COC Standards 2012 v1.1

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COC Standards 2012 v1.1
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Standards 2012 v1.
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  1. How many eligibility requirements for 2012 standards?
    12 Eligibility standards
  2. How many standards in the Standard revision 2012?
    34 standards
  3. Name the two (2) new standards which focus on:
    1. Patient-centered care

    2. Quality and outcomes
  4. Five (5) New Clinical Services and Continuum of Care Service Standards. (Name 2 or 3 of the 5)
    • 1. Risk Assessment & Genetic Counseling
    • 2. Palliative Care Services
    • 3. Patient Navigation
    • 4. Psychosocial Distress Screening
    • 5. Survival Care Plan
  5. What does the letter "E" stand for in:
    E3:Cancer Conference Policy
    Eligibility
  6. What is the purpose of the Clinical Services and the Continuum of Care Standards?
    To support quality of life alongside disease-directed treatment across the entire continuum of care.
  7. What year was the Cancer Campaign Committee was appointed by the ACOS?
    1913
  8. The purpose of the Cancer Campaign Committee?
    The purpose of the Cancer Campaign Committee was for analyzing case records with carcinoma of the cervix and uterus.
  9. What was introduced in 1921? and establishing the __________ __________ registry.
    In 1921 the "Concept of the Registry" was introduced for the bone sarcoma registry.
  10. What year was The "Cancer Campaign Committee" RENAMED to the "Committee on Treatment of Malignant Disease"?
    1930
  11. In 1930, the Committee on Treatment of Malignant Diseases published?
    "Standards for evaluation of cancer clinics and registries".
  12. In 1940, the Committee was renamed to ____?
    Committee on Cancer (COC)
  13. What was added by the COC and in What Year?
    1956 - the cancer registry added an Accredited Hospital cancer program.
  14. Integrated network Cancer Program (INCP)
    The organization owns, operates, leases, or is part of a joint venture with multiple facilities providing integrated cancer care and offers comprehensive services. At least 1 facility in the category is a hospital, and all facilities that are part of the Network are CoC-accredited cancer programs.
  15. What is the goal of the CoC?
    • * To decrease the morbidity and mortality caused by cancer through prevention, monitoring, comprehensive quality care, standard-setting, and education.
    • * The Commission conti the pursuit of this goal through the activities of 4 committees (Approvals; Cancer Liaison; Education and National Cancer Data)
  16. 4 Committees of CoC and explain them?
    • 1. Approvals: Establishes standards for approval of cancer programs
    • 2. Cancer Liaison: Oversees a nationwide network of more than 2,000 physician volunteers who provide local support for CoC programs
    • 3. Education: Responsible for the educational activities of the CoC
    • 4. National Cancer Data: Responsible for national studies of patient management and outcome for specific types of cancer
  17. Name the 6 CoC Committees?
    • 1. The Executive Committee
    • 2. The Accreditation Committee
    • 3. Committee on Cancer Liaison
    • 4. The Education Committee
    • 5. Quality Integration Committee
    • 6. Member Organization Steering Committee
  18. What manual does the CoC publishes? and its meaning.
    • The FORDS manual which stands for
    • Facility Oncology Registry Data Standards
  19. What is the purpose of Program Standards?
    • To document basic organizational structure of hospital tumor registries
    •  To ensure patient standard of care
    •  To make hospital tumor registries consistent across the board for survey
    •  To create a more honest way of judging the approval status for the hospital tumor registry
  20. What is INCP?
    • Integrated Network Cancer Program
    • Owns, operates, leases, or is part of a joint venture with multiple facilities providing integrated cancer care and offers comprehensive services.
    • At least 1 facility in the category is a hospital, and all facilities that are part of the network are CoC-accredited cancer programs.
    • Generally, characterized by a unified cancer committee, standardized registry operations with a uniform data repository, and coordinated service locations and practitioners.
    • Each entity meets performance expectations for the quality measures under the umbrella of the integrated program.
    • Participates in cancer-related clinical research either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office.
    • Training resident physicians is optional.
    • No minimum caseload required for this category.
  21. What is NCIP?
    • NCI-DESIGNATED COMPREHENSIVE CANCER CENTER PROGRAM
    • Secures a National Cancer Institute (NCI) peer-reviewed cancer center support grant and is designated a Comprehensive Cancer Center by the NCI.
    • Full range of diagnostic and treatment services provided, and staff physicians are available. 
    • Participates in basic and clinical research.
    • Training resident physicians is optional.
    • No minimum caseload required for this category.
  22. What is HACP?
    • HOSPITAL ASSOCIATE CANCER PROGRAM
    • * Accessions 100 or fewer newly diagnosed cancer cases each year.
    • * Limited range of diagnostic and treatment services available on site. Other services are available by referral. 
    • * Clinical research is not required.
    • * Training resident physicians is optional.
  23. What is PCP?
    • PEDIATRIC CANCER PROGRAM
    • Facility provides care only to children, or the pediatric oncology program is a component within a larger CoC-accredited facility.
    • Facility may be associated with a medical school and participate in training pediatric residents.
    • Facility or pediatric oncology program offers the full range of diagnostic and treatment services for pediatric patients either on site or by referral.
    • Facility is required to participate in cancer-related clinical research focused on pediatric patients either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office.
    • No minimum caseload requirement for this category.
  24. What is FCCP?
    • Freestanding Cancer Center Program
    • The facility is a non–hospital-based program and offers at least 1 cancer-related treatment modality.
  25. Survey Process
    CoC-accredited cancer programs are surveyed on a ______ schedule. Each ____, an initial _____ notification is provided to facilities due for survey.
    CoC-accredited cancer programs are surveyed on a triennial schedule. Each July, an initial e-mail notification is provided to facilities due for survey.
  26. Survey Process
    In preparation for survey, the cancer committee does the following three things:
    • The cancer committee does the following three things:Access program compliance to make sure they meet the CoC Standards outlined in the Cancer Program Standards 2012: Ensuring Patient-Centered Care
    • Reviews and completes the online SAR
    • Confirms the survey schedule and agenda with the cancer program surveyor.
  27. Survey Process
    The program must notify CoC staff of the conflict within __  days of receipt of the surveyor notification e-mail. When a conflict is confirmed, a ___ _____ assignment will be provided to the program within __ days of notification of the conf lict of interest.
    The program must notify CoC staff of the conflict within 14 days of receipt of the surveyor notification e-mail. When a conflict is confirmed, a new surveyor assignment will be provided to the program within 30 days of notification of the conflict of interest.
  28. Accreditation
    What is the Cancer Program Standard Rating System?
    • 1+  Commendation
    • 1    Compliance
    • 5    Noncompliance
    • 8    Not Applicable
  29. Accreditation
    A compliance rating assigned by each standard is assigned by...? Name the 3 Assignees
    • The Program
    • The Surveyor, and
    • The CoC Staff
  30. Accreditation
    The Commendation rating (1+) is valid for ____ Standards.
    The Commendation rating (1+) is valid for 8 Standards.
  31. Accreditation
    Which standards are eligible for Commendation?
    • Standard 1.3
    • Standard 1.9
    • Standard 1.11
    • Standard 1.12
    • Standard 2.1
    • Standard 2.2
    • Standard 5.2
    • Standard 5.6
  32. Accreditation Awards
    What are Accreditation Awards based on and whom by?
    • Accreditation Awards
    • Consensus ratings
    • By...
    • * the Surveyor
    • * CoC Staff
    • * Program Review Subcommittee
  33. Accreditation Awards
    A program earns one of the following Accreditation Awards?
    • 3-year Commendation Accreditation
    • 3-year Accreditation
    • 3-year with Contingency
    • Non-Accreditation
  34. Accreditation Awards
    What is the 3-year Commendation?
    • Complies with all standards at the time of survey/receives a commendation rating for 1 or more standards.
    •   Gold    = 7-8 commendation
    •   Silver  = 4-6 commendation
    •   Bronze = 1-3 commendation
  35. Accreditation Awards
    What is a 3-year Accreditation?
    • Complies with all the standards at the time of the survey but does not receive the commendation rating for any standards.
    • Or, is awarded when all deficiences are resolved regardless the number of commendations rewarded at surveys
  36. Accreditation Awards
    What is a 3-year with Contingency?
    1-7 deficiencies at the time of survey

    Program undergoing initial accreditation=1 or 2 dificiencies in standards 1.1-1.12
  37. Accreditation Awards
    What is a Non-Accreditation?
    8 or more deficiencies at the time of survey

    Program undergoing initial accreditation=3 or more dificiencies in standards 1.1-1.12 or 1 or more dificiencies in other standards.
  38. Outstanding Achievement Award (OAA)
    Who are eligible to receive the OAA, and with the EXCEPTION of?
    • All programs currently accredited by the CoC are eligible to receive the CoC Outstanding Achievement Award.
    • EXCEPT the NCIP facilities
  39. Outstanding Achievement Award (OAA)
    What is the purpose of the OAA?
    • Recognize the cancer programs that thrive for excellance patient care
    • Motivate other programs to work towards improving their care 
    • Foster communication b/t award recipients and other programs to share best practices, to serve as resources for other programs, act as a "champion" for CoC cancer program accreditation
  40. What year was the first survey for cancer clinics?
    1931
  41. The current CoC standards for cancer programs promote and support the 4 historic cornerstones of the Accreditation Program.
    These are: (1) a multidisciplinary cancer committee, (2) cancer conferences, (3) evaluation of quality outcomes and improvements, (4) and a cancer registry. 
  42. Who are eligible to participate in the CoC Accreditation Program?
    • Hospitals,
    • Freestanding treatment facilities, and
    • Integrated health care networks
  43. Name the Five (5) elements that are key to the success of a CoC-accredited cancer program?
    • Clinical services
    • Cancer committee
    • Cancer conference
    • Quality improvement (QI) program
    • Cancer registry and database
  44. Clinical services
    The clinical services provide state-of-the-art pretreatment evaluation, staging, treatment, and clinical follow-up for patients with cancer seen at the program for primary, secondary, tertiary, or end-of-life care. 
  45. Cancer committee
    The cancer committee leads the program through  setting goals, monitoring program activity, and  evaluating patient outcomes and improving care. 
  46. Cancer conference
    The cancer conferences provide a forum for patient consultation and contribute to physician education. 
  47. Quality improvement (QI) program  
    The quality improvement (QI) program  is the mechanism for evaluating and  improving patient outcomes. 
  48. Cancer registry and database
    The cancer registry and database are the basis for monitoring the quality of care.
  49. Eligibility Requirements:

    Name the 5 Eligibility Structure requirements that include basic structure and services that are required of CoC-accredited cancer programs before a survey can take place:
    • Structure   
    • • Facility accreditation   
    • • Cancer committee authority  
    • • Cancer conference policy
    • • Oncology nurse leadership  
    • • Cancer registry
  50. Eligibility Requirements:

    Name the 7 Eligibility Services requirements that include basic structure and services that are required of CoC-accredited cancer programs before a survey can take place:
    • Services
    • • Diagnostic imaging  
    • • Radiation oncology services  
    • • Systemic therapy services  
    • • Clinical trial information  
    • • Psychosocial support services  
    • • Rehabilitation services  
    • • Nutritional services
  51. E1: Facility Accreditation
    The facility is accredited by a recognized federal, state, or local authority.
  52. E2: Cancer Committee Authority
    Bylaws or policy and procedure define the cancer committee's authority and responsibility for the program.
  53. E3: Cancer Conference Policy
    Policy establishes the cancer conference program and addresses the frequency, format, multidisciplinary attendance, attendance rate, prospective case presentations and total case presentations, discussion of stage and treatment planning, clinical trial options, and methods to address activities that fall below expected levels.
  54. E4: Oncology Nurse Leadership
    A nurse provides leadership for this program.
  55. E5: Cancer Registry Policy and Procedure
    The policy and procedure addresses the use of CoC data elements and codes along with all other cancer registry activities.
  56. E6: Diagnostic Imaging
    Services are provided either on-site or by referral.
  57. E7: Radiation Oncology Services
    Radiation treatment service locations 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.
  58. E8: Systemic Services
    Policies or procedures are in place to guide the safe administration of systemic therapy provided either on-site and/or at locations that are facility owned or supervised by members of the facility’s medical staff (physician offices).
  59. E9: Clinical Trial Information
    A policy or procedure is used to inform patients about clinical trials.
  60. E10: Psychosocial Services
    A policy or procedure is in place to ensure patient access to psychosocial services either on-site or by referral.
  61. E11: Rehabilitation Services
    Rehabilitative services are provided either on-site or by referral.
  62. E12: Nutrition Services
    Nutrition services are provided either on-site or by referral.
  63. Standard 1.1 Physician Credentials
    • Physicians are currently board certified or in the process of certification.
    • Demonstrates ongoing cancer-related education by annually earning 12 cancer-related continuing medical education (CME) hours. (A maximum of 6 hours can be earned through educational activities within the facility; however, all 12 hours may be earned through educational activities that are external to the facility.) This option will be used for deficiency resolution.
  64. Standard 1.2 Cancer Committee Membership
    • The cancer committee is multidisciplinary. Category-specific members are:
    • 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
  65. Standard 1.3 Cancer Committee Attendance
    Each required cancer committee member attends 50% of meetings annually.
  66. Standard 1.4 Cancer Committee Meetings
    The cancer committee meets at least once each calendar quarter.
  67. Standard 1.5 Goals
    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.
  68. Standard 1.6 Cancer Registry Quality Control Plan
    The cancer committee establishes and implements a registry qualitycontrol plan each year. The plan addresses all required criteria.
  69. Standard 1.7 Monitoring Cancer Conference Activity
    The cancer conference coordinator monitors the cancer conference programannually and reports conference activity to the cancer committee each year.
  70. Standard 1.8 Monitoring Community Outreach
    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.
  71. Standard 1.9 Clinical Trials Accrual
    • 2015 phase in
    • 6% of the number of annual analytic cases; 8% of the numberof annual analytic cases for commendation
    • Coordinator/representative reports on activity yearly.
  72. Standard 1.10 Annual Educational Activity
    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.
  73. Standard 1.11 Cancer Registrar Education
    All registry staff participate in an annual educational activity.
  74. Standard 1.12 Public Reporting of Outcomes
    Cancer committee develops and disseminates a report of patient outcomesto the public each year. This standard is for Commendation only.
  75. Standard 2.1 CAP Protocols
    90% of eligible pathology reports include the required data items as specified in the site-specific CAP protocols.
  76. Standard 2.2 Nursing Care
    Care is provided by nurses with specialized knowledge and skills; competency is evaluated annually.
  77. Standard 2.3 Risk Assessment and Genetic Testing and Counseling
    Risk assessment and genetic testing and counseling are provided either on-site or by referral, by a qualified genetics professional.
  78. Standard 2.4 Palliative Care Services
    Palliative care services are provided either on-site or by referral.
  79. Standard 3.1 Patient Navigation
    • 2015 phase in
    • The cancer committee assesses the community to identify barriers to care, provides navigation services either on-site or by referral orin partnership with local or national organizations, and assesses and reports on the process annually. The assessment is documented.
  80. Standard 3.2 Psychosocial Distress Screening
    • 2015 phase in
    • The cancer committee develops and implements a process to assess and address the psychosocial distress of patients with cancer.
  81. Standard 3.3 Survivorship Care Plan
    • 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.
  82. Standard 4.1 Prevention Program
    Each year, 1 prevention program is offered to address the needs of the community and reduce the incidence of a specified cancer type.
  83. Standard 4.2 Screening Program
    Each year, 1 screening program is offered to decrease the number of patients with late-stage disease. Patients with positive findings are followed.
  84. Standard 4.3 CLP Responsibilities
    The CLP uses NCDB data to evaluate and interpret program performance; program performance is reported to the cancer committee at least 4 times annually.
  85. Standard 4.4 Accountability Measures
    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.
  86. Standard 4.5 Quality Improvement Measures
    Each year, performance levels defined by the CoC are met for each QI measure.
  87. Standard 4.6 Monitoring Compliance with Evidence-Based Guidelines
    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.
  88. Standard 4.7 Studies of Quality
    Each year, 3 studies of cancer patient care quality and outcomes are conducted.
  89. Standard 4.8 Quality Improvements
    Each year, 2 improvements in patient care are implemented.
  90. Standard 5.1 Cancer Registrar Credentials
    Case abstracting is performed by a CTR .
  91. Standard 5.2 Abstracting Timeliness
    Each year, 90% of cases are abstracted within 6 months of the date of first contact.
  92. Standard 5.3 Follow-Up of All Patients
    80% follow-up from reference date
  93. Standard 5.4 Follow-Up of Recent Patients
    90% follow-up rate for patients diagnosed in the last 5 years
  94. Standard 5.5 Data Submission
    Complete data for all cases submitted each year as specified in the Call for Data
  95. Standard 5.6 Accuracy of Data
    Each year, the cases submitted meet the quality criteria specified inthe Call for Data; cases with errors or rejected cases are corrected and resubmitted by the deadline specified in the Call for Data.
  96. Standard 5.7 Commission on Cancer (CoC) Special Studies
    The program participates as specified by the CoC.

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