Download Regulations for Cancer Care Quality Assurance Measures

Regulations for Cancer Care Quality Assurance Measures
Article 1
These regulations are enacted pursuant to Paragraph 2, Article 15 of the Cancer
Control Act.
Article 2
The medical institutions of cancer control as indicated in these regulations refer
to hospitals, with 100 or more beds to provide cancer screening, diagnosis, and
treatment.
Article 3
Medical institutions of cancer control shall provide cancer patients with the
services of cancer prevention, screening, diagnosis, treatment, rehabilitation,
patient support, surveillance, and hospice and palliative care. If any of these
services are not available, the institutions shall have a referral system providing
a referral service.
Article 4
Medical institutions of cancer control shall set up a cancer care quality team,
composed of multidisciplinary departments, including medical and
administrative departments, which specialize in cancer care. The tasks of such a
team are as follows:
1.
To plan, supervise and evaluate cancer projects within the institution.
2.
To establish annual major tasks, objectives, priorities in order, executive
strategies and related mechanisms for cancer projects.
3.
To supervise the management of cancer registry databases.
4.
To develop a peer review mechanism within the institution in order to
evaluate the quality of cancer treatment and care.
5.
To review and analyze the results of cancer treatment and publish reports
of cancer treatment and care every year.
The cancer care quality team shall draw up an appropriate meeting
schedule and format.
Article 5
Medical institutions of cancer control shall establish a cancer registry database,
which includes cancer occurrences, diagnoses and treatment, and surveillance.
The data shall be analyzed and reported every year.
The data collection for the aforementioned database shall be implemented by
qualified cancer registry technicians who are officially employed by the
institutions and certified by the central competent health authority.
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The institutions shall employ a minimum of 0.5 cancer registry technicians for
every 750 new diagnosed cancer cases each year.
The institutions shall complete the cancer registry for each individual case
within one year since the case is confirmed, and report the data to authorized
academic research organizations in accordance with the contents, formats, and
timelines stipulated by the central competent health authority.
Article 6
The data collection, processing, protection, and utilization for the cancer registry
database shall be implemented in accordance with the following guidelines:
1. The supervision and management of the database are the responsibilities of
physicians who shall develop standard operational procedures and
handbooks for data collection, processing, and protection. The standard
operational procedures shall be implemented accordingly.
2. Operational guidelines shall be drawn up for relevant personnel within the
institutions to access cancer registry database.
3. Regulations for the review of cancer registry database shall be prescribed to
examine the accuracy and completeness of cancer stages and other registered
information.
Article 7
Medical institutions of cancer control shall regularly follow up their cancer
patients whose cancer information is recorded in the database. The follow-up
rate of at least 70% of cancer survival cases shall be maintained.
Cases that cannot be followed up within 15 months are defined as missing cases,
whose proportion of total cases shall be less then 30% and detailed in written
reports.
Article 8
Each year, cancer care quality teams or committees shall randomly select at least
10% of cancer cases for information review, and prepare written reports on
review procedures, methods, and results.
Article 9
Medical institutions of cancer control shall stipulate a treatment guide for
various types of cancer, and the following integrated and continuous cancer
treatment and care shall be given by multidisciplinary medical teams:
1. Psychological counseling, social work, spiritual care.
2. Oncology nursing, pain control.
3. Nutrition, health education, and drug information.
4. Rehabilitation.
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5. Transitional service upon discharge from hospital.
6. Hospice and palliative care or home care services.
7. Information on patient support groups.
Article 10
Medical institutions of cancer control shall provide individualized treatment
plans and assign designated physicians to take in charge of the following tasks:
1. To be in charge of integrating and coordinating the cancer treatment and
care provided by the medical teams, and regularly report the treatment
progress at the multidisciplinary medical team meetings.
2. To precisely record information on the clinical and pathological cancer
stages and treatment and care process of cancer patients, and regularly
summarize the progress and treatment plan in patients’ medical records.
Article 11
Medical institutions of cancer control shall establish an appropriate meeting
schedule for multidisciplinary medical teams. The meeting hours may be
recorded as continual education credits or hours within the institutions.
The meetings of multidisciplinary medical teams shall be recorded, including
the meeting place, date, list of participants and their expertise. In addition, such
record shall clearly indicate whether the case discussed is a pre-evaluation or a
post-report.
Article 12
Cancer care quality teams or committees shall stipulate an annual quota for the
multidisciplinary medical teams to propose case discussions for different
cancers. Among the cases, there should be at least 50% cases discussed with
respect to problem solving, pre-treatment evaluations, and cancer staging
determination or treatment strategies.
Article 13
Medical institutions of cancer control shall improve and implement the record of
cancer staging information through the multidisciplinary medical team meetings.
Article 14
Medical institutions of cancer control shall allow patients and their family
members to thoroughly understand the examination results and treatment
options; provide patient-centered treatment and care; and establish a mechanism
for the patients and their family members to participate in the decision-making
process with regard to the treatment.
Article 15
Medical institutions of cancer control shall establish quality assurance projects
for the following units and administer them accordingly to meet the purposes of
quality improvement:
1. Pathology units.
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2. Radiotherapy units.
Article 16
Medical institutions of cancer control shall conduct pathological tests on all
surgically removed organs, tissue, and cytological specimens. Clinical
physicians shall provide related clinical information as a reference for
pathological tests when submitting the specimens.
Histopathologic reports shall provide sufficient information for the reference of
clinical physicians, regarding treatment or cancer staging determination.
Article 17
Medical institutions of cancer control shall develop a mechanism for the security
monitoring and management of cancer patients’ treatment and care, and write up
reports or records for the following circumstances regarding patients’ safety:
1. Handling and disposal of cytotoxic substances.
2. Appropriate isolation for infection control and radiation protection.
3. Management of syringes and needles.
4. Treatment for oncologic emergencies.
5. Pain control.
Article 18
Medical institutions of cancer control shall provide nurses possessing required
professional knowledge and skills to take care of cancer patients and provide the
following guidelines for the nurses:
1. Handling of cytotoxic substances (including exosmosis, safe disposal and
destruction.)
2. Management of blood products.
3. The care of patients who are receiving radiotherapy and patients of
immunodeficient disorders.
4. Oncologic emergencies.
5. Pain control.
6. Health education for patients and their family members.
7. Radiation safety and protection.
8. Handling of symptoms and emergencies.
9. Intravenous administration.
10. Consent for non-administration of CPR.
11. Continuous improvement in the quality of care.
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Article 19
Medical staff in the medical institutions of cancer control shall possess
professional knowledge of hospice and palliative care. They shall also provide
cancer patients with hospice and palliative care such as necessary pain control
and symptom relief.
Article 20
Medical institutions of cancer control shall provide cancer patients and their
family members with sufficient information about cancer prevention, screening,
diagnosis, treatment, and hospice and palliative care.
Article 21
Medical institutions of cancer control shall establish designated units, and
appoint designated staff to conduct community health education and publicizing
plans, and work cooperatively with the Department of Health, health centers or
other relevant organizations.
Article 22
Medical institutions of cancer control shall provide a cancer public health
education plan. This plan shall include objectives, activities and strategies,
content of services, and result evaluation, and shall be reviewed and revised
annually.
Article 23
Medical institutions of cancer control shall provide the following services
according to the patients’ needs:
1. Nutrition or dietary education.
2. Cancer health education and intervention such as quitting smoking and betel
nut chewing, and vocational exposure to risk factors.
3. In coordination with governmental policies on cancer screening, taking an
initiative to provide cancer screening services to patients in the institution,
their family members, and community members.
Article 24
Medical institutions of cancer control shall establish a database of those at high
risk of cancer for cancer screening, surveillance, and research purposes in
accordance with the contents, format, and timelines prescribed by the central
competent health authority.
Article 25
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Medical institutions of cancer control shall provide education in cancer
prevention, diagnosis, treatment, hospice and palliative care, ethics, quality
review, communication skills and database management to the members of
cancer medical teams such as physicians, nursing staffs, other medical staff,
cancer registry technicians, and social workers etc, and establish a mechanism
for achievement evaluation.
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Article 26
Medical institutions of cancer control shall establish a cancer treatment quality
improvement plan, and develop a mechanism to monitoring the continuing
improvement of treatment quality.
This cancer treatment quality improvement plan shall involve many
professionals whose job responsibilities are clearly distinguished and recorded
in a written report.
Article 27
Each year, cancer care quality teams shall appoint two or more topical subjects
for further improvement, which shall be included in the quality improvement
plan.
Enhancing the survival rate of cancer patients shall be one of the major focuses,
and the survival rates shall be analyzed for different types of cancer annually.
Cancer care quality teams shall define one or more methods to measure the
quality of each subject, which require further improvement. Based on that, each
subject can be reviewed and evaluated to understand the achievement.
Article 28
Medical institutions of cancer control shall administer quality review activities
regarding the treatment and care of post-cancerous patients.
1. Control of physical symptoms.
2. The psychological, social, and spiritual needs of post-cancerous patients and
their family members.
Article 29
Medical institutions of cancer control shall participate in the following treatment
quality assurance projects held by the Department of Health, Executive Yuan.
1. Mammography.
2. Pap smear.
3. Colposcopy.
4. Pathology.
5. Hospice and palliative care.
Article 30
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These regulations shall come into force from the date of promulgation.
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