Download (Std 1.4) Helpful Tips for Cancer Committee Meeting Agendas and

Tips for Cancer Committee Meeting Agendas and Minutes
A clear agenda is an excellent tool for an effective meeting and can also provide an outline for well written committee minutes, which are essential
for documenting compliance to Commission on Cancer Standards.
1. Keep accurate attendance. Use a formal roll call or a member sign-in sheet at the meeting.
2. Time sensitive meetings: If a meeting is time sensitive, indicate the estimated number of minutes assigned to each topic.
3. Effective discussion: Create an agenda guide for the chairman and key committee members that indicates why an agenda topic is included
and what MUST be discussed and/or if a decision is needed.
4. Report responsibility: Indicate the committee member who is responsible for the meeting report/presentation.
5. Paper or no Paper: As appropriate, create handouts that are clearly marked for easy identification or create a power point that is concise.
6. CoC Standards: Indicate the corresponding standard definition or number to clarify an agenda item in the minutes.
7. Template for minutes: An agenda can easily be adapted to a format for minutes that includes a discussion summary and action plans. See
minutes template below.
8. Be prepared: Distribute the agenda prior to the meeting so the cancer committee members have a chance to review and add other items.
9. Note: Consent Agendas are not to be used for cancer committee meetings. The Program Review Subcommittee of the Commission on
Cancer made the ultimate decision to no longer accept Consent Agenda utilization because demonstrating compliance to the majority of the
standards needs to include documentation of discussion in the cancer committee meeting minutes. With those types of agendas, we were
seeing that the subsequent minutes were not documenting any review, attachment, or decision making in regards to the standards.
10. If there are attachments to the minutes that relate to a standard, the minutes need to state so and the attachments should be numbered or
lettered for clarity to the readers.
11. Clearly indicate what required members are present or if the person attending is the designated alternate and for who.
Cancer Committee Meeting Summary/Minutes
Monday, December 1, 2015 @ 2:00pm (CST)
(Check box if attended)
Cancer Committee Members (75% attendance required)
☒ [Name] – [Specialty/Role]
☒[Name] – [Specialty/Role]
☒[Name] – [Specialty/Role]
☐ [Name] – [Specialty/Role]
☒ [Name] – [Specialty/Role]
☐ [Name] – [Specialty/Role]
☒ [Name] – [Specialty/Role]**
☒ [Name] – [Specialty/Role]**
☒ [Name] – [Specialty/Role]
Additional Individuals in Attendance
☐ [Name] – [Specialty/Role]
** = Designated Alternate
AGENDA
TOPIC
Related
Standard/
ER
Call to Order
All
DISCUSSION
Meeting was called to order. Review and approval of August meeting Minutes.
General Announcements:
NA

[Insert here]

[Insert here]
Clinical Goal: [Insert goal here]
2016 Cancer

[Insert discussion and FU of goal here]
Program
Std.1.5
Programmatic Goal: [Insert goal here]
Goals

[Insert discussion and FU of goal here]
2015 Quality Improvement Follow-Up
(1) DCIS Receptor Study and Improvement Plan – Dr. [Name]
FU on 2015
Results: Positive - all case of DCIS had receptor studies performed. Negative - that
Quality Study
Std 4.7 & sometimes there was a delay (due to Pathologists not following the protocol). No one
& Quality
Std 4.8
individual was at fault, but we all have to try to do better.
Improvement
Improvement: If the excision/TM shows no residual disease, it is the responsibility of the
Pathologist signing out the excision/TM to order the receptor study on the core biopsy. The
delay in ordering the receptor studies will improve with Pathologists review of the protocol.
COC Standards and ER Review for 2015
Cancer Committee Membership: The required and recommended members were
Designating
discussed. With a few changes due to turn-over, discussion of re-appointments for an
CC
Std1.2
additional one-year term:
Coordinators
Cancer Committee Coordinators for 2014
Cancer Conference Coordinator – [Name]
RECOMMENDATION/
ACTION
Approved. No action
required.
Announcements
Discuss status at end of
year.
Discuss status at end of
year
 The QI will be
presented to the
hospital administration
leadership.
 Confirmation of
coordinators are
confirmed by CC
and documented
in minutes.
ER Review
ER2-ER4,
ER7
Cancer Registry Quality Coordinator – [Name]
Quality Improvement Coordinator – [Name]
Community Outreach Coordinator – [Name
Clinical Research Coordinator – [Name
Psychosocial Services Coordinator – [Name
ER2. The Cancer Committee is authorized by the By-Laws of the Medical Executive
Committee to oversee the cancer program.
ER3. The Cancer Conference Policy will remain the same for frequency, format,
composition, and attendance rates for 2014.
ER4. [Name] ONS, BSN provides leadership for oncology patient care and will oversee staff
competency testing this year.
ER7. Radiation Oncology Services are provided on-site and is an accredited program.
Policy & Procedure, Quality & Safety and Quality Assurance documents are maintained in
the dept.
Standard 1.4 Cancer Committee Meetings: Remain on current schedule (one per quarter).
 ER P&Ps will be
updated and dated, as
well as revised in CoC
Datalinks.
Standard 1.6 Cancer Registry Quality Control Plan: QCP for 2016. Cancer Registry will
come up with 1 or 2 additional measures at a staff meeting. The quality control procedure
remains the same for 2016; physician review to be reported at next meeting.
Standard 1.7 Monitoring Cancer Conference: Discussed with the membership the areas of
evaluation for conference.
Review and
Discuss CC
functions
Stds 1.4,
1.6, 1.7,
1.8, 1.10,
1.12; 4.1,
4.6-4.8
Standard 1.8 Monitoring of Prevention, Screening, and Outreach Activities– Coordinator
presented 2014 Community Outreach Summary Report (prevention and screening
programs provided during the year). Cancer committee discussed how effective the
activities were. (See attached Community Outreach Summary Report).
Standard 1.10 Clinical Educational Activity: Asked for suggestion for topics.
Standard 1.12 Public Reporting of Outcomes: Preparing public reporting of outcomes
referencing Standards 4.1 and 4.2 for Std 1.12 commendation.
Standard 4.1 Cancer Prevention Programs: Analyze recent community needs assessment
and determine who should be targeted for prevention programs for 2015.
Standard 4.6 Monitoring compliance with Evidence-Based guidelines: Select physician,
area of study focus, treatment guidelines: pending.
Standard 4.7 Studies of Quality: pending
Standard 4.8 Quality Improvement: pending
 Std 1.6 physician
review to be
reported at next
meeting.
 Select educational
activity topic for 1.10
at next meeting.
Review and
Discuss CC
functions
Other
Update on
registry
software
Support
Group Info
Std 4.3
Standard CLP Responsibilities: Dr. [Name] presented a report she created to examine the
Hospital Benchmark Reports (see PPT attached). Cancer committee to discussed.
 CLP will present
at next meeting
Three software companies have provided demos to the cancer registries within the network.
Next step in the review process will be to talk to people using these products with a list of
technical questions to ask these users.
NA
Support Group Update: The Yoga Group for Cancer Survivors will meet 1/10/2016
With no further business, the meeting was adjourned.
Recorded/Transcribed by: [Name] – [Role]
Reviewed/Approved by: [Name] – Cancer Committee Chair
Future Cancer Committee Meeting Dates @ 2:00pm CST
DATES
Next meeting: January
21, 2016
CALENDAR OF REQUIREMENTS TO TRACK COMPLIANCE
ER/
Standard
ER1
ER2
ER3
ER4
ER5
ER6
ER7
ER8
ER9
ER10
ER11
ER12
1.1
1.2
1.3
1.4
1.5
Definition and Requirements
Facility is accredited by a recognized federal, state, or local authority appropriate by facility type. Upload
certification.
Cancer Committee Authority is established and documented by the facility. (Upload Bylaws, Facility P&P)
Cancer Conference Policy and Procedure is used to establish the annual cancer conference activity.
Upload most recent version of policy. Create Frequency and Format Grid.
Oncology Nurse Leadership: Identify the nurse(s) responsible for leadership across the continuum of care
who utilizes ONS guidelines and/or other recognized national organizations to develop policy and procedures
to guide patient care.
Cancer Registry Policy and Procedure addresses the use of CoC data elements and codes along with all
other cancer registry activities. Upload table of contents for most recent version.
Identify the Diagnostic Imaging Services that are provided either onsite or by referral. Upload certification,
attestation letter, or documentation that describes QA practices.
Radiation Treatment Service locations are currently accredited by a recognized authority or follow standard
quality assurance practices. Upload certification, attestation letter, or documentation that describes QA
practices.
Systemic Therapy Services: Upload Policy and Procedures that are in place to guide the safe administration
of systemic therapy provided either onsite, at locations that are facility owned, or at locations that are
contracted by the facility or supervised by members of the facility’s medical staff, including physician offices.
Clinical Trial Information: Upload policy & procedures used to provide cancer related clinical trial information
to patients.
Psychosocial Services: Upload policy or procedure that ensures access to psychosocial services and
identifies the psychosocial services provided on-site or by referral.
Rehabilitation Services: Upload policy or procedure that ensures access to rehabilitation services and
identifies the services provided either on-site or by referral.
Nutrition Services: Upload policy or procedure that ensures access to nutrition services either on-site or by
referral.
Physician Credentials: Upload bylaws that address current board certification of physicians OR
provide a roster of physicians in the listed specialties who provide cancer care, with documentation of board
certification.

If physician providing cancer care is in the process of board certification or is not board certified, upload
documentation of 12 cancer-related CMEs for each calendar year of the survey cycle.
Cancer Committee Membership: Each year the cancer committee includes the required physicians from the
diagnostic and treatment specialties, the required non physicians from administrative and supportive services.
 Cancer Program Coordinators assigned for: Cancer Conference, Quality Improvement, Cancer Registry
Quality, Community Outreach, Clinical Research , Psychosocial Services.
 Cancer Program Coordinators report to committee annually
Cancer Committee Attendance: Each required member attends AT LEAST 75 % of the cancer committee
meetings held during any given year.
Cancer Committee Meetings: Cancer committee meets at least quarterly.
Cancer Program Goals: Each year the cancer committee establishes (E), implements (I) and monitors (M) at
least 1 clinical and at least 1 programmatic goal for the endeavors related to cancer care. Each goal is
evaluated at least twice each calendar year. Evaluation is documented in minutes.
 Clinical: Involves diagnosis, treatment, services and care of patients
 Programmatic: Directed toward the scope, coordination, practices, and processes of care for patients
1stQtr
2ndQtr
Mtng
Mtng
3rd
Qtr
Mtng
4thQtr
Mtng/
Annual
Report
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
E
E
I
I
M
M
1.6
1.7
1.8
1.9
1.10
1.11
1.12
2.1
2.2
2.3
2.4
3.1
Cancer Registry Quality Control (QC) Plan: Each calendar year, the cancer committee establishes and
implements a plan to annually evaluate the quality of the cancer registry data and activity. The plan includes
procedures to monitor and evaluate each required control plan component.

The cancer committee establishes and implements a quality control plan to evaluate the required areas of
X
cancer registry

The Cancer Registry Control Coordinator, under the direction of the cancer committee, performs the
required quality control review (including physician review) as outlined in the plan.

The findings and recommendations from the annual review are reported to the cancer committee and
X
documented in the minutes.
Monitoring Cancer Conference Activity: Cancer conference coordinator monitors and evaluates the cancer
conference activities and reports findings each calendar year. Report is documented in the cancer committee
X
minutes.
Monitoring Prevention, Screening, and Outreach Activities: Each calendar year, the Community Outreach
Coordinator, under the direction of the cancer committee, monitors the effectiveness of prevention (Standard
4.1), screening (Standard 4.2), and outreach activities. The activities and monitoring results are documented in
X
an annual community outreach activity summary that is presented to the cancer committee at the end of each
calendar year.
Clinical Research Study Accrual: Required % of patients are accrued to the cancer-related clinical trials
X
each year. The clinical trial coordinator reports clinical trial participation to the cancer committee each year.
Clinical Educational Activity: Cancer Committee offers at least one cancer-related educational activity, other
than cancer conferences, to physicians, nurses, and other allied health professionals. The activity is focused
on the use of AJCC staging in clinical practice, which includes the use of appropriate prognostic indicators and
evidence based national guidelines used in treatment planning.
Cancer Registrar Education: Each calendar year, all members of the cancer registry staff participate in one
cancer-related educational activity applicable to their role.
Public Reporting of Outcomes: Each year, the cancer committee develops and disseminates a report of
X
patient or program outcomes to the public.
CAP Protocols and Synoptic Reporting: Each calendar year, 95 percent of the eligible cancer pathology contain all required data elements of the College of
American Pathologists (CAP) protocols and are structured using the synoptic reporting format as defined by the CAP Cancer Committee.
 10% of eligible pathology reports are reviewed by a physician each year to review compliance with CAP
X
and synoptic reporting
X
 95% of pathology reports follow the synoptic format and contain all data elements
Oncology Nursing Care: Oncology nursing credentials are confirmed and reported annually to the cancer committee
X
 25% of oncology nurses hold one a current OCN certifications
X
 Annual evaluation of nursing competency (education) is documented and presented to CC (minutes)
X
 Policy and procedure in place to evaluate oncology nursing competency
Genetic Counseling and Risk Assessment: Cancer risk assessment, genetic counseling, and testing services are provided to patients either on-site or by
referral, by a qualified genetics professional.

The process for referring or providing cancer risk assessment, genetic counseling, and genetic testing
services to patients is monitored and reviewed by the cancer committee and documented in the minutes.
X

A member of the genetics team must is a required member of the cancer committee if these services are
provided on-site.
Palliative Care Services: Palliative care services are available to patients either on -site or by referral.
 The process for referring or providing palliative care services to patients is monitored and reviewed by the
cancer committee and documented in the minutes.
X
 A member of the palliative care team is a required member of the cancer committee if these services are
provided on-site.
Patient Navigation Process: A patient navigation process, driven by a triennial Community Needs Assessment, is established to address health care disparities
and barriers to cancer care. Resources to address identified barriers may be provided either on-site or by referral.


3.2
3.3
4.1
4.2
4.3
4.4
X
Conduct community needs assessment at least once during a 3 year survey cycle
Established a navigation process and identify resources to address barriers that are provided either on-site
X
or by referral to a community-based or national organizations.
 Each year, barriers to care are assessed and the navigation process is evaluated, documented and the
X
X
findings are reported to the cancer committee.
 Each calendar year, the patient navigation process is modified or enhanced to address the barrier or
X
additional barriers identified by the Community Needs Assessment.
Psychosocial Distress Screening: Each calendar year, the cancer committee develops and implements a process to integrate and monitor on -site
psychosocial distress screening and referral for the provision of psychosocial care.

Psychosocial representative on the cancer committee is required to oversee this activity and report to the
cancer committee annually

The cancer committee develops and implements a process to integrate, provide, and monitor on-site
X
psychosocial distress screening and referral for the provision of psychosocial care that includes all of the
standard process requirements.

All cancer patients must be screened for psychosocial distress a minimum of one time during a pivotal
medical visit as determined by the cancer program.

The psychosocial distress screening process is evaluated, documented, and the findings are reported to
X
the cancer committee y the Psychosocial Services Coordinator.
Survivorship Care Plan: The cancer committee develops and implements a process to disseminate a comprehensive care summary and follow-up plan to
patients with cancer who are completing cancer treatment. The process is monitored, evaluated, and presented at least annually to the cancer committee and
documented in minutes.

The cancer committee develops a process to generate and disseminate a comprehensive treatment
X
summary and survivorship care plan to eligible cancer patients who have completed cancer treatment.

The process is monitored, evaluated, and presented to the cancer committee annually, and documented
X
in the minutes.
X

The number of eligible patients who received a survivorship care plan meets the implementation criteria.
Cancer Prevention Programs: Each calendar year, the cancer committee organizes and offers at least one cancer prevention program designed to reduce the
incidence of a specific cancer type and targeted to meet the prevention needs of the community. Each prevention program is consistent with evidence-based
national guidelines for cancer prevention.
X

The cancer committee assesses the cancer prevention needs of their community and patient population.
See 1.8

The cancer committee organizes and offers at least one cancer prevention program.

The prevention program is consistent with evidence-based national guidelines and evidence-based
See 1.8
interventions for cancer prevention.
Cancer Screening Programs: Each calendar year, the cancer committee organizes and offers at least one cancer screening program that is designed to
decrease the number of patients with late-stage disease and is targeted to meet the screening needs of the community. Each screening program is consistent
with evidence-based national guidelines and interventions and must have a formal process developed to follow up on all positive findings.
X

The cancer committee identifies the cancer screening needs of its community and patient population.
See 1.8

The cancer committee organizes and offers at least one cancer screening program.

The cancer screening program is consistent with evidence-based national guidelines and evidence-based
See 1.8
interventions.

Each screening program has a process developed to follow up on all positive findings of participants.
See 1.8
Cancer Liaison Physician: A Cancer Liaison Physician (CLP) serves in a leadership role within the cancer
program and is responsible for evaluating, interpreting, and reporting the cancer program’s performance using
X
X
X
X
National Cancer Data Base data. The CLP, or an equivalent designee, reports the results of this analysis to
the cancer committee at least four times each calendar year.
Accountability Measures: Each calendar year, the expected Estimated Performance Rates (EPR) is met for
X
each accountability measure as defined by the Commission on Cancer.

The cancer committee monitors the program’s expected Estimated Performance Rates for all
X
accountability measures using the CP3R. The monitoring activity is reported in cancer committee minutes.
If not in compliance, action plan is developed and implemented.
Quality Improvement Measures: Each calendar year, the expected Estimated Performance Rates (EPR) is
met for each quality improvement measure as defined by the Commission on Cancer.
4.5
4.6
4.7
4.8
5.1
5.2
5.3
5.4
5.5
5.6
5.7
X

The cancer committee monitors the program’s expected Estimated Performance Rates for all quality
X
measures using the CP3R. The monitoring activity is reported in cancer committee minutes. If not in
compliance, action plan is developed and implemented.
Monitoring Compliance with Evidence-Based Guidelines: Each calendar year, the cancer committee
designates a physician member to complete an in-depth analysis to assess and verify that cancer program
patients are evaluated and treated according to evidence-based national treatment guidelines. Results are
presented to the cancer committee and documented in cancer committee minutes.
Studies of Quality: Each calendar year, the cancer committee, under the guidance of the Quality Improvement Coordinator, develops, analyzes, and
documents the required number of studies (based on the program category) that measure the quality of care and outcomes for cancer patients.

Study topics must be selected based on a problematic quality-related issue relevant to the cancer
X
program. Completion of a study of quality must provide data results that serve as the first step in the
quality improvement process. The findings of the studies are documented in the minutes.
Quality Improvements: Each calendar year, the cancer committee, under the guidance of the Quality
Improvement Coordinator, implements two cancer care improvements. One improvement is based on the
results of a quality study completed by the cancer program that measures the quality of cancer care and
outcomes. One improvement can be based on a completed study from another source. Quality improvements
are documented in the cancer committee minutes and shared with medical staff and administration.
Cancer Registrar Credentials: Case abstracting is performed by a Certified Tumor Registrar
RQRS Participation: From initial enrollment and throughout the accreditation period, the cancer program
actively participates in RQRS, submits all eligible cases for all valid performance measures, and adheres to
X
X
X
the RQRS terms and conditions.

RQRS data and performance reports are reviewed by cancer committee at least semi-annually and
X
X
X
documented in the cancer committee minutes.
Follow up of ALL patients: 80% follow up rate is maintained from the cancer registry reference date
Follow up for RECENT patients: A 90 percent follow-up rate is maintained for all eligible analytic cases
diagnosed within the last five years or from the cancer registry reference date, whichever is shorter.
Data Submission: Each year, complete data for all requested analytic cases are submitted to the NCDB in
X
accordance with the annual call for data
Accuracy of Data: Annually, cases submitted to the NCDB that were diagnosed January 1, 2003 or later meet
X
the established quality criteria and resubmission deadline specified in the annual call for data.
Commission on Cancer Special Studies: The program participates in special studies as selected by the
Commission on Cancer.
X
X
X
X
X