Download CC Responsibilities 2012 - Eligibility Standards

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.