Download Clinical Trial Accrual - Tumor Registrars association of Maryland

 Tumor Registrars
Association of Maryland
Educational Meeting
American College of Surgeons
Commission on Cancer
• Current Activities
– Accreditation
– Cancer liaison
– Education
– Member organizations and advocacy
– Quality integration & national cancer
data base
Accreditation
• New standards well accepted in U.S.
• Standards Advisory Group for
Excellence (SAGE) to address issues
• Best practices repository
• Veterans affairs programs – (1/3)
Cancer Liaison Program
•
•
•
•
Enhance relationship and support of ACS
Enhance education of CLP’s
Focus groups to understand CLP needs
In-person training at state CLP meetings
Education
• New CoC online education
• Video vignettes
• Annual Survey Savvy workshop
– Best practices
Membership Organization
Committee
• Upswing in membership
• New members
– Hematology Oncology Pharmacy
Association
– National accreditation program for
Breast Centers
– American Society of Plastic Surgeons
– Increasing communication and
collaboration
New Advocacy Subcommittee
• Identifying clear legislative priorities
• Collaborating with member
organizations
• Coordinate with college advocacy
office
• Oct. 2013, legislative briefing
Quality Integration and NCDB
• New measures in development for
implementation in CP3R and RQRS
– Breast, non-small cell lung and gastroesophageal cancers
• Other measures
– Patent experience
– Quality of life
– Cost
Physician Credentials
S1.1:
“Diagnostic and treatment services are
provided by or referred to the leadership
and cancer program evaluation and
management team physicians who are
currently board certified, or the
equivalent, in their general specialty,
or are in the process of becoming board
certified.”
Physician Credentials
• Standard changed because:
– It didn’t address physicians who
will not be board-certified
– No possibility for deficiency
resolution
Physician Credentials
• As of 1/1/2012, the cancer program
leadership team member who serves in a
required physician position on the cancer
committee, are either board-certified, or in
the process of becoming board-certified, or
• Demonstrate ongoing cancer related
education by annually earning twelve (12)
cancer-related CME hours
Physician Credentials
• A maximum of six (6) hours can be earned
through activities within the facility, six (6)
hours must be earned through activities
that are external to the facility
• All twelve (12) hours may be earned
through activities that are external to the
facility
• This option will be used for deficiency
resolution
Physician Credentials
• Documentation may include one of the
following:
– Medical staff bylaws that address current
board certification of physicians;
– Roster of board certification status for
physicians;
– Documentation of 12 annual cancer-related
CME hours for physicians who are not boardcertified or board eligible
Cancer Committee Membership
S1.2
“The membership of the cancer
committee is multidisciplinary,
representing physicians from the
diagnostic and treatment specialties
and non-physicians from administrative
and supportive services. Coordinators
who are responsible for specific areas of
program activity are designated from the
membership.”
Cancer Committee Membership
The Standard for Coordinators include:
1. Cancer Conference Coordinator:
Monitoring staging, evidence-based treatment
guidelines and cancer conference activities.
A CTR who is abstracting can fulfill this role.
Reports at least annually to the cancer
committee
Cancer Committee Membership
2. Quality Improvement Coordinator:
Evaluates and focuses efforts on patient
outcomes. Monitors the quality
improvement program activity and reports
the findings annually to the cancer
committee. ACTR who is abstracting
cannot be selected for this role.
Cancer Committee Membership
3. Cancer Registrar Quality Coordinator:
Monitors the quality of cancer registry data
and reports the findings to the cancer
committee at least annually. A CTR who is
abstracting can be selected for this role.
4. Community Outreach Coordinator:
Monitors outreach activity and reports
findings to the cancer committee at least
annually. A CTR who is abstracting cannot
be selected for this role.
Cancer Committee Membership
5. Clinical Research Representative or
Coordinator:
Tracks patients enrolled in clinical trials or
referred for enrollment in clinical trials at other
facilities or physician offices. A Cancer
Registrar who is abstracting cannot be
selected for this role.
6. Psychosocial Services Coordinator:
An oncology social worker or other mental
health professional trained in psychosocial
aspects of cancer care assesses, improves,
and expands services. A CTR who is
abstracting cannot be selected for this role.
Cancer Committee Membership
• Additional Required members:
Categories have additional required
members, if services are provided on site
• Each program assesses the need for
additional cancer committee members
based on the cancer patients served and
their program offerings on site.
Cancer Committee Attendance
S1.3
“Each required member attends at
least 50% of the cancer committee
meetings held during any given
year.”
Cancer Committee Attendance
• Minutes document the attendance at each
meeting. Cancer Committee monitors the
attendance and addresses low attendance
• Teleconference calls are acceptable for
compliance
• Commendation: Each required member
attends at least 75% of the cancer
committee meetings held during any given
year
Cancer Program Goals
S1.5:
“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.”
Cancer Program Goals
• Annual goals:
– Provide direction for strategic planning
of cancer program activities
– Serve as the basis for cancer program
evaluation
Cancer Program Goals
• Compliance
– The cancer committee establishes goals
appropriate to the program
• Scope will vary depending on program size
• Use of goal-setting tool (SMART) is
recommended
– Activities related to each goal must be
implemented, monitored, evaluated and
documented in cancer minutes at least
twice annually
Cancer Program Goals
• Goals:
– Are not required to be completed
each year
• Not completed may be carried over
into the next year
– Should not be a restatement of a CoC
standard
– Are to be established at the beginning
of each year and evaluated mid-year
and at the end of same year
Cancer Registry Quality
Control Plan
S1.6:
“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.”
Cancer Registry Quality
Control Plan
• Rating the Standard:
– Cancer committee establishes and implements
a plan to evaluate the required areas
– Each year the cancer committee performs the
required quality control review as outlined in
the plan
– Each year review findings are reported to the
cancer committee
– Each year the findings are documented in
minutes
Monitoring Conference Activity
S1.7:
“ The cancer conference coordinator
monitors and evaluates the cancer
conference activities and reports
findings to the cancer committee at
least annually.”
Monitoring Conference Activity
• Rating the Standard, Part 1
– The cancer conference coordinator monitors
and evaluates cancer conference activities,
including:
• Conference frequency
• Multidisciplinary attendance
• Total case presentation
• Discussion of stage, prognostic indicators
and treatment planning using evidencebased treatment guidelines
• Clinical trial options
• Adherence to conference policy
Monitoring Conference Activity
• Rating the Standard, Part 2
– The cancer conference coordinator
reports the findings of the cancer
conference evaluation to cancer
committee
– Report is documented in cancer
committee minutes
Monitoring Community
Outreach
S1.8:
“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”.
Community Outreach
Coordinator Responsibilities
• Contribute to the development of
community outreach activities
–
–
–
–
–
–
Work with outreach organizations
Ensure activities meet community needs
Ensure activities follow accepted guidelines
Ensure positive findings are followed
Evaluate the effectiveness of referral
Create summary
• Summary addresses all of these areas
Monitoring Community
Outreach
• Rating the Standard
– Cancer committee monitors effectiveness
of community outreach activities annually
– Activities and findings are documented in
community outreach activity summary
– Summary is shared with cancer committee
– Summary is documented in CC minutes
Question
• The standard asks that the community
outreach coordinator monitors the
effectiveness of community outreach
activities.
How do you measure the effectiveness?
Answer
• Effectiveness for a screening activity might
be the rate of diagnosis made in the group
screened or perhaps this is an increase in
screening participation because of a new
tool or new communication strategy
• Effectiveness in a prevention activity could
include the number of participants who
stopped smoking or who began to change
their lifestyle at the completion of the
program
Did we miss
the date?
Clinical Trial Accrual
S1.9:
“As appropriate to the cancer program
category, the required percentage of
patients is accrued to cancer-related
clinical trials each year. The clinical trial
coordinator or representative reports
clinical trial participation to the cancer
committee each year.”
-Version 1.1 made no changes
Clinical Trial Accrual
• Key Point – Phase in Time Period
– Until 2015, cancer programs are
expected to achieve the minimum and
commendation accrual percentages set
forth in Standard 5.2 as published in
Cancer Programs Standards 2009,
Revised Edition and based on the
facility category as of 2011
Clinical Trial Accrual
• Programs participating in cancer-related clinical
research demonstrate that an independent peer
review mechanism consistent with national
standards is in place and used
• Research projects must be approved by an
internal or external institutional review board (IRB)
• Patients participating in clinical trials must give
their informed written consent, unless verbal
consent has been specified by the IRB
Patient Eligibility
• When does the patient count?
– Seen at your program for diagnosis and/or
treatment and placed on a cancer-related clinical
trial through your program
– Seen at your program for diagnosis and/or
treatment and placed on a cancer-related clinical
trial through the office of a staff physician
– Seen at your program for diagnosis and/or
treatment and placed on a cancer-related clinical
trial through another program (referral)
– Seen at your program for any reason and placed
on a cancer prevention or cancer control clinical
trial
Clinical Trial Accrual
• Treatment-related clinical trial groups
examples:
– NCI-sponsored cooperative cancer
clinical trial groups
– Pharmaceutical company research
– Locally developed, investigator-initiated,
peer-reviewed research
Clinical Trial Accrual
• Cancer prevention and cancer control
research examples include:
– Primary prevention of cancer
– Early detection of cancer
– Quality of life related to cancer
(supportive care trials)
– Economics of care related to cancer
Clinical Trial Accrual
• Key to successful compliance
– A research coordinator, data manager,
or other clinical research professional
available to assist with enrolling
patients, monitoring patient accrual,
and identifying and providing
information and education about new
cancer related clinical trials
Clinical Trial Accrual
• Who can fill the clinical research
representative or coordinator role?
–
–
–
–
Clinical trail principal investigator
Clinical trial data manager
Clinical trial research associate
Clinical research nurse
• Appointed by the cancer committee
• Member of the cancer committee
• NOTE: A cancer registrar who is
abstracting cannot be selected to fulfill
this coordinator role
Percentage Requirements
Annual Analytic Cases – Effective in 2015
Clinical Educational Activity
S1.10:
“Each year, the cancer committee offers at least
1 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 or other appropriate
staging in clinical practice, which includes the
use of appropriate prognostic indicators and
evidence-based national guidelines used in
treatment planning.”
-One activity required annually; additional
activities encouraged
-Focus on stage and prognostic indicators
and evidence-based guidelines
What’s New in Version 1.1?
• The cancer committee must monitor the
success of and attendance at educational
activities each year
• To fulfill the educational requirement of the
standard, a webinar is to be a minimum of
one cumulative hour annually. The
webinar is to be viewed as a group with a
physician leader from the cancer
committee designated to facilitate
discussion
Clinical Educational Activity
• Can be a review of a single cancer site
• Can be a general presentation on staging
and site specific prognostic indicators and
evidence-based guidelines in treatment
planning
• Must not be held during cancer conference
• Encouraged to apply for CME
Clinical Educational Activity
• Documentation
– Overview or objectives of the content
presented, including AJCC or other
appropriate staging in clinical practice
– The use of appropriate prognostic
indicators
– Evidence-based national guidelines
used in treatment planning
– Published notice or agenda for each
year
Cancer Registrar Education
S1.11:
“Each year, all members of the
cancer registry staff participate in 1
cancer-related educational activity
other than cancer conferences.”
Cancer Registrar Education
• Documentation
– Educational activity for each staff member
– May include CE summary forms or meeting
agenda and materials
• Rating
– Commendation: all registry staff participate in
annual education, and
– All CTR staff attend a national or regional
meeting once during the 3-year survey cycle
Public Reporting of Outcomes
S1.12:
“Each year, the cancer committee
develops and disseminates a report
of patient or program outcomes to
the public.”
Public Reporting of Outcomes
• The content of the report (each year)
includes outcome information on 1 or
more of the following standards:
–
–
–
–
–
4.1 Prevention programs
4.2 Screening programs
4.4 Accountability measures
4.5 Quality improvement measures
4.6 Monitoring compliance with
evidence-based guidelines
– 4.7 Studies of quality
– 4.8 Quality improvements
Public Reporting of Outcomes
• The report must be published in
electronic or printed format and must
be distributed to an audience external
to the facility and medical staff
Public Reporting of Outcomes
• Documentation:
– The program provides copies of patient
outcomes each year distributed to the public
• Commendation rating only:
– Each year, the program develops and
disseminates a report of patient or program
outcomes to the public
CAP Protocols
S2.1:
“College of American Pathologists (CAP)
protocols are followed to report the
required data elements in 90% of the
eligible cancer pathology reports.”
-Standardized and complete reporting
aids multidisciplinary care of the
patient with cancer
-Created by CAP in 186
-Part of CoC requirements since 2004
-Standard 4.6
CAP Protocols
• The standard applies to the following
specimens:
– Resected specimens with an invasive histology
– Resected breast specimens with ductal
carcinoma in situ (DCIS) histologic features
• Cancer committee responsible for:
– 10% random review of CAP eligible pathology
reports each year
– 300 report maximum
– QC review performed by pathologist or other
cancer committee members
Synoptic Reporting
Requirements
• Cancer committee encourages adoption of
synoptic format
• New definition of synoptic reporting
developed by CAP cancer committee
– All required cancer data from an applicable
cancer protocol that are included in the report
must be displayed using a format consisting of
the required checklist item/required data element
(RDE0, followed by its answer (response)
• “tumor size: 5.5cm”
– Outline format without the paired RDE: response
format is not considered synoptic
Synoptic Reporting
Requirements
• Each diagnostic parameter pair (checklist
RDE: response) is listed on a separate line
or in a tabular format
– Achieves visual separation
– Note: anatomic site or specimen, laterality and
procedure can be combined on the same line
– pTNM can be combined on the same line
– Negative margins can be listed on the same
line (example: proximal, distal, radial margins
for colorectal cancer)
Unacceptable Synoptic Report Example
Diagnosis:
Colon, right hemicolectomy:
-Invasive adenocarcinoma, 3.4 x 3.0 cm
involving muscularis propria
-All margins negative
- No lymphatic invasion
- No metastatic tumor identified
Not acceptable as synoptic style reporting:
Not all elements are present and diagnostic
parameter pair is absent
Nursing Care
S2.2:
“Oncology nursing care is provided by
nurses with specialized knowledge and
skills. Competency is evaluated
annually.”
Nursing Care
• Education focuses on administration of
cancer treatment
– Safe
– Consistent
– Across continuum of care
• ONS resources for education are used
–
–
–
–
Cancer basics course
Chemotherapy and biotherapy course
Radiation therapy course
Core curriculum for oncology nursing
Nursing Care
• Documentation
– Program completes the SAR
– Surveyor reviews policies for evaluating
competency
– Surveyor discusses nursing education
– Curricula
• Oncology competencies are evident in
documentation provided
Nursing Care - Rating
• Meets compliance requirements and
• Commendation
– 25% of chemotherapy-trained nurses
employed by the facility (full-time, part-time, or
PRN) hold a current oncology nursing
certification (see list included in Definition and
Requirements)
Cancer Risk Assessment and
Genetic Counseling
S2.3:
“Cancer risk assessment, genetic
counseling, and testing services are
provided to patients either on-site or by
referral, by a qualified genetics
professional.”
Background
• Knowledge of a hereditary cancer risk
goes back to the early 20th century
• Currently at least 54 known hereditary
cancer syndromes
• Identification of a hereditary cancer
syndrome can significantly reduce
morbidity and mortality from cancer as well
early detection and cancer prevention
Who Should Perform CRA/GC?
• An American Board of Genetic Counseling
(ABGC) board certified (CGC)/board
eligible or (in some states) a licensed
genetic counselor
• An American college of Medical Genetics
(ACMG) physician board certified in
medical genetics
• A Genetics Clinical Nurse (GCN) or an
Advanced Practice Nurse in Genetics
(APNG), credentialed through the Genetics
Nursing Credentialing Commission (GNCC)
Palliative Care Services
S2.4:
“Palliative care services are
available to patients either on-site
or by referral.”
Palliative Care
• Palliative care optimizes patient and family’s
quality of life by anticipating, preventing, and
treating suffering associated with serious illness
• Palliative care addresses physical, intellectual,
emotional, social, and spiritual needs.
Additionally, it enhances patient autonomy by
facilitating access to information and choice
• Palliative care is a team-based approach
applicable from the time of diagnosis throughout
the continuum of any serous illness and during
the bereavement period regardless of prognosis
or anticipated treatments
Palliative Care
• No specific therapy is excluded from
consideration. The test of palliative
intervention or support lies in the
agreement that the expected outcome is
relief from distressing symptoms, easing
of pain, and improvement in quality of life
• The decision to intervene is based on the
treatment’s ability to meet the stated
goals regardless of its impact on the
underlying disease
How Does Palliative Care Differ
From Hospice?
• Non-hospice palliative care is appropriate at any
point in a serious illness. It is provided at the
same time as life-prolonging treatment. No
prognostic requirement, no need to choose
between treatment approaches
• Hospice is a form of palliative care that provides
care for those in the last weeks/few months of life.
Patients must have a 2 MD-certified prognosis of
<6 months + give up insurance coverage for
curative/life prolonging treatment in order to be
eligible
The Palliative Care Team
• Core components:
–
–
–
–
Physician
Nurse
Social worker
Pastoral or spiritual counselor
• Rationale: The concept of “Total Pain”
which recognizes four dimensions of
distress: physical, psychological, social,
and spiritual
The Palliative Care Team
•
•
•
•
•
•
Pharmacists
Mental health clinician
Trained volunteer
Occupational and physical therapists
Other therapists as available or needed
Home health aides
Accomplishments in the
New Manual
• Development of standards to support
patient-centered care
–
–
–
–
–
Patient navigation*
Psychosocial distress screening*
Survivorship care plan*
Genetic assessment and counseling
Palliative care services
*Phase in by 2015
Prevention Programs
S4.1:
“Each year, the cancer committee
provides at least 1 cancer prevention
program that is targeted to meet the
needs of the community and should be
designed to reduce the incidence of a
specific cancer type. The prevention
program is consistent with evidencebased national guidelines for cancer
prevention.”
Prevention Programs
• Examples of cancer prevention
programs:
– Chemoprevention programs
– Education/cancer awareness
– Skin cancer prevention
– Smoking cessation
– Smoking prevention in adolescents
– Nutrition, physical activity and weight
loss programs
Prevention Programs
• Resources available for evidencebased national guidelines related to
cancer prevention:
– Agency for Healthcare Research and
Quality
– Cancer Control P.L.A.N.E.T.
– Centers for Disease Control and
Prevention
– National Cancer Institute
– American Cancer Society
Prevention Programs
• Resources available for evidencebased national guidelines related to
cancer prevention:
– Agency for healthcare Research and
Quality
Prevention Programs
• Rating the Standard
Each year:
1. The cancer committee assesses the
prevention needs of the community.
2. The cancer committee provides at least 1
cancer prevention program.
3. The cancer prevention program is consistent
with evidence-based national guidelines and
evidence-based interventions
Screening Programs
S4.2:
“Each year, the cancer committee provides
at least 1 cancer screening program that is
targeted to decreasing the number of patients
with late-stage disease. The screening program
is based on community needs and is consistent
with evidence-based national guidelines and
evidence-based interventions. A process is
developed to follow up on all positive findings.”
Screening Programs
• Cancer screening programs include:
– Breast: radiographic and physical
examinations
– Colon: colonoscopy, flexible sigmoidoscopy,
fecal occult blood testing
– Cervix: Papanicolaou testing with or without
HPV testing
– Prostate when advised by a physician
– Skin surveys
ACS Resources for Physicians
http://www.cancer.org/professinals
• American Cancer Society Guidelines for
prevention, early detection, surveillance
• Fact Sheets: summaries for 11 cancer sites
• Ready-to-Use PowerPoint presentations of
risk factors & early-detection for 5 major sites
• ColonMD: Clinicians’ Information Source
• ProstateMD: Clinicians’ Information Source
2012 ACS – CoC Collaborative
Action Plan
• Share commitment to improve quality of care
• Increase community awareness of prevention and
early detection
• Provide information and supportive services
• SMART Goals:
– Specific, Measurable, Attainable, Realistic,
Timely
• Evaluate effectiveness annually
• Modify as indicated
CLP Responsibilities
S4.3:
“A Cancer Liaison Physician serves in a
leadership role within the cancer program
and is responsible for evaluating, interpreting,
and reporting the program’s performance
using the National Cancer Data Base (NCDB)
data. The CLP, or an equivalent designee,
reports the results of this analysis to the
cancer committee at least 4 times a year.”
Rating the Standard
1. The CLP evaluates and interprets the
program’s performance using the NCDB
data
2. The CLP, or an equivalent designee,
reports this information to the cancer
committee at least four times each year
3. The CLP is present during the CoC
survey and meets with the surveyor
CLP Selection Criteria
• Member of the medical staff
• Willing to assume the role of liaison between the
cancer program and the CoC
• Willing to serve as a liaison with the ACS
• Exhibits leadership qualities
• Interested in monitoring, interpreting and reporting
the program’s performance on quality
improvements
• The candidate should be familiar with or willing to
learn the NCDB tools and the quality improvement
processes being used by the facility
Studies of Quality
Specifications by Category
Category
Required number of studies of the
quality of cancer care and
outcomes
INCP
3
NCIP
3 (published studies of quality are acceptable)
VACP
1 study of the quality of cancer care and outcomes
1 additional program-defined study or study of
quality defined at the SISN or regional level
ACCP, CCCP,
2
CCP, PCP, FCCP
Studies of Quality
• Does not fulfill requirements for this
standard:
– Repeated study topics
– Activities that duplicate study topics and
criteria without analysis of the findings
– Ongoing monitoring activities
– Study from outside organization that does NOT
follow the study criteria
– Data review from the CoC quality reporting
tools (CP3R, benchmarks, survival, RQRS,
etc.)
Accountability Measures
S4.4:
“Annually, performance levels are met for
each of the specified accountability
measures as defined by the Commission
on Cancer.”
Quality Improvement Measures
S4.5:
“Quality Improvement Measures
Annually, performance levels are met for
each of the specified quality improvement
measures as defined by the Commission
on Cancer.”
Monitoring Compliance with
Evidence-Based Guidelines
S4.6:
“Monitoring Compliance with
Evidence-Based Guidelines
Each year, a physician member of the cancer
committee performs a study to assess whether
patients within the program are evaluated
and treated according to evidence-based
national treatment guidelines. Study results
are presented to the cancer committee and
documented in cancer committee minutes.”
Monitoring Compliance with
Evidence-Based Guidelines
Purpose
• Ensure evaluation and treatment conforms
to:
– Evidence-based national guidelines
– AJCC stage or other appropriate staging
– Appropriate prognostic indicators
• Supports that treatment is planned using
– The right step
– In the right order
– At the right time
Monitoring Compliance with
Evidence-Based Guidelines
• Study components:
– Identify the guidelines used
– Confirm the stage and prognostic factors
affecting treatment choice
– Compare the treatment with the guidelines
• Report results to the cancer committee
– Document performance
– Identify improvements
Monitoring Compliance with
Evidence-Based Guidelines
• Guidelines Resources
–
–
–
–
–
NCCN
ASCO
ASCRS
STS
AHNS
• And when you have completely run out of
ideas: www.guideline.gov/
Studies of Quality
S4.7:
“Each year, based on category, the
quality improvement coordinator, under
the direction of the cancer committee,
develops, analyzes, and documents the
required studies that measure the quality
of care and outcomes for patients with
cancer.”
Quality Improvements
S4.8:
“Annually, the quality improvement coordinator,
under the direction of the cancer committee,
implements 2 patient care improvements. One
improvement is based on the results of a
completed study that measures cancer
patient quality of care and outcomes. One
improvement can be identified from another
source or from a completed study.
Improvements are documented in the cancer
committee minutes and shared with medical staff
and administration.”
Quality Improvements
• Quality improvement improves patient care by
– Actins taken
– Processes implemented
– Services created
• Correction action needed
– Any area that falls below acceptable norms
– When undesirable performance is identified
• Results and recommendations are documented in
cancer committee minutes that are shared with
medical staff and administration
Quality Improvements
• The cancer committee needs to be
involved in identifying and developing
improvements
– Does this new process benefit the cancer
patients at the facility?
• NCOP: at least 2 improvements affecting
patient care are implemented centrally,
departmentally, through disease site
teams, or through other programappropriate methods as directed by the
cancer center. One improvement is linked
to a completed study of quality