final canswer forum live 2 12 2020 for webinar forum live feb... · for standard 2.2. however, for...
TRANSCRIPT
1
2
3
STORE – Answer
According to SEER, First course of treatment includes all methods of treatment recorded in the treatment plan and administered to the patient before disease progression or recurrence.
4
Data Submission – Answer
The annual call for data is not phased out for 2020 but may be phased out in 2021. The revision of the data submission standards will be evaluated and shared with the registry community effective 2022.
5
Standard 1.3 and 1.4 – Answer
Yes, it would be the same.
6
Standard 1.1 – Answer
Yes, the letter needs to be from the Medical Center leadership ‐ the CEO or a member of the Medical Center's leadership team. For example, COO, CFO, or Hospital Administrator.
7
Standard 1.1 – Answer
The requirements of the letter are listed in Standard 1.1. Sample language is not available for this standard because it needs to be specific to each program.
8
Standard 1.1 – Answer
The timing of this letter of commitment is at least once during the survey cycle, so it should be when it is most appropriate for your cancer program. However, the intent is that your facility’s leadership will commit to providing the necessary resources needed to develop and sustain the cancer program as well as commit to providing the resources needed for equipment, personnel and administrative support. This letter is a demonstration by your hospital leadership that they are aware of all the activity in your cancer program.
Your program may want to include the recent cancer program activity as well as outline upcoming initiatives. The letter may be put out later in the cycle to include these OR you can amend the letter to include new initiatives.
Addressing activity from the previous survey cycle does not comply with the standard.
9
Standard 1.1 – Answer
Standard 1.1 is not the Facility Charter, but a letter from the facility's leadership demonstrating their commitment to the Cancer Program and meeting the CoC standards.
10
Standard 2.1 – Answer
Coordinators can be appointed from the required or the non‐required members.
11
Standard 2.1 – Answer to both questions
Yes, the CLP is the cancer committee chair’s alternate.
The program cannot name their own alternate for the chair.
12
Standard 2.1 – Answer
No, the CoC is not indicating a 3‐year term.
Appointments need to occur during the first meeting of a calendar year at least one time during the three‐year accreditation cycle. If any changes to committee membership are made during the cycle, you will need to document it in the minutes. This includes member replacement, interim members, and change in alternates. Programs may choose to appoint more often.
13
Standard 2.1 – Answer
It is a recommendation, not a requirement.
14
Standard 2.2 – Answer to both questions
Technically, if the CLP reports on RQRS at cancer committee twice per year it will comply for Standard 2.2.
However, for Standard 2.2, the CLP is the quality leader and should be using all the NCDB tools to identify, analyze and present the data to the cancer committee. Standard 2.2 is intended to focus on areas of concern or where expected performance is not being met.
15
Standard 2.2, 6.4, 7.1 – Answer
Under Standard 6.4, it does state that the CLP may report RQRS data and performance in partial fulfillment of Standard 2.2. Standard 7.1 does not require that the CLP monitor the measures. While reports from 6.4 and 7.1 technically may meet the requirements of 2.2, it is recommended the CLP use this opportunity to report on other NCDB data, specifically areas of concern and/or where benchmarks are not being met.
16
Standard 2.3 – Answer
There is no required format or content for the agenda. That is up to the hospital policy and procedures. Many review requirements vary per program due to specific program activity, so this should be determined at the local level.
17
Standard 2.3 – Answer
Consent agendas are allowed starting in 2020 for items that do not require discussion (for example, appointment of cancer committee members).
18
Standard 2.5 – Answer to both questions
Reporting on number of cases discussed is required to be part of the coordinator report.
These required elements are to be reported at the conference level so tracking at the individual level is necessary. The choice of the tracking method rests with the cancer committee.
Reports on individual patient discussions should not be provided to the CoC.
19
Standard 2.5 – Answer
We anticipate creating resources by the end of the first quarter and over the course of 2020.
20
Standard 3.2 – Answer
Certificate(s) of accreditation or quality assurance practices are the documentation that must be submitted for compliance.
21
Standard 4.5 – Answer
You will need to track the types of services that the patients are referred to receive and this would be the responsibility of your palliative care team. If palliative cancer treatment is one of your palliative care services, you will need to track patients that are offered these. A list of services can be found on page 31 of the manual.
22
Standards 4.5, 4.6, 4.7 – Answer
That will be left to the program since the CoC standards are not tied to ICD‐10.
23
Standard 4.8 – Answer
The timing of when your program would deliver a SCP would need to be determined by the survivorship team and the cancer committee.
24
Standard 4.8 – Answer
Yes, it can.
25
Standard 4.8 – Answer
You can do survivorship care plans are one of your three services, but they are not required.
26
Standard 5.2 – Answer
As stated in the standard, “the policy and procedure must address the sites of service where screenings occur, including at the CoC‐accredited facility and/or with designated providers (offices of Medical Oncologist or Radiation Oncologists affiliated with the program).” Programs are to define when patients receive distress screening. The program's plan should include mechanisms to screenall cancer patients, regardless of inpatient or outpatient status. Please refer to the Bibliography for additional information.
27
Standard 5.3 – Answer
Yes. 5.3 is a phase in standard. This oversight was identified and updated in the pdf shortly after its publication.
28
Standard 7.3 – Answer
There are a variety of areas where a program may identify a QI initiative outside of NCDB data, including problems identified during annual review of clinical services required by other standards, the results of a Standard 7.2 study, or any other quality‐related identified problem specific to your program.
29
General – Policies and Procedures
Policies and procedure are to be reviewed each calendar year by the cancer committee. Policies and procedures can be reviewed throughout the year so that it is not such a burden on the committee.
30
General – Answer
The 2021 Pre‐Review Questionnaire (PRQ) will be available in the Fall of 2020 to programs scheduled for 2021 surveys. We anticipate publishing resources by the end of the first quarter and over the course of 2020.
31
General – Answer
Standards 4.2 and 4.8 are to be implemented beginning January 1, 2021.
Implementation timelines will be announced for Standards 5.3‐5.8 as soon as they have been determined.
32
General – Answer
Please see the guidelines on page v of the 2020 standards.
For some standards, programs may choose to do the annual report during the first quarter of the following year. However, the annual reports cannot extend past that.
We apologize for any confusion caused by statements made during the Educational Summit.
33
General – Response
Thank you for the suggestion.
The date of implementation is noted on the cover of the manual as January 2020. The changes in the Optimal Resources for Cancer Care are robust, so each standard should be read in its entirety.
34
Standard 4.2 – Answer
We are working with the Oncology Nursing Society (ONS) to further define the CNEs. The information will be posted in The Brief and questions on this standard will be addressed in a future session of CAnswer Forum LIVE.
35
Answer given on next slide.
36
37
38
39
40