Meeting CoC Standards: Chapter 2 Clinical Services

Chapter 2 Clinical Services Previously in our series outlining key requirements to meet CoC eligibility standards, we identified documentation as being the key to successfully meet Commission on Cancer (CoC) Eligibility Requirements (ER) and Chapter 1 Program Management standards. From physician credentials to public reporting of outcomes, to achieve successful accreditation, annual documentation for twelve standards is required. In today’s overview, we will be taking a look at Chapter 2 Clinical Services.

Watch the Chapter 2 Clinical Services Webinar Replay >>

Chapter 2 Clinical Services Overview

Standard 2.1 College of American Pathologists Protocols and Synoptic Reporting

The standard 2.1 states that, beginning in 2017, 95% of the eligible cancer pathology reports contain all required data elements of the CAP protocols and are structured using the synoptic reporting format as defined by the CAP Cancer Committee. The most significant change to note this year is that Standard 2.1 will no longer have accommodation rating, only compliance or non compliance.

CAP protocols are important as clinicians need a consistent and complete pathology report. By using CAP protocol templates, the same information is reported in the same way across all facilities. This allows for interpretation across facilities when patients need treatment at a different institution.

Not every case is eligible for a CAP protocol. Those eligible include pathology reports created by the program from resected specimens with a diagnosis of invasive cancer or ductal carcinoma in situ (DCIS). As AJCC is not implementing the new staging system until January 1, 2018, CAP recommends that hospitals use the current version of the CAP protocol are used (AJCC 7th Edition) through the end of the year.

Quality control review is required for this standard. This includes a minimum, random sample of 10% of eligible pathology reports or a maximum of 300; and this will depend on your caseload. The report of the review and findings are documented in the cancer committee minutes.

Standard 2.2 Oncology Nursing Care

The standard 2.2 states, oncology nursing care is provided by nurses with specialized knowledge and skills. Nursing competency is evaluated each calendar year. Results are reported to the cancer committee and documented in the cancer committee minutes. This person will be responsible for providing all documentation for this standard and reporting to cancer committee; continuing education on cancer treatment is required to maintain competency.

Educational models for Oncology Nursing Certifications include, but are not limited to Oncology Certified Nurse (OCN), Advanced Oncology Certified Nurse (AOCN), Certified Pediatric Oncology Nurse (CPON), Certified Pediatric Hematology Oncology Nurse (CPHON). Documentation for the SAR includes full time, part time and PRN.

Watch the Chapter 2 Clinical Services Webinar Replay >>

Standard 2.3 Genetic Counseling and Risk Assessment

The standard 2.3 states that cancer risk assessment, genetic counseling and genetic testing are provided to patients either on-site or by referral to a qualified genetics professionals. Genetic counseling and risk assessment must include pretest and posttest counseling.

The following statement from the NCI provides an overview and a good description of the process, “cancer risk assessment and genetic counseling is a process of communication between genetics professionals and patients with the goal of providing individuals and families with information on the relevant aspects of their genetic health, available testing and management options, and support as they move toward understanding and incorporating this information into their daily lives.”

Specialized training for cancer genetics should be ongoing; required documentation for the SAR must be uploaded each year of the survey cycle.

Standard 2.4 Palliative Care Services

The standard 2.4 states that palliative care serves are available to patients either on-site or by referral.

They must be available through a full range of services to optimize the quality of life and end of life care and provided by a multidisciplinary team. If the services are provided on site, a member of the palliative services team is a required member of the cancer committee and must meet the 75% attendance requirement.

Annually, the cancer committee defines and identifies the on-site and off-site services and also monitors, evaluates and makes recommendations for improvements. The review, discussion and recommendations are documented in the minutes.

Meeting Standards for Chapter 2 Clinical Services

To help you meet the standards in chapter two, identify an individual who will be responsible for compliance with each standard. Set up the cancer committee calendar at the beginning of each year and notify the responsible person of the date their report is due to be presented. Work with them, but do not do the work for them. If an issue is identified that could lead to non-compliance set up a subcommittee to deal with issues between the cancer committee meetings.

And as always, don’t wait until the last minute to update your SAR.

Watch the Chapter 2 Clinical Services Webinar Replay >>

Total Solution Provider to Meet Chapter 2 Clinical Services Requirements for CoC

As your total-solution cancer registry software provider, ONCO offers only the best in unparalleled customer support and innovative technology infrastructure. Learn more about ONCO’s suite of oncology solutions to navigate seamlessly through the CoC accreditation process and help your organization gain and maintain accreditation.

Contact us today at 800-604-7538 to schedule a complimentary demonstration today.

For a more in depth look at Chapter 2 Clinical Services, watch the online recording as presented by the Director of Consulting Services for Onco, Inc., Sharon Metzger, CTR.

Related blogs by Onco: