Meeting CoC Standards - OncoLog · Cancer Risk Assessment/Genetic Counseling Cancer Genetics...
Transcript of Meeting CoC Standards - OncoLog · Cancer Risk Assessment/Genetic Counseling Cancer Genetics...
Meeting CoC Standards
Chapter 2
Clinical Services
Sharon Metzger, CTR
Director of Consulting Services
Onco, Inc
Welcome
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Goals for Today
Review the requirements to meet the standards in Chapter 2
Identify requirements for documentation and compliance
Share examples, offer suggestions and provide clarification
Required Documentation
CoC accredited cancer programs document cancer program activity
using multiple sources, including policies, procedures, manuals, tables
and grids; however, cancer committee minutes are the “primary
source” for all documentation of cancer program activities*
All meeting minutes should contain sufficient detail to accurately
reflect the activities of the cancer committee, as well as demonstrate
compliance with the CoC standards.*
• *Cancer Program Standards: Ensuring Patient-Centered Care page 11
Chapter 2: Clinical Services
Standard 2.1 College of American Pathologists Protocols
and Synoptic Reporting
Standard 2.2 Oncology Nursing Care
Standard 2.3 Genetic Counseling and Risk Assessment
Standard 2.4 Palliative Care Services
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Standard 2.1 College of American Pathologists
Protocols and Synoptic Reporting
Each calendar year 95% of the eligible cancer pathology
reports contain all required data elements of the CAP
protocols and are structured using the synoptic reporting
format as defined by the CAP Cancer Committee
Why are CAP protocols important?
Provides clinicians with a standardized, consistent, complete report
Standardized terminology and required data elements prevent
misinterpretation
Standardized and complete reporting that aids multidisciplinary care of
cancer patients
Eligible Cases
Included:
Pathology reports created by the program from resected specimens
with a diagnosis of invasive cancer
Pathology reports created by the program from resected breast
specimens with a diagnosis of ductal carcinoma in situ (DCIS)
Excluded:
Diagnostic biopsy specimens
Cytology specimens
Special studies
Reports of carcinoma in situ (except DCIS)
Eligible Cases: Clarification
For accreditation purposes, the Cancer Protocols are required to be used
for reporting of the definitive resection specimen in which there is
invasive malignancy or DCIS (whether neoadjuvant therapy is used or not).
For patients that require multiple operative procedures to accomplish
definitive resection, only the primary operative procedure requires use of
the Cancer Protocol format.
A CAP Cancer Protocol is not required for an additional excision performed
after the definitive resection even if there is residual disease.
CAP/AJCC 8TH Edition
In June 2017, CAP released 53 updated versions of protocols to reflect
changes to tumor staging in the 8th Edition of the AJCC Tumor Staging
Manual.
AJCC is not implementing the new staging system until January 1, 2018
CAP recommends hospitals start using the updated version on January 1,
2018 to ensure that the latest staging information is used
Until then, CAP recommends that the current version of the CAP protocol
are used (AJCC 7th Edition)
CAP Protocol Template website
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Synoptic Reporting Requirements
Definition of synoptic reporting requirements by CAP:
Each diagnostic parameter is listed on a separate line or in a tabular
format, to achieve visual separation
Narrative style comments are permitted, in addition to, but not as a
substitute for, synoptic reporting
The CAP cancer protocol checklist format, as published, is an
acceptable style of synoptic formatting
Synoptic Report
CARCINOMA OF THE COLON OR RECTUM
Specimen: Terminal ileum, cecum, appendix, ascending colon
Other organs received: None
Procedure: Right hemicolectomy
Tumor site: Cecum
Tumor size: 8.5 x 4.9 x 3.6 cm
Macroscopic tumor perforation: Not identified
Histologic type: Adenocarcinoma
Histologic grade: High grade (poorly differentiated)
Microscopic tumor extension: Tumor penetrates to the surface of the visceral peritoneum
(serosa)
Margins:
Mesenteric: Involved by invasive carcinoma
Proximal: Uninvolved by invasive carcinoma
Distal: Uninvolved by invasive carcinoma
Treatment effect: No prior treatment
Lymph-vascular invasion: Present
Perineural invasion: Not identified
Tumor deposits (discontinuous extramural extension): Present
Specify number of tumor deposits identified: 3
Pathologic staging (pTNM):
Primary Tumor (pT): pT4a Regional Lymph Nodes (pN): pN1b Number lymph nodes
examined: 25 Number lymph nodes involved: 3
Distant metastases (pM): pMn/a
Unacceptable Synoptic Report Example
Diagnosis:
Colon, right hemicolectomy:
Invasive adenocarcinoma, 3.4 x 3.0 cm involving muscularis
propria
All margins negative
No lymphatic invasion
No metastatic tumor identified
Quality Control Review Required
A minimum, random sample of 10% of eligible pathology reports; or
A maximum of 300
The cancer committee may delegate this review to a pathologist who will
report the findings to the cancer committee annually
The report of the review and findings are documented in the cancer
committee minutes
Documentation for the SAR
For each year of the survey cycle:
Year of pathology reports being reviewed
Total number of CAP eligible surgical cases
Number of CAP eligible reports reviewed by the Cancer Committee
Of the reports reviewed, enter the number in compliance
Percent of reports reviewed that were in compliance
Identifying cases to be reviewed during the survey
The cancer registrar:
Uploads an accession listing for each year of the survey cycle that
includes eligible cases (class 10-22 with surgery at your facility) and the
surgical code or name of the surgical procedures.
The surveyor:
Selects 30 cases which will have the pathology report reviewed and
returns those cases back to the registrar
Documentation for the SAR
Cancer Registrar completes the first 3 columns
Surveyor complete the last 3 columns
Year Accession
Number
Site CAP Elements
Compliance
Synoptic
Format
Comments
2015 201500001 Breast
2015 201502822 Prostate
2015 201583746 Colon
2015 201523451 Ovary
2015 201587788 Bladder
On the day of the survey
Surveyor reviews 30 pathology reports
Confirms that all required data elements are present in 90/95% of reports
reviewed
Confirms synoptic format in 95% of reports reviewed
Completes the last three columns of the table in the SAR
Year Accession
Number
Site CAP Elements
Compliance
Synoptic
Format
Comments
2015 201500001 Breast
2015 201502822 Prostate
2015 201583746 Colon
2015 201523451 Ovary
2015 201587788 Bladder
Rating Compliance
For 2017:
95% compliance with synoptic format on cancer pathology reports as
defined by the CAP cancer committee
95% of the cancer pathology reports include ALL required data
elements as outlined in the CAP protocols
Prior to 2017:
90% of cancer pathology reports include the required data elements
Audit Timeline: Clarification
Audit reporting timeline:
The standard does not state when a year must be reviewed
10 percent or 300 max reports must be reviewed to determine compliance
You do not need to wait until a full year of pathology reports are complete to
do the audit
Standard 2.2 Oncology Nursing Care
Oncology nursing care is provided by nurses with specialized
knowledge and skills. Nursing competency is evaluated each
calendar year. Results are reported to the cancer committee
and documented in the cancer committee minutes
Nursing Education
Oncology nursing education focuses on administration of cancer treatments
in a safe and consistent manner through the Oncology Nursing Society
(ONS) or Oncology Nursing Certification Corporation (ONCC)
Educational courses may include:
ONS Cancer Basics Course
ONS Chemotherapy Basics Course
ONS/ONCC Chemotherapy Biotherapy Certificate Course
ONS/ONCC Radiation Therapy Certificate Course
Nursing Competency
Oncology nursing education and competency are required for all areas
where cancer care is provided
The annual nursing competency evaluation of oncology knowledge and
skills is completed, documented and approved by the cancer committee
Oncology nursing certification for all nurses providing oncology care is
STRONGLY encouraged
All nurses who administer chemotherapy need documented certification of
chemotherapy training for both in-patient and out-patient units
Oncology Nursing Certifications
Include but are not limited to:
Oncology Certified Nurse (OCN)
Advanced Oncology Certified Nurse (AOCN)
Certified Pediatric Oncology Nurse (CPON)
Certified Pediatric Hematology Oncology Nurse (CPHON)
Advanced Oncology Certified Clinical Nurse Specialist (AOCNS)
Advanced Oncology Certified Nurse Practioner (AOCNP)
Certified Breast Care Nurse (CBCN)
Documentation for the SAR
Upload the oncology nursing competency policies or procedures and the
cancer committee minutes that document the committee’s review of the
competency training results
Complete the table in the SARYear (each year of the survey cycle)
# of nurses providing oncology care employed by the facility (FT/PT/PRN)
# of oncology nurses who are oncology certified nurses
Ratio of oncology certified nurses
Year # of nurses providing
oncology care
# of nurses who are
oncology certified
Ratio of oncology
certified nurses
2014 18 6 33%
2015 26 7 27%
2016 27 8 30%
Rating Compliance
Nurses with specialized oncology knowledge and skill are available at the cancer
program
Organizational policies and procedures are in place to evaluate oncology nursing
competency
Nursing competency for all oncology nurses employed and/or contracted (FT/PT) is
evaluated each year under the direction of oncology nursing leadership
Oncology nursing competency is reported to the cancer committee and
documented in the minutes
COMMENDATION
25% of oncology nurses employed and/or contracted with the facility
(including FT/PT) hold a current, applicable oncology nursing certification
Clarification
Do nurses need an oncology certification to administer chemo?
Must all educational programs be provided by ONS or ONCC?
Are all RNs included in the denominator?
Are LPNS included in the denominator?
Are per-diem staff included in the Part-time category?
Standard 2.3 Genetic Counseling and Risk
Assessment
Cancer risk assessment, genetic counseling and genetic testing are
provided to patients either on-site or by referral to a qualified genetics
professional
A genetics professional is a required member of the cancer committee, if the
services are provided on-site
Genetic counseling and risk assessment must include pretest and posttest
counseling
Genetic services not provided on-site, must be provided through a formal
referral to other facilities or local agencies
Annually, the cancer committee monitors, evaluates, and makes
recommendations for improvements. The discussion and recommendations are
documented in the cancer committee meeting minutes
Cancer Risk Assessment/Genetic Counseling
Cancer Genetics Overview (PDQ®)–Health Professional Version
A process of communication between genetics professionals and patients with the
goal of providing individuals and families with information on the relevant aspects
of their genetic health, available testing and management options, and support as
they move toward understanding and incorporating this information into their daily
lives.
Genetic Counseling generally involves the following 6 steps:Family and medical history assessment
Analysis of genetic information
Communication of genetic information
Education about inheritance, genetic testing, management, risk reduction, resource and
research opportunities
Supportive counseling to facilitate informed choices and adaptation to the risk or
condition
Follow-up
..
Genetics professionals
American Board of Genetic Counseling (ABGC) or American Board of Medical
Genetics (ABMG) board-certified/board-eligible or a licensed genetic counselor
American College of Medical Genetics (ABMG) physician/PhD board-certified/board
eligible in clinical or medical genetics
Genetics Clinical Nurse (GCN), an Advanced Practice Nurse in Genetics (APNG), or
an Advanced Genetics Nursing-Board Certified (AGN-BC) credentialed through the
American Nurses Credential Center (ANCC)
Advanced practice nurse oncology nurse or Physician Assistant with a graduate
level (masters or PhD) degree with specialized education in cancer genetics and
hereditary predisposition syndromes
Board-certified/board eligible physician with experience in cancer genetics
Documentation for the SAR
Upload for each year of the survey cycle:
Policies or procedures for providing cancer risk assessment, genetic
counseling, and genetic testing services
Cancer committee minutes that document the processes implemented
to monitor and evaluate the services and referrals
Cancer committee review
Primary name/credential of individuals providing genetic counseling
Date the cancer committee monitored and reviewed the
process for referring and providing genetic counseling
and risk assessment each ear
1/5/14 1/6/15 4/11/16
Year Name Credentials
2014
2015
2016
Miles Metzger, PhD
Dunkin Kawesch, CGC
Oliver Ingram, RN,
American College of Medical Genetics (ABMG)
American Board of Genetic Counseling (ABGC)
Advanced Genetics Nursing-Board Certified (AGN-BC)
Policies and Procedures
No minimum list of requirements by the CoC
Set goals for the service
Identify which services will be offered on-site or by referral
If referred, establish the formal referral process
Identify which facilities or groups will provide services
If on-site, name the members of team, and their roles
Determine who will be the required member of the cancer committee
Define the minimum qualifications for each team member
Decide which national genetics guidelines will be followed
Define the process for pre and post test counseling
Decide what type of follow-up will done and by whom
Rating Compliance
Cancer risk assessment, genetic counseling, and genetic testing services
are provided to patients either on-site or by referral by a qualified
genetics professional
The process for referring or providing cancer risk assessment, genetic
counseling, and genetic testing services to patients is monitored and
reviewed by the cancer committee and documented in the minutes
Clarification
Requirement for a genetics professional on the cancer committee
Referral policy
Tracking the number of referrals
Sources for required documentation
Standard 2.4 Palliative Care Services
Palliative care serves are available to patients either on-site or by
referral
Full range of services to optimize the quality of life and end of life care
Services are provided by a multidisciplinary team
A member of the palliative services team is a required member of the cancer
committee, if the services are provided on-site
The cancer committee defines and identifies the on-site and off-site services
The cancer committee monitors, evaluates and makes recommendations for
improvements
Types of palliative care services
Team-based care planning that involves the patient and family
Pain and non-pain based symptom management
Communication among patients, families, and provider team members
Attention to spiritual comfort
Psychosocial support for patients and families
Bereavement support for families and care team members
Hospice care
Palliative Care in Cancer
Improve the quality of life of patients who have a serious or life
threatening disease, such as cancer
Goal is not to cure but to prevent or treat, as early as possible, the
symptoms and side effects of the disease
Comprehensive palliative carePhysical
Emotional
Practical
Spiritual
Difference between palliative care and hospice
Documentation for the SAR
Upload for each year of the survey cycle:
Policies and procedures for providing services on-site or by referral
Cancer committee minutes that document the process implemented to
monitor and evaluate services and referrals
.
Palliative care services On-site Referred
Pain and non-pain management
Spiritual Counseling
X
x
Bereavement support for patients and families x
Psychosocial support for patients and families
In-patient Hospice
X
x
Cancer committee review Year: 2014 Year: 2015 Year: 2016
Date the cancer committee monitored and reviewed the
process for referring and providing palliative services each
year
1/5/14 1/8/15 4/2/16
Documentation for the SAR
Palliative Care Team Members
Specialty Name and credentials of team member
Physician Tom Smith, MD, FACP
Nurse Nancy Nurse, RN, MSN
Social Worker
Pastoral Care
Louise Day, LSW-C
Rev Joseph Luca
Mental Health Gary Vaughn, MD, FACP
Rating Compliance
Palliative care services are available to patients either on-site or by
referral
The process for referring or providing palliative care services is monitored
and reviewed by the cancer committee and documented in the minutes
Clarification
Policy and Procedures
Review and monitoring in the minutes
NCI-P no longer exempt from Standard 2.4
Adding, modifying, or increasing referrals to Palliative Care Services cannot
be used as a goal for Standard 1.5.
Required Documentation for Chapter 2: Clinical Services
STANDARD DOCUMENTATION COMMENT
2.1: College of
American Pathologists
Protocols and Synoptic
Reporting
Not applicable Pathology reports reviewed day of survey.
Provide accession list for years of survey cycle,
with surgical code or name, to the surveyor by
uploading to the ‘Agenda, Presentations, and
Accession List” link in the SAR before survey.
2.2: Oncology Nursing
Care
Nursing competency policy or procedures.
Cancer committee minutes that document the
committee’s review of the results and outcomes from
the annual oncology competency evaluation.
Complete and upload for each calendar
year
2.3: Genetic
Counseling &
Risk Assessment
Policies or procedures for providing cancer risk
assessment, genetic counseling, and genetic testing
services on-site or by referral.
Cancer committee minutes that document the
processes implemented to monitor and evaluate the
services and referrals.
Complete and upload for each calendar year
2.4: Palliative Care
Services
Policies or procedures for providing palliative care on-
site or by referral.
Cancer committee minutes that document the
processes implemented to monitor and evaluate the
palliative care services and referrals.
Complete and upload for each calendar year
Suggestions
Identify an individual who will be responsible for compliance with each
standard
2.1 Pathologist
2.2 Oncology nursing leader identified in ER 4
2.3 Genetics professional on the cancer committee
2.4 Palliative care team member
Set up the cancer committee calendar at the beginning of each year and
notify the responsible person of the date their report is due to be
presented
If an issue is identified that could lead to non-compliance set up a sub-
committee to deal with issues between the cancer committee meetings
Don’t wait until the last minute to update your SAR
Resources to assist you in meeting documentation requirements:
CAnswer Forum http://cancerbulletin.facs.org/forums/
Standards Resource Library
http://cancerbulletin.facs.org/forums/CAnswerForumHome/StandardResourceLibrary
CoC Webinars in CoC Datalinks
Cancer Program Standards: Ensuring Patient-Center Guidelines 2016
http://www.cap.org/web/oracle/webcenter/portalapp/
Cancer Genetics info from NCI: https://www.cancer.gov/about-cancer/causes-
prevention/genetics/overview-pdq
Palliative Care info from NCI: https://www.cancer.gov/about-cancer/advanced-cancer/care-
choices/palliative-care-fact-sheet
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Next Webinar in the Series
Meeting CoC Standards
Chapter 3
Continuum of Care Services
December 6, 2017
12 noon – 1 pm