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Eligibility STRUCTURE E1: Facility Accreditation E2: Cancer Committee Authority St. Luke’s Episcopal Hospital Cancer Committee Responsibilities Commission on Cancer – 2012 Standards 2012 Responsible Status Brief Description of Standard E Walker contacted Lisa Bush– Inquiry about renewal Obtaining a copy of any updated accreditation past 6/2012. The program is accredited by a recognized federal, state, or local authority appropriate to the facility type. DNV Accreditation expiration 6/11/2012 E Walker consulting with Medical Director, then will update with Med Staff Services Copy of Bylaws 2011 on file - Need to update and add “goal setting” to Purpose M Cassity, coordinator, Tumor Boards Updated to 2012 standards and presented to Feb 15 2012. Approved 2-15-12 Cancer Committee. Cancer committee authority is established and documented by the facility. Committee: goal setting, planning, initiating, implementing, evaluating and improving cancer related activities. In St. Luke’s Medical Staff Bylaws/ Organization Manual, p. 6, 2011. Need to add “goal setting” to the Purpose. Cancer conference policy or procedure is used to establish the annual cancer conference activity. Tumor board grid for 2011 presented to 2-15-12 Cancer Committee and approved. N McClure, RN, OCN, MBA Nursing policies current and updated. C Ahlschlager, CTR Updating of manual in progress. V Baron, BS, RN, Director, Oncology Service Line Verify that all diagnostic services for oncology patients follow policies and procedures to guide safe performance of diagnostic exams Provide documentation that radiation treatment service locations are currently accredited by recognized authority and follow standard QA practices**, ***. E3: Cancer Conference Policy E4: Oncology Nurse Leadership E5: Cancer Registry Policy and Procedure SERVICES E6: Diagnostic Imaging V Baron, BS, RN, Director E7: Radiation Oncology Services A nurse provides leadership for oncology patient care across the care continuum. (Document standards and guidelines of Oncology Nursing Society, etc/ and hospital policies current.) Cancer Registry policy and procedure manual is used and specifies that current CoC data definitions and coding instructions are used to describe all reportable cases. See p. 35-36 CoC 2012 Standards manual. CoC wants as documentation the current Table of Contents of the policy and procedure manual. Policies for Cancer Committee Approval: Quality Control of Registry Data and AJCC and Collaborative Stage staging polices being updated for presentation to Cancer Committee for approval. All diagnostic services for cancer patients will be listed in the Survey Application Record. (Version 2009 still in the CoC SAR site) Accrediting organization include: American College of Radiology (ACR), American Society for Radiation Oncology (ASTRO), and American College of Radiation Oncology (ACRO). **Machine Specific QA Practices: Annually the program provides a copy of the certificate of accreditation, attestation letter, or documentation that describes the patient-specific and machine specific QA practices in radiation oncology for preferred location ***Patient Specific QA Practices: Patient identification verified by 2 independent methods at beginning of encounter; patient-specific QA is done before initiation of IMRT; independent check of dose calculation done for every new or changed treatment before started. E8: Systemic Therapy Services N McClure, BN, RN, MBA, OCN, Inpatient Oncology Nurse Manager and S. Ervin, RN, OCN, Outpatient Oncology Nurse Manager S Seributra, RN; L Camacho, MD E9: Clinical Trial Information C. White, LMSW-AP, CCM E10: Psychosocial Services L. Stacks, PT E11: Rehabilitation Services J. Koetting, RD E12: Nutrition Services Need documentation of 3 Essential Features: 1. Nursing staff trained for specialized care 2. Facilities equipped to provide the care 3. Distinct set of policies or procedures to guide nursing care of cancer patients receiving systemic therapy. Procedure “Guidelines for Patient Access to Clinical Cancer Research Trials 2012” approved at 2-15-12 Cancer Committee. Policy or procedure is in place to ensure patient access to psychosocial services either on-site or by referral. Policy or procedure is in place to access rehab services on site or by referral. Policy or procedure is in place to ensure patient access to nutrition services on site or by referral. Need verification/ documentation that all policies and procedures for administration of chemotherapy, etc., are updated and current; need documentation that nurses follow all standards and guidelines of the ONS, ASCO, or NCCN or other national organization are followed. Proof of annual certifications and training (in services). Update policy for providing research information to patients for presentation to Cancer Committee for approval (annually). Stock the patient education libraries and keep the Cancer Center website update with references to research. Documentation needed. Program provides to CoC a copy of the facility-wide or cancer program policy or procedure that ensures access to psychosocial services and identifies the psychosocial services provided on site or by referral. (See Policy Manager on The Source) Documentation required. Policies are in place. (See Policy Manager on The Source) Documentation required. Policies are in place. (See Policy Manager on The Source) Standard 1 – Program Management Standard 1 Standard 1.1 Physician Credentials Standard 1.2 Cancer Committee Membership Responsible E Walker, coordinator cancer program. Dr. Camacho and Cancer Committee appoint Coordinators at the Feb 15 Cancer Committee. Also, welcome new members from physical therapy, dietary, and integrative medicine. Status Cancer Program does have the total numbers of each board certified specialty that was entered into the last Survey Application Record (SAR). Cancer Program will obtain proof of board certification from Med Staff Services or by contacting the physicians. Medical Staff Bylaws do specify to a certain degree. (See Bylaws, Section 3.3 Qualifications and Obligations of Membership/ 3.3.1 General.) E Walker contacted the Med Staff Services office (Robert Sabino) to obtain documentation of board certification of required board certification specialties and others. Sent list of physicians in all specialties in addition to the required specialties to Med Staff Services-2/20/12 Per St. Luke’s Medical Staff Bylaws, the Chief of the Medical Staff has appointed the recommended and required physicians to the Cancer Committee. Medical Director has appointed required non-physicians to the Cancer Committee. Coordinators appointed and approved at the 2-15-12 Cancer Committee (except for the Psychosocial Services Coordinator). The Psych Services Coordinator will be nominated and appointed at the April Cancer Committee Brief Description of Standard Diagnostic and treatment services are provided by or referred to physicians who are currently board certified in their general specialty or are in the process of becoming board certified. Documentation required: A copy of the medical staff bylaws that address current board certification of physicians or provides a roster of physicians in the listed cancer care specialties with documentation of board certification. 2/22/12 – List of physicians in oncology related specialties and those “required” sent to Med Staff Services for confirmation of board certification in their respective medical specialties. Membership of cancer committee is multidisciplinary, representing physicians from the diagnostic and treatment specialties and non-physicians from administrative and supportive services. Coordinators for specific areas of the cancer program mission are designated from the membership. Coordinators from Cancer Committee include: Cancer Conference Coordinator Quality Improvement Coordinator Cancer Registry Quality Coordinator Community outreach Coordinator Clinical Research Representative/ Coordinator Psychosocial Services Coordinator meeting. Option: Appoint genetics professional/counselor (but not necessary since this service is not offered on-site) Contact American Cancer Society and invite a staff representative to be on the committee. Standard 1.3 Cancer Committee Attendance E. Walker will compile questions about the new Standards and contact the CoC for answers. Minutes document attendance at each meeting. Send reminders/calendars for meetings. Cancer Committee members monitor attendance. Contacted the CoC and learned that this standard means that each individual member must attend 50% of meetings for the program to meet the standard or 75% of the meetings for the program to be awarded commendation. 35 members attended the first meeting of 2012. Each required member attends at least 50% of the cancer committee meetings held during any given year. (75% attendance for commendation.) Required members: diagnostic radiologist, pathologist, surgeon, medical oncologist, radiation oncologist, Cancer Liaison Physician, cancer program administrator, oncology nurse, social worker or case manager, certified tumor registrar (CTR), performance improvement or quality management representative, palliative care team member, clinical research representative, (if on-site) genetics professional/counselor), rehabilitation representative. All required members were in attendance at the 2/15/12 meeting. Valid excused absences and use of teleconference for some. Ms. Walker will find a larger meeting room, possibly DAC C-018/C-088 for the rest of 2012. Standard 1.4 Cancer Committee Meetings E. Walker schedules meetings following CoC Standards 2012. Medical Director monitors. St. Luke’s Cancer Committee meets 6 times a year and meeting fall within the calendar quarters. (August meeting may move to July due to Conf Room closures in Aug-Sept). Update: August meeting will remain in August and take Each year, the cancer committee meets at least once each calendar quarter. Note: The Oncology Collaborative Practice Team is the quality management and improvement sub-committee. Also, the new 2012 Standards will be monitored through this committee, unless it appears there needs to be a separate sub-committee on the new standards. An anticoagulation sub-committee meets when required only. Special Note: Compliance is based on meetings held Standard 1.5 Cancer Program Goals Medical Director & Cancer Committee Members-document in minutes. Integrative Care Project Linda Cole V. Baron, Oncology Service Line Nutrition Service/ Dietitians place in DAC C-018/C088— confirmed through St. Luke’s Conference Center. Two goals were discussed at the Dec. 14, 2011 Cancer Committee. Goals were reintroduced at the Feb. 15 meeting: Clinical Goal: Oncology and Integrative Care Project on 20 Tower, Inpatient Programmatic Goal: Provide more nutritional services through a dietitian devoted to oncology inpatients and outpatients . Provide a supplement guide to nutrition for cancer patients. quarterly and not on the total number of meetings held each year. Each year, the cancer committee establishes, implements, and monitors at least 1 clinical and at least 1 programmatic goal for the endeavors related to cancer care. Each goal is evaluated at least twice annually. The evaluation is documented in cancer committee minutes. Goals cannot be a restatement of a CoC standard. Goals are to be established at the beginning of each year and evaluated mid-year and end of year. The Cancer Committee at the 2/15/12 meeting approved the clinical goal and the programmatic goal. Standard 1.6 Cancer Registry Quality Control Plan Standard 1.7 Monitoring Conference Activity C. Ahlschlager, CTR, and Dr. Laura Sulak, Quality Control of Cancer Registry Physician Coordinator Updating quality control plan and activities. Continuing to monitor random samplings. The cancer committee establishes and implements a plan to annually evaluate the quality of cancer registry data and activity. The plan includes procedures to monitor and evaluate each component. (See list on page 48-49 of Standards). Cancer Registrar and Physician Coordinator will continue reports to Cancer Committee and continue monitoring. M. Cassity and Dr. Escudier, Cancer Conference Coordinator Routine evaluation of cancer conferences/tumor boards in these 7 areas: Conference frequency Multidisciplinary attendance The cancer conference coordinator monitors and evaluates the cancer conference activities and reports findings to the cancer committee at least annually. Standard 1.8 Monitoring Community Outreach Lawrence Foote, MD, Community Outreach Coordinator, and E Walker, Coordinator of Cancer Program Total case presentation Prospective case presentation Discussion of stage, prognostic indicators, treatment planning with evidence-based guidelines Options for clinical trials Adherence to conference policy (May discuss genetic testing, palliative care, psychosocial care and rehab services) St. Luke’s Tumor Board Procedures for Frequency and Format 2012 were approved by the 2/15/12 Cancer Committee. The Final Summation of the 2011 Tumor Board Grid was approve by the Cancer Committee on 2-15-12. Provide written report on screening needs of the community. Provide schedule of prevention/early detection/screening activities. Contacting American Cancer Society to provide representative to St. Luke’s (and Cancer Committee), plus continue programs such as Reach to Recovery, Transportation program, Look Good, Feel Better, Strides Against Breast Cancer, etc. The community outreach coordinator monitors the effectiveness of community outreach activities on an annual basis. The activities and findings are documented in a community outreach activity summary that is presented to the cancer committee annually. Responsibilities of community outreach coordinator: Director of the program’s outreach department or A staff member of the program’s outreach department (must be affiliated or employed by the program). Coordinator duties: Contribute to development of community outreach activities Work with community outreach organizations such as American Cancer Society/ CanCare Provide prevention and early-detection/ screening programs reflecting the needs of the community Ensure prevention and early-detection/screening On agenda for April 18 meeting: 1. Outline of community outreach activity summary report: community need, activity, summary of effectiveness 2. Documentation for providing a skin cancer screening— reflecting the need of the community. 3. Approve skin cancer screening follow-up policy for all positive findings 4. Plan on evaluating effectiveness of access and referral processes. Standard 1.9 (Phase in for 2015) Clinical Trial Accrual Sopar Seributra, RN, CCRP, oncology research nurse coordinator and Dr. Camacho, director of cancer research The Guidelines for Patient Access to Clinical Cancer Research Trials 2012 was approved at the 2/15/12 Cancer Committee. 2011 Total Research Patient Accrual presented in the Cancer Program 2011 Achievements on 2/15/12 (Item 2/ Old Business section of the Minutes). In 2011, St. Luke’s had a 6.2% accrual of patients on clinical research trials. Standard 1.10 Clinical Educational Activity activities follow national guidelines Ensure mechanism in place for follow-up of all positive findings in screenings Evaluate effectiveness of access and referral processes **New: Create a community outreach activity summary report that outlines the activities provided, the results of outreach program and follow-up. Identify areas of community need, specific community outreach activities performed and summary of effectiveness of each activity. (Above reported in cancer program annual report.) As appropriate to the cancer program category, the required percentage of patients is accrued to cancerrelated clinical trials each year. The clinical trial coordinator or representative reports clinical trial participation to cancer committee each year. For Academic Comprehensive Cancer Program: A screening process is in place to identify patient eligibility. Cancer Committee evaluates and assesses the clinical trial screening process to identify and address barriers to patient participation Identified areas in need of improvement are addressed and follow-up action plan developed. Minimum number of patient entered in clinical trials if 6% of annual analytic accession. (Meet the Standard). Whereas 8% or over earns commendation rating. Document patient accrual to cancer-related clinical trials in the Cancer Committee minutes each year. Each year the cancer committee offers at least 1 cancerrelated educational activity, other than cancer conferences, to physicians, nurses, and other allied health professions. The activity is focused on the use of AJCC or other Standard 1.11 Cancer Registrar Education Standard 1.12 Public Reporting of Outcomes appropriate staging in clinical practice, which includes the use of appropriate prognostic indicators, and evidencebased national guidelines used in treatment planning. Each year, all members of the cancer registry staff participate in 1 cancer-related educational activity other that cancer conferences. Education can be at local, state, regional or national level. Applies to full-time, part time, and contract registrars. All CTR attend one national or regional cancer-related meeting once during the 3-year survey cycle. Each year, the cancer committee develops and disseminates a report of patient or program outcomes to the public. The content of the report includes outcome information on 1 or more of the following standards: Standard 4.1 Prevention; Standard 4.2 Screening; Standard 4.4 Accountability Measures; Standard 4.5 Quality Improvement Measures; Standard 4.6 Assessment of Evaluation and Treatment Planning; Standard 4.7 Studies of Quality; and Standard 4.8 Quality Improvements.