Commission on Cancer 2012 Standards

1. Ensuring (Quality) Patient-Centered Care Commission on Cancer2012 Standards PA Assoc. of Cancer RegistrarsSept. 26, 2011

2. Disclosures. • None

3. Objectives. • Discuss the early origins of the Cancer Program Standards. • Describe the quality focus of the 2012 version of the Cancer Program Standards. • Demonstrate how the 2012 Cancer Program Standards will help individual cancer programs improve their quality of care.

4. The Surgery Story.The ACoS and the CoC How exactly did it all come to be?

5. Surgery Prior to the 19th Century. • Amputations due to trauma. • Dressing and “probing” of combat injuries. • Operating for “stones”. • Mainly bladder stones. • Trephining, Removal of Abdominal Tumors, etc. • Mainly anecdotal accomplishments.

6. The Ascendancy of Surgery. • Anesthesia (1846) and Asepsis (1867+). • 1880s – The Golden Age of surgery. • In one New York Hospital the percentage of patients undergoing surgery increased from 18% to 69% between 1900 to 1920. • The glamour and rewards of surgery attracted men with inadequate training and less than mature judgment to perform surgery of questionable necessity and/or quality.

7. How It All Got Started. The State of Medicine (Surgery) at the beginning of the 20th Century. “It would be futile to attempt to estimate the amount of suffering caused by the ignorance, incompetence, commercialism and criminal indifference of those who call themselves disciples of Aesculapius.” Medical Chaos and Crime Norman Barnesby, MD (1910)

8. The Quest for Quality. • Along with the surgical charlatans there were also surgeons of conscience and quality. • American Surgical giants began to appear: • Samuel Gross • McBurney • J. B. Murphy • Halsted • Mayo • Ochsner

9. The Quest for Quality. • Lesser known but just as important foundation corner stone surgeons: • Franklin H Martin – Chicago • Edward Martin – Philadelphia • Earnest A. Codman - Boston

10. The origins of surgical societies in the U.S. Early 1900’s Society of Clinical Surgery Edward Martin, MD Philadelphia Clinical Congress of the Surgeons of North America Franklin Martin, MD Both contributed to the formation of the American College of Surgeons - 1913 How Did We Get Here?

11. The Quest for Quality.

12. Edward Martin, MD, FACS John Rhea Barton Prof. of Surgery Univ. of Penna. 1911-1918

13. In the Beginning. The American College of Surgeons. Initial Committees. College Formation Committee. Franklin Martin, MD, Chair. Committee on the of Standardization of Hospitals. E. A. Codman, MD, Chair. Precursor of the JCAHO. The “End Results” of Surgery guy.

14. The Quest for Quality.

15. Ernest Amory Codman1869 - 1940 • The first anesthesia record. • Along with Harvey Cushing - as medical students. • Surgical career. • Interest in diseases of the shoulder and sarcoma of bone. • The “End Result” in surgery. • A Study in Hospital Efficiency-pub. 1914 • Established a registry of bone sarcoma.- 1921.

16. The American College of Surgeons. “To serve all with skill and fidelity”

17. Cancer and its Treatmentcirca 1920. • A surgeon’s disease. • “You’ve got to cut it out!” • No medical oncology. • A new modality for treatment appears! • RADIUM. • The Committee to Study the Treatment of Malignant Disease with Radium and X-rays. • ACS, Board of Regents - October 1921.

18. Cancer and its Treatmentcirca 1920. • The Committee’s first project – May, 1922 • Secure reliable data regarding treatment of cervical cancer in established clinics: • Surgery. • Radium. • Roentgen rays.

19. The Registry Conceptcirca 1920. • Codman approaches the Committee to fund and support his bone sarcoma registry - 1922 • His registry required: • Detailed History of the patient’s tumor episode. • X-ray prints. • Microscopic slides.

20. “My computer seems a little slow today”

21. The ACoS’s Interest in Cancer Care. • Founding purpose of the College was to look at and improve the quality of surgery in the U.S • Attention on Cancer an early concern. • Committee on the Treatment of Malignant Disease with Radium. - 1921 • Committee on the Treatment of Malignant Disease. - 1930 (Advocated the development of Cancer Clinics in the General Hospital of the U.S. – 1930) • Committee on Cancer. – 1939 • Commission on Cancer - (Multidisciplinary) – 1956

22. Commission on Cancer. • The Commission on Cancer 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.

23. American Academy of Hospice and Palliative Medicine American Academy of Pediatrics American Association for Cancer Education American Cancer Society American College of Obstetricians and Gynecologists American College of Oncology Administrators American College of Physicians-American Society of Internal Medicine American College of Radiology American Dietetic Association American Head and Neck Society American Hospital Association American Joint Committee on CancerAmerican Medical Association American Pediatric Surgical Association American Psychosocial Oncology Society American Society of Breast Surgeons American Society for Therapeutic Radiology and Oncology American Society of Clinical Oncology American Society of Colon and Rectal Surgeons American Urological Association Association of American Cancer Institutes Association of Cancer Executives Association of Community Cancer Centers Association of Oncology Social Work Canadian Society for Surgical Oncology Centers for Disease Control and Prevention College of American Pathologists Department of Defense Department of Veterans Affairs International Union Against Cancer - UICC National Cancer Institute: Surveillance, Epidemiology, and End Results Program National Cancer Institute: Outcomes Research Branch National Cancer Registrars Association National Comprehensive Cancer Network National Consortium of Breast Centers, Inc. National Society of Genetic Counselors National Surgical Adjuvant Breast and Bowel Project North American Association of Central Cancer Registries Oncology Nursing SocietySociety of Gynecologic Oncologists Society of Nuclear Medicine Society of Surgical Oncology Society of Thoracic Surgeons CoC Member OrganizationsThere are 47 member organizations affiliated with the CoC and involved in cancer care: They include:

24. In the Beginning. • “The College is convinced that….it is possible effectively to reduce the suffering and mortality from cancer by an organized application of the knowledge that already is available.” • Bulletin of the ACS, June, 1931 • This article laid out the Minimum Standards for Cancer Clinics.

25. Early Standards. • Organization. • All Departments to participate. • A secretary > Registrar. • Social service worker. • Assigned to follow patients in the Registry for 5 years.

26. Early Standards. • Conferences. • Education of the hospital staffs. • InfectiousDiseases were the main concerns of the primary care medical staffs at that time. • The forerunner of today’s Tumor Conference. • Dx and Tx of individual cases are discussed. • Multi-disciplinary.

27. Early Standards. • All Patients in whom the diagnosis of cancer is being considered. • Voluntary or obligatory depending on the vote of the medical staff. • Equipment. • Appropriate medical and surgical equipment. • Staffed and equipped patient care areas and operating rooms. • An apparatus for X-ray therapy. • An amount of radium sufficient to ensure effectivetreatment.

28. Early Standards. • Detailed Record-Keeping. • The details of history and physical exam for cancers in different regions of the body. • The details of the treatment by surgery, X-ray or radium. • Periodic follow-up exams at intervals for at least 5 years following treatment. • Treatment. • By members of the staff of the cancer clinic.

29. The Original Intent. • Focus on care and support of the cancer patient. • Education of medical staffs. • Accurate recording of information and details of the cancer event. • Standardization of equipment and treatment modalities. • Accurate follow-up and data gathering.

30. And then like Topsy, it “just growed”.

31. Growth and Development • From the very simple and straightforward 1933 document to the 1995 revision of the STANDARDS – 151 standards, 47 of which were mandatory. • Newest revision – went into effect Jan. 1, 2004 • 36 standards – all are/were mandatory! • Currently undergoing an overhaul- ready NOW.

32. A Driving Force!

33. I.O.M.’s Concerns. • Too much emphasis on procedure. • Was your Annual Report sent to be printed by Nov. 30 • Micromanagement. • Did you dot your i’s and cross your t’s? • Why don’t you use your wonderful database (NCDB) more effectively?

34. CoC Identified Concerns. • Multiple Standards covering the same activity • Duplication of requirements set by other organizations. • Limited explanation of intent/expectations. • Problems measuring compliance. • Limited focus on outcomes. • Micromanagement of processes.

35. Growth and Development. • Count on Periodic Updates and Modifications. • Probably every several (5-7) years. • Done through the work and contributions of “expert” committees from all appropriate disciplines. • Taking into account the advances in knowledge in the field of Oncology at all levels.

36. Something to think about! • “It is not necessary to change, Survival is not mandatory.” W. Edwards Deming

37. Current Standards. • Divided into 8 chapters. • Some chapters have as few as one Standard (Chap 1) • Some as many as eleven. (Chap.2). • Quick review of Standards. • You’ve covered and followed them well • But that was then and this is now

38. Cancer Program Standards 2012 Project • Five workgroups established (multiple organizations and disciplines involved) Category and Eligibility, Cancer Committee Activities, Clinical Management, Registry Operations, and Outcomes • Focus: • Continuum of care • Performance measurement and outcomes • Direct patient care benefit • Established a Wiki page for feedback and comments • Standards Pilot testing in 20% of accredited programs February through June, 2011(release final version July/August 2011) • Survey Savvy Programs in Chicago, Orlando, and Los Angeles • New standards implementation, January 1, 2012

39. An Interesting “Coming-Together”. • The 2012 CoC Standards. • Process actually began in Feb. 2010 • The ACoS’s Campaign to re-emphasize over-all surgical quality care. Feb. 2011 • “Inspiring Quality, Highest Standards, Better Outcomes.” David B. Hoyt, MD, FACS

40. The American College of Surgeons. “To serve all with skill and fidelity”

41. The CoC and Quality Improvement Fundamentals. • Substantial and accurate databases. • National Cancer Database • Accreditation and verification processes. • Annual (SAR Updates) and triennial (Survey) • Infrastructure for a continuous learning process. • Continuous quality improvement.

42. “Our goals will be to inspire and engage stakeholders across the health care continuum to join in the effort to improve quality using the most fundamental metric: Did the patient have the best outcome we could give him or her individual circumstances? We know when we focus on the patient we deliver better care, our patients heal faster, and we learn more.” David B. Hoyt, MD, FACS Executive Director, ACoS March 2011

43. Something else to think about! • “People don't resist change. They resist being changed!” Peter Senge

44. 2012 Major Changes in Standards • Cancer program categories • Eligibility requirements for all accredited programs • Patient centered standards: • Patient navigation • Psychosocial distress screening • Survivor care plans • Palliative care • Cancer risk assessment and genetic counseling

45. 2012 Major Changes in Standards • Cancer prevention and cancer screening initiatives • Quality of patient care • Studies of quality and outcomes • Cancer clinical trials

46. The 2012 Standards and the Quality Imperative • Not a repeat of Dr. Greene’s earlier, excellent review of the 2012 Standards. • Let’s now focus on how certain of the new Standards enhance the move to: QUALITY CARE in CANCER

47. Program Management Section. • 1.1 Physician Credentialing. • Board Certification or moving toward it in the five key specialties. • 1.3 Cancer Committee Attendance. • 50% for required members. • 75% attendance of required members will earn a commendation.

48. Program Management Section. • Std. 1.5 Establish at least 1 clinical and 1 programmatic goal annually - evaluate and report on each to CC at least 2x annually.

49. Program Management Section. • Std. 1.6 Cancer Registry Quality Control Plan • Physician review of randomly selected analytic cases looking at: • Abstracting timeliness. • Case finding. • Accuracy of abstracted data. • 15% random review instead of 10%.

50. Program Management Section. • Std. 1.9 The CC develops and implements a process to screen patients to determine eligibility for available cancer-related clinical trials. • A Clinical Trials Coordinator or Representative is appointed. • Must report to the Cancer Comm. at least annually.