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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.

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Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective

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  1. 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

  2. Objectives of the Presentation • Identify the survey participants role in the survey process • Learn now to stay prepared for survey • Provide the necessary survey documentation • Identify what to document

  3. Sample Survey Agenda 8:00 am Surveyor meets cancer team 10:00 am Tour the facility & campus* 12:00 pm Attend tumor board/cancer conf * 1:00 pm Cancer registry 2:30 pm Surveyor private time 3:00 pm Summation with cancer team members • Required activity. Tour required if applicable to program & category. Minimum 6 hour visit

  4. Day 1 8:00 am Meet with Administrators 8:30 am Meet with Cancer Team 11:00 am Tour the facility & campus* 12:00 pm Attend tumor board/cancer conf * 1:00pm Chart Review* 2:30 pm Cancer registry Day 2 8:00am Tour second facility* 9:00am Chart Review * 10:30am Surveyor team private time 11:00am Summation with Cancer Team members Sample Survey Agenda for a Network * Required activities. Chart review must be done for each facility, but only 2 must be visited.

  5. Required members Cancer Committee Chair Member of Administration or Representative Cancer Liaison Physician (Community Outreach Coordinator) Cancer Conference Coordinator Quality Improvement Coordinator Cancer Registrar Quality Control of Cancer Registry Data Coordinator Recommended members* Oncology Nursing Rehabilitative Services Pastoral Care Research Nurse or Data Manager Social Services or Discharge Planning Dietary/Nutritional Services Pain Control/Palliative Care Physician or Specialist Pharmacy Hospice Public Education The Cancer Team • * Applicable to program & category.

  6. Medical Chart Review • 25 cases • Verifying • Abstracting timeline (≤ 6 months) • CAP protocols • AJCC stage complete (T, N, M, & Stage Group) • Who staged the case? • Follow-up date

  7. Documents* to Provide Surveyor • Documents provided in advance to surveyor • Documents made available to surveyor • May be sent in advance *All documents are sent to Chicago for shredding Refer to page 7 of Commission on Cancer Cancer Program Standards 2004 for a complete list.

  8. Documents Provided in Advance • Institution’s Accreditation Certificate or letter from accrediting body • Bylaws, policies, etc • Designate responsibility & accountability of Cancer Committee

  9. Documents Provided in Advance • Cancer Committee minutes • Attachments • Subcommittees or work group minutes • Annual goals • Time frame for evaluation & completion • Coordinator’s responsibilities continued…

  10. Documents Provided in Advance • Cancer conferences/tumor boards • Annual frequency & format • Multidisciplinary attendance • Annual case presentations • Monitoring of cancer conference(s) activity & corrective action continued…

  11. Documents Provided in Advance • Outcomes analysis • Results • Methods of analysis • Annual report (if published) continued…

  12. Documents Provided in Advance • Documentation of referred radiation oncology services & resources* • Documentation that identifies the medical oncology unit/functional equivalent (if applicable)* • Physician staging policy/procedure* *CoC Website -- Resources & Tools for Cancer Programs continued…

  13. Documents Made Available (optional to send) • Annual quality control activities • Current credentialing of registry staff (NCRA CTRs) • Case abstracting by a CTR or data supervision responsibilities by a CTR • Organizational chart for nursing • …… Refer to page 7 of Commission on Cancer Cancer Program Standards 2004 for a complete list.

  14. Eight Areas of Evaluation • Institutional & Programmatic Resources • Cancer Committee Leadership • Cancer Data Management & Cancer Registry Operations • Clinical Management • Research • Community Outreach • Professional Education & Staff Support • Quality Improvement

  15. Chapter 1: Institutional & Programmatic Resources • Purpose • Confirms accreditation • Standard 1.1 • State licensure acceptable

  16. Chapter 2: Cancer Committee Leadership • Purpose • Establish cancer committee responsibility & accountability • Highlighted changes • Standard 2.2 - Multidisciplinary membership • Standard 2.3 - Activity coordinators • Standard 2.4 - Meeting schedule & structure

  17. Chapter 2: Cancer Committee Leadership • Highlighted changes • Standard 2.5 - Annual goals & objectives • Clinical • Community outreach • Quality improvement • Programmatic

  18. Chapter 2: Cancer Committee Leadership • Standard 2.6 – Cancer conf frequency • Standard 2.7 – Multidisciplinary attendance • Standard 2.8 – Number of cases presented • Standard 2.9 – Cancer Comm monitors & evaluates • Frequency* & attendance • Total & prospective case presentation *Recommendations for frequency & format based on category

  19. Chapter 2: Cancer Committee Leadership • Highlighted changes • Standard 2.10 - Cancer registry quality control plan • Standard 2.11 - Analyze & report outcomes* • Committee selected site & outcome • Committee selected dissemination • Commendation defined *Commendation available

  20. Chapter 3: Cancer Data Management & Cancer Registry Operations • Purpose • Ensure accurate & timely data collection • Highlighted changes • Standard 3.1 - CTR case abstracting • Standard 3.3 - Abstracting timeliness* • Standards 3.4, 3.5 - Follow-up • Cancer Registry Operations *Commendation available

  21. Chapter 3: Cancer Data Management & Cancer Registry Operations • Highlighted changes • Standard 3.6 - NCDB data submission • Standard 3.7 - NCDB data submission quality* • Standard 3.8 - CoC special studies • Cancer Registry Operations *Commendation available

  22. Policy / Procedure Case accessions into the registry Cancer registry job description Case eligibility criteria Casefinding CoC data standards & coding instructions Confidentiality & release of information Data collection Dates of implementation or changes in policies or registry operations Follow-up procedures Maintaining & using the suspense file Quality control of registry data Staging systems used Registry Procedure Manual(s)

  23. Chapter 4: Clinical Management • Purpose • Identify minimum scope of clinical services • Highlighted changes • Standard 4.1 – Radiation services • Standard 4.2 – Inpatient medical oncology unit

  24. Chapter 4: Clinical Management • Standard 4.3 - AJCC staging* • Staging form in medical record required • Effective January 1, 2005 • Committee develops staging policy & procedure • Definition of managing physician • Placement of forms & acceptable completion methods • Quality control of completeness & accuracy • Resolution of differences *Commendation available

  25. Chapter 4: Clinical Management • Highlighted changes • Standard 4.4 - Oncology nursing knowledge & skills • Standard 4.5 - Nursing direction of the oncology unit or FE

  26. Chapter 4: Clinical Management • Standard 4.6 – Patient Management & Treatment Guidelines • CAP guidelines* • 90% of pathology reports • Random review of analytic cases • Is there a plan to implement & monitor CAP protocols documented in cancer committee minutes? • Standard 4.7 – Rehabilitation services *Medical record review

  27. Chapter 5: Research • Purpose • Promote clinical trial participation • Highlighted changes • Standard 5.1 - Cancer-related clinical trial information • Standard 5.2 - Cancer-related clinical trial accrual* • 2% to 10% requirement based on category *Commendation available

  28. Chapter 6: Community Outreach • Purpose • Ensure availability of supportive services, prevention, & early detection • Highlighted changes • New Cancer Liaison Physician role • Standard 6.1 - Supportive services • Standard 6.2 - Two prevention or early detection programs • Standard 6.3 - Monitor community outreach annually

  29. Chapter 7: Professional Education & Staff Support • Purpose • Promotes increased knowledge • Highlighted changes • Standard 7.1 - One cancer-related educational activity • Standard 7.2 - Registry staff cancer-related education* *Commendation available

  30. Chapter 8: Quality Improvement • Purpose • Evaluate & improve the of quality of cancer services, patient care & outcomes • Highlighted changes • Standard 8.1 - Studies of quality & outcomes • Number & type based on category • Year completed

  31. Chapter 8: Quality Improvement • Highlighted changes • Standard 8.2 - Improvements affecting patient care • 2 improvements* *Commendation available

  32. Bylaws Reporting to Cancer Committee Job Descriptions for Coordinators AJCC Staging Policy Quality Improvement & Assurance Clinical Management Treatment Guidelines Resource List Clinical Trials Information Community Outreach Helpful Tools Available on the Web -Sample Best Practices* *Located on Commission on Cancer web site.

  33. Helpful Tools Available on the Web* • Cancer Program Tracking Tools • AJCC Staging Quality Control Tool • Cancer Registry Abstracting Quality Control tool • Cancer Conference Grid • Pathology Report Quality Control Tool • Program Activity Template • Study of Quality Commission on Cancer web site

  34. Cancer committee leadership (2.2, 2.3, 2.4, 2.5) Conference activity (2.6, 2.7, 2.8) Outcomes analysis (2.11) CTR Abstracting (3.1) Abstracting backlog (3.3) Treatment services (4.1, 4.2) AJCC staging (4.3) Nursing care (4.4, 4.5) Patient guidelines (4.6) Rehabilitation (4.7) Research (5.1, 5.2) Community Outreach (6.1, 6.2, 6.3) Education (7.1, 7.2) Quality Improvement (8.1, 8.2) Survey Application Record (SAR) Annual Updates

  35. Thank you to the Commission on Cancer for some of the slides • Asa Carter (312) 202-5180 • acarter@facs.org • Vicki Chiappetta (312) 202-5288 • vchiappetta@facs.org • Lisa Landvogt (312) 202-5314 • llandvogt@facs.org

  36. QUESTIONS?

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