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

March 2015 CoC Source

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CoC News

Congratulations to the Preliminary 2014 OAA Recipients

The 76 cancer programs listed below represent the preliminary list of Outstanding Achievement Award (OAA) recipients from surveys performed during 2014. “Preliminary” simply means that these facilities have been identified as OAA recipients and confirmed by the Commission on Cancer (CoC)’s Program Review Subcommittee. However, additional cancer programs may be added or facility names may be corrected.

We ask that all programs surveyed in 2014 review this list and contact the Accreditation team at accreditation@facs.org by Friday, March 13, if you believe that your cancer program may be eligible to earn the OAA (met all seven commendation standards), but is not included on the list, or if your facility name is listed incorrectly.

The finalized 2014 OAA recipient list will be published online following the confirmation deadline. More details regarding accessing the marketing materials and OAA trophy will be e-mailed directly to your Cancer Program Administrator at each facility.

It is essential that contact information for the Cancer Program Administrator (found under the “Manage Staff Contacts” section in CoC Datalinks) is up-to-date and accurate. Any OAA questions should be sent to accreditation@facs.org.

 Facility

City, State 

Community Hospital of Monterey Peninsula *

 Monterey, CA

 Huntington Memorial Hospital

 Pasadena, CA

 Marin General Hospital *

 Greenbrae, CA

 St. Jude Medical Center *

 Fullerton, CA

 Boulder Community Health

 Boulder, CO

 Lutheran Medical Center

 Wheat Ridge, CO

 Saint Joseph Hospital SCL Health

 Denver, CO

 Hartford Hospital

 Hartford, CT

Norwalk Hospital 

 Norwalk, CT

 The Hospital of Central Connecticut

 New Britain, CT

 VA Connecticut Healthcare System

 West Haven, CT

 Beebe Healthcare

 Rehoboth Beach, DE

 Medical Center, Navicent Health *

 Macon, GA

St. Joseph's/Candler Health System 

 Savannah, GA

 The Queen's Medical Center *

Honolulu, HI

 Mercy Medical Center

 Cedar Rapids, IA

 Mercy Medical Center-North Iowa

 Mason City, IA

 Loyola University Medical Center *

 Maywood, IL

 Memorial Hospital of Carbondale

 Carbondale, IL

 Palos Community Hospital *

 Palos Heights, IL

 Rush University Medical Center **

 Chicago, IL

 Saint Anthony's Health Center

 Alton, IL

 Baptist Health Lexington

 Lexington, KY

 Our Lady of the Lake Regional Medical Center *

 Baton Rouge, LA

 Beth Israel Deaconess Medical Center

 Boston, MA

 Union Hospital *

 Elkton, MD

 University of Maryland St. Joseph Medical Center

 Towson. MD

 Eastern Maine Medical Center

 Bangor, ME

 McLaren - Northern Michigan

 Petoskey, MI

 Mount Clemens Regional Medical Center

 Mount Clemens, MI

 Park Nicollet Methodist
Hospital *

 Minneapolis, MN

 St. Francis Regional Medical Center

 Shakopee, MN

 St. Joseph's Medical Center *

 Brainerd, MN

 Lake Regional Health System

 Osage Beach. MO

 FirstHealth Moore Regional Hospital **

 Pinehurst, NC

 High Point Regional Health *

 High Point, NC

 Southern New Hampshire Medical Center

 Nashua, NH

 Community Medical Center

 Toms River, NJ

 University Medical Center of Princeton at Plainsboro

 Plainsboro, NJ

 Good Samaritan Hospital Medical Center **

 West Islip, NY

 St. John's Riverside Hospital *

 Yonkers, NY

 Staten Island University Hospital *

 Staten Island, NY

 Akron General Medical Center

 Akron, OH

 Aultman Hospital

 Canton, OH

 Fairview/Lakewood Hospital 
Integrated Network Cancer Program

 Cleveland, OH

 Good Samaritan Hospital

 Dayton, OH

 Humility of Mary Health Partners

 Youngstown, OH

 Mercy Medical Center *

 Canton, OH

 St. Rita's Medical Center **

 Lima, OH

 Comanche County Memorial Hospital *

 Lawton, OK

 Saint Francis Hospital

 Tulsa, OK

 Eastern Regional Medical Center *

 Philadelphia, PA

 Hospital of the University of PA – * Abramson Cancer Center

 Philadelphia, PA

 Penn Presbyterian Medical Center

 Philadelphia, PA

 Penn State Milton S. Hershey Medical Center *

 Hershey, PA

 Pottstown Memorial Medical Center **

 Pottstown, PA

 Thomas Jefferson University Hospital

 Philadelphia, PA

Roper Hospital

Charleston, SC 

 Baylor University Medical Center

Dallas, TX 

 Medical City Dallas Hospital

Dallas, TX 

 Texas Health Presbyterian Hospital Dallas **

Dallas, TX 

 Texas Health Presbyterian Hospital Plano

Plano, TX 

University of Texas Southwestern St. Paul Hospital  

Dallas, TX 

 University of Texas Southwestern Zale Lipshy Hospital *

Dallas, TX 

 Riverside Walter Reed
Hospital *

Gloucester, VA 

 Southside Regional Medical Center *

Petersburg, VA 

 Virginia Hospital Center-Arlington *

Arlington, VA 

 PeaceHealth Lower Columbia Region

Vancouver, WA 

Swedish Health Services

Seattle, WA  

Wenatchee Valley Hospital and Clinics

Wenatchee, WA 

Agnesian Healthcare

Fond Du Lac, WI 

Aurora BayCare Medical
Center *

 Green Bay, WI

Holy Family Memorial Medical Center

Manitowoc, WI  

 Mercy Medical Center *

Oshkosh, WI 

St. Joseph' s Hospital

West Bend, WI  

 Charleston Area Medical Center

 Charleston, WV

* Congratulations to the 25 facilities that achieved the OAA at their previous CoC accreditation survey in 2011.

** Congratulations to the six facilities that achieved the OAA four consecutive survey cycles since the inception of the OAA program (2005, 2008, 2011, and 2014 surveys).


Advocacy Update

Public Policy and Cancer

The CoC Advocacy Committee is carefully monitoring the work of the House Energy and Commerce Committee’s 21st Century Cures Initiative.  More information is available on the Energy & Commerce Committee website.  If you have comments that you would like the committee to consider, please send them to clp@facs.org.


Accreditation Corner

CoC Call for 2016 Surveyors

The CoC is looking for physicians involved in cancer care who would be interested in becoming CoC surveyors. 

We are specifically looking for Network Surveyors who are actively practicing (treating, teaching, or administrative role) within a CoC-accredited Integrated Network Cancer Program. Surveyors must be current members of a cancer committee within a CoC-accredited network and be familiar with CoC Standards.

Surveyors will travel nationwide to survey cancer programs seeking accreditation or reaccreditation. Surveyors will meet and present to key facility administration and the cancer committee at each program, review charts and cases, and assess program compliance with the requirements for all standards.

If you have any questions, or would like to learn more about the minimum qualifications to become a CoC surveyor or to request an application, please e-mail Allison Knutson, Manager of Accreditation and Standards at aknutson@facs.org.

View our Surveyor Profiles.

Check Out the CAnswer Forum's New Look

The CAnswer Forum software was recently upgraded and now has a new look. Many panicked when they first logged on to the new forum because it looked so different. Forum users wondered how they would find anything or where to submit a question. But when they began navigating the system, they realized that only the layout has changed, along with a few minor revisions.  

This article will highlight some improvements that have been made to the CAnswer Forum and offer some tips for navigating the system.

First, the Best Practice Repository and the Resource Repository have merged to create the Standards Resource Library. You will find the new library housed on the CAnswer Forum home page. The library is one central location for our constituents to review previously asked and answered questions, submit new questions, and view examples and resources for each standard all within the same database, to help guide programs to comply with the standards. 

Using the Standards Resource Library

For example, if you are looking for guidance setting your Clinical and Programmatic goals (Standard 1.5), log on to the CAnswer Forum and under 2012 Standards click on the subforum chapter 1 Program Management, then click 1.5 Cancer Program Goals. This will open pages of questions and answers on setting goals. If you hover over a question topic, a preview box will open allowing you to read a portion of the question, and then determine if the question includes information you are looking for before you open the question. If it isn’t what you are looking for, you can quickly move to the next question. Once you find the information you are seeking, click on the title and open the question.

   

If you would like to see resources and examples on Standard 1.5, click the link located at the top of the page to review the documents posted for Standard 1.5.

Here you will find a number of examples of goals and information provided by other CoC-accredited programs. 

The CoC is working diligently to develop, review, and post quality examples and resources to the new library. As potential documents and resources are identified by cancer programs and Survey Application Records (SAR), they are sent to the Standards Resource Review Group. This group consists of 12 CoC surveyors who review each example to ensure that it meets the standard, is clear and concise, and is easily adaptable for use by other programs. 

Accessing the Library

If you are currently a registered user of the CAnswer Forum, log on and check out the new Standards Resource Library located on the home page. If you are not a registered user of the CAnswer Forum, please complete the registration process on the CAnswer Forum. Once you have finished a one-time registration, the system will send you an e-mail asking you to confirm your registration by visiting the link provided. After this, you will have full access to the CAnswer Forum, including the Standards Resource Library. If you don’t confirm your registration, when you try to log on you will be notified that you have been banned from the system, and you will not have access. Please watch for the e-mail after you have registered. You may need to check your spam or junk mail to locate the e-mail.

Using the Forum’s Search

The CoC asks users to search previously answered questions before they submit a new question to the CAnswer Forum. In the new forum layout, you can perform a basic global search by entering your keywords into the Search Forum located at the top right of the page. This will return any results matching your keywords. This may produce a large list of questions depending on the keywords. You may wish to narrow your search field. The forum has an Advanced Search. You can access the Advanced Search by clicking on the down arrow in the search box and selecting it from the menu. Advanced Search allows you to fine tune your search to include specific forums or search by a specific user.

How can you control your search results? This site uses a keyword-based Boolean search. This means that you can search for multiple keywords but not specific phrases. The default comparison is to use AND. This means that if all of your keywords appear in the content, it can be returned in the search results. You can also use OR, NOT, or the – (minus sign). Short, common, and “bad” words are omitted from the search criteria.

If you have searched the system and did not find the answer to your question, you are ready to submit a new question. First, locate the forum to which you wish to submit a question. In this example, we will choose “Ask the Pathologist.” Next locate and click the sub-forum you wish to query, “Genitourinary.” 


Another subforum page will open with all the Genitourinary sites listed. For this example we will choose Prostate Gland.


When you click on Prostate Gland, it will open the pages where all of the questions about the Prostate were submitted and answered. On this page you will click on new topic, which will open a box for you to insert a title for your question, with another space under it labeled write something. This is where you type in your question. Once you have completed your entry, click the box at the bottom right side that is labeled Post. A tip for posting a question is to always go to the lowest sub-forum to post your question.

Prostate Gland


We hope these tips and highlights will help you navigate the CAnswer Forum. You can find additional information by clicking on the Help button on the lower right corner of the forum pages. If you are not a registered user of the CAnswer Forum, we encourage you to register and start using the examples and resources, ask questions, search topics, and connect with the latest CoC activities. 

If you have additional questions:

Note. Please include your facility name and Facility Identification Number (FIN) in ALL e-mails.

Understanding Standard 1.8: Monitoring Community Outreach

CoC surveyors and staff have noticed a pattern of noncompliance in regards to Standard 1.8, for which additional clarification and education on the standard may be beneficial to cancer programs. 

As the standard reads, “The Community Outreach Coordinator monitors the effectiveness of the community outreach activities on an annual basis. The activities and findings are documented in a community outreach activity summary that is presented to the cancer committee annually.”

Standards 4.1 (Prevention) and 4.2 (Screening) require that cancer programs provide at least one cancer prevention and screening program each year. Standard 1.8 refers to monitoring these activities and programs, ensuring that the prevention and early-detection screening programs meet the needs of the community and follow national guidelines and evidence-based interventions. 

The issues we frequently see when reviewing the SAR and the community outreach summary are:

  • The annual summary report is not provided; it may consist of just a marketing flyer or a basic Excel spreadsheet listing the names and dates of programs. 
  • Non-applicable community outreach activities are listed (including survivorship events, wig programs, open houses, general health fairs).
  • The summary report is not shared with the cancer committee and documented in the meeting minutes.
  • The most common deficiency criterion is that the “summary reports” do not document that the coordinator and cancer committee are monitoring the effectiveness of the activities and programs offered each year.

You may ask, “What does the CoC mean by “effectiveness” and what does the surveyor want to see here?”

Example of Effectiveness of Screening Programs: Rate of cancer diagnosis in the group screened or an increase in participation of the screening program because of a new tool or new communication strategy. 

Example of Effectiveness of Prevention Programs: Tracking the number of individuals who stopped smoking or ceased using tanning beds, or who began to change their lifestyle after participating in the prevention program.

When discussing and analyzing the effectiveness of your cancer program’s outreach programs, ask the following questions:

  • How many participants? Is this less or more than the last activity? Why?
  • How do you measure if programs are valuable and useful to your community? What is the impact?
  • How are these programs designed to reduce the incidence of a specific cancer type or decrease the number of patients with late-stage diseases?
  • How are you ensuring (tracking) that participants with positive findings at screening programs are following-up with the appropriate health care professionals? Is your follow-up process functioning properly? Are people being notified of positive results? Could your referrals process be confusing or unhelpful to the screened individuals? 
  • How many people quit smoking? Smoked less? Changed their habits? 
  • Based on the results of your analysis/monitoring, do you need to make any changes to the outreach programs? 

The community outreach summary should include, at a minimum:

  • Name of the program and type of activity (prevention, screening, or support)
  • Date the program took place and the number of participants (How did you track attendance and/or participation?)
  • National guidelines and/or evidence-based interventions the screening and prevention programs follow
  • An outline of the mechanisms and processes to ensure that follow-up occurs for all positive findings identified through early-detection/screening activities
  • Results and summary of the effectiveness of each activity

Remember: Standards 4.1 and 4.2 only require the cancer committee to provide at least ONE prevention and ONE screening program each year, which in turn require thorough monitoring and documentation. The CoC does not require programs to produce and monitor a “laundry list” of all facility-wide community outreach programs. 

At the time of survey, relevant activities, reports, minutes, and documentation in the SAR will be reviewed; combined with discussions with the surveyor(s) that include the Community Outreach Coordinator and members of the cancer committee. These activities will assist in determining if a program has fulfilled all of the criteria for this standard.

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

If you have additional questions:

Note. Please include your facility name and Facility Identification Number (FIN) in ALL e-mails.

Appealing the Accreditation Award

https://www.facs.org/quality-programs/cancer/accredited/info

Below is information on appealing an accreditation award or standard deficiency as rated on the initial CoC-accredited Cancer Program Survey Performance Report (PR):

Guidelines for Appeals

✓ If the cancer program disagrees with the interpretation for the standard(s) deficiency or non-commendation rating and the supporting documentation was within the Survey Application Record (SAR) at the time of survey, an appeal is eligible.

✓ If the supporting documentation was uploaded to the SAR and available for the surveyor at the time of the survey, but was overlooked by the CoC, an appeal is eligible.

X   If documentation or information to support the deficient standard(s) was not in the SAR at the time of survey or within the 3 days post-survey, the standard is not eligible for appeal.

X   Cancer committee minutes, pathology reports, other supporting documentation that have been amended post-survey are not eligible for appeal.

X   Any documentation submitted that has not been reviewed by the Cancer Committee during the survey cycle is not eligible for appeal.

Steps to Submit Appeal Documentation

  • Upload applicable Appeals documentation by accessing the ‘Appeals’ section located within the Survey Application Record (SAR) menu in CoC Datalinks.
    • Appeals will not be reviewed without supporting documentation for each standard being appealed.
    • Documentation demonstrating resolution or action plans will not be reviewed or processed as part of the appeal.
  • All appeal documentation will only be accepted using the electronic submission process available via the Appeals section in CoC Datalinks.  
NOTE: Cancer programs with a current “Non-Accreditation” status must: 
    • Email an Appeals cover letter along with supporting documentation directly to Vicki Chiappetta within 30 calendar days from receipt of the PR. (Mailing of documentation through US mail will not be accepted.)
  • Appeals must be submitted within 30 CALENDAR DAYS of receipt of the initial PR.  
  • Appeals are reviewed and processed monthly through the Program Review Subcommittee (PRS). Depending on when the appeal is submitted, it may not reach PRS until the following monthly meeting.

Note: Do not submit deficiency resolution documentation with appeals to the CoC as these are two different processes.  Deficiency resolution documentation should not be uploaded until after the appeal response has been received by the cancer program.

The verdict of any appeal will be sent by an automated e-mail notification directly to the cancer program’s contact staff (Cancer Committee Chair, Cancer Program Liaison, Cancer Program Administrator, and Hospital Registrar) to communicate an updated PR is available.  The updated PR can be accessed via the CoC Datalinks Activity Menu.

2015 Commendation Standards and OAA Criteria:  Programs must achieve commendation in all seven standards to be eligible for OAA.  These include: Standards 1.9, 1.11, 1.12, 2.1, 2.2, 5.2, and 5.6.

NOTE:  30 days after receiving your initial Performance Report, (appeal time period), the report is final.  No further requests for changes to commendation standards will be accepted after that time period.

HIPAA and Protected Health Information

In concordance with the HIPAA guidelines, the CoC cannot accept documentation that includes patient identifying information (protected health information [PHI]).  Receipt of PHI violates the business associate agreement between the American College of Surgeons and the CoC-accredited cancer program.  

This applies to documentation submitted for survey, appeals, and/or deficiency resolutions.  Documents that may include PHI, but are not limited to:  accession lists, suspense reports, pathology reports, collected data for studies.  Special care should be taken to ensure that all PHI is removed before documentation is uploaded to the SAR.

In compliance with the American College of Surgeons HIPAA Privacy and Security Policy, appropriate supervisory and managerial staff of the American College of Surgeons will be notified when documentation that includes PHI has been received.  The American College of Surgeons Privacy Official will make a determination about a notification to the CoC-accredited cancer program and disposition of the documentation that includes PHI.  

Programs will be required to remove or block the patient information and resubmit the documentation as soon as possible after receiving notification from the American College of Surgeons Privacy Official.

Create an Agenda to Keep Meetings On Track

An agenda is a list of items to be discussed at a formal meeting.  A consent agenda allows members to vote on a group of items without discussion.  It is required that the cancer committee meeting minutes document discussions to demonstrate compliance to the CoC standards. Therefore, utilization of a consent agenda is not to be used with cancer committee meetings.

Creating an effective agenda is one of the most important elements for a productive meeting. Here are some reasons why the meeting agenda is so important.

The Agenda

  •  Communicates important information such as:
    1. Topics for discussion
    2. Presenter or discussion leader for each topic
    3. Time allotment for each topic
  • Provides an outline for the meeting (how long to spend on which topics)
  • Can be used as a checklist to ensure that all information is covered
  • Lets participants know what will be discussed if it's distributed before the meeting. This gives them an opportunity to come to the meeting prepared for the upcoming discussions or decisions
  • Provides a focus for the meeting (the objective of the meeting must be clearly stated in the agenda)

By sticking to a detailed, yet flexible agenda, you can keep your meeting streamlined and focused, ensuring that you meet all of your goals for your meeting in the shortest amount of time.


National Cancer Data Base News

Have Your FIN Handy

Each day, the National Cancer Data Base (NCDB) receives a massive number of communications from our hospitals. We receive questions about your NCDB data submissions, your Rapid Quality Reporting System (RQRS) submissions, as well as the various NCDB tools specific to your facility.  Please note that in responding to your inquiries, we often need to look up information regarding your facility. The easiest identifier for NCDB staff to use for this task is your Facility Identification Number (FIN). In order to facilitate timely, high-quality support to you, NCDB now requires that your FIN be included in all your communications to us.  

Reminder: Send in Correction Records

The deadline for correction of edit errors in the ongoing NCDB Call for Data is midnight Central time, the night of Wednesday, April 1, 2015. To prevent receiving a deficiency on Standard 5.6, all cases diagnosed in 2003 and later must be corrected and resubmitted by that date.  Currently, if you do not have a registrar available to check submission results, your program should assign someone else to conduct the review.

  • All rejected records must be corrected and resubmitted by April 1, unless the reason for rejection was that the case should not have been submitted (for example, cases diagnosed before the program’s Reference Date do not need to be resubmitted because they should not have been submitted at all).  
  • All records with data quality problems diagnosed in 2003 and later must be corrected and resubmitted by April 1.  Run the file you submitted through the applicable edits using GenEDITS Plus to determine which cases need correction.  NCDB welcomes corrections to cases diagnosed prior to 2003, but that is not required for compliance with Standard 5.6.

Resubmissions are made the same way as Call for Data submissions. Data submitted by April 1 will be used for NCDB reports during the coming year. Please direct questions about NCDB submissions to ncdb@facs.org.

NCDB Releases New Survival Application and Reporting Policy

In February, the NCDB released an updated survival application that allows cancer programs to have more control over their survival reports by selecting the types of cases included.  Also available is the ability to stratify results by stage and age, sex, and Charlson-Deyo Comorbidity Index score.  The report generates five-year survival graphs and tables with confidence intervals.  For more information on the reports, please visit the NCDB Survival Webpage.

The NCDB and CoC also released a clarification of the reporting policy for survival data.  The policy of the CoC and the NCDB is to prohibit public reporting of survival rates from CQIP or the NCDB Survival Reports.  For more information please view the letter from the CoC leadership. 

If you have any questions, please contact NCDB@facs.org

Release of Registry Plus Online Help Version 14 for 2014

A new version of Registry Plus Online Help (RPOH) has been released by the Centers for Disease Control and Prevention’s (CDC) Division of Cancer Prevention and Control.  RPOH is part of the Registry Plus software suite for cancer registries.  This new RPOH version is available from the CDC.

RPOH is an integrated, user-friendly help system for cancer registrars and others who work with cancer data. Developed in support of the CDC's National Program of Cancer Registries (NPCR), RPOH facilitates the abstraction of cancer cases by centralizing standard abstracting and coding manuals required by cancer registry standard setters into one accessible, easy-to-use resource. The manuals within RPOH are cross referenced, indexed, and context linked, making the information readily available to the user, so RPOH can eliminate the need to refer to printed manuals.

The following manuals are included in this release: 

  • NAACCR (North American Association of Central Cancer Registries) Data Standards and Data Dictionary for record layout version 14
  • Online help for the NAACCR Edits Metafile V14A
  • FORDS (Facility Oncology Registry Data Standards) 2013 
  • Collaborative Stage Data Collection System [CS]: User Documentation and Coding Instructions, Version 02.05 (including both Parts I and II)
  • SEER Program Coding and Staging Manual 2014 
  • ICD-O-3, Introductory Material and Morphology Numerical Lists
  • Multiple Primary and Histology Coding Rules (updated through 8/24/12)

Information Regarding Hematopoietic Conversions

Please be aware that as part of the Hematopoietic and Lymphoid project update for 2015, a conversion program has been written to convert some of the Hematopoietic data. Your registry software provider will include this conversion when the 2015 updates are made to your registry data, so please make note of the below information for use at that time.  You should also contact your software provider to find out when they are planning to update your data.  

Two documents have been posted on the Surveillance, Epidemiology, and End Results (SEER) Program website that outline the specifics and rationale for these conversions. The Hematopoietic Conversion Document provides details and rationale for the changes. The companion spreadsheet shows what the computer conversion will do. 

A summary of the conversion is provided here.

Step 1 of the Conversion: Obsolete histologies will be converted to current histologies 

  1. The current histology (2010+) can be found in the Hematopoietic & Lymphoid Neoplasm Database & Coding Manual (See Appendix E in the manual). 
  2. The histology conversions are being applied to cases diagnosed 1/1/2010 and forward. After the conversion, revised edits will not allow obsolete codes to be used for cases diagnosed 1/1/2010 and forward. 
  3. The histology conversion will result in a CS schema change for some cases. Detailed information has been provided on how those conversions are handled. This information can be found in the “Hematopoietic Conversion Edits Impact Workgroup Statement,” which will be posted on the SEER website. 

Step 2 of the Conversion: Grade will be assigned to current histologies 

  1. Grade will be assigned to histologies for which only one grade is applicable. 
  2. For the purpose of the conversion only a default grade will be assigned to histologies for which there are two or more applicable grades. 
  3. Grade 9 will be assigned to histologies for which there is no defined grade. 

Step 3 of the Conversion: Primary site will be assigned to current histologies (please see the conversion document for specific histology/primary site instructions)

  1. Primary site will be assigned to histologies for which only one primary site is applicable (e.g. Leukemias must have primary site C421). The primary site will be enforced through edits for cases diagnosed 2010 and forward. 
  2. C421 (bone marrow) will be assigned to leukemia/lymphomas or histologies prominent in the bone marrow with primary site C420, C423, and C424. 
  3. Manual review will be required for all remaining histologies (mostly lymphomas) with primary site C420, C423, or C424 to assign a more appropriate primary site. Applicable edits will be enforced for cases diagnosed 1/1/2010 and forward only. 

The 2015 update of the Hematopoietic Manual and Database was posted to the SEER website in January. 


Resources for Cancer Liaison Physicians

Cancer Liaison Physician Designated Alternate

A cancer program may select a designated alternate for the Cancer Liaison Physician (CLP). The appointment of the designated alternate must be done at the first cancer committee meeting of the year, and the decision should be clearly documented in the cancer committee minutes. There can be only one designated alternate for the appointed CLP.

The designated alternate for the CLP is not considered the co-CLP, a position that requires submission of a formal CLP application.

The appointed CLP is responsible for:

  • Preparing four data reports for the cancer committee meetings
  • Annually completing the CLP Activity Report in the Survey Application Record
  • Attendance at 75 percent of cancer committee meetings
  • Attendance at survey and meeting with surveyor

The designated CLP alternate must:

  • Meet the eligibility requirements of a CLP

The designated CLP alternate may:

  • Share in meeting the required 75 percent cancer committee meeting attendance for Standard 1.3
  • Deliver data reports prepared by the appointed CLP
  • Be approved for CoC Datalinks access

Save the Date! Attention All CLPs

This year the Committee on Cancer Liaison will hold two breakfast meetings for Cancer Liaison Physicians (CLPs) to hear new initiatives and to network with CLPs from across the U.S.  

The first CLP breakfast meeting will be held in conjunction with the 2015 American Society of Clinical Oncology ”Transforming Data Into Learning” annual meeting at 6:30 am on Monday, June 1, at the Hyatt Regency McCormick, Chicago, IL.  Please contact clp@facs.org if you plan to attend and include your facility’s name.  

The second CLP breakfast meeting will be held in Chicago on Monday, October 5, in conjunction with the American College of Surgeons Clinical Congress.  

We hope to see you there!


Educational Programs and Resources

Register Now for CoC June Education Programs

Registration is now open for the CoC's June Education Programs. 

Special Pre-Conference Workshop 

NCDB Tools Workshop: Maximizing NCDB Data to Improve Your Cancer Program 

June 17, 2015 

Noon – 5 pm

This half-day program will review the current uses and future updates for the National Cancer Data Base (NCDB) quality tools. NCDB quality tools will be reviewed with a focus on how the data can be used to inform decisions for cancer program administration and by cancer physicians. Learn about the uses for the cancer registry and how patient navigators can use the data. Reasons and examples of tool development, expectations and current uses of the NCDB quality tools will be presented by  NCDB staff, clinical leadership, and external users. 

Fees: 

$300 on or before May 15

$350 after May 15

Lunch will be served at 11:30 am. 

REGISTER NOW!

Survey Savvy 

June 18-19, 2015

Survey Savvy, provides in-depth review of the information your cancer committee needs to coordinate a high-quality, patient-centered, multidisciplinary cancer program. Developed by CoC staff and CoC committee leadership, this program addresses your cancer programs' most common questions, issues, and concerns regarding CoC standards and compliance. 

Whether your cancer program is preparing for a re-accreditation survey or looking for clarification on the standards, this program provides increased understanding of standard requirements and implementation. Through lectures, panel presentations, and the opportunity to meet and speak with experts, cancer program members will learn how to use the CoC standards as a framework to develop a comprehensive cancer care program that delivers high-quality and patient-centered care. 

Fees: 

$750 on or before May 15 

$850 after May 15

Visit the Survey Savvy web page for further meeting information, hotel information, and to register. Space is limited.

REGISTER TODAY 

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


News from ACoS Cancer Programs

NAPBC News

Register Today: Pursuing Excellence through NAPBC Accreditation

Date: Friday, April 24

Location: Denver, CO

www.facs.org/napbcworkshop

Register today for the Pursuing Excellence through NAPBC Accreditation workshop at the Westin Westminster Denver-Boulder Hotel on Friday, April 24, 2015.

This program is designed for members of the multidisciplinary breast health care team (physicians, nurses, administrators, cancer registrars) newly employed at an NAPBC-accredited program or working at a non-accredited breast center considering NAPBC accreditation.

By attending this workshop, you will be able to: 

  • Discuss the current NAPBC standards, the accreditation process, and the value of accreditation in terms of quality care, patient satisfaction, staff support, and clinical outcomes.
  • Identify the roles and disciplines that need to be included in the accreditation process and discuss the need for their support.
  • Apply the required breast center components, accreditation standards, and compliance strategies to successfully achieve NAPBC accreditation.
  • Navigate the NAPBC Pre-Application and Survey Application Record (SAR).
  • Maximize your on-site NAPBC survey visit.
  • Develop systems to maintain NAPBC accreditation.

Registration Fee 

$550—Registration and payment is received by April 21, 2015

$600—On-site registration 

Registration for this event includes meeting materials, a copy of the NAPBC Standards Manual ($50 value) and breakfast, lunch and breaks during the meeting.

Workshop Location and Hotel Accommodations 

The NAPBC workshop will be held at the Westin Westminster Denver-Boulder Hotel, 10600 Westminster Blvd., Westminster, CO  80020. Reservations can be made online or by phone (1-888-627-8448). If booking by phone, use the event name "2015 ACS NAPBC Workshop" to get the group rate of $159/night + tax.

Space is limited.  Visit the NAPBC Workshop web page to register today!

Please share this information with other members of your staff who would benefit from attending this workshop.


News from the Oncology Community

March Is Colorectal Cancer Awareness Month

Find resources for your use and information about the 80% by 2018 initiative here.  

The CoC and the American Cancer Society have collaborated to improve the quality of cancer care since the founding of both organizations in 1913.  As member organizations of the National Colorectal Cancer Roundtable (NCCRT), the CoC and the Society are rallying around the Roundtable’s goal of increasing colorectal screening rates to 80 percent by 2018.  

 

CoC Chair Daniel P. McKellar, MD, FACS, recently joined Richard Wender, MD, Chief Cancer Control Officer of the American Cancer Society and Chair of the NCCRT, to discuss the critical public health goal of reaching 80 percent colon cancer screening rates by the end of 2018. CoC-accredited cancer programs can make a significant contribution in reducing the burden of colorectal cancer in the communities they serve through education of the public and community outreach and screening initiatives. Watch the discussion between Drs. McKellar and Wender

For more information on the 80% by 2018 initiative and resources available to CoC-accredited cancer programs from the American Cancer Society and the NCCRT, visit the Cancer Liaison Program site. The CoC encourages its accredited programs to visit the NCCRT website and join the more than 170 organizations who have signed the 80% by 2018 pledge.

The NCCRT, established by the American Cancer Society and the Centers for Disease Control and Prevention in 1997, is a national coalition of public and private organizations dedicated to reducing the incidence of and mortality from colorectal cancer in the U.S., through coordinated leadership, strategic planning, and advocacy. 

NCRA News

Free Online Course

Beyond Cancer: Building a Survivorship Care Plan

The National Cancer Registrar Association (NCRA) has developed the Beyond Cancer course to provide cancer registrars with the knowledge and skills needed to develop a survivorship care plan. These plans are designed to ensure facilities deliver high-quality, patient-centered care. The course is complimentary to NCRA members. Continuing education credits may be purchased separately.


Learn More about NCRA 2015 Workshops 

NCRA's 41st annual educational conference is May 20–23, at the San Antonio Rivercenter in San Antonio, TX. The theme is “On a Mission: Education for a Changing Environment.” NCRA is offering several workshops, including two post-conference workshops: Cancer Informatics for Registrars: From Bedside to Big Data and Intensive CTR Exam Prep. The popular Fundamentals of Abstracting Workshop will also be offered in 2015. This workshop runs concurrent with the conference and is intended for cancer registry employees with between six months and two years of experience. Separate registration for all workshops is required. Learn more about NCRA’s conference and workshops at www.ncra-usa.org/conference


Interested in Becoming a Mentor? 

The NCRA Mentoring Program has grown substantially since it began three years ago. Its purpose is to assist students and cancer registrars in earning the Certified Tumor Registrar (CTR) credential and to help current CTRs advance their careers. Seasoned cancer registrars are encouraged to participate as mentors. To access the frequently asked questions regarding the program, and to complete an online Information Form, go to www.ncra-usa.org/mentoring


NCRA’s 2015 CTR Exam Prep Resources

The NCRA has revised its popular Certified Tumor Registrar (CTR) Exam Study Guide for 2015. Five new case studies have been added, and a companion CD contains additional study resources. NCRA’s popular online practice test has also been updated to reflect changes with the 2015 exam and the live CTR Prep webinar series has been archived, so students can access anytime. To learn more, go to www.CancerRegistryEducation.org/ctr-prep.

Training for Psychosocial Distress Program Accepting Applications

The Screening for Psychosocial Distress Program trains cancer care providers on how to develop, implement, and maintain psychosocial screening programs to meet the CoC’s new quality care standard. Applications to attend the program will be accepted until April 1.

Funded by a grant from the National Cancer Institute, the Screening for Psychosocial Distress Program is a joint project of Yale University School of Nursing and the American Psychosocial Oncology Society (APOS). With an international faculty of leading psychosocial cancer care professionals and researchers, the program will train two cancer care providers from one cancer care facility over two years. The first year includes an introductory one-day workshop held during the APOS conference in Washington, DC on July 29, and continues with four conference call teaching sessions throughout the year. The second year includes an advanced one-day workshop and two conference call teaching sessions throughout the year.

Attendance at the training by two people from each cancer facility will enhance successful implementation and ongoing maintenance of a psychosocial screening program. Funding for the Screening for Psychosocial Distress Program covers the APOS conference registration and allows for a per-person stipend to cover the attendance cost. The program enrolls up to 18 cancer care facilities each year for a total of 36 participants. 

25th World Congress of Lymphology

The National Lymphedema Network invites you to the 25th World Congress of Lymphology (WCOL) September 7–11 at the Hilton Union Square, San Francisco, CA. The congress will be a premiere global meeting dedicated to both basic and clinical lymphology as well as other disorders of the lymphatic system. The congress will provide an exclusive opportunity for clinical and basic scientists, researchers, and practicing health care professionals to collaborate on our theme "Lymphology: Past, Present, and Future." The WCOL's program will include: a faculty of distinguished global experts presenting and discussing late-breaking findings on a wide variety of topics, immersion in unique instructional sessions, easy access to a comprehensive industry exhibition hall, and, this year, a special companion program tailored for patients.