TApT Frequently Asked Questions

Any CoC accredited program that is interested in participating in this project is encouraged to do so. The “Intent to participate survey” can be found on the project website and is due by February 15. Completion of the survey link ensures your participation.

Please be aware of some participation requirements:

• Must have completed >10 TURBT procedures in calendar year 2024
• Must have pharmacy on site OR access and ability to provide intravesical chemotherapy instillation with gemcitabine or mitomycin within 24 hours or procedure 
• Be willing/able to review reports or charts to identify patients that have undergone a TURBT in the specified time frame.
• Current BLCT1 measure  ≤90%
• Must have support of cancer committee and pharmacy (if available)

We do not recommend participation for programs that are at or above 90% compliance with BLCT1. This would leave very little room for improvement and the amount of time and effort spent for this project may not result in much progress for your program. However, if you want to share your best practices or tips for how your program is achieving such success, please reach out to cancerqi@facs.org.

If your program does not have a pharmacy on site, and you do not have a partnership or ability to obtain pharmacy services within 24 hours of the procedure, this project is not a good fit. If you’d like to discuss this further, please reach out to cancerqi@facs.org.

At least one member from each team is required to attend or listen to the recording after the call. While it is not a requirement that all QI team members attend every call, it is encouraged. 

This project collects data on all patients undergoing TURBT procedure that fit eligibility criteria for quality measure BLCT1 (see below).

We will also collect a brief pre, mid, and post survey to better understand implementation strategies, barriers, and successes. We will also ask your team to complete a current state process map, root cause analysis, and future state workflow over the course of the project. More information and templates for completing these PI tools will be provided over the course of the project.

You must submit all patients, within the specified time frame (or 20% of the population you serve if over 20 patients per time period), that underwent a TURBT.

You do not need to abstract data concurrently, but you will need to conduct a retrospective chart review or pull data via a specific report to ensure inclusion of patients. Non-PHI will be entered into REDCap via a web link sent to the primary contact.

REDCap is a data collection tool that can be accessed online to complete your data.

No. The software is accessed through a link on the project web page and completed online. This secure database is unique to the American College of Surgeons and does not require any downloads or IT interface with your systems. You will not need IT permissions or admin rights to access the program.

No, though it is strongly encouraged that the team discuss the qualitative points in the questionnaire prior to completing. A primary contact is required, and the email associated with this primary contact will be the one used to communicate about the project and access subsequent questionnaires. If this individual leaves or needs to be changed, you will need to contact cancerqi@facs.org to change the primary contact in the REDCap for your program.

No. Patients will not sign a participation agreement or a consent. We are not gathering any patient identifying data.

Please contact cancerqi@facs.org and specify which form you need to update. You will be provided with a survey link and an access code to make the necessary changes.
Each form is assigned a unique access code. If you need to update multiple forms, a separate code will be provided for each.

In general, if any component of care is delivered within your facility where processes, staffing, or systems can be guided or improved the patient may be appropriate for inclusion. Conversely, if there is no operational control or influence over key aspects of care (e.g., nursing, pharmacy, or treatment delivery), the patient should not be included.

Administration of BCG immediately following surgery is uncommon. In most cases, BCG represents a planned postoperative treatment regimen, typically initiated one week or more after TURBT. This scenario falls outside the scope of the QI project and would not be included.

The aggregate size is appropriate to include.

Yes, the case should still be considered. At the time of the procedure, and within the 24-hour window for IVC administration, final pathology results are typically not yet available. Therefore, IVC would generally still be considered. If the surgeon determines that IVC is not appropriate based on clinical judgment, this decision and its rationale should be documented in the synoptic report. In such cases, omission of IVC would not be counted against performance, as it reflects appropriate clinical decision-making.

No, “papillary urothelial carcinoma” is considered part of the standard low-grade urothelial carcinoma classification and should not be categorized as a variant histology. Variant histologies refer to the subtypes of squamous cell, sarcomatoid, plasmacytoid, adenocarcinoma, micropapillary, and neuroendocrine / small cell carcinoma. Therefore “Other Variant Histology” should not be selected in this case.

This would typically be after a patient leaves the OR, or once they arrive in recovery. It may depend what is documented.

This should be answered from a clinical perspective at the time of the procedure.

The intention was to reflect billing/coding practices.

Each TURBT should be documented on separate case forms. If one patient has two TURBTS, then two data forms will be submitted.

If there is no documentation indicating an issue, and no documentation that there is reason to suspect one, questions on the case form regarding involvement may be answered “no” rather than “unknown.”

Yes, a “complete resection” or “resection to base” can be considered a resection to muscle.

You need to complete the intent to participate survey by February 15. Complete the form. Completion of this form ensures automatic participation. Please save the Date for March 13 at 11 am CT for a kickoff call. A link to register for this kickoff call will be sent to the listed primary contact. Documentation indicating your participation will be given to you by the end of the year and you will upload an attestation form certifying your full participation by December 2026. You will need to provide status updates/documentation in meeting minutes programs progress to the cancer committee. It is encouraged that you complete the 7.3 reporting template, but is not required. 

If you leave the project before all data cycles have been submitted and all cohort calls have been conducted, you will need to identify a different QI project for the year and will not receive credit for participation. You will need to follow all requirements of the 7.3 QI standard. 

Yes, we encourage participation by programs working toward their first accreditation as long the application for accreditation has been submitted and an ID number has been issued. This will be a Facility Identification Number (FIN). This Identification Number is a required field in the initial Intent to Participate.

Yes, participation in this project and completing requirements may be counted toward a deficiency resolution for standard 7.3. It may not be applied to an unrelated standard. 

No. You simply need to upload the attestation form at the end of the calendar year. This form is sent out by cancerqi@facs.org following receipt of all data cycles. It is strongly encouraged you also save copies of the data you submitted and any other QI worksheets, RCA documents, or correspondence from the project. These will need to be uploaded to demonstrate your 2026 compliance in your Pre-Review Questionnaire (PRQ) during the year of your next site visit. Although sites do not need to complete the template, they may find it beneficial for summarizing the project and tracking the updates to the cancer committee

For Network Accreditations (INCP/NCIN) this project is done at the child level only. A second QI project including all sites would need to be done.