Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective Standards first published in 1930 by the Committee on the Treatment of Malignant.

Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective
Standards first published in 1930 by the Committee on the Treatment of Malignant Diseases. First surveys performed in 1931. Most recognize the historical four main components of a cancer program: cancer committee, cancer conferences, cancer registry, patient care evaluation The cancer conference and cancer committee were required from the beginning. The cancer registry requirement was added in 1956. The final component, patient care evaluations, was added in 1976 with CoC-initiated studies. Cancer program standards continued to expand and change over time. Volume I: Cancer Program Standards introduced defined standards, a numbering system, and numeric rating. Cancer Program Standards 2004 takes the next step and focus on quality and outcomes. Suzanna S. Hoyler, CTR Director, WCI Information Management Washington Hospital Center Washington, DC COC Network Surveyor

Objectives of the Presentation
Identify the survey participants role in the survey process Learn now to stay prepared for survey Provide the necessary survey documentation Identify what to document Overview of the Standards Registrar’s role in the survey Important tips and tools Putting the standards into practice Putting the standards in practice Staying prepared Registrar’

Sample Survey Agenda 8:00 am Surveyor meets cancer team
10:00 am Tour the facility & campus* 12:00 pm Attend tumor board/cancer conf * 1:00 pm Cancer registry 2:30 pm Surveyor private time 3:00 pm Summation with cancer team members Tour required if applicable to program and category Affilitate Hospital Cancer Program & Freestanding Cancer Center program exempt from inpt med oncology unit or functional equivalent. CHCP, Hosp Assoc Ca Prog, & Integrated Ca Program – only required to have functional equivalent. COMP – can have either inpt med onc unit or functional equivalent Funcitonal equivalent – certain beds or an area of an inpt unit serves as equivalent med onc unit. Required activity. Tour required if applicable to program & category. Minimum 6 hour visit

Sample Survey Agenda for a Network
Day 1 8:00 am Meet with Administrators 8:30 am Meet with Cancer Team 11:00 am Tour the facility & campus* 12:00 pm Attend tumor board/cancer conf * 1:00pm Chart Review* 2:30 pm Cancer registry Day 2 8:00am Tour second facility* 9:00am Chart Review * 10:30am Surveyor team private time 11:00am Summation with Cancer Team members * Required activities. Chart review must be done for each facility, but only 2 must be visited.

The Cancer Team Required members Cancer Committee Chair
Member of Administration or Representative Cancer Liaison Physician (Community Outreach Coordinator) Cancer Conference Coordinator Quality Improvement Coordinator Cancer Registrar Quality Control of Cancer Registry Data Coordinator Recommended members* Oncology Nursing Rehabilitative Services Pastoral Care Research Nurse or Data Manager Social Services or Discharge Planning Dietary/Nutritional Services Pain Control/Palliative Care Physician or Specialist Pharmacy Hospice Public Education Tour required if applicable to program and category Affilitate Hospital Cancer Program & Freestanding Cancer Center program exempt from inpt med oncology unit or functional equivalent. CHCP, Hosp Assoc Ca Prog, & Integrated Ca Program – only required to have functional equivalent. COMP – can have either inpt med onc unit or functional equivalent Funcitonal equivalent – certain beds or an area of an inpt unit serves as equivalent med onc unit. * Applicable to program & category.

Medical Chart Review 25 cases Verifying
Abstracting timeline (≤ 6 months) CAP protocols AJCC stage complete (T, N, M, & Stage Group) Who staged the case? Follow-up date 11/16/2018

Documents* to Provide Surveyor
Documents provided in advance to surveyor Documents made available to surveyor May be sent in advance *All documents are sent to Chicago for shredding Refer to page 7 of Commission on Cancer Cancer Program Standards 2004 for a complete list.

Documents Provided in Advance
Institution’s Accreditation Certificate or letter from accrediting body Bylaws, policies, etc Designate responsibility & accountability of Cancer Committee

Cancer Committee minutes Attachments Subcommittees or work group minutes Annual goals Time frame for evaluation & completion Coordinator’s responsibilities continued…

Cancer conferences/tumor boards Annual frequency & format Multidisciplinary attendance Annual case presentations Monitoring of cancer conference(s) activity & corrective action Annual goals Time frame for evaluation and completion Assigned coordinators Responsibilities of other committee members continued…

Outcomes analysis Results Methods of analysis Annual report (if published) continued…

Documentation of referred radiation oncology services & resources* Documentation that identifies the medical oncology unit/functional equivalent (if applicable)* Physician staging policy/procedure* *CoC Website -- Resources & Tools for Cancer Programs continued…

Documents Made Available (optional to send)
Annual quality control activities Current credentialing of registry staff (NCRA CTRs) Case abstracting by a CTR or data supervision responsibilities by a CTR Organizational chart for nursing …… Check Page 7 in the standards Refer to page 7 of Commission on Cancer Cancer Program Standards 2004 for a complete list.

Eight Areas of Evaluation
Institutional & Programmatic Resources Cancer Committee Leadership Cancer Data Management & Cancer Registry Operations Clinical Management Research Community Outreach Professional Education & Staff Support Quality Improvement Cancer Program Standards 2004 provides eight areas of evaluation with 36 standards. All standards are mandatory. Surveyor’s purpose is to validate that your program has accomplished these.

Chapter 1: Institutional & Programmatic Resources
Purpose Confirms accreditation Standard 1.1 State licensure acceptable Chapter 1: Institutional and Programmatic Resources. Purpose: The standard confirms the accreditation standing for the facility or facilities. Standard The facility is accredited by a recognized authority appropriate to the facility type. -Confirms the accreditation standing of the facility applying for approval -The requirements are stratified by category -State licensure has been added to the list of recognized authorities so that hospitals choosing not to be accredited by the JCAHO are now eligible to participate in the CoC Approvals Program.

Chapter 2: Cancer Committee Leadership
Purpose Establish cancer committee responsibility & accountability Highlighted changes Standard Multidisciplinary membership Standard Activity coordinators Standard Meeting schedule & structure Chapter 2: Cancer Committee Leadership Purpose. The standards establish the cancer committee’s leadership responsibility and accountability for cancer program activities at the facility. Standard The cancer committee membership is multidisciplinary representing physicians from the diagnostic and treatment specialties and non-physicians from administrative and supportive services. -Multidisciplinary membership of the committee is maintained. Additional required members are specified by category - examples are hospice/home care nurse or administrator, pain control/palliative care physician or specialist, data manager. -Recommendations for additional members included: dietary/nutrition specialist, pharmacist, ACS cancer control specialist, member of the public. Standard One coordinator is designated for each of the four areas of cancer committee activity: cancer conference, quality control of cancer registry data, quality improvement, and community outreach.Activity coordinators required for cancer conference, quality control or registry data, quality improvement, community outreach. -The Cancer Liaison Physician is the Community Outreach Coordinator. -Both physicians and nonphysician members of the committee can be designated. One member cannot serve more than one role. Standard 2.4 The cancer committee meeting schedule and structure fulfills the requirements for the category. -Regular meeting allow the committee to carry out its responsibilities. -Additional required meetings specified by category – Network Cancer Program meets every other month. -Recommendations for subcommittees and workgroups specified by category. Standard 2.5 The cancer committee develops and evaluates the annual goals and objectives for the clinical, community outreach, quality improvement, and programmatic endeavors related to cancer care. -The Cancer Committee is responsible for goal setting, planning, initiating, implementing, evaluating, and improving all cancer-related activities in the facility.

Highlighted changes Standard Annual goals & objectives Clinical Community outreach Quality improvement Programmatic Chapter 2: Cancer Committee Leadership Purpose. The standards establish the cancer committee’s leadership responsibility and accountability for cancer program activities at the facility. Standard The cancer committee membership is multidisciplinary representing physicians from the diagnostic and treatment specialties and non-physicians from administrative and supportive services. -Multidisciplinary membership of the committee is maintained. Additional required members are specified by category - examples are hospice/home care nurse or administrator, pain control/palliative care physician or specialist, data manager. -Recommendations for additional members included: dietary/nutrition specialist, pharmacist, ACS cancer control specialist, member of the public. Standard One coordinator is designated for each of the four areas of cancer committee activity: cancer conference, quality control of cancer registry data, quality improvement, and community outreach.Activity coordinators required for cancer conference, quality control or registry data, quality improvement, community outreach. -The Cancer Liaison Physician is the Community Outreach Coordinator. -Both physicians and nonphysician members of the committee can be designated. One member cannot serve more than one role. Standard 2.4 The cancer committee meeting schedule and structure fulfills the requirements for the category. -Regular meeting allow the committee to carry out its responsibilities. -Additional required meetings specified by category – Network Cancer Program meets every other month. -Recommendations for subcommittees and workgroups specified by category. Standard 2.5 The cancer committee develops and evaluates the annual goals and objectives for the clinical, community outreach, quality improvement, and programmatic endeavors related to cancer care. -The Cancer Committee is responsible for goal setting, planning, initiating, implementing, evaluating, and improving all cancer-related activities in the facility. Comm outreach: improve fu for positive findings from prostate screening program Set up a GI support group ‘Clinical: earn the COC outstanding achievement award Quality improvement: implement use of AJCC staging form in Medical record Clinical Goal: improve turn-around time for chemo administration improve wait time in breast surgery clinic.

Standard 2.6 – Cancer conf frequency Standard 2.7 – Multidisciplinary attendance Standard 2.8 – Number of cases presented Standard 2.9 – Cancer Comm monitors & evaluates Frequency* & attendance Total & prospective case presentation These standards establish the cancer committees new involvement in setting the goals and expectations for the cancer conference activity at the facility. Standard The cancer committee establishes the cancer conference frequency and format on an annual basis. Standard 2.7 – The cancer committee establishes the multidisciplinary attendance requirements for cancer conference on an annual basis. Standard 2.8 – The cancer committee ensures that the required number of cases are discussed at the cancer conferences on an annual basis and that at least 75 percent of the cases discussed are presented prospectively. Standard 2.9 – The cancer committee monitors and evaluates the cancer conference frequency, multidisciplinary attendance, total case presentations and prospective case presentation on an annual basis. Emphasize that, through the cancer conference coordinator, the committee is responsible for setting the cancer conference expectations each year. The coordinator is also responsible for monitoring the conference activity to ensure that goals are met, and sharing this information with the cancer committee for their information and action. *Recommendations for frequency & format based on category

Highlighted changes Standard Cancer registry quality control plan Standard Analyze & report outcomes* Committee selected site & outcome Committee selected dissemination Commendation defined Standard The cancer committee establishes and implements a plan to evaluate the quality of cancer registry data and activity. The plan includes procedures to monitor casefinding, accuracy of data collection, abstracting timeliness, follow-up, and data reporting on an annual basis. -The minimum scope of the plan and required activities are outlined in the manual. -For example: Determining the time frame, scope and methods of evaluation, and who will be involved in the evaluation. -This offers flexibility to use non cancer committee members, and resident or medical students, if available at the facility. Standard Each year, the cancer committee analyzes patient outcomes and disseminates the results of the analysis. -This is the first standard eligible for commendation. -This replaces the previous annual report requirement. -The committee selects the site to be evaluated and chooses the outcome. -Evaluation of survival is the preferred choice, but the committee can select another outcome (e.g. quality of life) -The committee also determines the audience and method for dissemination of the analysis. -If an annual report is published each year, or if more than one analysis of outcomes is performed, the program is eligible to receive a commendation for this standard. *Commendation available

Chapter 3: Cancer Data Management & Cancer Registry Operations
Purpose Ensure accurate & timely data collection Highlighted changes Standard CTR case abstracting Standard Abstracting timeliness* Standards 3.4, Follow-up Cancer Registry Operations Chapter 3: Cancer Data Management and Registry Operations Purpose: The standards ensure accurate and timely collection of cancer patient data which allows for the evaluation of patient outcomes and identification of opportunities for improvement. Lifetime follow-up of patients included in the database encourages clinical follow-up and surveillance of additional primaries. Standard Case abstracting is performed or supervised by a Certified Tumor Registrar (CTR). -Standard to be phased-in by January 1, -Built-in flexibility includes facility employed CTR, contracted staff, registry service companies. Facilities without a CTR show recruitment efforts and/or plans to certify current staff within the phase-in period. -New programs must meet the standard at initial survey. Standard 3.3 – For each year between survey, 90 percent of cases are abstracted within six months of the date of first contact. -Ongoing timely abstracting is expected. Patterns of accession will be monitored through NCDB submissions. -Though an extension was given to delay the start of abstracting of 2003 cases because of the FORDS changes, the Committee on Approvals also recognizes that many programs will not be able to complete this abstracting on-time (June 30, 2004). In light of this, the Committee on Approvals extended the abstracting deadline for 2003 cases until September 30, 2004, and clarified that abstracting for 2004 cases must begin and end on-time. -A commendation has been defined for this standard, but is not applicable during 2004 because of the phase-in of the new standards and the extension given to complete the 2003 case abstracting. Standard 3.4 and 3.5 – Annual follow up of analytic cases required as in the past -However, the standards for follow-up of living patients and the lost-to-follow-up designation have been eliminated. -In addition, the required overall follow-up percentage has been changed which should provide assistance to registries with older reference dates. Standard 3.6 Complete data for all analytic cases are submitted to the National Cancer Data Base in accordance with the annual Call for Data. -This is not a new standard, but the annual submission of complete data will be more closely monitored. -The process has changed so that the specifications for the call for data are posted on the ACoS website and data submission occurs through the password protected CoC Datalinks portal. Standard 3.7 Cases submitted to the NCDB for the most recent accession year requested meet the established quality criteria included in the annual call for data. -This is a new standard which requires that programs correct errors identified on the edit report posted on the ACoS Web site and resubmit corrected cases to meet a data quality standard. A commendation has been established for this standard to recognize programs that meet the data quality standard on the initial submission of data. Standard 3.8 – The facility participates in special studies as requested by the CoC. -Participation in CoC studies is now required. -Some or all facilities will be selected to participate in one or more studies. The criteria for the study and deadline for submission is specified in the study information provided by the CoC. -Generally, CoC studies will not fulfill the criteria for standards outlined in chapter 8. *Commendation available

Chapter 3: Cancer Data Management & Cancer Registry Operations
Highlighted changes Standard NCDB data submission Standard NCDB data submission quality* Standard CoC special studies Cancer Registry Operations Chapter 3: Cancer Data Management and Registry Operations Purpose: The standards ensure accurate and timely collection of cancer patient data which allows for the evaluation of patient outcomes and identification of opportunities for improvement. Lifetime follow-up of patients included in the database encourages clinical follow-up and surveillance of additional primaries. Standard Case abstracting is performed or supervised by a Certified Tumor Registrar (CTR). -Standard to be phased-in by January 1, -Built-in flexibility includes facility employed CTR, contracted staff, registry service companies. Facilities without a CTR show recruitment efforts and/or plans to certify current staff within the phase-in period. -New programs must meet the standard at initial survey. Standard 3.3 – For each year between survey, 90 percent of cases are abstracted within six months of the date of first contact. -Ongoing timely abstracting is expected. Patterns of accession will be monitored through NCDB submissions. -Though an extension was given to delay the start of abstracting of 2003 cases because of the FORDS changes, the Committee on Approvals also recognizes that many programs will not be able to complete this abstracting on-time (June 30, 2004). In light of this, the Committee on Approvals extended the abstracting deadline for 2003 cases until September 30, 2004, and clarified that abstracting for 2004 cases must begin and end on-time. -A commendation has been defined for this standard, but is not applicable during 2004 because of the phase-in of the new standards and the extension given to complete the 2003 case abstracting. Standard 3.4 and 3.5 – Annual follow up of analytic cases required as in the past -However, the standards for follow-up of living patients and the lost-to-follow-up designation have been eliminated. -In addition, the required overall follow-up percentage has been changed which should provide assistance to registries with older reference dates. Standard 3.6 Complete data for all analytic cases are submitted to the National Cancer Data Base in accordance with the annual Call for Data. -This is not a new standard, but the annual submission of complete data will be more closely monitored. -The process has changed so that the specifications for the call for data are posted on the ACoS website and data submission occurs through the password protected CoC Datalinks portal. Standard 3.7 Cases submitted to the NCDB for the most recent accession year requested meet the established quality criteria included in the annual call for data. -This is a new standard which requires that programs correct errors identified on the edit report posted on the ACoS Web site and resubmit corrected cases to meet a data quality standard. A commendation has been established for this standard to recognize programs that meet the data quality standard on the initial submission of data. Standard 3.8 – The facility participates in special studies as requested by the CoC. -Participation in CoC studies is now required. -Some or all facilities will be selected to participate in one or more studies. The criteria for the study and deadline for submission is specified in the study information provided by the CoC. -Generally, CoC studies will not fulfill the criteria for standards outlined in chapter 8. *Commendation available

Registry Procedure Manual(s)
Policy / Procedure Case accessions into the registry Cancer registry job description Case eligibility criteria Casefinding CoC data standards & coding instructions Confidentiality & release of information Data collection Dates of implementation or changes in policies or registry operations Follow-up procedures Maintaining & using the suspense file Quality control of registry data Staging systems used

Chapter 4: Clinical Management
Purpose Identify minimum scope of clinical services Highlighted changes Standard 4.1 – Radiation services Standard 4.2 – Inpatient medical oncology unit Chapter 4: Clinical Management Purpose: The standards identify the minimum scope of clinical services needed to provide high-quality cancer care to patients. The managing physician is essential to coordinating a multidisciplinary team approach to patient care including the accurate and complete staging of each patient. Standard 4.3 AJCC staging is assigned by the managing physician and recorded on a staging form in the medical record on 90% of eligible annual analytic cases. -The standard is not new, but the requirement for a staging form is, and becomes effective with for cases diagnosed January 1, 2005. -The Committee on Approvals recently decided that staging by residents and fellows with a co-signature by a faculty or managing physician will meet the requirements for physician staging. Commendation is awarded for staging on more than 95% of eligible cases.

Standard AJCC staging* Staging form in medical record required Effective January 1, 2005 Committee develops staging policy & procedure Definition of managing physician Placement of forms & acceptable completion methods Quality control of completeness & accuracy Resolution of differences Chapter 4: Clinical Management Purpose: The standards identify the minimum scope of clinical services needed to provide high-quality cancer care to patients. The managing physician is essential to coordinating a multidisciplinary team approach to patient care including the accurate and complete staging of each patient. Standard 4.3 AJCC staging is assigned by the managing physician and recorded on a staging form in the medical record on 90% of eligible annual analytic cases. -The standard is not new, but the requirement for a staging form is, and becomes effective with for cases diagnosed January 1, 2005. -The Committee on Approvals recently decided that staging by residents and fellows with a co-signature by a faculty or managing physician will meet the requirements for physician staging. Commendation is awarded for staging on more than 95% of eligible cases. *Commendation available

Highlighted changes Standard Oncology nursing knowledge & skills Standard Nursing direction of the oncology unit or FE Standards 4.4 and Nurses with specialized knowledge and skills in oncology are provided. Annual competency evaluation. Standard Nursing care is provided by nurses with specialized knowledge and skills in oncology. Competency is evaluated annually. Standard An Oncology Nurse Manager or a Registered Nurse (RN) provides direction to the inpatient medical oncology unit or the functional equivalent as appropriate to the category. -An Oncology Nurse Manager or Registered Nurse provide day to day direction for the inpatient oncology unit or functional equivalent. These requirements specified by category. Standard 4.6 The guidelines for patient management and treatment currently required by the CoC are followed. -The guidelines currently required by the CoC are that 90 percent of pathology reports that include a cancer diagnosis will include the scientifically validated data elements outlined on the surgical case summary checklist of the College of American Pathologists publication, Reporting on Cancer Specimens. -This does not apply to cytologic specimens, diagnostic biopsies, palliative resection specimens, and special studies. -Though synoptic reporting is preferred, this is not required. A commendation has been defined for this standard is the program meets the requirement for the CAP guidelines and has also adopted the use of, and is monitoring compliance with, guidelines from other national organizations.

Standard 4.6 – Patient Management & Treatment Guidelines CAP guidelines* 90% of pathology reports Random review of analytic cases Is there a plan to implement & monitor CAP protocols documented in cancer committee minutes? Standard 4.7 – Rehabilitation services Please read the rating modification. Rating based on a documented implementation plan for this new standard. *Medical record review

Chapter 5: Research Purpose Highlighted changes
Promote clinical trial participation Highlighted changes Standard Cancer-related clinical trial information Standard Cancer-related clinical trial accrual* 2% to 10% requirement based on category Chapter 5: Research Purpose: The standards promote advancement in cancer treatment through the provision of clinical trial information and patient accrual to cancer-related clinical trials. Standard Information about the availability of cancer-related clinical trials is provided to patients through a formal mechanism. -By providing information about the availability of cancer-related clinical trials, the facility offers patients the opportunity to participate in the advancement of evidence-based medicine. -The provision of this information is through a formal mechanism such as pamphlets, newsletters, internet postings, etc. Standard 5.2 -As appropriate to the category, the required percentage of cases is accrued to cancer-related clinical trials on an annual basis. -The current 2% requirement for all programs expected to accrue patients to clinical trials no longer applies. A percentage is specified for each category, and several categories are exempt, ie, A Network Cancer Program accrues 6% of the number of patients seen in the Network and the Hospital Associate Cancer Program and Community Hospital Cancer Program are exempt. -Important to note that ALL programs designated as Community Hospital Comprehensive Cancer Programs are required to accrue patients to clinical trials. This is a major change to the requirements for this category. -A Commendation rating has been defined for this standard that requires reaching a higher percentage of accruals. The commendation applies to all programs. i.e., commendation Commun hosp comprehensive program, minimum requirement 2%, commendation 4% *Commendation available

Chapter 6: Community Outreach
Purpose Ensure availability of supportive services, prevention, & early detection Highlighted changes New Cancer Liaison Physician role Standard Supportive services Standard Two prevention or early detection programs Standard Monitor community outreach annually Chapter 6: Community Outreach Purpose: The standards ensure that supportive services, prevention and early detection opportunities are provided to cancer patients and their families. Standard Supportive services are provided on-site or coordinated with local agencies and facilities. -Total patient care extends beyond that provided by physicians and nurses. Supportive services assist patients and their families to cope with changes resulting from a cancer diagnosis. -Supportive services address the needs of the majority of patients as well as provide for special populations or needs. The supportive services offered on-site will vary depending on the scope of the facility, local staff expertise, and patient mix. Supportive services not provided on-site are provided through referral to other facilities and/or local agencies such as the American Cancer Society. Standard Each year, two prevention or early detection programs are provided on-site or coordinated with other facilities or local agencies. -Prevention programs use strategies to modify attitudes and behaviors to reduce the risk of developing a malignancy. Early detection discovers cancer at an early stage when the application of prompt treatment can increase survival and decrease morbidity. -Commendation is awarded if the program offers three or more prevention or early detection programs annually. Standard The cancer committee monitors the community outreach activities on an annual basis. The findings are documented. -The Community Outreach Coordinator (Cancer Liaison Physician) assists the cancer committee in monitoring and enhancing the community outreach program.

Chapter 7: Professional Education & Staff Support
Purpose Promotes increased knowledge Highlighted changes Standard One cancer-related educational activity Standard Registry staff cancer-related education* Chapter 7: Professional Education and Staff Support Purpose: The standards promote increased knowledge through annual educational programs and registry staff participation in local, regional, or national educational activities. Standard Other than cancer conferences, the cancer committee offers one cancer-related educational activity each year. -Educational activities ensure that members of the cancer care team possess current knowledge of cancer prevention, early detection, diagnosis, treatment, and follow-up care. Examples include: educational symposium, lecture on cancer related topic, video conference. Standard Other than cancer conferences, all members of the cancer registry staff participate in a local, state, regional, or national cancer-related educational activity each year. -This includes clerical and non certified staff. -The Committee on Approvals recently changed the Commendation for this standard so that commendation will be awarded if all CTRs attend a national cancer-related educational activity once every three years. Because of this change, the commendation rating will not apply for surveys performed during 2004. *Commendation available

Chapter 8: Quality Improvement
Purpose Evaluate & improve the of quality of cancer services, patient care & outcomes Highlighted changes Standard Studies of quality & outcomes Number & type based on category Year completed Chapter 8: Quality Improvement Purpose: The standards ensure that cancer services, care, and patient outcomes are evaluated and improved so that patients receive care that is comparable to national standards. -The standards are basically the same as the current mandatory standards in Section 7 (7.2.1 and 7.5.1) Standard Each year, based on category, the cancer committee completes and documents the required studies that measure quality and outcomes. -The annual evaluation of services and care provides a baseline to measure quality and provides an opportunity to correct or enhance patient outcomes. -The studies should focus on quality-related issues relevant to the facility and the local patient population. -The number and type of studies are specified by category, ie, a Network Cancer Program completes 1 study based on registry data and 2 additional studies Standard Annually, the cancer committee implements two improvements that directly affect cancer patient care. The improvements are documented. -Implementation of improvements demonstrates a program’s continuous commitment to providing high quality cancer care. -Commendation is awarded when more than two improvements are implemented each year.

Chapter 8: Quality Improvement
Highlighted changes Standard Improvements affecting patient care 2 improvements* Chapter 8: Quality Improvement Purpose: The standards ensure that cancer services, care, and patient outcomes are evaluated and improved so that patients receive care that is comparable to national standards. -The standards are basically the same as the current mandatory standards in Section 7 (7.2.1 and 7.5.1) Standard Each year, based on category, the cancer committee completes and documents the required studies that measure quality and outcomes. -The annual evaluation of services and care provides a baseline to measure quality and provides an opportunity to correct or enhance patient outcomes. -The studies should focus on quality-related issues relevant to the facility and the local patient population. -The number and type of studies are specified by category, ie, a Network Cancer Program completes 1 study based on registry data and 2 additional studies Standard Annually, the cancer committee implements two improvements that directly affect cancer patient care. The improvements are documented. -Implementation of improvements demonstrates a program’s continuous commitment to providing high quality cancer care. -Commendation is awarded when more than two improvements are implemented each year. *Commendation available

Helpful Tools Available on the Web - Sample Best Practices*
Bylaws Reporting to Cancer Committee Job Descriptions for Coordinators AJCC Staging Policy Quality Improvement & Assurance Clinical Management Treatment Guidelines Resource List Clinical Trials Information Community Outreach *Located on Commission on Cancer web site.

Helpful Tools Available on the Web*
Cancer Program Tracking Tools AJCC Staging Quality Control Tool Cancer Registry Abstracting Quality Control tool Cancer Conference Grid Pathology Report Quality Control Tool Program Activity Template Study of Quality Commission on Cancer web site

Survey Application Record (SAR) Annual Updates
Cancer committee leadership (2.2, 2.3, 2.4, 2.5) Conference activity (2.6, 2.7, 2.8) Outcomes analysis (2.11) CTR Abstracting (3.1) Abstracting backlog (3.3) Treatment services (4.1, 4.2) AJCC staging (4.3) Nursing care (4.4, 4.5) Patient guidelines (4.6) Rehabilitation (4.7) Research (5.1, 5.2) Community Outreach (6.1, 6.2, 6.3) Education (7.1, 7.2) Quality Improvement (8.1, 8.2) This is the list of areas of the SAR that will be updated annually. Note that key areas of programmatic activity are included in this list. CTR abstracting, Abstracting backlog, AJCC staging, and Quality Improvement activities. This list of standards for annual updates is included in the newly revised SAR Training Guide posted on the American College of Surgeons Web site.

Thank you to the Commission on Cancer for some of the slides
Asa Carter (312) Vicki Chiappetta (312) Lisa Landvogt (312)

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Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective Standards first published in 1930 by the Committee on the Treatment of Malignant.

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Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective Standards first published in 1930 by the Committee on the Treatment of Malignant.

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Presentation on theme: "Commission on Cancer Standards: Staying Prepared – A Surveyor’s Perspective Standards first published in 1930 by the Committee on the Treatment of Malignant."— Presentation transcript:

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