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

February 2016 CoC Source

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CoC News

2015 Year-End OAA Recipients Announced

Congratulations! The 24 Commission on Cancer (CoC)-accredited cancer programs listed below represent the preliminary list of Outstanding Achievement Award (OAA) recipients from surveys performed July 1–December 31, 2015. This preliminary list identifies programs as OAA recipients and indicates confirmation by the CoC's Program Review Subcommittee. However, additional cancer programs may be added or facility names may be corrected.

Combined with OAA recipients surveyed January 1–June 30, 2015 a total of 47 facilities achieved the OAA in 2015.

The OAA acknowledges cancer programs that achieve excellence in providing quality care to cancer patients and demonstrate a commendation level of compliance with seven standards during their accreditation survey cycle.

We ask that all programs surveyed July 1–December 31, 2015, please review this list and contact the Accreditation team at accreditation@facs.org by February 12, 2016 if you believe that your cancer program may be eligible to earn the OAA, but is not included on the list or if your facility name is listed incorrectly.

The finalized July 1–December 31 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 each facility’s cancer program administrator, hospital registrar and marketing representative. Therefore, it is essential that all contact information under the "Manage Staff Contacts" section in CoC Datalinks is up-to-date and accurate.

Facility

City

State

 Fairbanks Memorial Hospital 

 Fairbanks

 AK*

 Princeton Baptist Medical Center

 Birmingham

 AL

 Washington Hospital
Healthcare System

 Fremont

CA**

 Feather River Hospital

Paradise

 CA

 Danbury Hospital

 Danbury

 CT

 Johnson Memorial Hospital

 Stafford Springs

 CT

 Martin Health System

 Stuart

 FL*

Midtown Medical Center -
John B. Amos Cancer Center

 Columbus

 GA*

 Elmhurst Memorial Hospital

 Elmhurst

 IL**

 King's Daughters' Health

 Madison

 IN

 University of Louisville Hospital

 Louisville

 KY

Owensboro Health
Regional Hospital

 Owensboro

 KY*

 Pikeville Medical Center

 Pikeville

 KY

 Lafayette General Medical Center

 Lafayette

 LA

 St. Dominic-Jackson
Memorial Hospital

 Jackson

 MS

 Forsyth Regional Cancer Center

 Winston-Salem

 NC

 The Valley Hospital

 Ridgewood

 NJ

 Oregon Health & Science University

 Portland

 OR*

 Abington Memorial Hospital

 Abington

 PA*

Reading Hospital

Reading

 PA

 Roger Williams Medical Center

Providence

 RI

 Texas Health Harris Methodist Hospital Fort Worth

Fort Worth

TX*

 Baylor Medical Center
at Grapevine

Grapevine

 TX

 Riverside Regional
Medical Center

Newport News

VA*

* Congratulations to the 8 facilities that achieved the OAA two consecutive survey cycles (2012, 2015).

** Congratulations to the 2 facilities that achieved the OAA three consecutive survey cycles (2009, 2012, 2015).

Any OAA questions should be sent to the CoC Accreditation and Standards team at accreditation@facs.org.

Meet CoC Staff at Upcoming Exhibits

The Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC) will be exhibiting at the following meetings.  Plan to stop by our booth and meet our staff.

February
DDI Week 2016 (Sponsored by the Cleveland Clinic Digestive Disease Institute)
February 2–7 in Boca Raton, FL
Exhibit days: February 4–6

April
NCoBC 2016  (Sponsored by the National Consortium of Breast Centers)
April 9–13 in Las Vegas, NV
Exhibit days:  April 9–11

NCRA’s 42nd Annual Educational Conference (Sponsored by the National Cancer Registrars Association)
April 10–13 in Las Vegas, NV
Exhibit Days: April 11–13

ASBrS 17th Annual Meeting (Sponsored by the American Society of Breast Surgeons)
April 13–17 in Dallas, TX
Exhibit Days: April 14–16

Accreditation Corner

2016 SAR and PAR Now Available

For cancer programs preparing for a 2016 accreditation survey, the 2016 Survey Application Record (SAR) is now available for completion. Programs are responsible for completing SAR data fields and uploading appropriate documentation demonstrating standards compliance for activity years 2013, 2014, and 2015.

Please plan your work accordingly. The SAR must be completed at least 30 calendar days before the confirmed survey date for the surveyor to begin the pre-review and it will be closed for edits 14 calendar days before the survey date. Note that the “Accession List” section and the CAP Review table in Standard 2.1 will remain open during these two weeks.

Cancer programs that are not scheduled for a 2016 survey now have access to the 2016 Program Activity Record (PAR). Because some data fields were revised in 2016 from the previous 2015 SAR/PAR, you will need to review and make sure all tables and fields are completed for each calendar year. Keep in mind that all previous versions of the SAR and PAR are now locked and cannot be edited. Any changes that need to be made or new data to be entered for 2013, 2014, 2015, and/or 2016 may be completed through the 2016 PAR only.  

Cancer programs should always be working out of the current year’s version of the SAR or PAR when entering activities. An exception is when submitting appeals or deficiency resolutions, you will submit through the survey SAR only.

For questions regarding the SAR or PAR, e-mail SAR@facs.org.

Standard 2.2 - Revisions to Commendation Calculation

With the release of the Cancer Program Standards (2016 Edition), there is an important change to how the commendation percentage of oncology nurse certifications is calculated for Standard 2.2. 

Effective January 1, 2016, commendation is awarded when 25 percent of oncology nurses employed and/or contracted with the facility (including full-time and part-time positions) hold a current, applicable oncology nursing certification. This means that the denominator in the commendation calculation no longer depends on whether the oncology nurse is chemotherapy-trained. Instead, the denominator includes any nurse providing direct oncology care to cancer patients. 

This change will encourage and reward the presence of highly trained oncology nurses for all aspects of oncology care. Accredited cancer programs that do not provide chemotherapy at their facility will now also be eligible to earn commendation for this standard. 

Note that all nurses who administer chemotherapy to patients are still required to have documented certification of chemotherapy training for inpatient and outpatient units.

Become an INCP Surveyor

The CoC is recruiting physicians and oncology administrators involved in cancer care who would be interested in becoming CoC surveyors. Specifically, we are seeking  surveyors to conduct surveys for Integrated Network Cancer Programs (INCP).

Qualified physician candidates must be actively practicing (treating, teaching, or in an administrative role) within a CoC-accredited INCP, be a current member of a cancer committee within a CoC-accredited cancer program, and be knowledgeable of CoC Standards. 

Qualified administrator candidates must have recognized experience and service in oncology administration for a CoC-accredited INCP, be a current member of a cancer committee within a CoC-accredited cancer program and be knowledgeable of CoC Standards. 

Surveyors will travel nationwide to survey INCPs seeking CoC 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, contact Allison Knutson, Manager of Accreditation and Standards, at aknutson@facs.org.

View our Surveyor Profiles.

Become an OMH Surveyor

The CoC is recruiting medical oncologists interested in becoming surveyors for the developing Oncology Medical Home (OMH) accreditation program. 

We are looking for board-certified medical oncologists who are in active practice. Qualified candidates must have knowledge of the medical home concept through previous experience in a medical home practice and/or through other OMH educational activities. Applicants must have excellent oral and written communication skills with the ability to convey knowledge and suggestions compassionately, clearly, and professionally. Public speaking experience and computer proficiency are essential.

Surveyors will travel nationwide to survey oncology practices seeking accreditation through the CoC OMH program. Surveyors will meet and present to key facility administrators and the OMH committee at each practice, review medical charts, and assess practice compliance with the requirements for all standards.

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

National Cancer Data Base News

NCDB Call for Data 2016: Rolling Right Along!

Receipts for all required submissions to the National Cancer Data Base (NCDB) must be time-stamped by 12:00 Midnight (CST) on February 15, for compliance with Standard 5.5. See the submission website for registrars for details.

Thank You for Your Data
Major kudos to those programs that submitted their data early in January! By January 15, 525 programs had submitted their registry data. The NCDB will remain open until 12:00 Midnight on April 1 to receive corrections and delayed submissions for Standard 5.6, and will close for routine submissions immediately after that.

Submission Review and Tracking: A Collaborative Effort
The NCDB expects programs to check their NCDB Submission History in CoC Datalinks to monitor the submission and processing of their data. More programs are proactively tracking their data than ever before. Data files that have been successfully processed will have a status of “Records written to NCDB analytical database.” If your data file has a status of “validated and edited” for more than two days, there may be a problem with the processing of your submission. If you note any issues with your data submission, contact the NCDB at ncdb@facs.org

In addition, the NCDB has generated new reports for internal use so that staff can follow-up with facilities that may be having issues during the actual submission window. These reports will serve as the basis for automatic alerts that will be incorporated into the new system build for 2017. It is the NCDB’s goal not to have a single, preventable deficiency for the 2016 Call for Data.

Editing with Ease
For the first time, the NCDB is offering a preconfigured GenEDITS Plus software installation file that includes all required edits, metafiles, and configuration files built into the installation (no .ini or .rmf files to copy over). After you have installed the software, browse to your data file and click Run EDITS! As of January 20, more than 1,200 programs had downloaded the new NCDB GenEDITS Plus. Use of this new setup by programs has streamlined data editing efforts, greatly reducing registrar frustration and the amount of edits support required by the NCDB.

Extensions
The NCDB grants limited extensions for Standard 5.5 under unusual circumstances. If your program needs an extension, send the request to Kathleen Thoburn at kthoburn@facs.org with the reason and the expected date for submission. Extensions must be granted before the February 15 submission deadline.

Apply for NCDB PUF Through February 19

The NCDB announces the opening of the Participant User File (PUF) application. The NCDB will accept applications for site-specific files, which include cases diagnosed between 2004 and 2013. The application period will be open through February 19.

The NCDB PUF is a Health Insurance Portability and Accountability Act (HIPAA)-compliant data file containing cases submitted to the Commission on Cancer's (CoC) NCDB and complies with the terms of the business associate agreement between the American College of Surgeons and CoC-accredited cancer programs (no patients or facilities can be identified). The PUF 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.

Before submitting a PUF, you are advised to read the information provided on our website. A critical information tool for all applicants is our Getting Started document, to understand the variables and limitations that could impact your proposed study. It is also important to review the PUF data dictionary to ensure you are able to conduct your proposed study with the variables available.

Applicants are expected to:

  • Be added as a PUF applicant with a CoC Datalinks Username and password. (See your hospital registrar for assistance.) 
  • Complete the PUF application, including disease site requested, co-investigators, study questions, analysis plan, and other relevant information.
  • Receive a letter of support from your cancer program's cancer committee chair. That letter is to be on your facility’s letterhead and uploaded at the time of your application submission in order to be reviewed.
  • Review the American College of Surgeons' CoC NCDB PUF Purpose and Terms of Agreement and Data Use Agreement (DUA) to determine if any conflicts may arise at your facility or in your intentions with the PUF. 
  • Assess your facility's institutional review board policy. 

Successful PUF applicants awarded through the 2016 January call will receive files in spring 2016. Prior to the download of the file a DUA must be signed electronically before the data can be received.

An applicant who is found to be out of compliance with the PUF Program Policies, following receipt of a PUF file, may be barred from receiving future PUF files. If multiple issues are found within the same institution, the institution may be suspended from the PUF application process.

For additional information about the PUF, visit our website.

Questions regarding the NCDB PUFs or the request for applications process for a PUF may be directed to the NCDB technical staff at NCDB_PUF@facs.org.

Resources for Cancer Liaison Physicians

Why Have a CLP Alternate?

The role of the Cancer Liaison Physician (CLP) is required to obtain and maintain CoC accreditation. However, a busy physician with a growing practice may find it challenging to report and attend Cancer Committee meetings. Therefore, a CLP-designated alternate is recommended to report and attend cancer committee meetings in place of the CLP.

Standard 1.3 requires that a designated alternate be named and entered in the cancer committee minutes of the first meeting of the year. No formal application is required for the CLP alternate. CLP alternates are not required to complete the CLP activity report nor are they required to prepare and present quarterly reports, using the National Cancer Data Base tools, to the cancer committee. The CLP alternate mainly serves the purpose of meeting the 75 percent meeting requirement. If your program meets only four times a year and a CLP alternate is in attendance at one of those meetings; then the CLP alternate must present a report to the cancer committee. If you have questions, e-mail CLP@facs.org.

Expiring CLP Term - January 1

CLPs serve a three-year term and are eligible to serve an unlimited number of terms based on performance and evaluation data collected at the time of survey. More than 100 CLP terms expired on January 1, 2016, and each cancer committee must determine whether their CLP is appropriately serving in this role or if another candidate would be better suited to the position.

Notification and instructions have been sent to cancer committee chairs of programs with a CLP whose term is expiring. Cancer registrars will be notified as well*. The facility must either reappoint the CLP for another three-year term or recommend a replacement.

Please do not panic that January 1 has already passed. Although the CLP will not have access to their program's CoC Datalinks menu, the cancer committee may decide to extend the current CLP’s term date until a decision is made to reappoint or replace them. Your accreditation will not be affected. If the cancer committee decides to replace the CLP, the new appointment can be processed at any time with no consequences regarding accreditation.

Make sure the CLP activity report is up-to-date as well as all other parts of your Survey Application Record (SAR) and Program Activity Record (PAR), where your CLP will provide feedback.

Please update and confirm your CLP’s contact information in CoC Datalinks. If you have questions or concerns, please e-mail us at clp@facs.org.

Note. If your accredited facility does not have a CLP in place, you are in jeopardy of noncompliance with CoC Standards 1.3 and 4.3. It is important that you make an appointment as soon as possible and that you designate an individual as the CLP in CoC Datalinks. If a CLP is not appointed for your facility and recorded in CoC Datalinks, the CoC recommends that the cancer committee chair be listed as the interim CLP until an official appointment is made.

*If the notification was sent to someone in error, please make sure your staff contacts are updated through CoC Datalinks. Notifications are sent electronically based on what is entered through your programs “Manage Staff Contacts” page.

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 for a maximum of two (2) three-year terms.   

Ingrid Lizarraga, MD, FACS
Iowa State Chair

Educational Programs and Resources

Register Today for Accreditation 101

Accreditation 101: Learning the Basics of CoC Accreditation and Standards
Date: April 1, 2016
Time: 7:00 am - 4:30 pm
Location: The Curtis Hotel, a Doubletree by Hilton, 1405 Curtis St., Denver, CO 80202

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 Fees
$750 on or before February 29
$850 after February 29 
$950 on-site

Register Now!

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.

Hotel
Reserve your hotel by March 8, for the group rate of $169/night + tax. Reference "CoC Accreditation 101" to receive the discounted rate.

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

Continuing education credit will NOT be offered for this program.

Registration for the CoC Annual Conference and NCDB Annual Workshop to Open in March

CoC Annual Conference
June 1-2, 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
On-site - $1195

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 CoC Source will be distributed when registration opens. Please stay tuned to the CoC Events page for further details. 

Full Day NCDB Workshop on June 3, 2016

Along with the CoC Annual Conference, the NCDB will host it's first full day workshop on June 3, 2016.

Program description:
Cancer Committee Members in CoC-accredited cancer programs hold the unique position of accessing their own cancer center data and comparing with other cancer center data for cancer care quality improvement.  The NCDB Annual Workshop will provide physicians and members of the cancer committee skills and knowledge to lead quality improvement initiatives within cancer programs, maximally utilizing the NCDB Quality Tools and Quality Measures.  Participants will learn from experts in the field and leave this workshop with the basics of creating and executing a quality improvement project, team building, interpretation of quality measures and other NCDB data tools. This workshop is highly interactive and will provide examples of best practices.

Further information on this workshop, along with pricing will be available in early March.

News from ACoS Cancer Programs

AJCC News

AJCC Staging Critical Clarifications for Registrars
It has come to the attention of the American Joint Committee on Cancer (AJCC) that there are some misconceptions regarding the staging rules for Melanoma. The AJCC will clarify these issues in the Cancer Staging Manual 8th Edition. 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 should  not perpetuate, and any errors in education provided outside of the AJCC must be corrected promptly.

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

New AJCC T, N, and M categories will implemented in 2016. The primary considerations when assigning 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  review this information and the other educational resources available on the Registrar Presentations page of the AJCC website.

Clinical Research News

Thank You for Participating in the CoC Special Study 
Thanks to the dedication and hard work of registry staff members at CoC-accredited cancer programs across the country, the data collection for the CoC Special Study investigating follow-up and recurrence after cancer treatment was a success. This study analyzed data from the National Cancer Data Base (NCDB) to assess optimal post-treatment surveillance testing for the detection of new primary cancer and local/regional and distant recurrence in breast, colorectal, and lung cancers. The data collection ran from April through July 2015. Data on more than 30,000 patient records were collected by registry staff, including imaging, co-morbidity, and recurrence information. Many lessons were learned through this process and will serve to inform the development of new processes.

A post-study survey was completed by more than 500 respondents who provided valuable feedback on the data items, challenges in obtaining follow-up information, and perceptions of recurrence data in the NCDB. The results from this survey confirm that registrars are invested in the future of the NCDB.  An overwhelming majority of registrars indicated their support regarding the importance of accurate recurrence data. Eighty percent of registrars responded that improving the collection of recurrence data is important to the mission of the CoC, with 53 percent calling it vital. The majority of registrars also indicated that prospective collection would facilitate the identification of patients with recurrence. If this type of data collection for recurrence were done prospectively, 69 percent of registrars indicated that recurrence data would be easier to collect, and 64 percent said outside records would be easier to obtain.

Thanks to all of your efforts, the investigators of the study can provide valuable input to the team currently working on revisions to the FORDS manual. The knowledge gained from this study, in particular with respect to recurrence data collected in the NCDB, will be important to the update of the FORDS manual.

Special study data are currently being analyzed. Results from the study will be published in the next one to two years. Study results will be shared with CoC-accredited cancer programs at that time; individual institutional results will not be shared.

We believe your dedication and hard work in this study will ultimately lead to improved treatment and care of cancer patients. Please send any additional feedback about the study to PCORIspecialstudy@facs.org.

Sincerely,

George J. Chang, MD, MS
Principal Investigator

Amanda B. Francescatti, MS
Project Manager, Cancer Programs

Caprice C. Greenberg, MD, MPH
Principal Investigator

Benjamin D. Kozower, MD, MPH
Principal Investigator

Daniel P. McKellar, MD, FACS
Chair, Commission on Cancer

David P. Winchester, MD, FACS
Medical Director, Cancer Programs

This work was supported, in part, through Patient-Centered Outcomes Research Institute (PCORI) Program Awards (CE-1304-6543; CE-1304-6855; CE-1306-00727).

News from the Oncology Community

NCRA News

Registration Open for NCRA 2016 
NCRA's 42nd annual educational conference, April 10–13 at the Westgate Resort Hotel in Las Vegas, NV, will promote the theme, A Winning Combination: Education, Networking, and Professional Development. The program has been designed to help registrars stay current with advancements and changes in the field. Several sessions will prepare registrars for the recent transition from Collaborative Stage (CS) to directly coded stage.

In addition to the plenary sessions, there are three concurrent tracks on critical subject matters, including central registry, hospital registry, and registry management. This range of topic areas will allow conference attendees to meet their individualized educational needs. More than 35 plenary and concurrent sessions are scheduled; registrars can earn over 18 continuing education credits. More detailed information, including how to register, can be found at www.ncra-usa.org/conference.

Access AJCC TNM Stage and Coding NCI-SEER Summary Stage Webinars
The National Cancer Registrars Association (NCRA) focused its 2014 and 2015 live webinars on creating high-quality training on the general rules of the American Joint Committee on Cancer (AJCC) Tumor, Node, Metastasis (TNM) Stage and the National Cancer Institute’s Surveillance, Epidemiology, and End Result Program Summary Stage as well as specific sites. NCRA has archived these webinars and created both a CD and an online product to provide registrars quick access to first-rate training on this subject. To learn more about NCRA’s training to prepare registrars for the transition from CS to directly coded stage, visit www.ncra-usa.org/transition.

2016 CTR Exam Prep Resources Available
NCRA has revised its popular study guide for the 2016 Certified Tumor Registrar (CTR) exam. Five new case studies have been added. The topics and dates for the winter 2016 online CTR Exam Prep Workshop have been determined and the online practice test has been updated to reflect changes with the 2016 exam.

New Professional Liability Insurance Program
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 for each occurrence/$6,000,000 aggregate. Members can get an instant quote for coverage online and save 5 percent by applying online.