Getting Ready for QOPI CertificationPart II

February 21,2012Use Mute Button on Phone

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For Assistance go to MOQC.org or call: 734.763.7398

Today’s Agenda

I. Certification Process OverviewII. Policy & Competency RequirementsIII. Data Submission Tips & TricksIV. MOQC ResourcesV. Future Webinar: Site Visit Preparation

QOPI Certification Overview

• Demonstrates highest level of commitment to quality and safety for oncology practices

• Prepares participants on how to conduct self assessments of policies, staff competencies & documentation associated with key processes in their offices

• Primary focus is on the safe administration of of chemotherapy and biologics

Chemotherapy & Biotherapy Administration

Patient Centered Care

Culture of Safety & Quality

Chemotherapy Plan

Drug Administration

Drug Preparation

Monitor & Assessment

Eligibility Requirements

• Starts with submitting data for all 5 modules during one collection round

• Compliance with QOPI chart selection & sampling methodology

• Achievement of QOPI scores to be Certification Eligible:– Overall Quality Score : 72.62% or higher– Adjuvant Treatment Score : 80% or higher

Certification ProcessQOPI Thresholds met Practice is EligibleCertification Password Obtained Complete Application & Payment based on

practice MD FTE (prior to March 22nd) Complete Site Assessment Questionnaire &

Attestation StatementSubmit ASCO Designated Documentation on

5 Safety Standards & 3 Medical Records

II. POLICY & STAFF COMPETENCY REQUIREMENTS

Staffing Related Policies/ Elements

Required Policy Elements: Who can perform the task & how are they deemed qualified

Chemo orders incl. oral are written & signed by L.I.P.

Chemo drugs preparation by qualified staff

Administration of chemo is only by qualified MD, PA/NP, RN

How new staff that administer are educated incl competency (skills) assessment/ verification

Chemotherapy administration competency monitoring schedule (how & how often- annually recommended)

Chemotherapy Orders, Preparation & Administration Policy/ Elements

Required ordering elements (or submit std order form)

Double check process elements required before preparation

Double check process elements required before administration

How cumulative doses are captured/ monitored (or submit form/ screenshot)

Intrathecal administration includes special preparation, storage & delivery requirements

How communication & documentation of toxicity will occur across sites of care within a practice if applicable

General Practice Policies/ Elements

Informed Consent process

Standard clinical assessment elements (ie. VS, Wt, Allergies etc.) (or submit standard form/ screenshot)

Medication reconciliation process incl. when & how collected

Extravasation management procedure including antidote order sets & procurement process

Missed appointment tracking & follow up process

How patients access providers during & after hours

Emergency preparedness policy incl. plan for life-threatening emergencies (or checklists)

ASCO.org \ Practice & Guidelines \ Quality Care \ Quality Measurement & Improvement \ ASCO-ONS Standards for Save Chemotherapy Administration \ Download: Sample Policies for Safe Administration of Chemotherapy

Staff Education Requirements

Testing: Acquiring Knowledge Competency Assessment: Demonstrating Proficiency

Required Staff Education & Competencies

• Testing assesses knowledge• Competency assessment evaluates skills and

performance• Both are required for staff who administer

chemotherapy with annual review that includes a competency assessment

• BLS: Minimum requirement for RNs • Submission of staff records required

III. DATA SUBMISSION TIPS & TRICKS

Certification Standards Overview• Each standard set up in the same manner:

– Standard Description– Policy Required (if applicable)– Acceptable Documentation to submit– Available References & Resources

• Only send documentation showing evidence that standard met – no highlighter!!

• De- identified records only- or need to resubmit• ASCO tells you which 5 modules to submit data

Chemotherapy Planning:Standards #2&3

#2 Required Documentation Prior to New Order Pathology Report Cancer Stage at diagnosis or current status History & PE ( including Ht, Wt) Allergies & history of hypersensitivity reactions Psychosocial assessment (ESAS, Distress Tool)

#2 Required Documentation Prior to New OrderChemotherapy Treatment Plan

– Goals of Therapy (curative / palliative) – Drug, dose & duration– Acknowledgement of patient understanding of

the information2 records sent demonstrating compliance

Chemotherapy Planning (cont.)

Chemotherapy Planning (cont.)

#3 Informed Consent Documentation RequiredSend two recent completed forms or notes with

policy

Oral Chemotherapy Documentation RequiredAll of the aboveFrequency of office visitsMonitoring parameters

Chemotherapy Orders:Standard 4

Orders RequirementsOrder forms list all chemo & dosing parametersFull generic name used Abbreviations follow Joint Commission

standardshttp://www.jointcommission.org/standards_information/npsgs.aspx

Completed unique order sets for 3 patients sent (including and anthracycline)

Chemotherapy Orders (cont.)

• Required Elements on a Chemotherapy Order:– Patient full name & 2nd identifier– Date Diagnosis– Regimen Name & Cycle # (Protocol Name /#)– Allergies, Ht/ Wt ( or other dose calc)– Dose calculation method (ie. creatinine clearance)– Route, Rate, Dosage, Length of Infusion, Sequence– Supportive care treatments

Drug Preparation: Standards 5 & 6

• Double Check Documented Prior to Preparation

• Chemotherapy Drugs Must be Labeled Immediately Upon Preparation – Standard format included in guideline– Time of expiration added when not for

immediate use

Drug Preparation: Standard 7 Intrathecal Administration

• Prepared only with other intrathecal agents• Uniquely identifiable intrathecal label• Stored in an isolated container/ location • Delivered to patient only with other meds for

CVS administration• All procedure areas in organization must

follow same policy incl. IR, Procedure Units

Chemotherapy Administration: Standard 8 Double Check

• In the presence of the patient, verify patient identification using at least 2 identifiers

• Confirm with patient planned treatment prior to each cycle

• Double check completed & documented (required elements listed in standards)

• Checklist, template recommended *** Competency validated on annual basis

Chemotherapy Administration: Standard 9 Extravasation Management

• Policies / guideline & order sets align with current literature ( 2009 ONS Chemotherapy & Biologics Guidelines And Recommendations For Practice )

• Antidotes & order sets must be accessible on site or need written procedure on where patient is sent or how antidote is sent to area NOTE: Totect treatment for anthracycline and hyaluronidase for plant alkaloids are current recommendations

Monitoring & Assessment:Standard 10: Emergency Preparedness

• Emergency protocols/ checklists are maintained for life–threatening emergencies– Who needs contacted to get help / responds– How are they contacted (i.e. page/phone number)– Assigned role of staff during the emergency– Procedures implemented when further care is

required (including transfers)

Monitoring & Assessment:Standard 11: Clinical Assessment

On each clinical visit including infusion the following is assessed / verified and documented:

– Clinical/ performance status– VS, Wt,– Allergies, previous reactions & treatment- related

toxicities– Psychological concerns (with plan if indicated)

Screenshot or form can be submitted or policy

Monitoring & Assessment:Standard 12: Medication Reconciliation

On each clinical visit including infusion review of the following will occur:

– Current medications– OTC meds– Complementary & alternative treatments

Changes are documented in the medical record

Monitoring & Assessment:Standard 13: Referral Resources

• Required to have listing of psychosocial & supportive care resources

• Resources include list of websites, booklets, community programs etc

Monitoring & Assessment:Standard 14/15: Access & Communication

#14 Missed Appointments– Need missed appointment policy &/or tracking

process which includes patient follow up (i.e. call, email to patient)

#15 Provider Communication – Process to provide 24/7 triage (i.e. on call process)

for care of toxicities– Ability to communicate toxicities across sites– Tracking of Safe Hand-Offs- HOLD

Monitoring & Assessment:Standard 16/17:Toxicity Monitoring

#16 Toxicities Assessment Documentation is Available for Planning Subsequent Cycles

– Flow sheets, provider notes of review

#17 Cumulative Doses are Tracked When Indicated

– i.e. Documentation of doxorubicin cumulative dosing for patient receiving AC protocol; EMR screenshot of tracking; flow sheet

Chemotherapy & Biotherapy Administration

Patient Centered Care

Culture of Safety & Quality

Chemotherapy Plan

Drug Administration

Drug Preparation

Monitor & Assessment

Next Steps• Assemble your team including physician

champion• Conduct a self assessment/ gap analysis

(MOQC tool)• Identify opportunities for improvement• Use ASCO & ONS resources• Work with MOQC colleagues to identify best

practices• Conduct Mock Survey

All QI information can be accessed via the MOQC.org website starting March, 2012.Please email jseversn@umich.edu or cmichale@umich.edu for log-in information.

MOQC Lunch & Learn Series

• To better meet your needs, we would like your feedback and input. Please complete Evaluation Survey at: https://umichumhs.qualtrics.com/SE/?SID=SV_ehqdiP2GOhwUxwg

• Future Webinars–Certification Part # 3 Site Visit Preparation–Improving Cancer Pain Management