question

A survey extension would be granted for

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natural disasters (floods, hurricanes) or disasters (fire). extensions are not granted for issues related to the registry operations such as delayed abstracting, deficiencies in Standards, software, conversion, or resignation of staff.

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SAR is the acronym for

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Survey application record

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The requirement for the percentage of patients enrolled in clinical trials each year differs by

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The program category. It is determined by the facility's cancer program.

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The requirement for cancer registry staff to attend educational activities

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All staff must attend on educational program other than cancer conferences.

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The requirement for cancer registry staff to attend educational activities

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All staff must attend one educational program other than cancer conferences

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To receive commendation, the cancer committee must develop and distribute a report on

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Patient outcomes and program outcomes

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How often is the cancer committee required to develop and distribute a report on patient outcomes or program outcomes?

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Every year

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When the cancer committee completes its report on either patient outcomes or program outcomes, it is required that the report be distributed to

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the public

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The acronym CPA stands for

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College of American Pathologists

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The pathologist must use CAP protocols to report the required data items on what percentage of eligible pathology reports

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90%

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Nurses who care for cancer patients must

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have specialized knowledge and skills in oncology nursing

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The competency of oncology nurses must be evaluated every

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Year

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What does NCDB stand for?

answer

National Cancer Data Base

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Cancer conference prospective cases include

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Patients who were previously presented at a cancer conference if there is a need to discuss systemic tx for dz progression following the completion of first course treatment, an patients who were previously dx if there is a need to discuss palliative care options

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The annual call for data specifies that specific years of historic data be resubmitted to NCDB. These historic cases must meet this requirement(s)

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Established data quality, Resubmission deadline

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When programs receive a three year accreditation with contingencies or provisional accreditation, they must resolve the deficiencies

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Within twelve months

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The percentage of cases presented annually at cancer conference are a minimum of

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15% of analytic cases

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The minimum percentage of prospective cases presented annually at cancer conference is

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80%

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At cancer conference, prospective case presentations include

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Patients who completed initial treatment after diagnosis who now need some form of palliative care

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There must be a policy and procedure for all systemic therapy that is

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Administered in a staff physician's office Off-site locations that have contracts with your hospital

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The Quality Improvement Coordinator

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Reports findings to the cancer liaison physician Is usually the cancer registrar

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The Cancer Registry Quality Coordinator

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cannot be a cancer registrar who abstracts cases or monitors data quality

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Cancer program goals

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Are established to ensure that the program meets CoC standards, Must be completed by the end of the year in which they were established

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The cancer committee is required to implement and monitor this number of clinical goals for cancer can on an annual basis

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Cance Committee must establish, implement, and monitor at least one clinical goal related to cancer care annually

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The activities related to clinical and programmatic goals set by the cancer committee must be documented in the cancer committee minutes

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Twice a year

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The cancer registry quality control plan is established by

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The cancer committee annually establishes and implement a plan to evaluate the cancer registry

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The cancer conference will

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provide consultative services regarding tx options and provide education to allied health professionals

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Prevention or screening/early detection programs must be monitored and those activities are reported to the cancer committee

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Annually

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The community outreach coordinator must be a

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person who was affiliated with or employed by the program

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The cancer registrar is not required to

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work with local community outreach programs such as the American Cancer Society to develop, implement, and monitor community outreach activities. This person is also required to ensure that a follow-up procedure is established that addresses the positive findings from the screening/prevention program.

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The cancer committee is required to present one clinical educational meeting annually. The meeting focus is

answer

on a particular cancer treatment including evidence based national guidelines currently used in treatment planning. This meeting can also address the use of AJCC or other appropriate staging in the clinical setting

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Registrars required to attend a cancer-related educational program other than cancer conference, include

answer

Non-CTRs

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CAP protocols must be followed to report the required data elements for

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Neither bx nor cytology are included in the CAP protocol requirement

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CAP protocols are required for resected specimens of

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In Situ Ductal Carcinoma

question

To assess compliance with the standard that requires data items be reported using CAP protocols, a quality control activity is to be completed annually that consists of a

answer

. Random 10% of eligible pathology reports

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The following percentage of eligible pathology reports must follow the CAP synoptic format to receive a commendation rating

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A. 95%

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It is required that genetic counseling be provided by the

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B. Genetics professional

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It is required that the patient have access to on-site

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patients must have access to cancer risk assessment, genetic counseling, and genetic testing either on-site or by referral.

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It is required that the patient receive genetic counseling and cancer risk assessment

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A. Pre- and post-genetic testing

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Palliative care services includes

answer

palliative care services begin at the time of diagnosis and are continuously available throughout treatment, follow-up and bereavement. These services are intended to optimize the quality of life by providing support for the patient, family and provider team. These services include psychosocial and bereavement support for all these individuals

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The cancer committee conducts a community needs assessment to identify health care needs of the population, barriers to care for patients, and gaps in available resources prior to planning and implementing the patient navigation process. The needs assessment is conducted

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Every three years

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The patient navigation process is implemented

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Prior to a diagnosis of cancer

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When a community needs assessment is completed, it

answer

community needs assessment must identify barriers that prevent timely access to diagnostic and treatment services, identifies health disparities and any shortfall in resources available to address these issues. The patient navigation process is established to help patients, families and their caregivers through the existing barriers and gaps in order to receive quality patient care.

question

After the Patient Navigation Process is established, the following is required

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Document activities and related outcomes associated with the patient navigation process

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The psychosocial representative is required to report to the cancer committee

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Annually

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Psychosocial screening is required at least one time during a "pivotal" medical visit. Pivotal medical visits include when the patient completes

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Chemotherapy and begins radiation therapy, all tx

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A comprehensive care summary and follow-up plans must be given to the patient

answer

At the completion of treatment

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The cancer committee is required to do a community based cancer prevention program

answer

Annually

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Cancer prevention programs may include

answer

Chemoprevention programs

question

A prevention program is

answer

Designed to reduce the incidence of a specific form of cancer

question

The Cancer Liaison Physician (CLP)

answer

Must be a member of the cancer committee

question

The Cancer Liaison Physician (CLP) reports to the cancer committee

answer

A minimum of four times a year

question

What tool does the Cancer Liaison Physician (CLP) use to evaluate and interpret the program's performance

answer

NCDB data

question

The cancer committee is required to monitor patient care using

answer

CoC quality reporting tools

question

The CoC defines a quality improvement measure as

answer

The quality of patient care is assessed using CoC reporting tools appropriate for patients who are treated at the facility's cancer program.

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Compliance with quality of care standards for both diagnosis and treatment of cancer patients is measured against

answer

Current CoC reporting tools

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The study to monitor compliance with evidence-based guidelines can include

answer

Uncommon cases Review of a single treatment for a specific site

question

Quality of care studies are developed by

answer

The quality improvement coordinator

question

For each quality improvement study, the quality improvement coordinator and the cancer committee are responsible for

answer

requires eight responsibilities for the quality improvement coordinator and the cancer committee to meet for each study which include identifying problematic quality-related issues, defining evaluation criteria, performing the study, summarizing the results, comparing data results with national benchmarks, designing/implementing an action plan, identifying steps to ensure action plan is implemented, and evaluating the effectiveness of that action plan

question

The requirements for Studies of Quality can be met by

answer

monitoring registry data can be used only once to satisfy the requirement. Analyzing the data on an annual basis will not meet this standard. The standard also states that ongoing monitoring activities do not fulfill this standard. An example of how the Quality Improvement Coordinator can meet the requirements of Studies on Quality includes evaluating areas that consider the entire spectrum of cancer care and focusing on areas with problematic quality related issues.

question

What number of patient care improvements must the quality improvement coordinator implement annually?

answer

Two

question

The quality improvement coordinator is required to do one patient care improvement based on

answer

Results of a completed study that measures both the quality of patient care and outcomes

question

The sources for patient care improvements include

answer

Actions to address undesirable performance Changes to improve acceptable performance

question

The patient care improvements are required to be

answer

patient care improvements be reported in the cancer committee minutes and shared with all of the medical staff and administration.

question

Cases may be abstracted by

answer

Some non-credentialed registry staff under the supervision of a CTR

question

Which cancer program category requires participation in training of resident physicians?

answer

The participation in training resident physicians is optional for NCI-designated Comprehensive Cancer Center Programs (NCIP) and Integrated Network Cancer Programs (INCP).

question

The CoC requires that abstracting staff hired before 1/1/12 have their CTR credential by

answer

January 1, 2015

question

A non-credentialed abstractor hired after January 1, 2012 must become credentialed (pass the CTR examination)

answer

Within three years of hire

question

If a non-credentialed abstractor hired after January 1, 2012 does not pass their CTR examination within the grace period indicated in Standard 5.1

answer

They may not abstract in any CoC accredited facilities

question

During the on-site visit, what documentation is provided to support compliance with the standard that relates to the qualifications of those performing abstracting for the registry?

answer

A. Verification of the date of hire to perform abstracting

question

The required follow-up rate for all eligible analytic cases since the registry's reference date is

answer

A. 80%

question

An 80% follow-up rate is required for eligible

answer

requires an 80% follow-up rate for all eligible analytic cases since the registry reference date. Standard 5.4 requires a 90% follow-up rate for eligible analytic cases diagnosed within the last 5 years. There is no required follow-up rate for non-analytic cases.

question

Follow-up is required for

answer

Standard 5.4 states follow-up is not required for any of the following: patients over 100 years old with the last contact date of more than 12 months, patients with Class of Case coded to 00 diagnosed on or after January 1, 2006, case types that are reportable by agreement, and patients who are residents of foreign countries.

question

The purpose of follow-up is

answer

long-term follow up is essential to evaluate cancer care outcomes and that accurate follow-up information allows the cancer program to compare its outcomes with regional, state and national statistics.

question

It is required that the registry perform follow-up on these cases

answer

B. All eligible analytic cases

question

Methods to obtain follow-up information include

answer

Contacting other facilities/hospitals Using internet programs that locate people

question

The following are excluded from follow-up data calculations for a pediatric cancer program

answer

Pediatric patients who are 27 years of age and over

question

The required follow-up rate for eligible analytic cases diagnosed within the last five years is

answer

90%

question

In addition to tracking the date of last contact, the cancer committee is interested in monitoring the use of unknown values in the following field(s) to ensure complete follow-up reporting

answer

Type of first recurrence

question

Cancer registry data that must be submitted to NCDB are

answer

All completed eligible analytic cases for the year specified in the Call for Data

question

A hospital program submits data to NCDB

answer

The timing of that submission will be specified in the Call for Data.

question

Every CoC approved hospital must submit data on an annual basis to the

answer

National Cancer Data Base

question

Submissions to NCDB include

answer

cases submitted to NCDB will be specified in the Call for Data.

question

Cases submitted to NCDB will be specified in the Call for Data

answer

When requested by NCDB

question

The National Cancer Data Base is what type of database

answer

A nationwide outcomes database

question

After a request for an initial survey, the program must submit data for

answer

The eligible analytic cases from the most recent complete abstracting year

question

The NCDB data can be used for

answer

Monitoring changes and variations in patient care Benchmarks for a quality improvement project

question

Accuracy standards for cases submitted to NCDB must be met for cases diagnosed

answer

January 1, 2003 and later

question

Cases rejected by NCDB for not meeting quality standards must be corrected and resubmitted by

answer

The deadline specified in the Call for Data

question

The rejected cases resolution (correction) and resubmission to the NCDB is monitored by the

answer

Cancer committee

question

The CoC does special studies

answer

Periodically

question

When the CoC designs a special study, the following must participate

answer

Those programs specified by CoC

question

Special studies are designed to

answer

Provide feedback to improve patient care Set performance benchmarks

question

The CoC specifically mentions using Pareto charts to report quality improvement findings. A Pareto chart is a

answer

Bar graph

question

The following are NCDB reporting tools available through the CoC Datalinks Portal

answer

NCDB Hospital Comparison Benchmark and Survival Reports CP3R and RQRS

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