commission on cancer standards: staying prepared – a surveyor’s perspective

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*

12:00 pm12:00 pm Attend tumor board/cancer conf *Attend tumor board/cancer conf *

1:00 pm1:00 pm Cancer registryCancer registry

2:30 pm2:30 pm Surveyor private timeSurveyor private time

3:00 pm3:00 pm Summation with cancer team membersSummation with cancer team members

•Required activity. Tour required if applicable to program & category.

Minimum 6 hour visitMinimum 6 hour visit

Sample Survey Agenda for a Sample Survey Agenda for a Network Network Day 1Day 1

8:00 am8:00 am Meet with AdministratorsMeet with Administrators

8:30 am 8:30 am Meet with Cancer TeamMeet with Cancer Team

11:00 am11:00 am Tour the facility & Tour the facility & campus*campus*

12:00 pm12:00 pm Attend tumor Attend tumor board/cancer conf *board/cancer conf *

1:00pm1:00pm Chart Review*Chart Review*

2:30 pm2:30 pm Cancer registryCancer registry

Day 2Day 2

8:00am8:00am Tour second Tour second facility*facility*

9:00am9:00am Chart Review *Chart Review *10:30am10:30am Surveyor team Surveyor team

private timeprivate time11:00am11:00am Summation with Summation with

Cancer Team Cancer Team membersmembers

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

The Cancer TeamThe Cancer Team

Required membersRequired members– Cancer Committee ChairCancer Committee Chair– Member of Administration or Member of Administration or

RepresentativeRepresentative– Cancer Liaison Physician Cancer Liaison Physician

(Community Outreach (Community Outreach Coordinator)Coordinator)

– Cancer Conference Cancer Conference CoordinatorCoordinator

– Quality Improvement Quality Improvement CoordinatorCoordinator

– 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.

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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


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

Coordinator’s responsibilitiesCoordinator’s responsibilities

continued…


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…


Outcomes analysisOutcomes analysis– ResultsResults– Methods of analysisMethods of analysis– Annual report (if published)Annual report (if published)

continued…


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)*

Physician staging policy/procedure*Physician staging policy/procedure*

*CoC Website -- Resources & Tools for Cancer Programs continued…

Documents Made Available Documents Made Available (optional to send)(optional to send)

Annual quality control activitiesAnnual quality control activities

Current credentialing of registry staff Current credentialing of registry staff (NCRA CTRs)(NCRA CTRs)

Case abstracting by a CTR or data Case abstracting by a CTR or data supervision responsibilities by a CTRsupervision responsibilities by a CTR

Organizational chart for nursing Organizational chart for nursing

…………Refer to page 7 of Commission on Cancer Cancer Program Standards 2004 for a complete list.

Eight Areas of EvaluationEight Areas of Evaluation

Institutional & Programmatic ResourcesInstitutional & Programmatic ResourcesCancer Committee LeadershipCancer Committee LeadershipCancer Data Management & Cancer Registry Cancer Data Management & Cancer Registry OperationsOperationsClinical ManagementClinical ManagementResearchResearchCommunity OutreachCommunity OutreachProfessional Education & Staff SupportProfessional Education & Staff SupportQuality ImprovementQuality Improvement

Chapter 1: Institutional & Chapter 1: Institutional & Programmatic ResourcesProgrammatic Resources

PurposePurpose– Confirms accreditationConfirms accreditation

Standard 1.1Standard 1.1– State licensure acceptableState licensure acceptable

Chapter 2: Cancer Committee Chapter 2: Cancer Committee LeadershipLeadership

PurposePurpose– Establish cancer committee responsibility & Establish cancer committee responsibility &

accountabilityaccountability

Highlighted changesHighlighted changes– Standard 2.2 - Multidisciplinary membershipStandard 2.2 - Multidisciplinary membership

– Standard 2.3 - Activity coordinatorsStandard 2.3 - Activity coordinators

– Standard 2.4 - Meeting schedule & structureStandard 2.4 - Meeting schedule & structure


Highlighted changesHighlighted changes– Standard 2.5 - Annual goals & objectivesStandard 2.5 - Annual goals & objectives

ClinicalClinical

Community outreachCommunity outreach

Quality improvementQuality improvement

ProgrammaticProgrammatic


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


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

Committee selected disseminationCommittee selected dissemination

Commendation definedCommendation defined

*Commendation available

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


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


Registry Procedure Manual(s)Registry Procedure Manual(s)

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

Chapter 4: Clinical ManagementChapter 4: Clinical Management

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

unitunit


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

*Medical record review


Chapter 5: ResearchChapter 5: Research

PurposePurpose– Promote clinical trial participationPromote clinical trial participation

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


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

PurposePurpose– Promotes increased knowledgePromotes increased knowledge

Highlighted changesHighlighted changes– Standard 7.1 - One cancer-related Standard 7.1 - One cancer-related

educational activityeducational activity– Standard 7.2 - Registry staff cancer-related Standard 7.2 - Registry staff cancer-related

education*education*


Chapter 8: Quality ImprovementChapter 8: Quality Improvement

PurposePurpose– Evaluate & improve the of quality of cancer Evaluate & improve the of quality of cancer

services, patient care & outcomesservices, patient care & outcomes

Highlighted changesHighlighted changes– Standard 8.1 - Studies of quality & Standard 8.1 - Studies of quality &

outcomesoutcomesNumber & type based on categoryNumber & type based on category

Year Year completedcompleted

Chapter 8: Quality ImprovementChapter 8: Quality Improvement

Highlighted changesHighlighted changes– Standard 8.2 - Improvements affecting Standard 8.2 - Improvements affecting

patient carepatient care2 improvements*2 improvements*


Helpful Tools Available on the Web Helpful Tools Available on the Web -- Sample Best Practices*Sample Best Practices*

BylawsBylaws

Reporting to Cancer Reporting to Cancer CommitteeCommittee

Job Descriptions for Job Descriptions for CoordinatorsCoordinators

AJCC Staging PolicyAJCC Staging Policy

Quality Improvement Quality Improvement & Assurance& Assurance

Clinical ManagementClinical ManagementTreatment Guidelines Treatment Guidelines Resource ListResource ListClinical Trials Clinical Trials InformationInformationCommunity OutreachCommunity Outreach

*Located on Commission on Cancer web site.

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)

Conference activity (2.6, Conference activity (2.6, 2.7, 2.8)2.7, 2.8)

Outcomes analysis (2.11)Outcomes analysis (2.11)

CTR Abstracting (3.1)CTR Abstracting (3.1)

Abstracting backlog (3.3)Abstracting backlog (3.3)

Treatment services (4.1, Treatment services (4.1, 4.2)4.2)

AJCC staging (4.3)AJCC staging (4.3)

Nursing care (4.4, 4.5)Nursing care (4.4, 4.5)

Patient guidelines (4.6)Patient guidelines (4.6)

Rehabilitation (4.7)Rehabilitation (4.7)

Research (5.1, 5.2)Research (5.1, 5.2)

Community Outreach (6.1, Community Outreach (6.1, 6.2, 6.3)6.2, 6.3)

Education (7.1, 7.2)Education (7.1, 7.2)

Quality Improvement (8.1, Quality Improvement (8.1, 8.2)8.2)

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

Asa Carter (312) 202-5180Asa Carter (312) 202-5180– [email protected]@facs.org

Vicki Chiappetta (312) 202-5288Vicki Chiappetta (312) 202-5288– [email protected]@facs.org

Lisa Landvogt (312) 202-5314Lisa Landvogt (312) 202-5314– [email protected]@facs.org

mailto:[email protected]



QUESTIONS?QUESTIONS?

commission on cancer standards: staying prepared – a surveyor’s perspective

Documents

cancer standards

cancer team10

cancer team11

survey processlearn

facility campus

documentsample survey

program category

survey participants