Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Queensland's first public Mohs surgery service at Sunshine Coast Health delivers precise, tissue-sparing periocular skin cancer treatment with superior cure rates and optimised outcomes.
Dates: January 2026 - ongoing
Implementation sites: Caloundra Hospital, Sunshine Coast Hospital and Health Service
Partnerships: Caloundra Auxiliary
Aim
To launch Queensland's first public Mohs service at Sunshine Coast Health, Caloundra Health Service, to provide patients with superior, tissue-sparing periocular skin cancer treatment, delivering better cure rates, functional outcomes, and same-day care than traditional excision can.
Outcomes
- Successfully implemented Queensland's first public Mohs service at Caloundra Health Service, operational from February 2026.
- Published evidence shows Mohs achieves superior cure rates and reduced recurrence versus traditional excision.
- Published evidence demonstrates enhanced patient functional/cosmetic outcomes from tissue-sparing surgery and same-day reconstruction.
- Monthly lists optimise theatre efficiency, reducing waitlists and pathology burden through this innovative public service.
- Patient-level PREMs and PROMs data will be collected and collated, available for June Showcase from initial five lists.
Background
Queensland bears the world's highest skin cancer incidence, with non-melanoma skin cancers like cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (cBCC) affecting hundreds of thousands annually, driven by intense UV exposure and an ageing population (3-5). Periocular skin cancers pose unique challenges due to complex eyelid anatomy, where incomplete excision risks recurrence, orbital metastasis, disfigurement, and vision loss (1). Traditional wide local excision, the prior standard, removes predetermined healthy margins without real-time margin control, leading to higher recurrence rates (up to 10-15% for high-risk cases), excessive tissue loss, prolonged pathology waits, and fragmented care across excision and reconstruction phases (1,2,6,7).
These issues compound healthcare inefficiencies at Sunshine Coast Health, requiring high-risk periocular cases to be performed at the tertiary facility due to onsite pathology requirements for frozen section cases. This created theatre disruptions, extended oculoplastic waitlists, increased pathology burden, and patient burdens of multi-day processes, driving restrictions, and wound care risks. No public Mohs surgery service existed in Queensland, limiting equitable access to this gold-standard, tissue-sparing technique proven superior for local control (>99% cure rates for primary BCC) (8).
A recent study on the theoretical modelling of the cost effectiveness of Mohs vs. WLE in the United States of America (USA) concluded that all-in costs per patient (including the cost of treating incomplete/recurrences) were US $4365.57 for Mohs and US $4699.41 for WLE, making Mohs US$333.83 cheaper than WLE. The study reported that there was a 99.9% probability of Mohs being more cost effective compared with WLE and could cost over three times it current rate and still be more cost-effective than WLE (9).
Mohs is an innovative way to remove skin cancers and is being used in a widening field; previously only for cBCCs and cSCCs it is now being used for rarer skin cancers with good results (10). Furthermore, Mohs provides the opportunity for high-quality care which is normally only available to patients in the private sector, making health care more equitable and accessible to all Sunshine Coast residents.
The central problem addressed was: How to deliver precise, same-day Mohs surgery for high-risk periocular skin cancers locally, improving cure rates, patient outcomes, and resource efficiency? This project established Queensland's first public multidisciplinary Mohs service at Caloundra Health Service, shifting from tertiary care, to integrate dermatologic excision, real-time histopathology, and oculoplastic. By tackling theatre inefficiencies, waitlist pressures, and an evidence-practice gaps, it aligns with Sunshine Coast Health's innovation goals for skin cancer management.
Methods
This quality improvement project employed a structured, systems-based methodology to design, implement, and iteratively refine Queensland's inaugural public Mohs surgery service at Caloundra Health Service, Sunshine Coast Health. An initial financial feasibility investigation demonstrated cost-effectiveness by comparing funding requirements against operational costs, while quantifying opportunity gains such as freed tertiary facility theatre capacity, optimised Caloundra Health Service theatre utilisation, and expanded fellow training opportunities to strengthen recruitment pipelines. These analyses secured stakeholder endorsement and facilitated progression to comprehensive project planning.
A multidisciplinary implementation team was assembled, comprising a dermatologist (Mohs surgeon), oculoplastic surgeon, anatomical pathology scientist, anaesthetist, peri-operative nursing staff, Ready for Surgery Team (RfST), Clinical Improvement and Implementation Project Officer and administrative personnel. Development was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework, a human factors engineering model that conceptualises healthcare delivery as interconnected sociotechnical work systems across five domains: people, tools/technology, tasks, environment, and organisation (11). SEIPS enabled systematic mapping of domain interactions to proactively identify barriers, facilitators, and redesign priorities, shifting focus from individual errors to holistic process optimisation (11). Regular stakeholder meetings integrated diverse clinical, operational, and administrative perspectives, promoting collaborative refinement and organisational buy-in across the care continuum.
Post-implementation Plan-Do-Study-Act (PDSA) cycles leverage patient-level data from the initial five lists, incorporating patient-reported experience measures (PREMs), patient-reported outcome measures (PROMS), and staff experience/satisfaction surveys. These inform workflow refinements, such as theatre scheduling and histopathology turnaround, ensuring continuous improvement and sustainability of the service.
Discussion
Success of this project hinged on a supportive implementation environment within Sunshine Coast Health, including aligned strategic priorities for innovation and improved patient outcomes. Caloundra Hospital Auxiliary served as vital partners, providing essential funding for laboratory equipment that enabled onsite frozen-section processing. Utilising the SEIPS framework provided a rigorous, systems-informed strategy that systematically addressed sociotechnical domains, ensuring comprehensive risk mitigation and stakeholder alignment from inception. Critical enablers included dedicated, enthusiastic multidisciplinary staff, dermatologist, oculoplastic surgeon, medical laboratory scientist, elective surgery coordinator and perioperative teams, who championed the service, alongside Executive endorsement that secured initial funding and theatre allocation.
Key lessons highlight the importance of proactive onboarding and workforce engagement well before the inaugural list. While early involvement of external clinicians facilitated planning, their status as non'Sunshine Coast Health employees introduced communication challenges, limited access to internal systems, and dependency on external schedules. Late onboarding also created avoidable inequities, with key contributors providing substantial input before being formally engaged and remunerated. Overall, this experience reinforces that specialised expertise should be recognised and resourced as a core project input from the outset, rather than relying on goodwill to bridge onboarding and operational gaps. Although financial feasibility was confirmed, equipping the laboratory required detailed capital planning and partner support, including from the Caloundra Hospital Auxiliary. Collectively, these findings emphasise the value of embedding core clinical personnel within the institution early to strengthen communication channels, reduce operational risk, and support long-term sustainability.
Other Queensland Health sites should investigate the applicability of this model within their own contexts. Facilities with existing infrastructure, such as space for a dedicated histopathology laboratory, appropriately trained staff and growing oculoplastic waitlists may be well positioned to explore the implementation of Mohs surgery for high-risk skin cancers. Such investigation could contribute to addressing the statewide non-melanoma skin cancer burden and help reduce tertiary referral pressures. The SEIPS methodology and PDSA cycles offer a transferable blueprint, adaptable to local contexts like periocular cancer caseloads.
Next steps at Caloundra Health Service focus on consolidating and scaling the existing model to enhance efficiency and patient outcomes. Priorities include increasing patient volume to six cases per list by mid-2026 and using insights from the June review, encompassing PREMs, PROMs, and staff feedback, to streamline workflows and reduce variability. These initiatives aim to optimise the Caloundra service, ensuring sustainable growth, strengthened capacity, and maximised clinical impact within Sunshine Coast Health.
References
1. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database: periocular squamous cell carcinoma. Ophthalmology. 2004;111(4):617-23.
2. Weesie F, Naus NC, Vasilic D, Hollestein LM, van den Bos RR, Wakkee M. Recurrence of periocular basal cell carcinoma and squamous cell carcinoma after Mohs micrographic surgery: a retrospective cohort study. Br J Dermatol. 2019;180(5):1176-82.
3. Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol. 2013;68(6):957-66.
4. Staples MP, Elwood M, Burton RC, Williams JL, Marks R, Giles GG. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust. 2006;184(1):6-10.
5. Green AC, Olsen CM. Cutaneous squamous cell carcinoma: an epidemiological review. Br J Dermatol. 2017;177(2):373-81.
6. Hunt WTN, Earp E, Brown AC, Veitch D, Wernham AGH. A review of Mohs micrographic surgery for skin cancer. Part 3: Squamous cell carcinoma. Clin Exp Dermatol. 2022;47(10):1765-73.
7. Shi K, Wang L, Srivastava D, Nijhawan RI. Mohs micrographic surgery for periocular skin cancer: a single-institution experience. Arch Dermatol Res. 2023;315(5):1181-6.
8. Soleymani T, Brodland DG, Arzeno J, Sharon DJ, Zitelli JA. Clinical outcomes of high-risk cutaneous squamous cell carcinomas treated with Mohs surgery alone: An analysis of local recurrence, regional nodal metastases, progression-free survival, and disease-specific death. J Am Acad Dermatol. 2023;88(1):109-17.
9. Rogers HW, Coldiron BM. A relative value unit-based cost comparison of treatment modalities for nonmelanoma skin cancer: effect of the loss of the Mohs multiple surgery reduction exemption. J Am Acad Dermatol. 2009;61(1):96-103.
10. Charalambides M, Yannoulias B, Malik N, Mann JK, Celebi P, Veitch D, et al. A review of Mohs micrographic surgery for skin cancer. Part 1: Melanoma and rare skin cancers. Clin Exp Dermatol. 2022;47(5):833-49.
11. Carayon, P. Wooldridge, A. Hoonakker, P. Hundt, A. S. & Kelly, M. (2020). SEIPS 3.0: Human-centered design of the patient journey for patient safety. Applied Ergonomics, 84, Article 103033. https://doi.org/10.1016/j.apergo.2019.103033.
Key contact
Dr Ebony Smith
Oculoplastic Surgeon
Sunshine Coast Hospital and Health Service