Eligibility Requirements for CoC Accreditation and Improving CancerCommittee Meetings

M. Kathleen Christian, MD, FACS, CoC Surveyor,Vice‐Chair, Accreditation and Standards Committee, Commission on Cancer

Basic Overview of  Eligibility Requirements for CoCAccreditation

Tips for Cancer Committee Meetings– Attendance

– Committee members’ responsibilities

– Meeting minutes format

– Coordinator reports

Objectives

Eligibility Requirements confirm that a CoC‐accredited program provide or refer the full scope of care services to cancer patients and are ready to be surveyed for accreditation.

Diagnose

Treat

Rehabilitate

Support

Provide essential leadership

Assure quality data

WhyEligibilityRequirements

Structure and Services =  Eligibility Requirements (ER)

Structure

Various health care services essential for comprehensive care

Provided on‐site or by referral

Same for all categories of cancer programs

WhyEligibilityRequirements

CancerCommitteeResponsibilities

New programs have ERs reviewed by surveyor

Monitor and assess each ER annually.

Address issues or gaps in care.

Opportunity to identify needed change to enhance 

services and expand coverage.

CancerProgramEligibilityRequirements

Vital Components of the Annual Assessment– Are the services adequate for patient needs?

– What services might be missing?

– How often are the services used?

– Is it easy to access the services?

– Is there enough staff to provide adequate services?

Facility Accreditation (ER1)Cancer Committee Authority (ER2)Cancer Conference Policy (ER3)Oncology Nurse Leadership (ER4)

Cancer Registry Policy and Procedures (ER5)

EligibilityRequirements:Structure

The facility is accredited by a recognized federal, state, or local authority appropriate to the facility type.

Ensures that care is provided in a safe environment

Cancer program provides copy of certificate or accreditationletter

ER1:FacilityAccreditation

Cancer committee authority is established and documented by the facility.

Formal assignment of authority to the cancer committee.

Cancer program uploads either: Bylaws; or Hospital or Medical Staff Policies & Procedures (P & P); or Other source documentation confirming authority

ER2:CancerCommitteeAuthority

A cancer conference policy and procedure is used to establish the annual cancer conference activity.

Policy addresses: Frequency and format of conferences

Multidisciplinary composition and attendance rate

Discussion of stage, prognostic factors, evidence‐based treatmentguidelines

Options for clinical trials

Number of case presentations (minimum 15% of analytic cases) andprospective presentation rate (minimum 80%)

How areas that fall below policy requirements will be addressed

ER3:CancerConferencePolicy

• A designated oncology nurse provides leadership foroncology patient care across the care continuum

Identify an oncology nurse leader who ensures that oncology nursing P&P follows recognized standards and guidelines from:

‐ Oncology Nursing Society‐ Other recognized nursing organizations

Applies to all inpatient and outpatient areas of the cancer program

ER4:OncologyNursingLeadership

The cancer registry policy and procedure manual is implemented and specifies that current Commission on Cancer data definitions and coding instructions are used to describe all reportable cases.

Examples of required information in manual:‐ Abstracting procedures‐ Case eligibility, finding and accessions‐ Disaster recovery policy‐ Follow‐up system and methods‐ Quality control of registry data‐ State registry reporting requirements and procedures

A complete list of required elements may be found on page 20 of the 2016 Edition of CoC Standards Manual

ER5:CancerRegistryPolicyandProcedure

Diagnostic Imaging (ER6)Radiation Oncology (ER7)Systemic Therapy (ER8)

Clinical Research Information (ER9)Psychosocial Services (ER10)Rehabilitation Services (ER11)Nutrition Services (ER12)

EligibilityRequirements:Services

Diagnostic imaging services are provided either on‐site or by referral.

Upload copy of certificate, attestation letter, or other documentation that describes patient‐specific and machine‐specific quality assurance practices.

Annually, programs indicate diagnostic imaging services available on‐site or by referral to be displayed on the “Find a CoC‐Accredited Program” locator on the CoCwebsite

ER6:DiagnosticImagingServices

ER6:DiagnosticImagingServices

Radiation treatment services are currently accredited by a recognized authority or, if not accredited, follow standard quality assurance practices. Services are available either on‐site, at locations that are facility owned, or by referral.

Radiation treatment facility is either accredited by recognized authority orfollow standard QA practices as outlined in CoC Standards Manual

Patient‐ and machine‐specific QA required

Upload copy of certificate, attestation letter, or documentation outliningquality assurance practices in radiation oncology for the program or mostcommon referral locations

ER7:RadiationOncologyServices

Policies and procedures are in place to guide the safe administration of systemic therapy provided either on‐ site, at locations that are facility owned, or at locations that are contracted by the facility or are supervised by members of the facility’s medical staff, including physician offices.

Essential features of safe treatment environments: Knowledgeable and skilled nursing staff. Facilities or specialized areas necessary to provide the care. Policies and procedures to guide the pharmacy and ensure compliance

with regulations. Policies and procedures to guide nursing care of cancer patients who are

receiving systemic therapy.

ER8:SystemicTherapyServices

Policies and procedures are in place to provide cancer‐related clinical research information to patients.

Outline the process of providing clinical research information and enrollment process to patients.  

Upload a copy of the most recent P&P regarding availability of cancer‐related research information for patients for on‐site studies or studies by referral. 

ER9:ClinicalResearchInformation

Policies and procedures are in place to ensure patient access to psychosocial services either on‐site or by referral.

Psychosocial services address physical, psychological, social, spiritual, and financialsupport needs that result from a cancer diagnosis and help ensure the bestpossible outcome.

Upload P&P that ensures access to psychosocial services either on‐site or byreferral, and includes annual monitoring of the referral process.

Annually, programs indicate psychosocial services available on‐site or by referral tobe displayed on the “Find a CoC‐Accredited Program” locator

ER10:PsychosocialServices

Policies and procedures are in place to ensure patient access to rehabilitation services either on‐site or by referral.

Cancer rehabilitation services include, but are not limited to: Lymphedema program Pain management Physical impairment and disabilities Lifestyle and weight management programs Physical and exercise therapy Physical impairments and disabilities Reflexology, Massage Therapy, Chiropractic Care Occupational therapy

ER11:RehabilitationServices

Policies and procedures are in place to ensure patient access to nutrition services either on‐site or by referral.

Services provide safe and effective nutritional care throughout the cancer continuum:  Prevention Treatment Rehabilitation Survivorship and quality‐of‐life

ER12:NutritionServices

ImprovingandManaging CancerCommitteeMeetings

Standard 1.3: Required Members must attend 75% of meetings each calendar year

Appoint Alternates

Spread out Responsibility

Attendance&CommitteeEngagement

Use a sign‐in sheet with names/positions listed

In the final minutes for each meeting, document whowas present

Though not optimal, phone conferencing does countfor attendance. Take roll call for phone‐in attendees.

TrackingAttendance

Name Role 1/15/16 4/15/16 7/15/16 11/15/16 Signature

Dr. SmithDr. Jones (alternate)

Diagnostic Radiologist/CLP

X X X

Dr. BingDr. Kenyon (alternate)

Pathologist/CCC X X X

Dr. WitherspoonDr. Pitt (alternate)

Med Onc/Cancer Conference Coordinator

X X X

Dr. SwiftDr. Knowles (alternate)

Radiation Oncologist X X

Regina Falange, OSW-CKen Adams (alternate)

Social Worker/Psychosocial Services Coordinator

X X X

Rachel Greene, APRNRoss Geller, APRN(alternate)

Oncology Nurse/Quality Improvement Coordinator

X X X

Phoebe Buffet, CCRPJoey Tribianni, CCRP (alternate)

Clinical ResearchCoordinator

X X X

Phone or video conference counts the same as in‐personattendance

Do not appoint extra members

Formal medical staff appointment to cancer committee

Send out survey to members to get best date and time for everyone

Reminder emails and/or phone calls

Have fewer meetings

Plan meetings for the following year

At 4Q meeting

Send agenda early

AttendanceTips

Can meet between general cancer committee meeting

No attendance requirement

Must report to the general cancer committee

The Cancer Committee minutes must contain the required contentfor the standard the subcommittee may be reporting on.

Subcommittees

DivideandConquer

Responsibilities for standards should be spread across all required membersCancer Committee Role ER/Standard

Responsibility

Cancer Committee Meeting(s) which require reports

Palliative Care Professional 2.4 At least one meeting each calendar year

Genetics Professional  2.3 At least one meeting each calendar year

Cancer Conference Coordinator ER 3, 1.71Q (annual review of ER P&P) 

4Q (annual report on cancer conference monitoring)  

Quality Improvement Coordinator 4.7, 4.81Q (identify two problems to study for Std 4.7)

At least one more meeting to report results and report on implemented quality improvements

Cancer Registry Quality Coordinator ER 5, 1.61Q (annual review of ER P&P)

4Q (annual report on quality review) 

Community Outreach Coordinator 4.1, 4.2, 1.81Q (identify needs)

4Q (Community Outreach Report)

Clinical Research Coordinator ER 9, 1.91Q (annual review of ER P&P)

4Q (Clinical Research Accrual Report )

Psychosocial Services Coordinator ER 10, 3.21Q (annual review of ER P&P, establish psychosocial process)

4Q (Evaluate process and provide Annual Psychosocial Services Summary)

Oncology Nurse ER 4, 2.21Q (annual review of ER P&P)

2Q/3Q/4Q (Report on outcome of nursing competency evaluations)

CLP 4.3, 4.4, 4.5, 5.2

At least four meetings per calendar year (recommend reporting on other tools in addition to 

those required under 4.4 and 4.5). 

5.2 requires reports semi‐annually. 

Standards Potential Responsible Person Meetings which require reports

Remaining ERs CPA, CCC, Any required or non-required committee member 1Q (annual review of ER P&P)

1.1 CPA, CCC, Any required or non-required committee member None, but responsible for SAR

1.2 CCC 1Q (appoint required members and alternates)

1.3 CCC All meetings 1.4 CCC 1Q (establish meeting schedule)

1.5 CPA, CCC, Any required or non-required committee member1Q (establish goals) 2Q/3Q (first review)

4Q (second review)1.10 CPA, CCC, Any required specialty physician 1Q/2Q (develop program)1.11 CTR, Cancer Registry Quality Coordinator None, but responsible for SAR

1.12 Marketing + coordinator related to standard used in public reporting 4Q

2.1 Pathologist or any physician on the cancer committee At least one meeting to report audit results

3.1Social Worker, Oncology Nurse, Any required or non-required committee member with appropriate background

1Q (review CNA & choose barrier)4Q (evaluate process)

3.3Oncology Nurse, Physician champion, Any required or non-required committeemember with appropriate background

1Q (establish process)4Q (review process and standard compliance)

4.6 CLP, CCC, Any Required or Non-Required Physician1Q/2Q (decide topic)

One additional meeting to report results5.1 CTR, Cancer Registrar Quality Coordinator None, but responsible for SAR5.3 CTR, Cancer Registrar Quality Coordinator None, but responsible for SAR5.4 CTR, Cancer Registrar Quality Coordinator None, but responsible for SAR

5.5 CTR, Cancer Registrar Quality Coordinator None, but responsible for data submission

5.6 CTR, Cancer Registrar Quality Coordinator None, but responsible for data submission

5.7 Varies Varies

Minutes

• Standards Resource Library Tips for Cancer Committee Agenda and Minutes

• Clearly mark which standard is being discussed Clearly indicate when there is an attachment for the

standard and document the committee’s response

• If SAR asks which meeting minutes discuss a specificstandard, make sure the correct meeting date isidentified

Minutes must indicate when there is an attachment.

Minutes should document the committee’sdiscussion of attachments

Include the required contents of standard in the bodyof the minutes

Minutes

CoCStandard

Compliance/Benchmark

Recommendations Resolution/Action Follow-up/Date due

1.5 Each calendar year, the cancer committee establishes, implements, and monitors at least one clinical and one programmatic goal for endeavors related to cancer care

1/21/16: Programmatic goal—Bring palliative care onsite**Clinical goal—Provide survivorship care plans to 25% of eligible patients**

4/15/16: Programmatic Goal update‐‐Dr. Jones reports that the task force has developed policies and procedures for referral to in‐patient palliative care unit.Clinical Goal update—The updated SCP has been finalized and was presented to the committee. Committee 

7/15/16: Programmatic Goal update—Dr. Jones reports that palliative care is up and running and has started seeing patients onsite. 

11/17/16: Ms. Green reported that 26/100 of eligible patients have received SCP.

1/21/16: Goals adopted by committee. Dr. Jones will work with task force. To develop policy and procedure for inpatient palliative care use. Dr. Smith will update SCP to incorporate what we learned in 2015.

4/15/16: Committee approved updated SCP. Survivorship clinic will use new plans and distribute to eligible patients

7/15/16: Programmatic goal complete

11/17/16: Clinicalgoal complete

**These are not compliant goals and are used as a formatting example only. 

CoordinatorReports

Each coordinator should know at the beginning ofthe year at which meetings they will need to report

The coordinators should be very familiar with therequirements of the standards they report for sotheir report contains the required documentation

If using attachment for report, must include in theSAR

QUESTIONS?