Meeting CoC Standards

Chapter 2

Clinical Services

Sharon Metzger, CTR

Director of Consulting Services

Onco, Inc

Welcome

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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

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

Chapter 2: Clinical Services

Standard 2.1 College of American Pathologists Protocols

and Synoptic Reporting

Standard 2.2 Oncology Nursing Care

Standard 2.3 Genetic Counseling and Risk Assessment

Standard 2.4 Palliative Care Services

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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

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

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)

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.

CAP/AJCC 8TH Edition

In June 2017, CAP released 53 updated versions of protocols to reflect

changes to tumor staging in the 8th 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 7th Edition)

CAP Protocol Template website

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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

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

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

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

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

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 10-22 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

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

2015 201500001 Breast

2015 201502822 Prostate

2015 201583746 Colon

2015 201523451 Ovary

2015 201587788 Bladder

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

2015 201500001 Breast

2015 201502822 Prostate

2015 201583746 Colon

2015 201523451 Ovary

2015 201587788 Bladder

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

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

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

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

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

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)

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 SARYear (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

2014 18 6 33%

2015 26 7 27%

2016 27 8 30%

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

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?

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

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

..

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

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

Primary name/credential of individuals providing genetic counseling

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

Year Name Credentials

2014

2015

2016

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)

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

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

Clarification

Requirement for a genetics professional on the cancer committee

Referral policy

Tracking the number of referrals

Sources for required documentation

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

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

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 carePhysical

Emotional

Practical

Spiritual

Difference between palliative care and hospice

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

X

x

Bereavement support for patients and families x

Psychosocial support for patients and families

In-patient Hospice

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

Documentation for the SAR

Palliative Care Team Members

Specialty Name and credentials of team member

Physician Tom Smith, MD, FACP

Nurse Nancy Nurse, RN, MSN

Social Worker

Pastoral Care

Louise Day, LSW-C

Rev Joseph Luca

Mental Health Gary Vaughn, MD, FACP

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

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.

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 on-

site 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

Suggestions

Identify an individual who will be responsible for compliance with each

standard

2.1 Pathologist

2.2 Oncology nursing leader identified in ER 4

2.3 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 sub-

committee to deal with issues between the cancer committee meetings

Don’t wait until the last minute to update your SAR

Resources to assist you in meeting documentation requirements:

CAnswer Forum http://cancerbulletin.facs.org/forums/

Standards Resource Library

http://cancerbulletin.facs.org/forums/CAnswerForumHome/StandardResourceLibrary

CoC Webinars in CoC Datalinks

Cancer Program Standards: Ensuring Patient-Center Guidelines 2016

http://www.cap.org/web/oracle/webcenter/portalapp/

Cancer Genetics info from NCI: https://www.cancer.gov/about-cancer/causes-

prevention/genetics/overview-pdq

Palliative Care info from NCI: https://www.cancer.gov/about-cancer/advanced-cancer/care-

choices/palliative-care-fact-sheet

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Next Webinar in the Series

Meeting CoC Standards

Chapter 3

Continuum of Care Services

December 6, 2017

12 noon – 1 pm