Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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