Commission on Cancer Commission on Cancer Standards: Staying Prepared – Standards: Staying Prepared – A Surveyor’s PerspectiveA Surveyor’s Perspective
Suzanna S. Hoyler, CTRDirector, WCI Information ManagementWashington Hospital CenterWashington, DCCOC Network Surveyor
Objectives of the PresentationObjectives of the Presentation
Identify the survey participants role in the Identify the survey participants role in the survey processsurvey process
Learn now to stay prepared for surveyLearn now to stay prepared for survey
Provide the necessary survey Provide the necessary survey documentationdocumentation
Identify what to documentIdentify what to document
Sample Survey Agenda Sample Survey Agenda
8:00 am 8:00 am Surveyor meets cancer teamSurveyor meets cancer team
10:00 am10:00 am Tour the facility & campus*Tour the facility & campus*
12:00 pm12:00 pm Attend tumor board/cancer conf *Attend tumor board/cancer conf *
1:00 pm1:00 pm Cancer registryCancer registry
2:30 pm2:30 pm Surveyor private timeSurveyor private time
3:00 pm3:00 pm Summation with cancer team membersSummation with cancer team members
•Required activity. Tour required if applicable to program & category.
Minimum 6 hour visitMinimum 6 hour visit
Sample Survey Agenda for a Sample Survey Agenda for a Network Network Day 1Day 1
8:00 am8:00 am Meet with AdministratorsMeet with Administrators
8:30 am 8:30 am Meet with Cancer TeamMeet with Cancer Team
11:00 am11:00 am Tour the facility & Tour the facility & campus*campus*
12:00 pm12:00 pm Attend tumor Attend tumor board/cancer conf *board/cancer conf *
1:00pm1:00pm Chart Review*Chart Review*
2:30 pm2:30 pm Cancer registryCancer registry
Day 2Day 2
8:00am8:00am Tour second Tour second facility*facility*
9:00am9:00am Chart Review *Chart Review *10:30am10:30am Surveyor team Surveyor team
private timeprivate time11:00am11:00am Summation with Summation with
Cancer Team Cancer Team membersmembers
* Required activities. Chart review must be done for each facility, but only 2 must be visited.
The Cancer TeamThe Cancer Team
Required membersRequired members– Cancer Committee ChairCancer Committee Chair– Member of Administration or Member of Administration or
RepresentativeRepresentative– Cancer Liaison Physician Cancer Liaison Physician
(Community Outreach (Community Outreach Coordinator)Coordinator)
– Cancer Conference Cancer Conference CoordinatorCoordinator
– Quality Improvement Quality Improvement CoordinatorCoordinator
– Cancer RegistrarCancer Registrar– Quality Control of Cancer Quality Control of Cancer
Registry Data CoordinatorRegistry Data Coordinator
Recommended membersRecommended members**
– Oncology NursingOncology Nursing– Rehabilitative ServicesRehabilitative Services– Pastoral CarePastoral Care– Research Nurse or Data ManagerResearch Nurse or Data Manager– Social Services or Discharge Social Services or Discharge
PlanningPlanning– Dietary/Nutritional ServicesDietary/Nutritional Services– Pain Control/Palliative Care Pain Control/Palliative Care
Physician or SpecialistPhysician or Specialist– PharmacyPharmacy– HospiceHospice– Public EducationPublic Education
•* Applicable to program & category.
04/19/2304/19/23 66
Medical Chart ReviewMedical Chart Review
25 cases25 cases
VerifyingVerifying– Abstracting timeline (Abstracting timeline (≤ ≤ 6 months)6 months)– CAP protocolsCAP protocols– AJCC stage complete (T, N, M, & Stage AJCC stage complete (T, N, M, & Stage
Group)Group)Who staged the case?Who staged the case?
– Follow-up dateFollow-up date
Documents* to Provide SurveyorDocuments* to Provide Surveyor
Documents provided in advance to Documents provided in advance to surveyorsurveyor
Documents made available to surveyorDocuments made available to surveyor– May be sent in advanceMay be sent in advance
*All documents are sent to Chicago for shredding*All documents are sent to Chicago for shredding Refer to page 7 of Commission on Cancer Cancer Program Standards 2004 for a complete list.
Documents Provided in AdvanceDocuments Provided in Advance
Institution’s Accreditation Certificate or Institution’s Accreditation Certificate or letter from accrediting bodyletter from accrediting body
Bylaws, policies, etcBylaws, policies, etc– Designate responsibility & accountability of Designate responsibility & accountability of
Cancer CommitteeCancer Committee
Documents Provided in AdvanceDocuments Provided in Advance
Cancer Committee minutes Cancer Committee minutes – Attachments Attachments – Subcommittees or work group minutesSubcommittees or work group minutes
Annual goalsAnnual goals– Time frame for evaluation & completionTime frame for evaluation & completion
Coordinator’s responsibilitiesCoordinator’s responsibilities
continued…
Documents Provided in AdvanceDocuments Provided in Advance
Cancer conferences/tumor boardsCancer conferences/tumor boards– Annual frequency & formatAnnual frequency & format– Multidisciplinary attendanceMultidisciplinary attendance– Annual case presentationsAnnual case presentations– Monitoring of cancer conference(s) activity & Monitoring of cancer conference(s) activity &
corrective actioncorrective action
continued…
Documents Provided in AdvanceDocuments Provided in Advance
Outcomes analysisOutcomes analysis– ResultsResults– Methods of analysisMethods of analysis– Annual report (if published)Annual report (if published)
continued…
Documents Provided in AdvanceDocuments Provided in Advance
Documentation of referred radiation Documentation of referred radiation oncology services & resources*oncology services & resources*
Documentation that identifies the medical Documentation that identifies the medical oncology unit/functional equivalent (if oncology unit/functional equivalent (if applicable)*applicable)*
Physician staging policy/procedure*Physician staging policy/procedure*
*CoC Website -- Resources & Tools for Cancer Programs continued…
Documents Made Available Documents Made Available (optional to send)(optional to send)
Annual quality control activitiesAnnual quality control activities
Current credentialing of registry staff Current credentialing of registry staff (NCRA CTRs)(NCRA CTRs)
Case abstracting by a CTR or data Case abstracting by a CTR or data supervision responsibilities by a CTRsupervision responsibilities by a CTR
Organizational chart for nursing Organizational chart for nursing
…………Refer to page 7 of Commission on Cancer Cancer Program Standards 2004 for a complete list.
Eight Areas of EvaluationEight Areas of Evaluation
Institutional & Programmatic ResourcesInstitutional & Programmatic ResourcesCancer Committee LeadershipCancer Committee LeadershipCancer Data Management & Cancer Registry Cancer Data Management & Cancer Registry OperationsOperationsClinical ManagementClinical ManagementResearchResearchCommunity OutreachCommunity OutreachProfessional Education & Staff SupportProfessional Education & Staff SupportQuality ImprovementQuality Improvement
Chapter 1: Institutional & Chapter 1: Institutional & Programmatic ResourcesProgrammatic Resources
PurposePurpose– Confirms accreditationConfirms accreditation
Standard 1.1Standard 1.1– State licensure acceptableState licensure acceptable
Chapter 2: Cancer Committee Chapter 2: Cancer Committee LeadershipLeadership
PurposePurpose– Establish cancer committee responsibility & Establish cancer committee responsibility &
accountabilityaccountability
Highlighted changesHighlighted changes– Standard 2.2 - Multidisciplinary membershipStandard 2.2 - Multidisciplinary membership
– Standard 2.3 - Activity coordinatorsStandard 2.3 - Activity coordinators
– Standard 2.4 - Meeting schedule & structureStandard 2.4 - Meeting schedule & structure
Chapter 2: Cancer Committee Chapter 2: Cancer Committee LeadershipLeadership
Highlighted changesHighlighted changes– Standard 2.5 - Annual goals & objectivesStandard 2.5 - Annual goals & objectives
ClinicalClinical
Community outreachCommunity outreach
Quality improvementQuality improvement
ProgrammaticProgrammatic
Chapter 2: Cancer Committee Chapter 2: Cancer Committee LeadershipLeadership
Standard 2.6 – Cancer conf frequencyStandard 2.6 – Cancer conf frequency
Standard 2.7 – Multidisciplinary attendanceStandard 2.7 – Multidisciplinary attendance
Standard 2.8 – Number of cases presentedStandard 2.8 – Number of cases presented
Standard 2.9 – Cancer Comm monitors & Standard 2.9 – Cancer Comm monitors & evaluatesevaluates– Frequency* & attendanceFrequency* & attendance– Total & prospective case presentationTotal & prospective case presentation
*Recommendations for frequency & format based on category
Chapter 2: Cancer Committee Chapter 2: Cancer Committee LeadershipLeadership
Highlighted changesHighlighted changes– Standard 2.10 - Cancer registry quality Standard 2.10 - Cancer registry quality
control plancontrol plan– Standard 2.11 - Analyze & report outcomes*Standard 2.11 - Analyze & report outcomes*
Committee selected site & outcomeCommittee selected site & outcome
Committee selected disseminationCommittee selected dissemination
Commendation definedCommendation defined
*Commendation available
Chapter 3: Cancer Data Management Chapter 3: Cancer Data Management & Cancer Registry Operations& Cancer Registry Operations
PurposePurpose– Ensure accurate & timely data collectionEnsure accurate & timely data collection
Highlighted changesHighlighted changes– Standard 3.1 - CTR case abstractingStandard 3.1 - CTR case abstracting– Standard 3.3 - Abstracting timeliness*Standard 3.3 - Abstracting timeliness*– Standards 3.4, 3.5 - Follow-up Standards 3.4, 3.5 - Follow-up – Cancer Registry OperationsCancer Registry Operations
*Commendation available
Chapter 3: Cancer Data Management Chapter 3: Cancer Data Management & Cancer Registry Operations& Cancer Registry Operations
Highlighted changesHighlighted changes– Standard 3.6 - NCDB data submissionStandard 3.6 - NCDB data submission– Standard 3.7 - NCDB data submission quality*Standard 3.7 - NCDB data submission quality*– Standard 3.8 - CoC special studiesStandard 3.8 - CoC special studies– Cancer Registry OperationsCancer Registry Operations
*Commendation available
Registry Procedure Manual(s)Registry Procedure Manual(s)
Policy / ProcedurePolicy / ProcedureCase accessions into Case accessions into the registrythe registryCancer registry job Cancer registry job descriptiondescriptionCase eligibility criteriaCase eligibility criteriaCasefindingCasefindingCoC data standards & CoC data standards & coding instructionscoding instructionsConfidentiality & Confidentiality & release of informationrelease of information
Data collectionData collectionDates of Dates of implementation or implementation or changes in policies or changes in policies or registry operationsregistry operationsFollow-up proceduresFollow-up proceduresMaintaining & using the Maintaining & using the suspense filesuspense fileQuality control of Quality control of registry dataregistry dataStaging systems usedStaging systems used
Chapter 4: Clinical ManagementChapter 4: Clinical Management
PurposePurpose– Identify minimum scope of clinical servicesIdentify minimum scope of clinical services
Highlighted changesHighlighted changes– Standard 4.1 – Radiation servicesStandard 4.1 – Radiation services– Standard 4.2 – Inpatient medical oncology Standard 4.2 – Inpatient medical oncology
unitunit
Chapter 4: Clinical ManagementChapter 4: Clinical Management
Standard 4.3 - AJCC staging*Standard 4.3 - AJCC staging*– Staging form in medical record requiredStaging form in medical record required– Effective Effective January 1, 2005January 1, 2005– Committee develops staging policy & Committee develops staging policy &
procedureprocedureDefinition of managing physicianDefinition of managing physicianPlacement of forms & acceptable completion Placement of forms & acceptable completion methodsmethodsQuality control of completeness & accuracyQuality control of completeness & accuracy
Resolution of differencesResolution of differences
*Commendation available
Chapter 4: Clinical ManagementChapter 4: Clinical Management
Highlighted changesHighlighted changes– Standard 4.4 - Oncology nursing Standard 4.4 - Oncology nursing
knowledge & skillsknowledge & skills– Standard 4.5 - Nursing direction of the Standard 4.5 - Nursing direction of the
oncology unit or FEoncology unit or FE
Standard 4.6 – Patient Management & Standard 4.6 – Patient Management & Treatment GuidelinesTreatment Guidelines– CAP guidelines*CAP guidelines*
90% of pathology reports90% of pathology reports
Random review of analytic casesRandom review of analytic cases
Is there a plan to implement & monitor CAP Is there a plan to implement & monitor CAP protocols documented in cancer committee protocols documented in cancer committee minutes?minutes?
Standard 4.7 – Rehabilitation servicesStandard 4.7 – Rehabilitation services
*Medical record review
Chapter 4: Clinical ManagementChapter 4: Clinical Management
Chapter 5: ResearchChapter 5: Research
PurposePurpose– Promote clinical trial participationPromote clinical trial participation
Highlighted changesHighlighted changes– Standard 5.1 - Cancer-related clinical trial Standard 5.1 - Cancer-related clinical trial
informationinformation– Standard 5.2 - Cancer-related clinical trial Standard 5.2 - Cancer-related clinical trial
accrual*accrual*2% to 10% requirement based on category2% to 10% requirement based on category
*Commendation available
Chapter 6: Community OutreachChapter 6: Community Outreach
PurposePurpose– Ensure availability of supportive services, Ensure availability of supportive services,
prevention, & early detectionprevention, & early detection
Highlighted changesHighlighted changes– New Cancer Liaison Physician roleNew Cancer Liaison Physician role– Standard 6.1 - Supportive servicesStandard 6.1 - Supportive services– Standard 6.2 - Two prevention or early detection Standard 6.2 - Two prevention or early detection
programsprograms– Standard 6.3 - Monitor community outreach Standard 6.3 - Monitor community outreach
annuallyannually
Chapter 7: Professional Chapter 7: Professional Education & Staff SupportEducation & Staff Support
PurposePurpose– Promotes increased knowledgePromotes increased knowledge
Highlighted changesHighlighted changes– Standard 7.1 - One cancer-related Standard 7.1 - One cancer-related
educational activityeducational activity– Standard 7.2 - Registry staff cancer-related Standard 7.2 - Registry staff cancer-related
education*education*
*Commendation available
Chapter 8: Quality ImprovementChapter 8: Quality Improvement
PurposePurpose– Evaluate & improve the of quality of cancer Evaluate & improve the of quality of cancer
services, patient care & outcomesservices, patient care & outcomes
Highlighted changesHighlighted changes– Standard 8.1 - Studies of quality & Standard 8.1 - Studies of quality &
outcomesoutcomesNumber & type based on categoryNumber & type based on category
Year Year completedcompleted
Chapter 8: Quality ImprovementChapter 8: Quality Improvement
Highlighted changesHighlighted changes– Standard 8.2 - Improvements affecting Standard 8.2 - Improvements affecting
patient carepatient care2 improvements*2 improvements*
*Commendation available
Helpful Tools Available on the Web Helpful Tools Available on the Web -- Sample Best Practices*Sample Best Practices*
BylawsBylaws
Reporting to Cancer Reporting to Cancer CommitteeCommittee
Job Descriptions for Job Descriptions for CoordinatorsCoordinators
AJCC Staging PolicyAJCC Staging Policy
Quality Improvement Quality Improvement & Assurance& Assurance
Clinical ManagementClinical ManagementTreatment Guidelines Treatment Guidelines Resource ListResource ListClinical Trials Clinical Trials InformationInformationCommunity OutreachCommunity Outreach
*Located on Commission on Cancer web site.
Helpful Tools Available on the Web*Helpful Tools Available on the Web*
Cancer Program Tracking ToolsCancer Program Tracking Tools– AJCC Staging Quality Control ToolAJCC Staging Quality Control Tool– Cancer Registry Abstracting Quality Control Cancer Registry Abstracting Quality Control
tooltool– Cancer Conference GridCancer Conference Grid– Pathology Report Quality Control ToolPathology Report Quality Control Tool– Program Activity TemplateProgram Activity Template– Study of QualityStudy of Quality
Commission on Cancer web site
Survey Application Record (SAR) Survey Application Record (SAR) Annual UpdatesAnnual Updates
Cancer committee Cancer committee leadership (2.2, 2.3, 2.4, leadership (2.2, 2.3, 2.4, 2.5)2.5)
Conference activity (2.6, Conference activity (2.6, 2.7, 2.8)2.7, 2.8)
Outcomes analysis (2.11)Outcomes analysis (2.11)
CTR Abstracting (3.1)CTR Abstracting (3.1)
Abstracting backlog (3.3)Abstracting backlog (3.3)
Treatment services (4.1, Treatment services (4.1, 4.2)4.2)
AJCC staging (4.3)AJCC staging (4.3)
Nursing care (4.4, 4.5)Nursing care (4.4, 4.5)
Patient guidelines (4.6)Patient guidelines (4.6)
Rehabilitation (4.7)Rehabilitation (4.7)
Research (5.1, 5.2)Research (5.1, 5.2)
Community Outreach (6.1, Community Outreach (6.1, 6.2, 6.3)6.2, 6.3)
Education (7.1, 7.2)Education (7.1, 7.2)
Quality Improvement (8.1, Quality Improvement (8.1, 8.2)8.2)
Thank you to the Commission on Thank you to the Commission on Cancer for some of the slidesCancer for some of the slides
Asa Carter (312) 202-5180Asa Carter (312) 202-5180– [email protected]@facs.org
Vicki Chiappetta (312) 202-5288Vicki Chiappetta (312) 202-5288– [email protected]@facs.org
Lisa Landvogt (312) 202-5314Lisa Landvogt (312) 202-5314– [email protected]@facs.org
Top Related