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Getting Ready for QOPI CertificationPart II
February 21,2012Use Mute Button on Phone
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For Assistance go to MOQC.org or call: 734.763.7398
Today’s Agenda
I. Certification Process OverviewII. Policy & Competency RequirementsIII. Data Submission Tips & TricksIV. MOQC ResourcesV. Future Webinar: Site Visit Preparation
QOPI Certification Overview
• Demonstrates highest level of commitment to quality and safety for oncology practices
• Prepares participants on how to conduct self assessments of policies, staff competencies & documentation associated with key processes in their offices
• Primary focus is on the safe administration of of chemotherapy and biologics
Chemotherapy & Biotherapy Administration
Patient Centered Care
Culture of Safety & Quality
Chemotherapy Plan
Drug Administration
Drug Preparation
Monitor & Assessment
Eligibility Requirements
• Starts with submitting data for all 5 modules during one collection round
• Compliance with QOPI chart selection & sampling methodology
• Achievement of QOPI scores to be Certification Eligible:– Overall Quality Score : 72.62% or higher– Adjuvant Treatment Score : 80% or higher
Certification ProcessQOPI Thresholds met Practice is EligibleCertification Password Obtained Complete Application & Payment based on
practice MD FTE (prior to March 22nd) Complete Site Assessment Questionnaire &
Attestation StatementSubmit ASCO Designated Documentation on
5 Safety Standards & 3 Medical Records
II. POLICY & STAFF COMPETENCY REQUIREMENTS
Staffing Related Policies/ Elements
Required Policy Elements: Who can perform the task & how are they deemed qualified
Chemo orders incl. oral are written & signed by L.I.P.
Chemo drugs preparation by qualified staff
Administration of chemo is only by qualified MD, PA/NP, RN
How new staff that administer are educated incl competency (skills) assessment/ verification
Chemotherapy administration competency monitoring schedule (how & how often- annually recommended)
Chemotherapy Orders, Preparation & Administration Policy/ Elements
Required ordering elements (or submit std order form)
Double check process elements required before preparation
Double check process elements required before administration
How cumulative doses are captured/ monitored (or submit form/ screenshot)
Intrathecal administration includes special preparation, storage & delivery requirements
How communication & documentation of toxicity will occur across sites of care within a practice if applicable
General Practice Policies/ Elements
Informed Consent process
Standard clinical assessment elements (ie. VS, Wt, Allergies etc.) (or submit standard form/ screenshot)
Medication reconciliation process incl. when & how collected
Extravasation management procedure including antidote order sets & procurement process
Missed appointment tracking & follow up process
How patients access providers during & after hours
Emergency preparedness policy incl. plan for life-threatening emergencies (or checklists)
ASCO.org \ Practice & Guidelines \ Quality Care \ Quality Measurement & Improvement \ ASCO-ONS Standards for Save Chemotherapy Administration \ Download: Sample Policies for Safe Administration of Chemotherapy
Staff Education Requirements
Testing: Acquiring Knowledge Competency Assessment: Demonstrating Proficiency
Required Staff Education & Competencies
• Testing assesses knowledge• Competency assessment evaluates skills and
performance• Both are required for staff who administer
chemotherapy with annual review that includes a competency assessment
• BLS: Minimum requirement for RNs • Submission of staff records required
III. DATA SUBMISSION TIPS & TRICKS
Certification Standards Overview• Each standard set up in the same manner:
– Standard Description– Policy Required (if applicable)– Acceptable Documentation to submit– Available References & Resources
• Only send documentation showing evidence that standard met – no highlighter!!
• De- identified records only- or need to resubmit• ASCO tells you which 5 modules to submit data
Chemotherapy Planning:Standards #2&3
#2 Required Documentation Prior to New Order Pathology Report Cancer Stage at diagnosis or current status History & PE ( including Ht, Wt) Allergies & history of hypersensitivity reactions Psychosocial assessment (ESAS, Distress Tool)
#2 Required Documentation Prior to New OrderChemotherapy Treatment Plan
– Goals of Therapy (curative / palliative) – Drug, dose & duration– Acknowledgement of patient understanding of
the information2 records sent demonstrating compliance
Chemotherapy Planning (cont.)
Chemotherapy Planning (cont.)
#3 Informed Consent Documentation RequiredSend two recent completed forms or notes with
policy
Oral Chemotherapy Documentation RequiredAll of the aboveFrequency of office visitsMonitoring parameters
Chemotherapy Orders:Standard 4
Orders RequirementsOrder forms list all chemo & dosing parametersFull generic name used Abbreviations follow Joint Commission
standardshttp://www.jointcommission.org/standards_information/npsgs.aspx
Completed unique order sets for 3 patients sent (including and anthracycline)
Chemotherapy Orders (cont.)
• Required Elements on a Chemotherapy Order:– Patient full name & 2nd identifier– Date Diagnosis– Regimen Name & Cycle # (Protocol Name /#)– Allergies, Ht/ Wt ( or other dose calc)– Dose calculation method (ie. creatinine clearance)– Route, Rate, Dosage, Length of Infusion, Sequence– Supportive care treatments
Drug Preparation: Standards 5 & 6
• Double Check Documented Prior to Preparation
• Chemotherapy Drugs Must be Labeled Immediately Upon Preparation – Standard format included in guideline– Time of expiration added when not for
immediate use
Drug Preparation: Standard 7 Intrathecal Administration
• Prepared only with other intrathecal agents• Uniquely identifiable intrathecal label• Stored in an isolated container/ location • Delivered to patient only with other meds for
CVS administration• All procedure areas in organization must
follow same policy incl. IR, Procedure Units
Chemotherapy Administration: Standard 8 Double Check
• In the presence of the patient, verify patient identification using at least 2 identifiers
• Confirm with patient planned treatment prior to each cycle
• Double check completed & documented (required elements listed in standards)
• Checklist, template recommended *** Competency validated on annual basis
Chemotherapy Administration: Standard 9 Extravasation Management
• Policies / guideline & order sets align with current literature ( 2009 ONS Chemotherapy & Biologics Guidelines And Recommendations For Practice )
• Antidotes & order sets must be accessible on site or need written procedure on where patient is sent or how antidote is sent to area NOTE: Totect treatment for anthracycline and hyaluronidase for plant alkaloids are current recommendations
Monitoring & Assessment:Standard 10: Emergency Preparedness
• Emergency protocols/ checklists are maintained for life–threatening emergencies– Who needs contacted to get help / responds– How are they contacted (i.e. page/phone number)– Assigned role of staff during the emergency– Procedures implemented when further care is
required (including transfers)
Monitoring & Assessment:Standard 11: Clinical Assessment
On each clinical visit including infusion the following is assessed / verified and documented:
– Clinical/ performance status– VS, Wt,– Allergies, previous reactions & treatment- related
toxicities– Psychological concerns (with plan if indicated)
Screenshot or form can be submitted or policy
Monitoring & Assessment:Standard 12: Medication Reconciliation
On each clinical visit including infusion review of the following will occur:
– Current medications– OTC meds– Complementary & alternative treatments
Changes are documented in the medical record
Monitoring & Assessment:Standard 13: Referral Resources
• Required to have listing of psychosocial & supportive care resources
• Resources include list of websites, booklets, community programs etc
Monitoring & Assessment:Standard 14/15: Access & Communication
#14 Missed Appointments– Need missed appointment policy &/or tracking
process which includes patient follow up (i.e. call, email to patient)
#15 Provider Communication – Process to provide 24/7 triage (i.e. on call process)
for care of toxicities– Ability to communicate toxicities across sites– Tracking of Safe Hand-Offs- HOLD
Monitoring & Assessment:Standard 16/17:Toxicity Monitoring
#16 Toxicities Assessment Documentation is Available for Planning Subsequent Cycles
– Flow sheets, provider notes of review
#17 Cumulative Doses are Tracked When Indicated
– i.e. Documentation of doxorubicin cumulative dosing for patient receiving AC protocol; EMR screenshot of tracking; flow sheet
Chemotherapy & Biotherapy Administration
Patient Centered Care
Culture of Safety & Quality
Chemotherapy Plan
Drug Administration
Drug Preparation
Monitor & Assessment
Next Steps• Assemble your team including physician
champion• Conduct a self assessment/ gap analysis
(MOQC tool)• Identify opportunities for improvement• Use ASCO & ONS resources• Work with MOQC colleagues to identify best
practices• Conduct Mock Survey
All QI information can be accessed via the MOQC.org website starting March, 2012.Please email jseversn@umich.edu or cmichale@umich.edu for log-in information.
MOQC Lunch & Learn Series
• To better meet your needs, we would like your feedback and input. Please complete Evaluation Survey at: https://umichumhs.qualtrics.com/SE/?SID=SV_ehqdiP2GOhwUxwg
• Future Webinars–Certification Part # 3 Site Visit Preparation–Improving Cancer Pain Management