Meeting CoC Standards

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2 Meeting CoC Standards Chapter 2 Clinical Services Sharon Metzger, CTR Director of Consulting Services Onco, Inc

3 Welcome Thank you for joining us today for our webinar We will take questions and comments at the end of the presentation You may enter your questions into the Question box on the GoToWebinar screen This webinar is being recorded and the recording, slide deck and Q&A will be made available at our website 1.0 CEs have been awarded by NCRA

4 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

5 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

6 Chapter 2: Clinical Services Standard 2.1 Standard 2.2 Standard 2.3 Standard 2.4 College of American Pathologists Protocols and Synoptic Reporting Oncology Nursing Care Genetic Counseling and Risk Assessment Palliative Care Services

7 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

8 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

9 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)

10 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.

11 CAP/AJCC 8 TH Edition In June 2017, CAP released 53 updated versions of protocols to reflect changes to tumor staging in the 8 th 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 7 th Edition)

12 CAP Protocol Template website

13 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

14 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

15 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

16 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

17 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

18 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 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

19 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 Breast Prostate Colon Ovary Bladder

20 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 Breast Prostate Colon Ovary Bladder

21 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

22 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

23 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

24 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

25 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

26 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)

27 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 SAR Year (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 % % %

28 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

29 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?

30 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

31 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

32 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

33 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 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 Primary name/credential of individuals providing genetic counseling Year Name Credentials 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)

34 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

35 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

36 Clarification Requirement for a genetics professional on the cancer committee Referral policy Tracking the number of referrals Sources for required documentation

37 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

38 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

39 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 care Physical Emotional Practical Spiritual Difference between palliative care and hospice

40 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 Bereavement support for patients and families Psychosocial support for patients and families In-patient Hospice X x x 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

41 Documentation for the SAR Palliative Care Team Members Specialty Physician Nurse Social Worker Pastoral Care Mental Health Name and credentials of team member Tom Smith, MD, FACP Nancy Nurse, RN, MSN Louise Day, LSW-C Rev Joseph Luca Gary Vaughn, MD, FACP

42 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

43 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.

44 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 onsite 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

45 Suggestions Identify an individual who will be responsible for compliance with each standard 2.1 Pathologist 2.2 Oncology nursing leader identified in ER 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 subcommittee to deal with issues between the cancer committee meetings Don t wait until the last minute to update your SAR

46 Resources to assist you in meeting documentation requirements: CAnswer Forum Standards Resource Library CoC Webinars in CoC Datalinks Cancer Program Standards: Ensuring Patient-Center Guidelines Cancer Genetics info from NCI: Palliative Care info from NCI:

47 Thank you We appreciate your time today. To schedule a demo of Oncolog Registry software or speak to someone, please call Visit us at: To schedule a demo of OncoNav Nurse Navigation software or speak to someone, please call

48 Next Webinar in the Series Meeting CoC Standards Chapter 3 Continuum of Care Services December 6, noon 1 pm