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Physicians are currently board certified or in the process of certification

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1.1: Physician Credentials

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Corporate administrator Oncology nurse from the ambulatory care setting Clinical research representative Physician member of the palliative care team Pharmacist Registered dietician Hospice nurse or administrator Rehabilitation representative Genetics professional/counselor, if these services are provided on-site

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1.2 Cancer Committee Membership

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Each required cancer committee member or the designated alternate attends 75% of meetings annually.

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1.3 Cancer Committee Attendance

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Each year, the cancer committee meets at least once each calendar quarter.

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1.4 Cancer Committee Meetings

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The cancer committee sets at least 1 programmatic and 1 clinical goal each year. Each goal is evaluated twice annually, and the evaluation is documented.

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1.5 Cancer Program Goals

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Who establishes, implements, and monitors at least 1 clinical and at least 1 programmatic goal for the endeavors related to cancer care?

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The cancer committee

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The cancer committee establishes and implements a registry quality control plan each year. The plan addresses all required criteria.

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1.6 Cancer Registry Quality Control Plan

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Who establishes and implements a plan to annually evaluate the quality of cancer registry data and activity?

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The cancer committee

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The cancer conference coordinator monitors the cancer conference program annually and reports conference activity to the cancer committee each year.

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1.7 Monitoring Conference Activity

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Who monitors and evaluates the cancer conference activities and reports findings to the cancer committee at least annually?

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The cancer conference coordinator

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The community outreach coordinator monitors the community outreach program annually, prepares the community outreach activity summary,and shares the report with the cancer committee each year.

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1.8 Monitoring Community Outreach

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2015 phase in - 6% of the number of annual analytic cases; 8% of the number of annual analytic cases for commendation. Coordinator/representative reports on activity yearly.

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1.9 Clinical Trial Accrual

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Each year, 1 educational activity is offered to physicians, nurses, and allied health professionals; the activity focuses on the use of stage, prognostic factors, and evidence-based treatment guidelines in treatment planning.

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1.10 Clinical Educational Activity

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All registry staff participate in an annual educational activity.

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1.11 Cancer Registrar Education

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Cancer committee develops and disseminates a report of patient outcomes to the public each year. This standard is for Commendation only.

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1.12 Public Reporting of Outcomes

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90% of eligible pathology reports include the required data items as specified in the site-specific CAP protocols.

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2.1 College of AmericanPathologists Protocols

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Care is provided by nurses with specialized knowledge and skills; competency is evaluated annually.

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2.2 Nursing Care

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Risk assessment and genetic testing and counseling are provided either on-site or by referral, by a qualified genetics professional.

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2.3 Risk Assessment and Genetic Counseling

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Palliative care services are provided either on-site or by referral.

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2.4 Palliative Care Services

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2015 phase in - The cancer committee assesses the community to identify barriers to care, provides navigation services either on-site or by referral or in partnership with local or national organizations, and assesses and reports on the process annually. The assessment is documented.

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3.1 Patient Navigation Process

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2015 phase in - The cancer committee develops and implements a process to assess and address the psychosocial distress of patients with cancer.

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3.2 Psychosocial Distress Screening

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2015 phase in - The cancer committee develops and implements a process to provide a comprehensive treatment summary and follow-up plan to patients who are completing treatment; the process is monitored, evaluated, and reported to the cancer committee each year.

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3.3 Survivorship Care Plan

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Each year, 1 prevention program is offered to address the needs of the community and reduce the incidence of a specified cancer type.

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4.1 Prevention Programs

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Each year, the cancer committee provides at least 1 _________________ that is targeted to meet the needs of the community and should be designed to reduce the incidenceof a specific cancer type.

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cancer prevention program

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Each year, 1 screening program is offered to decrease the number of patients with late-stage disease. Patients with positive findings are followed.

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4.2 Screening Programs

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Each year, the cancer committee provides at least 1_____________________ that is targeted to decreasing the number of patients with late-stage disease.

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cancer screening program

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The CLP uses NCDB data to evaluate and interpret program performance; program performance is reported to the cancer committee at least 4 times annually.

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4.3 Cancer Liaison Physician Responsibilities

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Who is responsible for evaluating, interpreting, and reporting the program's performance using the National Cancer Data Base (NCDB) data.

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The Cancer Liaison Physician

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Who reports to the cancer committee at least four times a year?

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The Cancer Liaison Physician

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Who are the required physicians of the Cancer Committee?

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1. Diagnostic radiologist 2. Pathologist 3. Surgeon (includes general surgeon and/or surgical specialist(s) involved in cancer care) 4. Medical oncologist 5. Radiation oncologist 6. Cancer Liaison Physician

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Who are the required non-physician members of the Cancer Committee?

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1. Cancer program administrator 2. Oncology nurse 3. Social worker or case manager 4. Certified tumor registrar (CTR) 5. Performance improvement or quality management representative 6. Palliative care team member, when these services are provided on site

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Who are the Cancer Committee Coordinators?

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1. Cancer Conference Coordinator 2. Quality Improvement Coordinator 3. Cancer Registry Quality Coordinator 4. Community Outreach Coordinator 5. Clinical Research Coordinator 6. Psychosocial Services Coordinator

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How many cancer related CME hours do the Physicians require annually?

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12 hours (annually)

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Each year, performance levels defined by the CoC are met for each accountability measure. Performance levels are met by each facility in the network and by the network overall.

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4.4 Accountability Measures

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Each year, performance levels defined by the CoC are met for each QI measure.

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4.5 Quality Improvement Measures

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A physician member of the cancer committee performs a study to assess that nationally recognized treatment guidelines are used in the formulation of the first course of treatment for patients newly diagnosed with cancer each year

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4.6 Monitoring Compliance with Evidence-Based Guidelines

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Each year, 3 studies of cancer patient care quality and outcomes are conducted.

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4.7 Studies of Quality

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Each year, 2 improvements in patient care are implemented.

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4.8 Quality Improvements

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Annually, the quality improvement coordinator, under the direction of the cancer committee, implements:

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2 patient care improvements.

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What are the patient care improvements based on?

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1. Results of a completed study that measures cancer patient quality of care and outcomes. 2. One improvement can be identified from another source or from a completed study.

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Case abstracting is performed by a Certified Tumor Registrar.

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5.1 Cancer Registrar Credentials

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Participates in RQRS, submits all eligible cases for all valid performance measures, and adheres to RQRS terms and conditions.

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5.2 Rapid Quality Reporting System (RQRS) Participation

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RQRS data are reported to the Cancer Committee how many time per year?

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Twice

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80% follow-up from reference date

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5.3 Follow-Up of All Patients

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90% follow-up rate for patients diagnosed in the last 5 years.

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5.4 Follow-Up of Recent Patients

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Complete data for all cases submitted each year as specified in the Call for Data

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5.5 Data Submission

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Each year, the cases submitted meet the quality criteria specified in the Call for Data; cases with errors or rejected cases are corrected and resubmitted by the deadline specified in the Call for Data.

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5.6 Accuracy of Data

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The program participates as specified by the CoC.

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5.7 Commission on Cancer Special Studies

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All reportable cases are followed, except:

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1. Residents of foreign countries 2. Cases that are reportable by agreement 3. Patients whose age exceeds 100 years and who are without contact for more than 12 months 4 . Patients diagnosed on or after January 1, 2006, and classified as Class of Case 00.

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Run chart (aka) a run-sequence plot:

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a graph that displays observed data in a time sequence.

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Pareto chart:

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A series of bars whose heights reflect the frequency or impact of problems.

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Cancer Committee authority is established by:

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the facility.

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Number of presentations required at Cancer Conferences:

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15% of total analytic caseload.

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What % of the cases at the Cancer Conferences need to be prospective?

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80%

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Cancer Registry quality control must evaluate how man cases?

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10% of analytic cases (Max. of 300)

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You will receive a commendation in Cancer Registry Education if:

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All Cancer Registry employees participate in yearly education AND all CTRs attend national or regional meeting during the 3 year cycle. (not NCI)

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Yearly the cancer committee develops and disseminates report of patient or program outcomes to the public.

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Public reporting of Outcomes (How are you telling the community about your Cancer Program? )

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What does the Public reporting of outcomes include:

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1. Prevention 2. Screening 3. Accountability 4. QI measures 5. Assessment of Evaluation & treatment 6. Quality Studies 7. Quality Improvements

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The Cancer Program will receive commendation on the CAP protocols if:

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95% of the reports are synoptic AND 95% include required elements

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When would you receive a Nursing Commendation?

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IF: 1. 25% of chemo nurses are OCN certified 2. Specialized nurses are available 3. P&P to evaluate competency yearly 4. Competency done yearly 5. Competency reported & documented to CA comm.

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5.6 Commendation of Accuracy of Data includes:

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The cases diagnosed on January 1, 2003, or later meet the quality criteria for the annual Call for Data on initial submission.

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