Standards 2012 Sec-2

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Standards 2012 Sec-2
2013-08-22 17:41:32

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  1. Commission on Cancer Mission
    A consortium of professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and the monitoring of comprehensive quality care.
  2. Name the two (2) new standards which focus on:
    • 1. Patient-centered care
    • 2. Quality and outcomes
  3. Eligibility Requirements
    • Required of all programs annually
    • Displayed in CoC Hospital Locator
    • Describes structure of program
    •   * Diagnostic & treatment services
    •   * Psyco-social and other support services
  4. Standards 1.1 - 1.12
    Program Management
  5. Standards 2.1 - 2.4
    Clinical Services
  6. Standards 3.1 - 3.3
    Continuum of Care Services
  7. Standards 4.1 - 4.8
    Patient Outcome
  8. Standards 5.1 - 5.7
    Data Quality
  9. Eligibility Requirements Created
    • Required of all programs annually
    • Displayed in CoC Hospital Locator
    • Describes structure of program
    •   *Diagnostic and treatment services
    •   *Psycho-social and other support services
  10. S1.1 Physician Credentials
    – Physicians who provide cancer care to patients are board certified or in the process of becoming board certified
  11. S1.2 Cancer Committee Membership

    The Coordinators are:
    – The cancer committee is multidisciplinary with physicians and non-physicians members

    • The Coordinators are:
    • 1. Cancer Conference 
    • 2. Quality Improvement 
    • 3. Cancer Registry Quality 
    • 4. Community Outreach 
    • 5. Clinical Research Representative
    • 6. Psych-social Services
  12. S1.3 Cancer Committee Attendance*
    – Each required member (physician and non-physician) attends at least 50% of the cancer committee meetings held annually 

    * Eligible for Commendation
  13. S1.4 Cancer Committee Meetings
    – The cancer committee meets each quarter, for a minimum of 4 times each year
  14. S1.5 Cancer Program Goals
    – At least 1 clinical goal and 1 programmatic goal are established each year, goals are monitored, evaluated, and documented in cancer committee minutes at least twice annually
  15. S1.6 Cancer Registry Quality Control Plan

    Required activities:
    Required scope of evaluation
     Minimum ?
     Maximum ?
    – Monitor and evaluate multiple areas of cancer registry activity and accuracy and completeness of abstracted data

    • 1. Required activities:
    •   -Random sampling of analytic caseload
    •   -Physician review
    • 2. Required scope of evaluation: 
    •   -Minimum: 10% of annual analytic caseload
    •   -Maximum: 300 cases annually
  16. S1.7 Monitoring Conference Activity
    • – Monitoring the cancer conference
    • Evaluate routinely:

     *Conference frequency; multidisciplinary attendance; total and prospective case presentation; discussion stage, including prognostic indicators, and treatment planning using evidence-based treatment guidelines; options for clinical trials
  17. S1.8 Monitoring Community Outreach
    – Monitor effectiveness of outreach activities on an annual basis
  18. S1.9 Clinical Trial Accrual*
    – Accrue the required percentage of patients to cancer-related clinical trials each year

    * Eligible for Commendation
  19. S1.10 Clinical Educational Activity
    – Offer at least 1 cancer‐related clinical education  activity other than cancer conferences annually 

    • Focus on selected treatment and AJCC staging
  20. S1.11 Cancer Registrar Education*
    All cancer registry staff participate in at least 1 cancer related education activity other than  cancer conference annually

    *Required for CTR staff including contract staff that work 3 or more consecutive months

    *Eligible for Commendation
  21. S1.12 Public Reporting of Outcomes*
    – Disseminates a report of outcomes to at least 1 of the following:

    *Prevention programs, screening programs,  accountability measures, quality improvement  measures, assessment of evaluation & treatment  planning, studies of quality, quality improvement
  22. Pop Quiz
    • In a CoC accredited cancer program, what  percent of the annual analytic caseload must  be evaluated by a physician appointed by the  cancer committee?
    a. None
    b. 10%
    c. 20%
    d. 100%
    • Answer:

    b. 10%
  23. S2.1 College of American Pathologists Protocols*

    CAP protocols
    Include the following:

    Excludes the following:
    – 90% of cancer pathology reports follow current CAP protocols

    • CAP protocols
    • Include the following:
    •  *Invasive histologic diagnosis with ductal carcinoma insitu (DCIS) histologic features

    • Excludes the following:
    •  *Diagnostic biopsy specimens, cytology specimens, and special studies
  24. S2.2 Nursing Care*
    - Oncology nursing care provided by nurses with specialized knowledge and skills

    *Based on resources available from the Oncology Nurses Society (ONS)

    * Eligible for Commendation
  25. S2.3 Risk Assessment and Genetic Counseling
    -Provided by a qualified genetic professional either  on‐site or by referral
  26. S2.4 Palliative Care Services
    -Palliative care services are available to patients either on-site or by referral

    *Provided by an interdisciplinary team of medical  and mental health professionals, social workers,  and spiritual counselors
  27. Pop Quiz
    • CoC standard 2.1 requires that 90% of path  reports with a cancer diagnosis contain the  required data elements from the CAP  protocol. To what type of specimen does this  apply?
    a. Cytology specimen
    b. Diagnostic biopsy specimen
    c. Resected specimen with invasive disease
    d. All of the above

    • c. Resected specimen with invasive disease 
  28. S3.1 Patient Navigation Process
    • Patient navigation process – Driven by community needs assessment

    – Helps to overcome healthcare barriers to cancer  treatment and address disparities
  29. S3.2 Psychosocial Distress Screening
    –Develop a process to incorporate screening of  psycho social distress into standard oncology care  and provide patients with distress with resources  and/or referral for psychosocial needs
  30. S3.3 Survivorship Care Plan
    – Provide patients completing cancer care with a  comprehensive care summary and follow‐up plan
  31. Pop Quiz
    • In cancer care, the purpose of what process is  to overcome health care system barriers and  to facilitate timely access to quality medical  and psychosocial care?
    a. Disease screening
    b. Patient navigation
    c. Psychosocial distress screening
    d. Survivorship care plan

    • b. Patient navigation 
  32. S4.1 Prevention Programs

    Prevention Programs
    Include, but are not limited to the following:
    – Provides annually at least 1 cancer prevention  program focused on decreasing the number of  patients with a specific type of cancer

    • Prevention Programs
    • Include, but are not limited to the following:
    •  1. Chemo-prevention
    •  2. Education/cancer awareness
    •  3. Skin Cancer prevention
    •  4. Smoke prevention
    •  5. Nutrition and weight loss programs
  33. S4.2 Screening Programs

    Cancer Programs
    Include, but are not limited to, the following:
    – Provides annually at least 1 cancer screening  program focused on an identified community  need

    • Cancer Programs
    • Include, but are not limited to, the following:
    •  1. Breast exams
    •  2. Colonscopy
    •  3. Skin surveys
  34. S4.3 Cancer Liaison Physician Responsibilities
    – Monitor, interpret, and report the program’s  performance using NCDB data to evaluate and  improve the quality of care

  35. S4.4 Accountability Measures
    • – Standard of care based on clinical trial evidence
    • – Compliance measured by current CoC quality  reporting tools
    • • Cancer Program Practice Profile Reports [CP3R]
  36. Cancer Program Practice Profile Reports [CP3R]
    Compliance measured by current CoC quality reporting tools
  37. S4.5 Quality Improvement Measures
    • – Measure that demonstrates good practice
    • – Compliance measured by current CoC quality  reporting tools
    • • Cancer Program Practice Profile Reports [CP3R]
  38. S4.6 Monitoring Compliance with Evidence-Based Guidelines
    – Perform a study to ensure that patient evaluation  and treatment  is compliant with evidence‐based  national guidelines
  39. S4.7 Studies of Quality
    • – Annually perform studies that measure the quality of care  and outcomes for cancer patient 
    • - Study focuses on areas with problematic quality-related issues relevant to the program and local cancer patient population.
  40. S4.8 Quality Improvements
    • –Annually implement 2 patient care improvements
    • • 1 based on the results of a completed study
    • • 1 based on any source
  41. Pop Quiz
    • In a CoC accredited cancer program the cancer  committee uses accountability measures and  quality improvement measures to evaluate:
    a. Cancer incidence
    b. Compliance with evidence based guidelines
    c. Quality of care
    d. Screening programs

    c. Quality of care
  42. S5.1 Cancer Registrar Credentials
    • – Case abstracting performed by CTR
    • • Non‐credentialed abstractor employed by facility on  1/1/12 must be certified by January 2015
    • • Non‐credentialed abstractor hired after 1/1/12 must be  certified within 3 years of hire
    • – High-quality data are essential to accurately access treatment outcomes and patient survival
  43. S5.2 Abstracting Timeliness*

    Abstracting timeliness refers to:
    • – 90% of cases are abstracted within 6 months of the date of first contact
    • Abstracting timeliness:
    • – Abstracting timeliness is calculated from the month and year recorded in the field "Date of First Contact"
    • – Based on the information recorded in the Data Case Completed-CoC field
    • – Maintained throughout the survey cycle

    * Eligible for Commendation
  44. S5.3 Follow-Up of All Patients
    • – All eligible analytic cases
    • • 80% follow‐up rate from registry reference date
  45. S5.4 Follow-Up of Recent Patients

    Cases that Do NOT have the be followed up:
    • – Recent eligible analytic cases
    • • 90% follow‐up rate within last 5 years or from registry  reference date, whichever is shorter
    • Cases that Do NOT have the be followed up:
    • 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 that 12 months
    • 4. Class of case 00 cases diagnosed on or after 1/1/2006
  46. S5.5 Data Submission

    Purpose of the Feedback:
    – Submit data each year for all requested analytic  cases to the NCDB for the annual call for data

    • Purpose of the Feedback:
    • The feedback enables cancer programs compare treatment and outcomes with regional, state, and national patterns of care
  47. S5.6 Accuracy of Data or Data Accuracy*
    • – Annually, cases submitted to NCDB diagnosed  1/1/2003 or later meet established quality criteria  and resubmission deadline specified in the annual  Call for Data
    • * Eligible for Commendation
  48. S5.7 Commission on Cancer (CoC) Special Studies
    • – Participate in special studies as selected
    • 1. Periodically design and conduct special studies
    • 2. Evaluate patient care, set benchmarks, and provide feedback to improve patient care in cancer programs
  49. Pop Quiz
    • A patient was diagnosed with colon cancer at  another facility on 1/1/12.  They came to your  facility and had surgery on 2/12/12. When  must this case be completed in order to meet  the abstracting timeliness requirement?
    a. 6/1/12
    b. 7/1/12
    c. 8/1/12
    d. 1/1/13

    c. 8/1/12
  50. Population-based registry vs. Hospital based registry
    Population-based serves a Wider range 

    Hospital-based registry Only serves that hospital and do NOT reflect the community.
  51. Standard Setters for the Cancer Registry

    • Population-based:
    •   SEER
    •   NCI

    • Hospital-based:
    •   ACoS
    •   CoC
  52. Reportable List
    The governing document for casefinding in the registry. Includes all diagnoses that are to be reported and clarify the types of diagnoses that are non-reportable.
  53. Population-based Central Cancer Registry
    • Casefinding is a system for locating every patient-inpatient or outpatient
    • - who is diagnosed and/or treated with a reportable diagnosis. Casefinding is like casting a net far and wide to "capture" all of the reportable cancer cases.
  54. Population-based Central Cancer Registry

    What to report?
    • Reference date
    • Diagnosis
    • Residency
    • Diagnostic confirmation
    • Class of case
    • Type of admission 
    •  -diagnosed by autopsy only
  55. Population-based Central Cancer Registry

    What to report? (continued)
    • Presence of active disese or receiving treatment
    •   - Analytic cases
    •   - Diagnosed and treated elsewhere admitted with active disease
    •   - Consult only
    •   - Transient treatment
    •   - Pathology only
  56. Population-based Central Cancer Registry
    Casefinding Methods (2 types)
    • Active
    • Active casefinding involves registry personnel retrieving all source documents (such as disease indices, pathology reports, etc.).

    • Passive
    • Passive casefinding occurs when other departments notify the registrar of potentially reportable cases.
  57. Population-based Central Cancer Registry
    Sources of cases - Hospital
    • Hospital
    • - Pathology reports
    • - Disease indices
    • - Radiation therapy reports
    • - Outpatient records
    • - Other departments
    • - Diagnostic radiology reports
  58. Population-based Central Cancer Registry
    Sources of cases - Non-hospital
    • Non-hospital
    • - Outpatient centers
    •   * Ambulatory surgery centers
    •   * Private clinics
    • - Freestanding outpatient cancer centers
    •   * Radiation therapy centers
    •   * Medical oncology centers
    • - Freestanding path labs
  59. Population-based Central Cancer Registry
    Sources of cases - Non-hospital
    • Non-hospital (continued)
    • - Physician's offices
    • - Hospices
    • - Nursing homes
    • - Bureau of vital statisics and coroners' office for death records
    • - Out-of-state facilities
  60. Population-based Central Cancer Registry
    Electronic reporting of casefinding sources documents
    • Electronic reporting source
    • - Electronic Disease indices
    • - Death certificates
  61. Pop Quiz
    • The population‐based central cancer registrymust include:
    a. All cancer cases residing in their geographic area
    b. All cancer cases diagnosed and/or treated intheir geographic area
    c. Only analytic cancer cases
    d. Only cancer cases diagnosed and/or treated inhospitals

    a. All cancer cases residing in their geographic area
  62. Population‐based Central Cancer Registry
    Administration & Operations

    Record consolidation (3 types)
    • Record consolidation
    • –Patient linkage
    • –Tumor linkage
    • –Consolidation
  63. Record consolidation definitions
    – Source record
    • Source record
    • • Individual report on a tumor sent from a reportingfacility to the central registry
    • – Original report from facility
    • – Not consolidated
    • – May or may not be retained by the registry in its original format
  64. Record consolidation definitions
    – Patient record
    • Patient record
    • • Individual person with one or more primarycancers/reportable neoplasms
    • – Patient record describes the consolidateddemographic record from one person’s sourcerecord
  65. Record consolidation definitions
    – Tumor record
    • Tumor record
    • • Complete set of information on a single primaryneoplasm
    • – Tumor record describes the consolidated tumor(medical) information from the source record(s)
  66. Record consolidation process
    – Tumor linkage
    • – Tumor linkage
    • • From a group of source records for a patient determinethe number of primary tumors
    • – Critical data items: topography, laterality, histology,behavior code, diagnosis data, & sequence number
    • • Automated, manual, combination of both
  67. Record consolidation process
    – Patient or Case linkage
    • Patient or Case linkage
    • - Match patient and all patient's in database
  68. Record consolidation
    • Linkage of both patient and tumor records (or combining information from multiple sources)
    • -to produce a single "best" value for each patient or tumor data
  69. Pop Quiz
    • The registry operation performed when thecentral registry combines information frommultiple sources is…

    a. Casefinding
    b. Death clearance
    c. Geocoding
    d. Record consolidation

    d. Record consolidation
  70. Methods of record linkage and matching
    (2 types)
    • Deterministic
    • • Exact match of all selected data items

    • Probabilistic
    • • Scoring algorithm is built
    • • The preferred method b/c it provides match even if all fields are exactly the same (ex. birth date)
  71. Pop Quiz
    • The record linkage method that requires an exact match of specified data items between records is:
    a. Deterministic
    b. Duplicate
    c. Probabilistic
    d. Research

    a. Deterministic
  72. Monitoring completeness and timeliness of data
    – Completeness
    – Timeliness
    • Monitoring completeness and timeliness
    • Completeness
    • • Edit checks
    • • Frequency of unknown or ill‐defined data codes

    • Timeliness
    • • Lag‐time in reporting
  73. Death certificate only or DCO
    The only information the cancer registry has in from the DCO
  74. Death clearance
  75. The process of matching registered deaths in a population against registered cancers in a population
  76. Pop Quiz
    • The process of matching registered deaths in apopulation against registered cancers in apopulation is:
    a. Death certificate only
    b. Death clearance
    c. Deterministic linkage
    d. Follow back

    b. Death clearance
  77. Timeliness can be monitored by:
    • The accrual method
    • -evaluation of the overall accumulation of cases over months or years

    • Process monitoring method
    • -evaluation of the length of time between critcal events in the data acquisition process
  78. Population‐based Central Cancer Registry
    Data Sets
    • Data set

    – Collection of data items maintained by a registry
  79. Population-based Central Cancer Registry
    Standard data item
    Standard data item

    – Data item whose codes, definitions, and codinginstructions are shared among registries
  80. Population-based Central Cancer Registry
    Data dictionary
    Data dictionary

    – Defines data items in a registry data set
  81. Pop Quiz
    • What includes the codes and definitions fordata items that are part of a registry’s dataset?
    a. Cancer registry
    b. Data dictionary
    c. Legislation
    d. National standards

    b. Data dictionary
  82. Pop Quiz
    • What type of study may be performed whenpeople report that several family members,friends, neighbors, or coworkers have beendiagnosed with the same or related cancer?
    a. Cancer cluster study
    b. Case control study
    c. Patterns of care surveillance
    d. Survival surveillance

    a. Cancer cluster study
  83. All case abstractors in facilities
    that submitted cancer data to the state central registry were
    required to abstract the same 5 cancer cases as part of a
    reliability study. This is a way to evaluate what aspect of data

    a. Accuracy
    b. Completeness
    c. Consistency
    d. Timeliness

    c. Consistency
  84. Population-based central cancer
    registries collect follow-up information so that what can be
    calculated and analyzed for the catchment area?

    a. Cancer patient survival
    b. Incidence
    c. Patients lost to follow-up
    d. Prevalence

    a. Cancer patient survival 
  85. A 10 percent sample of abstracts
    from Hospital A’s last data submission to the central registry was
    selected and specified data items were recoded by quality control
    staff using the text provided on the abstract. What type of quality
    control procedure is this?

    a. Casefinding study
    b. Reabstracting study
    c. Recoding audit
    d. Visual editing

    c. Recoding audit
  86. Recoding Audits
    Provide verification that coding guidelines and rules are correctly applied by the data collectors.
  87. Prospective Study
    Looking forward of cases at the present time for a specific period.

    Also, called "Cohort Study"
  88. Retrospective Study
    Looking back at cases already in the registry.
  89. On an annual basis in a CoC
    accredited cancer program, at least 80% of cases presented at cancer
    conferences must be:

    a. Didactic
    b. Prospective
    c. Retrospective
    d. Subsequent

    b. Prospective
  90. Cancer program adherence to CoC
    Cancer Program Standards is documented as part of the:

    a. Accreditation award
    b. Medical staff bylaws
    c. Policy and procedure manual
    d. Survey application record

    d. Survey application record (SAR)
  91. SAR
    Survey Application Record

    CoC web-enabled primary source of cancer program information