American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

December 2015 / January 2016 CoC Source

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American Cancer Society Updates Breast Screening Guidelines

As part of the American Cancer Society’s ongoing work, the breast cancer screening guidelines, intended to save lives by finding breast cancer early, were recently updated.  Published on October 20, in the Journal of the American Medical Association, the guidelines address screening for women at average risk of breast cancer.  An overview of the changes to the guidelines, including changes, can be found on the Society’s website.

The following video resources are available for the public and health care professionals seeking additional information about the screening guideline updates:   

  • American Cancer Society Breast Cancer Screening Guideline Overview
  • The Science Behind the New Breast Cancer Screening Guideline

In response to the numerous requests for additional information about the American Cancer Society breast cancer guideline changes, Chief Cancer Control Officer Richard C. Wender, MD, further explains the background, evidence, and methodology used to shape the guideline. This video is intended for health care professional use and was distributed to American College of Surgeons staff to share with state chairs, Cancer Liaison Physicians, and hospital cancer committees.  

The video can be downloaded from Dropbox (best viewed in Google Chrome).  

A YouTube link is also available to share, but it is an unlisted link that will not display on general internet searches.

If you have questions or require further resources, please contact your American Cancer Society representative.  

Advocacy Update

Contact Your Representative Now!

In late October, U.S. Reps. Lynn Jenkins (R-KS) and Richard Neal (D-MA) sponsored H.Res. 487, a nonbinding resolution that recognizes the importance of accreditation by the American College of Surgeons Commission on Cancer to ensure patient access to high-quality, comprehensive cancer care. The College is meeting with lawmakers to gain their support for the resolution. 

As part of that effort, Fellows of the American College of Surgeons are urged to visit SurgeonsVoice to request that their representative cosponsor the resolution.  If you are not a Fellow, contact your representative, who can be located on the GovTrack website

Accreditation Corner

Commission on Cancer Releases 2016 Standards Manual

The Commission on Cancer (CoC) has announced the release of the Cancer Program Standards: Ensuring Patient-Centered Care (2016 edition). The standards have been enhanced with clarifications and improved language for clearer comprehension of compliance criteria. A brief summary of the revisions is available on the American College of Surgeons website. 

The fundamental principles and standard requirements, although reorganized or rewritten, are similar to V 1.2.1 for many of the eligibility requirements and standards. Existing ambiguities or inconsistencies were clarified to reduce subjective interpretations and may represent a change in compliance criteria. The layout of the manual was modified for a consistent approach. Text and formatting were revised for simplicity and readability.

The 2016 Edition requirements in this manual are effective on January 1, 2016 (with the exception of the 2017 phase-in standards) and determine compliance with CoC standards. 

Standards identified as “phase-in” will go into effect January 1, 2017. Programs must be in compliance with the standard criteria by that date. Cancer programs will be rated on the standard compliance criteria that were in place for the activity years prior to the phase-in date. 

At the time of survey, activity years before 2016 will be rated at survey based on the previous CoC Standards Manual (V1.2.1). For example, programs surveyed in 2016 (for years 2013–2015) will be rated on standard rating compliance for V1.2.1. For surveys in 2017, activity years 2014–2015 will be rated on V1.2.1, while 2016 will be rated according to the 2016 edition.  

Get Your Manual

Cancer Program Standards: Ensuring Patient-Centered Care Manual (2016 edition)

Download the 2016 CoC Standards Manual

Hard copies will be available soon for order. 

Questions

Questions regarding the standards presented in Cancer Program Standards: Ensuring Patient-Centered Care (2016 edition) can be submitted to the CAnswer Forum Bulletin Board System. Reference this publication when submitting your question. 

2016 Surveys and Improvements to the SAR

2016 CoC surveys will be reviewed on cancer program activity for the complete years of 2013-2015 and will be assessed according to the Cancer Program Standards 2012: Ensuring Patient-Centered Care (Version 1.2.1).

The Survey Application Record (SAR), located in CoC Datalinks, is used by cancer programs to record cancer committee activity and documentation that demonstrates compliance with the CoC standards and eligibility requirements. Any information entered into the 2015 Program Activity Record (PAR) will be automatically transferred to the 2016 SAR. Because some data fields have changed, mostly from text to static options, you will need to review the SAR for completeness and update accordingly.

Enhancements to the 2016 SAR have been finalized based on feedback from surveyors, the customer service survey distributed to cancer program members, and cancer program users in order for them to align with recent revisions to CoC standards and compliance criteria. The CoC intends for cancer programs to experience the 2016 SAR as a more user-friendly tool that will offer assistance as they prepare for survey. 

Some high points of the SAR enhancements and additions include: 

  • A cleaner esthetic with less duplication required on the part of the programs
  • More drop-down options and fewer open text fields to reduce completion time
  • Easier to use and more intuitive for each standard
  • Added more text character space for comment fields
  • Standard 1.2 includes the ability to add designated alternate names next to the appointed required member names
  • Chapter 3 standard screens have been revised to match standard criteria
  • Standards 4.4 and 4.5 include the National Cancer Data Base’s (NCDB) Estimated Performance Rates Recommendations tables
  • Data and automated ratings for the Standard 5.7 CoC Special Study will be uploaded in January 2016

Plan your work accordingly. The SAR must be completed at least 30 calendar days before the confirmed survey date and will be locked for edits 14 days before the survey date. Any missing information or incomplete SAR tables after the 14-day window are subject to a deficiency.

Reminder that the News tab, located at the top of each page in Datalinks, is intended to provide the latest information about the standards, the survey, NCDB, educational events, and more. Don’t forget to use the I and FAQ icons to help you with completing the SAR.

If you have questions:

Note: Include your facility name and Facility Identification Number (FIN) in ALL emails.

We appreciate your cancer program’s commitment to high-quality cancer care and participation in the CoC Accreditation Program.

National Cancer Data Base News

NCDB to Accept PUF Applications in 2016

The National Cancer Data Base (NCDB) accepts applications for Participant User Files (PUF) on a semiannual basis. Look for an announcement in January with the dates for the next application period for organ-site specific files including cases diagnosed through 2013.

The NCDB PUF is a Health Insurance Portability and Accountability Act  (HIPAA)-compliant data file containing cases submitted to the CoC's NCDB and complies with the terms of the Business Associate Agreement between the American College of Surgeons and cancer programs accredited by the CoC. The PUF contains de-identified patient-level data and is designed to provide investigators at CoC-accredited cancer programs with a data resource they can use to review and advance the quality of care delivered to cancer patients through analyses of cases reported to the NCDB.  Prospective applicants can find more information on the PUF on the CoC website.

Direct questions regarding the NCDB PUF or the application process for a PUF to NCDB technical staff at NCDB_PUF@facs.org.

NCDB Announces 2016 Call for Data

The NCDB announced in November the 2016 Call for Data, an integral part of CoC accreditation. The information generated from the NCDB enables cancer programs to compare treatment and outcomes with regional, state, and national patterns.  This year all analytic cases diagnosed in 2014 must be submitted. In addition, cases added or changed by the hospital registrar since December 1, 2014, must be submitted for all analytic cases diagnosed between the cancer program’s Reference Year (or 1985 if the Reference Year is earlier than 1985) and 2013, inclusive.

Sometimes registries inadvertently fail to submit all required cases, resulting in a deficiency rating for Standards 5.5 and 5.6.  See Determining Compliance and Commendation for helpful details about how survey scores are assigned for these two Program Standards.

To facilitate the submission of high-quality data to the NCDB and reduce temporal pressure on vendors and registrars, this year initial submission of all required cases is due by 11:59 pm February 15, 2016, Central time.  Cases from any diagnosis year that are “rejected” have technically not been submitted, and must be corrected and resubmitted by April 1, 2016, for compliance with Standard 5.5.  Registries are strongly encouraged to submit their data early in January to allow time to address any issues that may arise before the submission deadline.

For more information on the Call for Data, visit the CoC website.

NCDB Quality Tools Released in November

During the month of November the NCDB released:

  • Cancer Quality Improvement Program (CQIP) 2015
  • Completeness and Default Over-Use Report
  • Updates to Cancer Program Practice Profile Reports (CP3R)

CQIP 2015

The CQIP report is unique in providing not only short-term quality and outcome data, but also long-term outcome data including five-year survival rates for commonly treated malignancies stratified by stage. CQIP allows each CoC-accredited program access to a confidential and individualized report (in PowerPoint format) to allow programs the ability to modify the presentations and select topic-based slides to review in meetings.

CQIP is accessed through CoC Datalinks, under NCDB Reporting Tools; the CQIP Reports link will provide access to the three most recent CQIP reports allowing programs to assess changes in their reports over time.

Completeness and Default Over-Use Report

The Default Completeness and Overuse Report for 2013 Diagnoses submitted during the 2015 Call for Data was released. This report gives CoC-accredited programs information about the completeness of required data items. Site-specific reports are available for: breast, colon, rectum, stomach, esophagus and esothagogastric junction, lung, cervical, endometrium, and ovary. This report is available under NCDB Data Transmission in your CoC Datalinks Activity Menu.

Updates to CP3R 

General updates to measure specifications were released in CP3R in November. These updates include modifications to measure exclusions, updates of histologies included in the gynecologic measure, and changes to the eligibility criteria for the breast cancer screening measure.

A complete list of updates and new measure documentation can be found on the CoC Quality Measures page.

If you have questions on this report, contact NCDB@facs.org.

Resources for Cancer Liaison Physicians

New on the Web

Be sure to check out a recording of the 2015 Cancer Liaison Physician (CLP) breakfast meeting and the fall edition of NewsCLiPs on the CLP website.

Welcome, New State Chairs

The American College of Surgeons and the CoC announce the appointment of a new state chair. A state chair’s term is three years with a maximum of two terms.

Maria Castaldi, MD, FACS

Manhattan Council State Chair

CLP Activity Report

The CLP must complete the CLP activity report. This report is found in CoC Datalinks and is part of your Survey Application Record during your survey year. It is accessible in the Program Application Record during non-survey years. Not only is it important to complete this report during the time of your program’s scheduled survey, it can also be beneficial to complete it during non-survey years to track activity annually.  

Educational Programs and Resources

2016 Education Workshop Dates Announced

In 2016, the CoC will host two Accreditation 101 workshops, one in the spring and one in the fall. In addition, the CoC Annual Conference (formerly Survey Savvy), which includes a full day NCDB pre-conference workshop, is scheduled for June. 

Accreditation 101: Learning the Basics of CoC Accreditation and Standards
April 1, 2016
Denver, CO 

By using the CoC eligibility requirements and standards as a guide and benchmarks, cancer programs will understand the components of high-quality, multidisciplinary, patient-centered cancer care.  This comprehensive, one-day seminar provides an overview of the CoC standards and an introduction to the accreditation process. This trusted and informative educational program is the only one actually developed and taught by the national organization that develops the CoC standards.  

Registration Fee
Early bird rate - $750
Regular rate - $850 

This fee includes a copy of the Cancer Program Standards 2012: Ensuring Patient-Centered Care (2016 edition) ($50.00 value), resource materials, breakfast, lunch, and breaks.

Registration set to open the week of January 11, 2016. 

Hotel Rate
$169/night 

Continuing education credit will NOT be offered for this program. 


CoC Annual Conference
June 2-3, 2016
Rosemont, IL (near O’Hare airport)

The CoC  Annual Conference offers an in-depth review of the information that an institution’s cancer committee needs to coordinate a high-quality, patient-centered, multidisciplinary cancer program. Developed by CoC staff and committee leadership, along with real-world experiences from accredited cancer programs, this program addresses a cancer program’s common questions and concerns regarding CoC standards and compliance.

Registration Fee
Early bird rate - $995
Regular rate - $1095 

This fee includes resource materials, breakfast, lunch, and breaks. 

Hotel Rate
$165/night 

Registration is set to open the first week of March 2016. 

A special Source will go out to announce when each registration site opens. Please stay tuned to the CoC Events page for further details. 

Please share this information with other members of your staff who would benefit from the information that is being presented.

News from ACoS Cancer Programs

AJCC News

AJCC Staging Critical Clarifications for Registrars

It has come to the attention of the AJCC that there are some misconceptions regarding the staging rules for Melanoma. The AJCC will be clarifying these issues in the 8th Edition Cancer Staging Manual. However, the AJCC recognizes it is critical to provide clarification and explanation on 7th edition staging rules for the registry community as part of the ongoing educational efforts.  We want to ensure that misconceptions do not perpetuate and that any errors in education provided outside of the AJCC are clarified as soon as possible.  

Therefore, a document with the 7th staging rules for both clinical and pathologic classifications for melanoma has been added directly on the AJCC home page.

There is also the implementation of New AJCC T, N, and M categories which will occur in 2016. The primary considerations when assigning American Joint Committee on Cancer (AJCC) staging classifications is timeframe and criteria. The clinical staging (or classification) timeframe includes information obtained from the time of diagnosis throughout the diagnostic workup and ends at the initiation of definitive treatment. Within the clinical staging timeframe, criteria include physical exam, imaging, endoscopies, and diagnostic biopsies. It is important to emphasize that the mere existence of a pathology report that includes microscopic assessment does not exclude it from the clinical staging criteria. If the assessment was a part of the diagnostic workup, it has occurred within the clinical timeframe and can be used for clinical staging. Read the full article on the AJCC website

Please take a moment to review this information and the other educational resources available on the Registrar Presentations page of the AJCC website. 

NAPBC News

Important Update on NAPBC 2016 Reaccreditation Surveys

The National Accreditation Program for Breast Centers (NAPBC) reaccreditation notifications have been sent to all centers with reaccreditation surveys due in 2016. Review the notification and the information below before logging into the portal to access and complete your survey application record (SAR).

Reaccreditation Survey due January–March 2016

Centers that have a reaccreditation survey due in the months of January, February, and March of 2016 will complete their SAR available now through the NAPBC center portal. Review the site instructions on how to navigate the center portal. 

To access your SAR after you log in, complete the following steps: 

  1. Update your center information on the application page
  2. Submit your application page
  3. Following submission of your application page, you will receive immediate access to a new SAR.

Reaccreditation Survey due April−December 2016

The NAPBC is implementing a new SAR in early 2016. Centers that have a reaccreditation survey due in the months of April through December 2016 will receive further instructions in January on how to access the new SAR. Do not document activity for your upcoming survey in the current system as it will not transfer to the new software. 

New Billing Process Starting in 2016

Effective with 2016 accreditation surveys, the accreditation fee will be billed on an annual basis. The annual fee invoice will be generated three months before the anniversary of your NAPBC accreditation date. Payment of the fee is due within 30 days of receipt of the invoice. Further information and annual fee amounts can be found on our website. 

If you require further assistance or have questions regarding the reaccreditation survey process, contact the NAPBC Administrative Office at napbc@facs.org

We look forward to working with you again as you prepare for survey.   

Webinars for Health Care Professionals Now Available

NAPBC and the American Cancer Society presented three webinars this fall on breast cancer-related topics, intended for primary health care providers in communities served by NAPBC-accredited breast centers. An expert from each organization presented during the live, 60-minute webinars.

The first webinar in September covered the role of genetic testing in screening and treatment of high-risk individuals followed by the October webinar on the modifiable risk factors for breast cancer such as weight, nutrition, and exercise. The final webinar, presented in November, covered screening guidelines and imaging modalities and coincided with the release of the American Cancer Society’s updated breast cancer screening guidelines. For a detailed explanation of the updated guidelines, view the American Cancer Society video on YouTube.

The live webinars were recorded and are now posted on the NAPBC’s website along with the presentations.

News from the Oncology Community

NCRA News

NCRA 2016 is April 10−13 in Las Vegas 
The National Cancer Registrars Association’s (NCRA) 2016 Annual Educational Conference will take place April 10−13 at the Westgate Resort Hotel in Las Vegas, NV. The theme is A Winning Combination: Education, Networking, and Professional Development. Registration information will be posted on the NCRA website and the brochure will be mailed in early January. 

NCRA Seeks Candidates for Volunteer Positions
Serving as a volunteer in NCRA is a way to develop leadership and management skills at the national level. NCRA's Board of Directors is seeking candidates for a number of volunteer positions. Learn more about open positions and complete an online candidate profile. The deadline is January 6, 2016.

Need Professional Liability Insurance?
The NCRA is partnering with CPH & Associates to provide a professional liability insurance program. This new benefit offers NCRA members discounted rates for coverage, with limits of $1,000,000 each occurrence/$6,000,000 aggregate. Members can get an instant quote for coverage online and save 5 percent by applying online. Visit the NCRA website to learn more about the new Professional Liability Insurance Program, including details on how to get started.

Learn More about Cancer Informatics
The NCRA designed a one-day workshop—Cancer Informatics for Registrars: From Bedside to Big Data—that was presented in conjunction with the 2015 NCRA Annual Educational Conference in San Antonio, TX. The workshop was created in response to members' requests for more detailed information on cancer registry informatics. The DVD captures the 11 workshop sessions. Order the DVD today

NCRA Posts Informational Abstract and Related Quizzes
To assist registrars in preparing abstracts, the NCRA's Education Committee created free Informational Abstracts (IA).These site-specific abstracts provide an outline for determining what text to include. Quizzes are now available to gauge understanding and include IA Quiz I: bladder, colon, prostate; and IA Quiz II: breast, lung, melanoma. Download the abstracts and take the quizzes.

Now Open! NCRA Call for Awards Nominations
NCRA’s annual awards program provides an opportunity to publicly acknowledge an outstanding cancer registrar. Review the award categories and download the nomination form. The submission deadline is January 31, 2016. 

Final Thoughts

A New Look for the Source

The next issue of the CoC Source will have a new look and new features. Watch your email in February 2016. 

Happy Holidays!

Happy Holidays from the staff of the Commission on Cancer and best wishes for a Happy, Healthy New Year.