Download CA Committee Guide Standards2012

COC – 2012 Cancer Committee Guide
Comprehensive Community Cancer Program
STANDARD
Eligibility
(Requirements)
NEW Section
E1 (1.1)
Facility
Accreditation
E2 (2.1)
Cancer
Committee
Authority
E3 (2.6)
Cancer
Conference
Policy
E4 (4.5)
Oncology Nurse
Leadership
E5 (3)
Cancer Registry
Policy and
Procedure
DEFINITION
Cancer Committee responsibilities for eligibility requirements
Structure E1-E5, Services E6-E12.
JAN
MAR
MAY
JULY
SEPT
NOV
X
X
The facility is accredited by a recognized federal, state, or local
authority.
 JCAHO Accreditation Date
Bylaws or policy and procedure define the Cancer Committees
authority and responsibility for the program
 Review medical Staff Bylaws
X
A cancer conference policy or procedure is used to establish the
annual cancer conference activity.
 Cancer Conference Policy Review
(15% case presentation, 80% prospective presentation)
A nurse provides leadership for oncology patient care across the
care continuum
X
 Oncology Nurse Leader Report
 ONS Standards and guidelines
The 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.
X
X


Cancer Registry P&P Manual Review- SAR, Disaster,
Recovery Policy, Request Log.
COC data standards – (FORDS)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1
STANDARD
E6 (4.1)
Diagnostic
Imaging
E7 (4.1)
Radiation
Oncology
Services
E8 (4.2)
Systemic
Services
E9 (5.1)
Clinical Trial
Information
E10 (6.1)(New)
Psychosocial
Services
E11 (4.7)
Rehabilitation
Services
E12 (New)
Nutrition
DEFINITION
JAN
MAR
MAY
JULY
SEPT
NOV
X
X
X
X
X
X
X
X
X
X
X
X
X
Diagnostic imaging services are provided either on site or by
referral.
X
 Radiology
X
 WIC
Radiation Treatment service locations are currently accredited by a
recognized authority or, if not accredited, follow standard quality
assurance practices. Services on site or referred
 Accreditation Date
 Radiation Department Report
A policy or procedure is in place to guide the safe administration
of systemic therapy either on site and/or at locations owned or
supervised by members of the medical staff
 Systemic Therapy administration policy
A policy or procedure is used to provide cancer-related clinical
trial information to patients.
 Report dissemination of clinical trials, i.e., pamphlets,
brochures, website, information packets.
 Clinical Trial Policy and Procedure
A policy or procedure is in place to ensure patient access to
psychosocial services either on site or by referral
 Psychosocial policy and procedure
A policy or procedure is in place to access rehabilitation services
either on site or by referral. Rehabilitation Services
 Rehabilitation services report: PT, Speech, Enterostomal,
OT, Exercise, Lymphedema.
 Rehab services policy and procedure
A policy or procedure is in place to access nutrition services either
or site or by referral
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
2
STANDARD
Services
Program
Management
1.1
Physician
Credentials
1.2 (2.3)
CA Committee
Membership
DEFINITION
 Nutrition Services Report
 Nutrition Services Policy and Procedure Review
Standards 1.1-1.12
Diagnostic and treatment services provided by Board Certified
Physicians.
 Bylaws – Board certification of Diagnostic Radiology,
Pathology, General Surgery, Radiation Oncology, Medical
Oncology Annual
JAN
X
MAR
X
MAY
X
X
JULY
X
SEPT
X
NOV
X
X
X
Cancer Committee Members are Multidisciplinary. Coordinators
responsible for specific areas of program activity. Annual
 Program coordinators – Ca Conf, QI, CA Reg Qual, Comm
Out, Clinical Research, Psychosocial services. ( Palliative
Care)
 Review coordinator roles and responsibilities
 Required Physician Members
x
X
X
1.3 (2.2)
Cancer
Committee
Attendance
Each required member attends at least 50% of the cancer
committee meetings held. Annual.
X

Commendation
1.4 (2.4)
Cancer
Committee
Meetings
Review attendance of Required Members (50% Required).
Recommended: Dietitian, Pharmacist, Rehab, Pastoral
Care, Psychiatry, ACS. Commendation=75%.
Each year, the cancer committee meets at least once each calendar
quarter.


Cancer Committee Schedule/Grid
Subcommittee Schedule (BPL)/Grid
X
X
3
STANDARD
DEFINITION
Each year, the cancer committee establishes, implements, and
monitors at least 1 clinical and 1 programmatic goal.
 Establish Goals
 Review and Approve Goals
 Evaluate Goals twice per year
Cancer committee establishes and implements a plan to annually
1.6 (2.10)
Cancer Registry evaluate quality of registry data and activity.
Quality Control
 Cancer Registry Monthly Status Report (CS)
Plan
 CA Registry Quality Coordinator report. Review Registry
Data Quality Plan.
1.5 (2.5)
Cancer
Program Goals
1.7 (2.7. 2.8, 2.9)
Monitoring
Conference
Activity
1.8 (6.3)
Monitoring
Community
Outreach
1.9 (5.2)
Clinical Trial
Accrual
2015 Phase In
Commendation
1.10 (7.1)
Clinical
Education
The cancer conference coordinator monitors and evaluates the
cancer conference activities and reports findings at least annually.
 Cancer conference frequency, format
 Cancer Conference Grid
 Cancer Conference Coord report
(15% case presentation, 80% prospective presentation)
The community outreach coordinator monitors the effectiveness of
community outreach activities on an annual basis.
 Community outreach coordinator report
 Community outreach coordinator activity Summary
The required percentage of patients is accrued to cancer-related
clinical trials each year.
CCC Program - 4% required, 6% commendation.
 Research Coordinator clinical trial accrual report- annual
Each year, the cancer committee offers at least 1 cancer-related
educational activity, other than cancer conferences. The activity is
focus on AJCC or other staging and includes use prognostic
JAN
MAR
MAY
JULY
SEPT
NOV
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
X
X
X
X
X
4
STANDARD
Activity
DEFINITION
indicators and evidence-based national guidelines.
 Plan 2 Educational Activities
 Document and report educational activities
Each year, all members of the registry staff participate in 1 cancer
1.11 (7.2)
related educational activity other than cancer conferences.
Cancer
Commendation-All CTR attend a national or regional cancer
Registrar
related meeting once during the 3-yr. cycle. All registry staff
Education
participate in a cancer related activity each year. Both required for
commendation.
Commendation
 Cancer Registry Coordinator report as necessary
Each year, the cancer committee develops and disseminates a
1.12 (2.11)
Pubic Reporting report of patient or program outcomes to the public
(Commendation)
of Outcomes
 The report includes outcome of 1 or more of: Prevention,
Commendation
Screening Programs, Accountability, QI, Tx Planning
 Report disseminated to the public presented to committee.
CLINICAL
2.1-2.4
SERVICES
2.1 (4.6)
College of
American
Pathologists
Protocols (CAP)
Commendation
2.2 (4.4)
Nursing Care
Commendation
JAN
MAR
MAY
JULY
X
SEPT
NOV
X
X
*
*
*
*
*
*
X
X
CAP protocols are followed to include the required data elements
in 90% if eligible pathology reports.
95% follow the synoptic format. (Both required for
commendation)
 Quarterly CAP review report
Oncology Nursing care is provided by nurses with specialized
knowledge and skills. Competency is evaluated annually
 Annual competency (ONS, Nursing Core Curriculum)
 Report # certified vs. trained oncology nurses. (25%
certified and available to program, P&P to evaluate
nursing competency, Nursing competency evaluated each
year and reported to committee for commendation).
X
X
X
X
X
5
STANDARD
DEFINITION
2.3 (New)
Risk
Assessment and
Genetic
Counseling
CONTINUUM
OF CARE
SERVICES
3.1 (New)
Patient
Navigation
Process
2015 Phase in
CA risk assessment, genetic counseling, and testing services
provided to patients on site or by referral, by a qualified genetics
professional.
3.2 (New)
Psychosocial
Distress
Screening
2015 Phase in
Develop and Implement a process to integrate and monitor on-site
psychosocial distress screening and referral.
 Select a Psychosocial Coordinator(Oncology Social
Worker)
 Psychosocial Coordinator Report
JAN
MAR
MAY
JULY
 Risk Assessment/Genetic counseling referral
3.1-3.3
Patient Navigation process driven by community needs assessment
is established address health care disparities and barriers to care
for patients
 Community needs assessment – once every 3 years
 Navigator Report
SEPT
NOV
X
X
X
X
X
X
X
X
X
X
3.3 (New)
Survivorship
Care Plan
2015 Phase in
Develops and implements a process to disseminate a
comprehensive care summary and FU plan to patients who are
completing treatment at least annually
 Develop Survivorship Care Plan
 Finalize Survivorship Care Plan
X
X
6
STANDARD
DEFINITION
PATIENT
OUTCOMES
4.1-4.8
4.1 (6.2)
Prevention
Programs
Each year, cancer committee provides at least 1 cancer prevention
program to meet the needs of community and is consistent with
evidence-based national guidelines.
 Develop a plan for prevention programs
 Community outreach coordinator report/Evaluation
 WIC
Each year, cancer committee provides at least 1 cancer screening
program to decrease late stage disease based on community needs
and is consistent with evidence based national guidelines.
 Develop a plan for screening programs
 Community outreach coordinator report/Evaluation
 WIC
CA Liaison Physicians is responsible for evaluating, interpreting
and reporting NCDB data. Reports at least 4 times a year.
 NCDB Analysis Reports
 Web based training (New or reappointment)
Annually performance levels are met for each the specified
accountability measures.
 CP3R Review and Action
 RQRS Review and Action
Annually performance levels are met for the specified quality
improvement measures as defined by the COC.
4.2 (6.2)
Screening
Programs
4.3 Cancer
Liaison
Physician
Responsibilities
4.4 (4..6)
Accountability
Measures
4.5 (4.6)
Quality
JAN
MAR
MAY
JULY
SEPT
NOV
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
7
STANDARD
Improvement
Measures


4.6 (4.3)
Assessment of
Evaluation an
Treatment
Planning
(Clinical Stage)
4.7 (8.1)
Studies of
Quality
2 required(CCP, CCCP)
3 required (INCP)
4.8 (8.2)
Quality
Improvements
DEFINITION
Measures selected by the COC, quality reporting tools
show a performance rate equal to or greater than the rate
specified by the COC.
CP3R Review and Action
Each year, a Physician performs a study to assess whether patients
are evaluated and treated according to evidence-based national
treatment guidelines.
 Appoint Physician
 Choose Study Site
 Present Clinical Stage/Appropriate Prognostic Indicator
study
Each year (Category), QI Coord develops, analyzes and
documents the required studies that measure the quality of care
and outcomes.
 Determines study topic, Develop Criteria
 Collect Data
 Present summary of findings/Compare with National
Benchmarks
 Recommendations/Design Action Plan
 Follow up
 QI Coordinator Report
Annually, QI coordinator implements 2 patient care improvements
 At least two improvements are implemented and
documented. 1 is based on the results of a completed study
that measures cancer patient quality of care and outcomes.
One study based on any source.
 QI Coordinator Report
JAN
MAR
X
MAY
JULY
SEPT
X
NOV
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
8
STANDARD
DEFINITION
DATA
QUALITY
5.1-5.7
5.1 (3.1)
Cancer
Registrar
Credentials
Case Abstracting is performed by a Certified Tumor Registrar
5.2 (3.3)
Abstracting
Timeliness
Commendation
5.3 (3.4)
Follow-Up of all
Patients
5.4 (3.5)
Follow-Up of
Recent Patients
5.5 (3.6)
Data
Submission
5.6 (3.7)
Accuracy of

Coordinator report number of FTE’s and CTR’s that
perform abstracting
 Abstractors obtain CTR within 3 years (2015) COC tracks
noncredentialed staff
90% of cases are abstracted within 6 months of the date of the first
contact with the program (95% commendation)
 Registry Monthly Status Report
80% follow-up rate is maintained from cancer registry reference
date
 Monthly FU survey worksheet
 Registry monthly status report
90% follow-up rate is maintained for all eligible analytic cases
diagnosed within the last 5 years.
 Monthly FU Survey worksheet
 Registry Monthly status report
Submit to the NCDB complete data for all requested analytic cases
for the annual Call for Data.
 Coordinator report as necessary
Annually, cases submitted to the NCDB diagnosed 2003 or later
meet established quality criteria and resubmission deadline.
JAN
MAR
MAY
X
JULY
SEPT
NOV
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
9
STANDARD
Data
Commendation
5.7 (3.8)
Commission on
Cancer Special
Studies
Eight (8)
Commendation
Standards

DEFINITION
Coordinator report data submission results as necessary
JAN
MAR
MAY
JULY
SEPT
NOV
X
The program participates in special studies as selected by the
Commission on Cancer.
 Data submitted by the established deadline
1.3, 1.9, 1.11, 1.12, 2.1, 2.2, 5.2, 5.6
AJCC Stage deleted. CA committee attendance added.
10
October 2012
W. Williams
11