplay between tumor progression and underlying liver disease. This dual pathological process creates a unique clinical scenario where therapeutic decisions must carefully balance oncological effectiveness with liver function preservation. The complexity is further magnified by the expanding therapeutic arsenal now available, encompassing surgical, locoregional, and systemic treatment options. This multilayered clinical landscape makes the multidisciplinary approach particularly crucial in HCC management, arguably more so than in other oncological settings, where the underlying organ function may be less critical in treatment selection and during follow-up. In this context, while guidelines offer clear indications for certain cases, many patients could benefit from multiple therapies, necessitating input from various specialties and making a multidisciplinary approach crucial and essential for optimal HCC management [31].

The Italian NHS is regionally decentralized, leading to varied organizational approaches in HCC management. In this context, it is important to acknowledge the organizational heterogeneity that characterizes HCC management across Italy. Hospitals differ in patient volumes, available resources, and the operating models of their multidisciplinary teams, ranging from the systematic discussion of all cases to a focus on only the most complex ones. Leadership of the pathway also varies, being assumed by hepatologists in several hospitals and by oncologists in others. Despite these differences, multidisciplinary care remains a central element, although its formalization and structuring are still heterogeneous and not always optimal across settings. The MDT Project fits within this complex landscape with the aim of establishing the foundations for a structured and scalable care model capable of supporting hospitals in the multidisciplinary and organizational management of HCC. The initiative represents a first step toward consolidating process standardization, strengthening hospitals’ organizational readiness, and creating favorable conditions for a more coherent and coordinated patient care pathway. In this regard, the project’s approach is consistent with literature highlighting the potential of external ICP certification to improve organizational quality and promote more uniform access to care [32, 33].

In this pilot phase, 13 Italian hospitals contributed to assessing the feasibility and applicability of the care model across settings characterized by heterogeneous structures, resources, volumes, and organizational maturity. These preliminary findings mainly describe organizational changes observed during the implementation of the care model and the ICPs, while clinical outcomes will require more time and will be addressed in future studies.

The application of the care model revealed progress particularly within the pillars related to clinical–organizational pathways and multidisciplinary areas in which targeted interventions tend to translate more rapidly into perceptible changes in daily practice. The alignment between these early improvements and the domains most directly addressed, such as the formalization of organizational flows, the definition of roles, and the coordination of decision-making moments, suggests that the tools introduced contributed to greater operational clarity and the adoption of more standardized practices. These aspects are typically the first to respond to the introduction of a shared organizational care model, as they require mainly internal adjustments that are more easily integrated into routine clinical activity compared with more structural changes, such as those related to information systems or systematic KPI monitoring. Among the interventions implemented through the action plans, the revision of admission processes was one of the most evident elements: the formalization of intake workflows, the introduction of reserved slots for specific phases of the pathway, and the reorganization of dedicated outpatient clinics contributed, where implemented, to a smoother management of the diagnostic–therapeutic process. In several hospitals, clinicians reported that, where implemented, these interventions appeared to support a smoother management of the care pathway, with a perceived reduction in waiting times for certain procedures and improved adherence to treatment timelines, a factor recognized as critical for optimizing HCC care [34]. Key facilitators included the active involvement of hospital management and quality offices, whose engagement in the project enabled the refinement of several activities proposed in the action plans for individual hospitals. Conversely, the most significant barriers concerned the limited availability of dedicated personnel, the high clinical workload, and the challenges associated with reallocating resources within complex healthcare structures, where coherence with multiple clinical–organizational governance needs must be ensured. The formalization of multidisciplinary team activities, including team composition, roles and responsibilities, meeting frequency, advance case preparation, shared evaluation criteria, and standardized post-meeting documentation, was considered particularly useful for improving decision-making consistency and communication among specialists. These elements are consistent with international literature, which highlights the importance of solid organizational structures to support multidisciplinary team governance [12,13,14, 35, 36]. In particular, Abuelgasim et al. emphasize the value of institutionalizing multidisciplinary teams at the corporate level, with regular meetings, standardized processes, and early sharing of clinical information [37]. In this regard, several clinicians reported, on the basis of information gathered from the newly introduced standardized post-multidisciplinary meeting documentation, a greater participation of core-team members and a more frequent discussion of newly diagnosed cases, which were interpreted as early signals of a more systematic and shared use of the collegial decision-making setting.

At the same time, it is important to acknowledge the intrinsic complexities of multidisciplinary work. As observed by Colli and Prati, even in highly structured contexts, group work may be influenced by dynamics such as conformity to dominant opinions or decision-making polarization, which can limit critical thinking and sometimes cause treatment delays owing to divergent viewpoints [38]. These reflections offer useful insight into why tools such as shared protocols, standardized case-presentation formats, and periodic audits represent essential components to support transparent and robust decision-making processes. In this sense, the interventions introduced by the project, including the development and certification of ICPs, shared case-discussion criteria, structured documentation of multidisciplinary team discussions, and the strengthening of audit activities, including proactive internal clinical audits of medical records for ex-post case evaluation, may help mitigate these risks, supporting a more consistent functioning of multidisciplinary teams over time.

In the hospitals where a case manager was introduced, the role provided support for operational coordination. Clinicians perceived the case manager as a facilitator, particularly in activities related to multidisciplinary meetings and in ensuring continuity across the different phases of the care pathway. This is consistent with the content of the action plans provided to hospitals, which in the initial phase were primarily oriented toward care pathway governance and support to the multidisciplinary team, rather than towards activities directly involving patients. Among the main facilitators, clinical teams highlighted the role of hospital management, which acknowledged the value of this function and enabled its implementation; conversely, the primary barriers included the need for dedicated personnel, the availability of specific training pathways, and the economic sustainability associated with introducing or reallocating staff. According to the survey findings, professionals also reported that the introduction of the case manager may have generated positive effects on patient-related aspects, as perceived by clinicians, although a direct evaluation from patients is not yet available. This perception is supported by the international literature, including the meta-analysis by Ahmed et al. (2024) [39], which demonstrates that multidisciplinary models with structured nurse-coordinated interventions result in tangible clinical benefits, including a significant reduction in all-cause mortality and hospitalizations. These findings suggest that organizational interventions may, over time, translate into measurable improvements in clinical outcomes and patient experience. However, such potential effects require confirmation through future studies specifically designed to capture patient-reported outcomes.

In contrast with the progress observed for more organizational aspects, advancements related to information systems were more limited, as reflected in the absence of statistical significance for the clinical and healthcare support systems and collaboration tools elements (p = 0.096 and p = 0.250, respectively). These areas require structural interventions and longer implementation horizons, often incompatible with the timeframe of projects of this type. Major barriers include the extended timelines needed to implement or update digital solutions, the complexity of harmonizing heterogeneous information systems, and the dependence on strategic decisions at institutional or national level. Similarly, challenges also emerged in the area of KPIs. As reported by healthcare professionals and already highlighted in prior studies on pathway governance and quality monitoring, there is still variability in the recognition of the importance of systematic data collection for effective process control [32, 37, 40], and clinicians often lack both adequate digital tools and dedicated personnel to support monitoring activities. Moreover, because KPI definition and monitoring are required for both the certification and maintenance of the ICP, these activities generate an additional workload for clinicians, particularly in settings where digital infrastructures do not adequately support such functions. It is therefore plausible that substantial improvements in this area will require planned medium- to long-term investments and strengthened technical capacities.

Within this framework, the development and certification of the ICP represented, for most hospitals, an important element in consolidating the care pathway. Internal and external audits, already recognized in the oncological literature as effective tools to monitor adherence to guidelines and improve care pathway quality [32, 41], were perceived as relevant educational opportunities. According to clinicians, these audits contributed to increasing awareness of clinical documentation, standardizing procedures, and enhancing overall consistency in care processes. The presence of clear reference standards and external validation, such as that provided through BV certification, was appreciated as it fostered the adoption of more uniform practices and reinforced organizational accountability. Moreover, since ICPs are formally approved by hospital management, they acquire the status of institutional policies, which can facilitate greater adherence among the professionals involved. The early engagement of administrative and quality offices strengthened their competencies and visibility, creating the conditions for these teams to autonomously update the ICPs or conduct internal audits in the future. Finally, the action plans developed within the project provide a structured framework that can support organizational improvements beyond the implementation period.

Finally, the limited improvement observed in the “integration of territorial care settings” element may reflect the broader policy context in which the project was conducted. Ministerial Decree 77, issued in 2022, introduced a national framework for the reorganization of territorial and community‑based healthcare services, with implementation required by 2026. During the project period (2021–2024), hospitals were therefore operating in a transitional phase, still adapting to the Decree’s requirements, with limited operational guidance available on how to restructure referral pathways and integrate community care structures into existing clinical workflows. This context may partly explain the limited progress observed in this area. As implementation of the Decree progresses, conditions may become more favorable for strengthening coordination beyond the hospital setting and supporting full integration of the HCC pathway within regional care networks.

This study has several limitations that should be considered when interpreting the findings. The MDT project was primarily designed to optimize organizational models for hepatocellular carcinoma management through governance-oriented interventions and tools (action plans, organizational maturity assessment, and development/certification of ICPs). As a result, it focused on strengthening organizational processes and hospital readiness rather than directly measuring clinical outcomes. Owing to time constraints, the study did not include systematic collection of clinical, economic, or patient-reported outcomes (PROs), and no structured cost analysis was performed. This reflects an iso-resource optimization strategy within participating hospitals, with the sole exception of introducing a case manager role in selected contexts. Future research should incorporate pre–post evaluations that include clinical, economic, and patient experience outcomes to allow a more comprehensive assessment of impact. Additionally, participating hospitals joined the project on a voluntary basis, potentially representing institutions already more attentive to organizational improvement. This may limit the generalizability of the findings to contexts with lower baseline engagement in governance and process optimization.

The pre–post, single-arm design without a control group limits causal inference: observed changes cannot be attributed exclusively to the intervention and may reflect secular trends or other external factors. Evaluation relied on a maturity model providing structured qualitative assessment based on predefined criteria and progressive levels of development and an exploratory survey of healthcare professionals’ perceptions. While informative for organizational change, these instruments do not yield quantitative estimates of clinical or economic impact and are susceptible to perception and response biases. Finally, the project was funded by a pharmaceutical company, which represents a potential source of bias. Mitigating measures included independent operations of the IQVIA implementation science team with direct interactions with participating hospitals and the development of ICP clinical components exclusively according to nationally endorsed guidelines, ensuring alignment with institutional recommendations.