 Tumor Registrars Association of Maryland Educational Meeting Hagerstown, Maryland September 20, 2013

Review And Analysis Of The SAR Gerald J. Béchamps, M.D., FACS Winchester, Virginia

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 gastro-esophageal 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 board-certified 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: 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 1.Minutes document the attendance at each meeting. Cancer Committee monitors the attendance and addresses low attendance 2.Teleconference calls are acceptable for compliance 3.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

SMART Specific Measurable Attainable Realistic Timely

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 evidence-based 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 evidence-based 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 evidence-based 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 evidence-based 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 The CLP evaluates and interprets the program’s performance using the NCDB data The CLP, or an equivalent designee, reports this information to the cancer committee at least four times each year 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 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, CCP, PCP, FCCP 2

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 program-appropriate methods as directed by the cancer center. One improvement is linked to a completed study of quality