Commission on Cancer Commission on Cancer Standards: Staying Standards: Staying Prepared – A Surveyor’s Prepared – A Surveyor’s Perspective Perspective Suzanna S. Hoyler, CTR Director, WCI Information Management Washington Hospital Center Washington, DC COC Network Surveyor
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Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective
Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective. Suzanna S. Hoyler, CTR Director, WCI Information Management Washington Hospital Center Washington, DC COC Network Surveyor. Objectives of the Presentation. - PowerPoint PPT Presentation
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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*
– 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
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)*
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
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
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
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
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
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
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
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)