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The eight most important things you should know about the 2016 Commission on Cancer Program Standards Clarifications

COC_blog.jpgEarlier this year, the Commission on Cancer released the 2016 Edition of the Cancer Program Standards: Ensuring Patient-Centered Care. This manual includes clarification and improved language to help further understand how the standards are intended and the criteria for compliance.

The most significant change is Standard 2.1. CAP Protocols will no longer have a rating of commendation, only Compliance and Non-Compliance. Beginning with 2017, cancer programs will be required to have a rate of 95% for CAP protocol compliance and 95% synoptic format.

  1. The most significant change is Standard 2.1. CAP Protocols will no longer have a rating of commendation, only Compliance and Non-Compliance. Beginning with 2017, cancer programs will be required to have a rate of 95% for CAP protocol compliance and 95% synoptic format.
  2. The #1 deficiency in 2015 – Standard 1.3 Cancer Committee Attendance – now has more clarification regarding designated alternates. These should be qualified and appropriately credentialed, and the designation should be documented at the first meeting of each year and recorded in the minutes. A designated alternate cannot be a required member of the Cancer Committee and cannot serve as alternate for multiple roles/members.
  3. Standard 1.8, Monitoring Community Outreach, was the second most common deficiency in 2015. Documentation in the form of an annual summary and in the minutes should reflect a review and discussion by the Cancer Committee if the prevention and screening activities are or are not producing the intended results (reducing the number of patients with a specific type of cancer and late-stage disease). The Committee must evaluate annually the scope of outreach and the methods to organize and offer programs. Also, the Community Outreach Coordinator cannot be an American Cancer Society representative.
  4. Standards 4.7 (Quality Studies) and 4.8 (Quality Improvements) were the third and fourth most common deficiencies during the 2015 surveys. Study topics must be based on problematic quality-related issues relevant to the Cancer Program and data compared with National Benchmarks/Guidelines. At least one Quality Improvement must be based on the results of a completed quality study.
  5.  Under Standard 4.3, the Cancer Liaison Physician now must upload a copy of the report presented to the Cancer Committee. A new template is available for this report, https://www.facs.org/quality-programs/cancer/clp/ncdbtools (see Tools and Tips for the CLP). The minutes of at least four reports on NCDB data, including Action and Response by the Cancer Committee, are included in the documentation. This standard was the fifth most common deficiency in 2015.

  6. Also beginning in 2017, all cancer programs will be expected to participate in RQRS (Standard 5.2-Rapid Quality Reporting System). Facilities will be required to submit cases each quarter, and the Cancer Committee minutes should demonstrate the report was reviewed at least semi-annually. For commendation, cancer programs will submit cases within three (3) months after the date of first contact as well as a report reviewed and documented by the Cancer Committee at least quarterly.
  7. Clarification has been provided for Standard 2.2-Nursing Care in that the denominator is all nurses who administer chemotherapy (instead of chemotherapy-trained) and includes all areas of the program where cancer care is provided.
  8. And lastly, documentation of the evaluation, discussion and action of the Cancer Committee is a theme throughout the manual in order to provide enough detail to accurately reflect compliance with the standards.

Whether your facility is seeking accreditation or preparing for a CoC survey, understanding and ensuring compliance with CoC standards is critical. CoC accreditation demonstrates a cancer center’s commitment to delivering high-quality care to its cancer patients and their families. Achieving and maintaining accreditation provides access to nationally recognized quality measures and standards of care to continually improve performance and patient care.

Resources:

Cancer Program Standards: Ensuring Patient-Centered Care – https://www.facs.org/quality%20programs/cancer/coc/standards

Brief Summary of 2016 Edition Revisions – https://www.facs.org/~/media/files/quality%20programs/cancer/coc/brief%20summary%20of%202016%20edition%20revisions.ashx

Topics: Cancer Registry