Commission on Cancer Mission The CoC is a consortium of professional organizations dedicated to improving survival and quality of life for cancer patients.

Commission on Cancer Mission

The CoC is a consortium of professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and the monitoring of comprehensive quality care.

Cancer Program Categories Redefined

• Table of criteria by category included in Appendix A: – Category definition– Specifies eligibility requirements– Defines criteria for standards

Eligibility Requirements Created

• Required of all programs annually

• Displayed in CoC Hospital Locator

• Describes structure of program– Diagnostic and treatment services– Psychosocial and other support services

Chapter 1- Program Management

• S1.1 Physician Credentials– Physicians who provide cancer care to patients are board

certified or in the process of becoming board certified

• S1.2 Cancer Committee Membership– The cancer committee is multidisciplinary with physicians

and non-physicians representing the full scope of care

• S1.3 Cancer Committee Attendance*– Each required physician and non-physician member

attends at least 50% of the cancer committee meetings held annually

* Eligible for Commendation

Chapter 1- Program Management

• S1.4 Cancer Committee Meetings– The cancer committee meets each quarter, for a

minimum of 4 times each year

• S1.5 Cancer Program Goals– At least 1 clinical goal and 1 programmatic goal are

established each year, goals are monitored, evaluated, and documented in cancer committee minutes at least twice annually

• S1.6 Cancer Registry Quality Control Plan– The cancer committee establishes and implements a

quality control plan to monitor and evaluate multiple areas of cancer registry activity

Chapter 1- Program Management • S1.7 Monitoring Conference Activity

– The cancer committee monitors the cancer conference activity through the work of the cancer conference coordinator

• S1.8 Monitoring Community Outreach– Based on needs of the community, the prevention and early-

detection/screening programs offered each year are monitored to ensure that appropriate services are provided. The coordinator leads activity, reports findings and annual summary to the cancer committee

• S1.9 Clinical Trial Accrual*– Based on category, the required percentage of patients is

accrued to cancer-related clinical trials each year* Eligible for Commendation

Chapter 1- Program Management

• S1.10 Clinical Educational Activity– Each year the cancer committee offers at least 1 cancer-

related educational activity focused on stage and treatment planning to physicians, nurses, and allied health professionals

• S1.11 Cancer Registrar Education*– All members of the cancer registry staff participate in a

cancer-related educational activity at the local, state, regional, or national level

*Eligible for Commendation

• S1.12 Public Reporting of Outcomes* (optional)– Each year the cancer committee develops and disseminates

a report of patient or program outcomes to the public* Eligible for Commendation Only

• S2.1 College of American Pathologists Protocols*– 90% of eligible pathology reports that include a cancer

diagnosis will contain the required data elements outlined by CAP

* Eligible for Commendation

• S2.2 Nursing Care*– Oncology nursing care is provided by nurses with

specialized knowledge and skills. Competency is evaluated annually

* Eligible for Commendation

Chapter 2 - Clinical Services

• S2.3 Risk Assessment and Genetic Counseling– The program provides cancer risk assessment and

genetic counseling to patients on-site or by referral by a qualified genetics professional

• S2.4 Palliative Care Services– Palliative care services are available to patients either

on-site or by referral

Chapter 2 - Clinical Services

Chapter 3 Continuum of Care Services

• S3.1 Patient Navigation Process– A patient navigation process, driven by a community

needs assessment, is established to address health care disparities and barriers to care for patients

• S3.2 Psychosocial Distress Screening– The cancer committee develops and implements a

process to integrate and monitor on-site psychosocial distress screening and referral for the provision of psychosocial care

Chapter 3Continuum of Care Services

• S3.3 Survivorship Care Plan– A survivorship care plan is prepared by the principal

provider(s) who coordinated the oncology treatment for the patient with input from the patient’s other care providers

– The survivorship care plan is given to the patient upon completion of treatment

Chapter 4 - Patient Outcomes

• S4.1 Prevention Programs– Annually the cancer committee identifies the cancer

prevention needs of the community and provides at least 1 cancer prevention program that is focused on decreasing the number of patients with a specific type of cancer

• S4.2 Screening Programs– Annually, the cancer committee provides at least 1 cancer

screening program that is focused on an identified community need to decrease the number of patients with late stage disease

Chapter 4 - Patient Outcomes

• S4.3 Cancer Liaison Physician Responsibilities– The primary responsibility of the CLP is to evaluate and

improve the quality of care by monitoring, interpreting, and reporting (four times per year) the program’s performance using NCDB data

• S4.4 Accountability Measures– The cancer committee reviews the quality of patient care

using CoC quality reporting tools, addressing performance rates that fall below levels established by the CoC

Chapter 4 - Patient Outcomes• S4.5 Quality Improvement Measures

– The cancer committee reviews the quality of patient care using CoC quality reporting tools, addressing performance rates that fall below levels established by the CoC

• S4.6 Assessment of Evaluation and Treatment Planning– Ensure evaluation and treatment conforms to evidence-

based national guidelines using AJCC stage or other appropriate staging and appropriate prognostic indicators

Chapter 4 - Patient Outcomes

• S4.7 Studies of Quality– Two studies focus on areas with problematic quality-

related issues relevant to the program and local cancer patient population

• S4.8 Quality Improvements– Two improvements implemented annually; 1 focused on

correction or improvement in performance that is based on the findings from a study of quality

Chapter 5 - Data Quality

• S5.1 Cancer Registrar Credentials– Beginning January 1, 2012, all cancer registry staff who

perform case abstracting at a CoC-accredited program must hold a current CTR credential or are abstracting under the supervision of a CTR

– A non-credentialed abstractor currently working must pass the CTR examination by January 2015

• S5.2 Abstracting Timeliness*– 90% of cases are abstracted within 6 months of the date

of first contact

* Eligible for Commendation

Chapter 5 - Data Quality

• S5.3 Follow-Up of All Patients– For all eligible analytic cases, an 80% follow-up rate is

maintained from the reference date

• S5.4 Follow-Up of Recent Patients– A 90% follow-up rate is maintained for all eligible analytic

cases diagnosed within the last 5 years or from the reference date, whichever is shorter

Chapter 5 - Data Quality• S5.5 Data Submission

– Complete data for all requested analytic cases are submitted to the National Cancer Data Base in accordance with the annual Call for Data

• S5.6 Accuracy of Data*– The cases diagnosed on January 1, 2003 or later satisfy

the established quality criteria by the deadline date specified in each Call for Data

* Eligible for Commendation

• S5.7 Commission on Cancer Special Studies– The program participates in special studies as selected by

the Commission on Cancer

Commendation Summary• Commendation applies to the following standards

– 1.3 Cancer committee attendance– 1.9 Clinical trial accrual– 1.11 Cancer registrar education– 1.12 Public reporting of outcomes– 2.1 Synoptic reporting of CAP required elements– 2.2 ONS credentialed nurses– 5.2 Abstracting timeliness– 5.6 Submission of accurate data

• All commendations are required (without a single deficiency) for consideration of the Outstanding Achievement Award

Resources

• Education and Support– Webinar Series – Part 1: Supporting Cancer Program

Operations– Webinar Series – Part 2: Supporting Patient Centered

Standards– Video Vignettes – Coming in 2012 (3 minute) video

presentations on each standard– Survey Savvy workshop – March 8-9, 2012 Chicago,

IL

Resources

• Education and Support– CAnswer Forum – On-line interactive forum provides

answers to questions about the standards and assists with standards interpretation http://cancerbulletin.facs.org/forums/

– Best Practices Repository – Provides tools and resources developed to help programs implement and meet the new standards https://www.socialtext.net/cancer_standards/coc_best_practices_repository

These standards were developed with the solitary goal of ensuring that patients with

cancer will receive quality care close to home

Thank You!

CoC Program Area Contact Information

http://www.facs.org/cancer/whocall.html