4/25/ and Beyond: The Survey Process. The Survey Process Survey Process Task Force

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1 2012 and Beyond: The Survey Process Thomas J. Tachovsky, MD, FACS Chair, Field Staff Sub-Committee, Commission on Cancer St. Luke s Health Care, Bethlehem, PA Lisa Landvogt, CTR Administrator, Commission on Cancer American College of Surgeons, Chicago, IL The Survey Process Pre 1995 Paper > Diskette > Web SAR & Paper > 2011 Web SAR 2012 Survey Process Task Force Linda Ferris, Ph.D., Chair, Association of Cancer Executives Task Force Members Commission members Surgeons Member organization representatives Commission leadership Surveyors Consultants Staff 1

2 Feedback First Conference Call July 23, 2010 Develop a questionnaire on the survey process targeted to cancer program constituents Initial feedback Cancer Liaison Physicians attending breakfast meeting at Clinical Congress, Washington, DC Surveyors and Consultants at October training session Follow-up calls November 2010 December CLPs 131 Responses from CLPs (65%) 45 surveyors and 30 consultants 45 responses from surveyor/consultant team (60%) Distribution by Cancer Program Category for All Responders 32% 20% 11% 5% 27% Network NCIP THCP VACP COMP CHCP 5% 2

3 Most Recent CoC Survey at Your Primary Facility Other 20 0 Have previous on-site surveys met your expectations? 96% said yes How can this be improved? Send less combative and harsh reviewers Surveyor did not complete record review Surveyor could be more up-front with deficiencies Survey Savvy was helpful Do you feel that the CoC employs a high quality surveyor team? 94% said yes Comments I found the surveyor team to be very forward thinking for our program in addition to their inspection of the program 3

4 How long did it take you to prepare for survey? Do you feel the survey process fosters multidisciplinary preparation on the part of the cancer program? 90% said yes How can this be improved? I think inclusion of high level administration is a very good improvement. They usually control the budget so their buy-in is essential. Needs to be mandatory to pass that all members attend: CEO, CLP, etc. Did preparation for the CoC survey enhance organization and coordination in your program? 71% said yes Comments Enhanced quality of data Not the program itself Yes, but only to a small degree 4

5 Based on the agenda, what is your level of satisfaction with the current survey process? Very satisfied: 18% Satisfied: 37% Somewhat satisfied: 13% Not satisfied: Less than 1% I don t know or no answer: 31% Importance of current survey components Survey component Very Important Important Somewhat important Not important Surveyor meeting with chief leadership Review of SAR with cancer committee Review of CP 3 R with cancer committee Surveyor tour of the facility Surveyor review of abstracting Surveyor review of health information Surveyor observation of cancer conference Surveyor meeting with the CLP Surveyor meeting with cancer registry staff Surveyor summation of findings Would the survey be more effective if the facility had the opportunity to share a presentation or poster highlighting an important aspect of cancer program? (41% said yes) Would you benefit from the surveyor s discussion during the survey of an identified need in your program? (79% said yes) Does the content of the CoC Cancer Program Standards Manual include all of the information needed to prepare for the survey? (64% said yes) 5

6 What one change or addition would most improve the survey agenda? CLP should take the lead and present CP 3 R information during the survey Discuss changes in standards and how we can implement them Greater focus on outcomes Program directed analysis Two day visit Provide best practices at survey 2012 New Standards Developed with the goal of improving care for cancer patients Addresses gaps in the continuum of care Emphasizes outcomes measurement and quality improvement Initiates more multidisciplinary involvement with focus on team process 2012 and Beyond: The Survey Process Keep in mind This is NOT a Cancer Registry Survey, It is a Cancer Program Survey 6

7 Current Survey Structure (2011) February-June, 2011 surveys: On-site testing of selected new standards to identify Programs that have already implemented Barriers to implementation Best practices that can be shared with other programs After standards published (July 2011), surveyor will discuss 2012 standards with cancer committee 2012 Surveys Survey will be based on current standards because we will be reviewing years 2009, 2010, 2011 Elimination of Outstanding Achievement Award for NEW programs Review and discussion of new standards Strategies for implementation Resources for cancer programs Identifying best practices 2012 Survey Process Enhance presentation to the Chief Leadership Focus on importance of new standards for patients and facilities Describe the value of the standards and maintaining Commission on Cancer accreditation Address added resources that will be required of the cancer program 7

8 2012: Survey Process Introduction of the new and greatly improved Survey Application Record (SAR) Adjustment and enhancement to the survey agenda Addressing and identifying program needs Automated review of abstracting timeliness through the National Cancer Data Base (NCDB) 2013 Survey Process Surveys will require implementation of 2012 standards that do not have a phase-in time period focus on eligibility requirements Survey review consists of 2012, 2011 and 2010 Mixture of old and new standards Continue with educational focus, resources and identification of best practices Questions? Please visit the CoC s CAnswer Forum to post questions on this Webinar. The URL and log in instructions can be found in an attachment posted along with the presentation handouts. 8