Commission on Cancer Standards: Staying Prepared

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Commission on Cancer Standards Staying Prepared
A Surveyors Perspective
Suzanna S. Hoyler, CTR Director, WCI Information
Management Washington Hospital Center Washington,
DC COC Network Surveyor
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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

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Sample Survey Agenda

• 800 am Surveyor meets cancer team
• 1000 am Tour the facility campus
• 1200 pm Attend tumor board/cancer conf
• 100 pm Cancer registry
• 230 pm Surveyor private time
• 300 pm Summation with cancer team members

• Required activity. Tour required if applicable to
  program category.
• Minimum 6 hour visit

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Sample Survey Agenda for a Network

• Day 1
• 800 am Meet with Administrators
• 830 am Meet with Cancer Team
• 1100 am Tour the facility campus
• 1200 pm Attend tumor board/cancer conf
• 100pm Chart Review
• 230 pm Cancer registry

• Day 2
• 800am Tour second facility
• 900am Chart Review
• 1030am Surveyor team private time
• 1100am Summation with Cancer Team members

Required activities. Chart review must be done
for each facility, but only 2 must be visited.
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The Cancer Team

• 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

• Applicable to program category.

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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

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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.
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Documents Provided in Advance

• Institutions Accreditation Certificate or letter
  from accrediting body
• Bylaws, policies, etc
• Designate responsibility accountability of
  Cancer Committee

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Documents Provided in Advance

• Cancer Committee minutes
• Attachments
• Subcommittees or work group minutes
• Annual goals
• Time frame for evaluation completion
• Coordinators responsibilities

continued
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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
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Documents Provided in Advance

• Outcomes analysis
• Results
• Methods of analysis
• Annual report (if published)

continued
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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
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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.
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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

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Chapter 1 Institutional Programmatic Resources

• Purpose
• Confirms accreditation
• Standard 1.1
• State licensure acceptable

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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

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Chapter 2 Cancer Committee Leadership

• Highlighted changes
• Standard 2.5 - Annual goals objectives
• Clinical
• Community outreach
• Quality improvement
• Programmatic

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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
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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
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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
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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
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Registry Procedure Manual(s)

• 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

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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

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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
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Chapter 4 Clinical Management

• Highlighted changes
• Standard 4.4 - Oncology nursing knowledge
  skills
• Standard 4.5 - Nursing direction of the oncology
  unit or FE

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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
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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
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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

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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
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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

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Chapter 8 Quality Improvement

• Highlighted changes
• Standard 8.2 - Improvements affecting patient
  care
• 2 improvements

Commendation available
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Helpful Tools Available on the Web - Sample Best
Practices

• 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

Located on Commission on Cancer web site.
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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
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Survey Application Record (SAR) Annual Updates

• 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)

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Thank you to the Commission on Cancer for some of
the slides

• Asa Carter [phone]
• acarter_at_facs.org
• Vicki Chiappetta [phone]
• vchiappetta_at_facs.org
• Lisa Landvogt [phone]
• llandvogt_at_facs.org

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QUESTIONS?