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

November 2015 CoC Source

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Lawmakers Consider Bills with Ties to CoC Accreditation

U.S. Reps. Lynn Jenkins (R-KS) and Richard Neal (D-MA) in late October sponsored H.Res.487, a non-binding resolution that recognizes the importance of accreditation by the ACS Commission on Cancer (CoC) 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 are urged to visit www.surgeonsvoice.org to contact their representative to ask her or him to cosponsor the resolution.  Others are urged to contact their representative to ask co-sponsorship as well.

CoC News

CoC Recognizes Outgoing Members and Leaders

The Commission on Cancer (CoC) recognizes the following departing members for their distinguished contributions to the work of the Commission:

Members

  • Nancy N. Baxter, MD, FACS, American Society of Colon and Rectal Surgeons
  • Elizabeth Ann Beierle, MD, FACS, American Pediatric Surgical Association
  • Ned Carp, MD, FACS*
  • Thomas Eisenhauer, MD, FACS*
  • Linda W. Ferris, PhD, Association of Cancer Executives 
  • Howard L. Kaufman, MD, FACS*
  • Rachael King, American Cancer Society Ex-Officio
  • Leslie J. Kohman, MD, FACS*
  • Luana R. Lamkin, RN, MPH, Association of Community Cancer Centers 
  • Nipun B. Merchant, MD, FACS*
  • Ryan P. Merkow, MD, Resident and Associate Society of the American College of Surgeons 
  • Val Moysaenko, MD, FACS*
  • Marcus Plescia, MD, MPH, Centers for Disease Control and Prevention
  • Patrick Ross, Jr., MD, PhD*
  • Lynne I. Wagner, PhD, American Psychosocial Oncology Society
  • William H. Ward, Jr., MD, Resident and Associate Society of the American College of Surgeons 
  • Scott M. Weissman, MS, CGC, National Society of Genetic Counselors, Inc. 

* Fellowship

Leadership

  • Ned Carp, MD, FACS, Vice-Chair, Quality Integration Committee
  • Linda W. Ferris, PhD, Chair, Accreditation Committee
  • Howard L. Kaufman, MD, FACS, Chair, Education Committee
  • Danny M. Takanishi, Jr., MD, FACS, Vice-Chair, Accreditation Committee

CoC Announces New Members and Leaders

The CoC is pleased to welcome the following individuals who were appointed to membership and leadership positions at our 2015 annual meeting held on October 6 at the ACS Clinical Congress in Chicago, IL.

Representing the Fellowship for a Three-Year Term

  • Joseph A. Blansfield, MD, FACS, Geisinger Medical Center, Danville, PA
  • Michael S. Bouton, MD, MA, FACS, Sanford Health, Fargo, ND
  • Kimberly Moore Dalal, MD, FACS, Mills-Peninsula Hospital, Burlingame, CA
  • Nestor F. Esnaola, MD, MPH, MBA, FACS, Fox Chase Cancer Center, Philadelphia, PA
  • Paul M. Goldfarb, MD, FACS, Oncology Associates, San Diego, CA
  • Paul Hansen, MD, Portland Providence Cancer Center (OR)
  • Ashwani Rajput, MD, FACS, University of New Mexico, Albuquerque
  • Curtis J. Wray, MD, FACS, UTHealth, Lyndon B. Johnson General Hospital, Houston, TX

Representing Member Organizations for a Three-Year Term

  • Academy of Oncology Nurse and Patient Navigators—Lillie D. Shockney, RN, BS, MAS, Johns Hopkins Breast Center, Baltimore, MD
  • American Association for Cancer Education—Kathleen Heneghan, RN, MSN, CPN, American Association for Cancer Education and American College of Surgeons Patient Education, Chicago, IL
  • American Cancer Society Ex-Officio—Lynne Padgett, PhD, Hospital Systems, American Cancer Society, Atlanta, GA
  • American College of Radiology 
    • Elizabeth K. Arleo, MD, New York-Presbyterian/Weill Cornell, New York, NY
    • Alan C. Hartford, MD, PhD, FACR, Dartmouth-Hitchcock Medical Center, Lebanon, NH
  • Resident and Associate Society of the American College of Surgeons—Sangeetha Prabhakaran, MD, Moffitt Cancer Center, Tampa, FL
  • American Pediatric Surgical Association—Kenneth W. Gow, MD, FACS, FAAP, Seattle Children's Hospital, University of Washington, and Seattle Cancer Care Alliance
  • American Psychosocial Oncology Society—Timothy Pearman, PhD, Northwestern Medical Group and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
  • American Society of Colon and Rectal Surgeons—Heidi Nelson, MD, FACS, Mayo Clinic, Rochester, MN
  • Association of Cancer Executives—Tammy McClanahan, RN, BSN, OCN, MHA, FACHE, Norton Healthcare, Louisville, KY
  • Association of Community Cancer Centers—Matt Sherer, MBA, MHA, Tallahassee Memorial Cancer Center (FL)
  • Centers for Disease Control and Prevention—Lisa C. Richardson, MD, MPH, Centers for Disease Control and Prevention, Atlanta, GA
  • National Coalition for Cancer Survivorship—Shelley Fuld Nasso, MPP, National Coalition for Cancer Survivorship, Silver Spring, MD
  • National Society of Genetic Counselors, Inc.—Jessica N. Everett, MS, CGC, University of Michigan, Cancer Genetics Clinic, Ann Arbor
  • Society of Immunotherapy of Cancer—Howard L. Kaufman, MD, FACS, Rutgers Cancer Institute of New Jersey, New Brunswick 
  • U.S. Department of Defense—Matthew T. Hueman, MD, FACS, Lieutenant Colonel, Medical Corps, U.S. Army, Walter Reed National Military Medical Center, Murtha Cancer Center; Bethesda, MD

Representing the Leadership

  • Lawrence N. Shulman, MD, Abramson Cancer Center, University of Pennsylvania, Philadelphia; Chair-Elect, Commission on Cancer
  • Danny Takanishi, MD, FACS, University of Hawaii at Manoa, Honolulu; Chair, Accreditation Committee
  • Bruce J. Averbook, MD, FACS, MetroHealth Center, Cleveland, OH; Vice-Chair, Accreditation Committee
  • Hisakazu Hoshi, MD, FACS, University of Iowa Hospitals and Clinics, Iowa City; Chair, Education Committee
  • Laurie J. Kirstein, MD, FACS, Cancer Institute of New Jersey, New Brunswick; Vice-Chair, Education Committee
  • Peter T. Hetzler, MD, FACS, Little Silver, NJ; Vice-Chair, Member Organization Steering Committee
  • Matthew A. Facktor, MD, FACS, Geisinger Medical Center, Danville, PA; Vice-Chair, Quality Integration Committee

Advocacy Update

Take Action Now

Contact your legislator to support these issues of importance to quality cancer care.   

The Planning Actively for Cancer Treatment (PACT) Act (H.R. 2846) will ensure that every Medicare-eligible cancer patient has access to cancer care planning and coordination to improve patient health and reduce inefficiencies in the system. 

Connect with your representative to make the case for cancer research and prevention funding to be top priorities in the year-end budget deal.  Congress is working to negotiate a final budget deal and complete its work on FY 2016 appropriations before the December 11 deadline.  

Contact your representative to co-sponsor a resolution on CoC accreditation. 

Accreditation Corner

Call for Abstracts for the 2016 Annual CoC Conference

The annual Commission on Cancer (CoC) Conference, formally known as Survey Savvy, offers an in-depth review of the information that a CoC-accredited facility’s cancer committee needs to coordinate a high-quality, patient-centered, multidisciplinary cancer program. 

Developed by CoC staff and committee leadership and utilizing real-world experiences from accredited cancer programs, this conference addresses programs’ common questions and provides guidance on implementation regarding CoC standards and compliance.

The CoC is seeking submissions for speakers to present on the following subjects:

  • Cost, value, and benefits of accreditation
  • Solutions and tips on using available staff and resources to meet compliance
  • Best practice examples for Standards 1.8, 3.1–3.3, and 4.6–4.8

We would like to have representation from a board spectrum of programs, from community-based to academic institution and facilities.

Submission Information

If interested, contact accreditation@facs.org by Monday, November 23, 11:59 PM (Central) with the following information: 

  • Full name, job title, and credentials
  • CoC-accredited facility name
  • Contact phone number
  • Contact e-mail address
  • List of previous speaking engagements
  • Attach a document that details your presentation, including subject, objectives, length, and how this presentation will help other programs

2016 Annual Commission on Cancer Conference

June 2–3, 2016
Hyatt Regency O’Hare
Rosemont, IL

Call for 2016-2017 Network Surveyors

The CoC is recruiting physicians involved in cancer care who would like to be CoC surveyors

We are specifically looking for surveyors to conduct two-day surveys at Integrated Network Cancer Programs. Qualified candidates must be actively practicing (treating, teaching, or in an 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 should be familiar with the CoC Standards.

Surveyors will travel nationwide to survey cancer programs seeking accreditation or reaccreditation with the CoC. Surveyors will meet with and present to key facility administration and cancer committee members at each program, review program documentation, 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 and applying to become a CoC network surveyor, please e-mail Allison Knutson, Manager of Accreditation and Standards.

CoC Standards 4.4 and 4.5 Implementation for Surveys in 2016

The Accreditation Committee has released the expected Estimated Performance Rates (EPR) for accountability and quality improvement measures assessed for the CoC Standards 4.4 and 4.5 for programs being surveyed in 2016. These standards require performance levels be met annually according to the specified accountability and quality improvement measures defined by the CoC. 

Expected EPRs

Expected EPRs have been established based on a review of current performance by CoC-accredited cancer centers for these measures. Each of the following measures listed below will be assessed and rated for 2016 surveys. EPRs remain the same as previously released for cases diagnosed in 2011–2012. 

Measure

Expected EPR*

2011

2012

2013

Standard 4.4 Quality Improvement

nBx - Image or palpation-guided needle biopsy (core or FNA) is performed to establish diagnosis of breast cancer.

N/A

80%

80%

G15RLN  - At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer.

N/A

NA

80%

12RLN - At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.

80%

85%

85%

LCT - Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is considered for surgically resected cases with pathologic, lymph node-positive (pN1) and (pN2) NSCLC.

N/A

N/A

85%

LNoSurg - Surgery is not the first course of treatment for cN2, M0 lung cases.

N/A

N/A

85%

RECRTCT - Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is considered; for patients under the age of 80 receiving resection for rectal cancer.

N/A

N/A

85%

Standard 4.5 Accountability Measures

BCSRT - Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer.

90%

HT - Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage II or stage III hormone receptor positive breast cancer.

90%

MASTRT - Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with >= 4 positive regional lymph nodes.

N/A

90%

90%

*Note. Programs meet the expected EPRs by using the point estimate of the EPR or the upper limit of the confidence interval being at or above the expected rate.  

Evaluation Criteria of Measures

To be compliant with Standards 4.4 and 4.5, cancer programs must meet one of the following: 

  • Meet the above performance rates either with their EPR in CP3R or the upper bound of the 95% confidence interval
  • If the EPRs and confidence intervals are below the EPR, cancer programs must establish and implement an action plan that reviews and addresses improving performance. 

For more information on how to use confidence intervals to rate compliance with Standards 4.4 and 4.5, please visit our Quality Measures page.

Visit our website for more information on definitions of accountability, quality improvement, and surveillance measures.   

If you have any questions about your CP3R rates, please e-mail NCDB staff at NCDB@facs.org.

SAR versus PAR

  • The Survey Activity Record (SAR) is completed and reviewed by the cancer program during the year that the program is due for survey. The SAR will close and remain in read-only format starting at three days post-survey.
  • The SAR is required to be completed 30 days before the confirmed survey date and will close two weeks before survey. If you have important changes for the SAR during these two weeks, you will need to communicate this to the surveyor so he or she is aware a certain screen may be incomplete.
  • The SAR will reopen on the day of survey. Any changes or documentation that need to be added before survey, as mentioned above, will need to be added on the day of survey. 
  • The SAR remains open for three business days post-survey for any changes that are specifically requested by the surveyor. Any changes made or documentation added without the surveyor’s knowledge will not be part of the rating entered for that standard. 
  • The Accession List link and the table in Standard 2.1 (CAP) for adding pathology report information for surveyor review will remain open during the two-week closure window.
  • Once you receive your initial survey Performance Report, you will have access to the current year’s Program Activity Record (PAR).
  • The PAR is available to all CoC-accredited cancer programs in survey year after the survey has been processed and in all nonsurvey years. All years that appear in the online record are editable. Information from last year’s PAR or SAR will be copied over to the current year’s PAR.
  • Each calendar year there will be a new PAR available to cancer programs not scheduled for survey. The previous year’s PAR will be in read-only format. Any changes you need to make to the PAR to years in your survey cycle can be made in the most current year’s PAR. 

There are always four years displayed in the SAR and PAR at any given time. The most recent year is always the current year. When a new calendar year begins (such as 2016), a new year for data entry is added throughout the SAR/PAR. The oldest year will be removed (such as 2012) from your view. Programs should only see years of activity in the SAR that the survey will be reviewed for compliance. All programs, whether they are up for survey that year or not, see the same years in the online document (SAR or PAR). Your view of years is not based on your individual cancer program.

Resources for Cancer Liaison Physicians

January 1 CLP Expirations

At the end of November, an e-mail will be sent to several accredited facilities regarding the term expiration of their Cancer Liaison Physician (CLP). Facilities are strongly encouraged to determine the reappointment or the new appointment of a CLP as soon as possible, as CoC Datalinks access will be inaccessible for the CLP. We realize that many facilities will have their cancer committee meetings after January 1, 2016. Therefore, no hard deadline is given. This may cause concern and raise questions about accreditation. The cancer committee may decide to extend the current CLP’s term until a decision is made to reappoint or replace before the meeting. This will allow the current CLP access to CoC Datalinks and the National Cancer Data Base (NCDB) tools. If the cancer committee decides to replace the CLP, the new appointment can be processed at any time with no consequences regarding accreditation. 

If you have any questions or concerns, please e-mail us at clp@facs.org

New Appointment Process

1. Log into CoC Datalinks

2. Go under Manage Staff Contact. 

3. Under the Pending Contacts section select Add Contact. 

4. Enter the CLP name and contact information in this window. 

5. Click the Save button. The new information will be sent directly to the Cancer Liaison Program for processing. An appointment letter will be sent to the CLP and a notification will be sent to the cancer program staff via e-mail. 

Remove Former CLP

1. Log into CoC Datalinks

2. Go under Manage Staff Contact. 

3. Click on the former CLP’s name to expand his or her record. 

4. Click the Remove button. A box will open asking if you want to remove this contact. Select OK. 

Reappointment Process

Send an e-mail to clp@facs.org with your CLP’s name and e-mail address that states that your program would like to reappoint the CLP to an additional term. An e-mail will be sent to the CLP and program staff confirming the reappointment. 

CoC Welcomes New State Chair

The CoC would like to welcome our newest State Chair:

Brian McKinley, MD, FACS

South Carolina, State Chair

Educational Programs and Resources

Information Coming Soon: 2016 CoC Workshops

In 2016, the CoC will host two Accreditation 101 workshops and the final dates and locations will be available soon. The first will be held during the early Spring and the second held in the early Fall.  Our annual Summer conference is also in development and will be held in Chicago in early June. Stay tuned to the CoC Source in the next few months for more details. 

News from ACoS Cancer Programs

AJCC News

AJCC Education Offerings

To assist with cancer staging education, the American Joint Committee on Cancer (AJCC) offers many free resources including:

  • AJCC Curriculum for Registrars 
    • Modules I, II, III, and IV recorded webinars
    • Webinars that may be played for large audiences
    • Slides and handouts available for group lectures
  • AJCC Presentations 
    • Registrars Guide to Chapter 1, AJCC Seventh Edition
    • Explaining Blanks and X, Ambiguous Terminology, and Support for AJCC Staging
    • Slides and handouts for use in group lectures

Two continuing education (CE) credits are being offered for Modules II–IV. The Module I, Module II, Module III, and Module IV recordings are available to access through the AJCC website. Module I Introduction is not eligible for CE credits.

Questions on staging rules and lecture content will be answered through the CAnswer Forum.

NAPBC News

Still Time to Register for the NAPBC Accreditation Workshop  

November 14 | Chicago, IL

There is still time to register for the National Accreditation Program for Breast Centers (NAPBC) Pursuing Excellence through NAPBC Accreditation workshop on November 14 in Chicago, IL. Register online by November 8 to receive a $50 discount.

This educational workshop will guide you through the accreditation process—from applying through achieving NAPBC accreditation.

Sessions in this program include: 

  • Understanding the NAPBC components and standards 
  • What to expect on the day of survey 
  • The importance of quality improvement and how NAPBC is making a difference 
  • What it takes to achieve NAPBC accreditation from an administrator's point of view

We encourage you and other members of the breast center staff (physicians, nurses, administrators, cancer registrars, and navigators) to attend this highly valued program. Attendees will have the opportunity to enhance their professional network by interacting with NAPBC staff, surveyors, and their peers. 

The National Cancer Registrars Association (NCRA) Program Recognition Committee has determined Pursuing Excellence through NAPBC Accreditation program supports 6 continuing education (CE) hours.

Visit our website for additional information on the workshop. We look forward to seeing you or a member of your breast center's staff at this program. If you have questions, contact NAPBC@facs.org.

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

Alliance for Clinical Trials News

New Cancer Surgery Manual

The American College of Surgeons and the Alliance for Clinical Trials in Oncology present the first comprehensive, evidence-based examination of cancer surgery techniques that are critical to achieve optimal outcomes in a cancer operation in a new manual, Operative Standards for Cancer Surgery. The first volume of this unique manual focuses on best practices for breast, colon, lung, and pancreatic surgery, describing the surgical procedures that directly affect cancer outcomes. Order your copy today

News from the Oncology Community

NCRA News

NCRA Posts Complimentary Staging Shorts
The National Cancer Registrars Association’s (NCRA's) Education Committee has created a series of Staging Shorts—10-minute narrated PowerPoint presentations on complicated staging issues. The first two to be posted in the Center for Cancer Registry Education (CCRE) are “Ambiguous Terminology” and “The Use of ‘Blank’ and ‘X’ for Stage Categories T, N, and M.” Visit the CCRE to learn more.

With Membership Renewal, Access to 50 Online Learning Products for $180 
NCRA is offering a special 2016 membership renewal subscription to its CCRE, which  includes access to more than 50 online learning products for $180. This special offer is the most cost-effective way to earn all the CEs needed to maintain the Certified Tumor Registrar (CTR) credential and to keep up to date with changes in the cancer registry profession. The subscription runs from January 5 through December 31, 2016.

Four Webinars on AJCC TNM Staging Remain
NCRA has designed a series of physician-led webinars on AJCC TNM Staging for Head and Neck Cancers and Cancer of Biliary Sites. There are four one-hour live webinars remaining in the series, including “Cancer of the Liver” presented by Michael Kluger, MD, MPH, on October 28 at 4:00 pm; “Treatment of Head and Neck Cancers” presented by Maen Hussein, MD, on November 4 at 2:00 pm; “Cancer of the Intrahepatic Bile Ducts” presented by Michael D. Kluger, MD, MPH, on November 18 at 4:00 pm; and “Cancer of the Gallbladder” presented by Steven Cunningham, MD, on December 2 at 2:00 pm. All times are Eastern. Go to www.CancerRegistryEducation.org/live-webinars to learn more and register. 

Danielle Chufar Scholarship Deadline is December 10 
The Danielle Chufar Memorial Annual Conference Scholarship provides financial support to an NCRA member who has no available funding to attend NCRA's Annual Educational Conference. The scholarship covers the conference registration fee, airfare (up to $600), and hotel for three nights. The theme for the 2016 essay is “How Does Education, Networking, and Professional Development Work Together to Create an Exceptional, Well-Rounded CTR Professional?” The deadline is December 10. Download the application at www.ncra-usa.org/conference

Sharpen Your Skills with NCRA's New Online Case Studies
NCRA has produced 15 online cancer case studies to provide opportunities for registrars to practice assigning AJCC TNM Stage and coding SEER Summary Stage. The correct answers and corresponding rationales are provided upon the completion of each case. The Online Case Studies can be found on NCRA’s CCRE.