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ACCC Members Respond to CoC’s Draft Standards

Randall Oyer, MD
July 22, 2019
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To demonstrate their delivery of comprehensive, high-quality cancer care, many cancer programs across the country seek accreditation from The American College of Surgeons Commission on Cancer (CoC).  When a program earns CoC accreditation, it is recognized for its commitment to excellence in multidisciplinary patient-centered care. The requirements to earn and maintain CoC accreditation are detailed in the Commission on Cancer’s Cancer Program Standards.  

Multiple developments are driving the rapid pace of change in cancer care. New discoveries about the biology of cancers as well as new drugs, indications, payment models, data collection and reporting requirements, and EHRs are just a few. Demonstrating quality care to all oncology stakeholders is more important than ever.

But reviewing and revising quality standards in this dynamic environment is no easy task.

Consider just the last seven years. In 2012, the CoC Cancer Program Standards were revised and updated. The addition of Chapter 3, “Continuum of Care Services,” introduced three new Standards: 3.1 Patient Navigation Process, 3.2 Psychosocial Distress Screening, and 3.3 Survivorship Care Plan.

In 2016, the CoC released a new edition of the Cancer Program Standards with further revisions.

Late last year, the CoC announced the launch of a project to “review, analyze, and improve the standards.” The goal: “to ensure that the CoC’s standards result in improvement of patient care, are clearly interpretable, and are accurately measuring the quality of a cancer program.”

Then in spring 2019, the CoC released the draft standards for public feedback. These were open for a several-week public comment period that closed on June 3. 

It’s no surprise that the CoC’s draft standards fueled a lively discussion ACCC’s members-only online discussion forum. ACCC members brought multidisciplinary perspectives to the proposed changes and encouraged one another to submit feedback to the CoC.

Although the official comment period ended in early June, ACCCBuzz asked to share a few of our members’ views on the likely real-world impact of some of the proposed changes in three areas: Cancer Registry Quality Control, Quality Improvement, and Survivorship Care Plan.

New Draft Standards 5.4, 5.5, 5.6, and 5.7 Dictating and Formatting of Operative Reports

  • The cancer registry quality control standard was due for a change. Including others (CTR, residents, advanced practice nurses, etc.) is a welcome revision. My program is fortunate to have access to a team of specialized CTRs who regularly review our abstracts, so for us this change is good.

     

  • While I appreciate the need to harmonize standards across a variety of their accreditations, the time frame the Commission on Cancer has proposed will be a burden to cancer programs. Implementation of the standards on 1/1/20 only allows around three months to mobilize members, form work groups, and change long-standing hospital and physician practices around the dictating and formatting of specific operative reports (proposed standards 5.4, 5.5, 5.6, 5.7). The use of “phase-in dates” for these proposed standards, similar to what was used during the 2012 changes, would ease our burden.

New Draft Standard 7.3 Quality Improvement

  • The Quality Improvement Standard (7.3) appears too narrow and a bit self-serving with the push to use NCDB/CQIP as the driver. The age of the data makes it frequently irrelevant, the cancer program is likely to have more pressing quality improvement needs that would bring value to patients/programs, and if you’re in compliance with most/all of them, it takes your focus away from tangible improvement to simply doing work to meet a standard. 

New Draft Standard XX Survivorship Care Plan No Longer Required

  • While I so appreciate the intent to expand the standard to ensure that survivorship is a longitudinal process and not encapsulated with the scope of one document, SCPs are the cornerstone of any good survivorship program, and it seems to me that by completely removing a standard that hundreds of organizations have spent millions of dollars to address over the last seven years is a huge mistake. . . .

     

  • My own personal opinion, after spending a lot of effort on improving our SCPs and the process by which we develop and distribute them, is that they are important. However, I think the current standard forces people to comply with a required percentage rather than looking at the value of the SCPs and their survivorship programs in general. I would like to see the college be less prescriptive regarding how we create and implement survivorship programs and encourage more efforts focused on how we improve the care we provide to cancer survivors.

     

  • Though I agree that a survivorship care plan is an important document, those of us in smaller community hospitals have struggled tremendously with achieving compliance. In a perfect world, where all oncology care is provided under one roof, and where there is a true survivorship program with nurses dedicated solely to this population, SCPs make sense. However, in the real world, we have very few, if any, employed physicians in smaller facilities. Our oncology physicians are in private practices utilizing a variety of EHRs that don't necessarily talk to one another. Many physicians are reluctant to allow navigators to access their EHR; therefore, we have to rely on the willingness and ability of their staff to provide us with records. Even when we are able to obtain all the records, create a SCP, and deliver copies of the document to the patient and provider(s), we have no way to monitor if, or how, the document was discussed with the patient. To date, I have not heard back from a single patient or practitioner indicating that the SCP was delivered in the manner it was intended.

     

  • For five years I have been trying to garner the cooperation of our physician Cancer Committee members, and though they are sympathetic to my dilemma, nothing has really changed. To improve compliance and understanding of what a SCP is, I developed a cover letter for patients and another for PCPs and oncology physicians explaining the purpose of the SCP, and that it is a requirement we need to fulfill in order to keep our CoC accreditation. The letter did not garner so much as a question from patients or practitioners. The standard is not working for us as community hospitals, and it is not working for the patients if the SCP is nothing more than a piece of paper outlining the diagnosis, treatment rendered, and potential long-term toxicities. As the standard reads at this time, navigators can develop and deliver the SCP to patients and practitioners, but then it must be discussed with the patient by a physician or advanced practitioner in a separate appointment set aside just for this purpose. So, even if we as nurse navigators were willing and able to take on this responsibility, the current and proposed revisions to the standard do not allow us to do so without advanced practitioner credentials.

On November 21, the Commission on Cancer Education Summit—2020: A Glimpse into the Future will focus on the update to the Standards. The following day, there will be half-day workshop on the data submission system and reports under the National Cancer Database’s (NCDB) new data platform, also slated for 2020. Learn more and stay tuned for updates.
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Randall A. Oyer, MD, is ACCC President-Elect and ACCC Liaison to the Commission on Cancer. Dr. Oyer is medical director of the Cancer Institute, medical director of Oncology, chair of Cancer Committee, chair of the Oncology Physicians Advisory Council, and medical director of the Cancer Risk Evaluation (Cancer Genetics) Program at Penn Medicine Lancaster General.

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