10/28/2011. Important Accreditation Facts: New Program Categories, Accreditation Awards, Commendations and the OAA

Transcription

1 Important Accreditation Facts: New Program Categories, Accreditation Awards, Robert Sticca, MD, FACS Chair, Program Review Subcommittee Commission on Cancer, Chicago, IL Cancer Program Standards 2012 Changes and Additions Redefined categories Created eligibility requirements Eliminated four standards Three standards unchanged Revised and updated 22 standards Developed new standards (5) Cancer Program Categories 2% 2% 2% 4% 17% 38% 35% COMP CHCP THCP VACP NCIP NCP Other 1

2 Cancer Program Categories Issues with current categories identified Programs able to select category based on caseload Community Hospital Cancer Program Community Hospital Comprehensive Cancer Program Perceive increased value or importance at higher level Some requirements outdated Cancer Program Categories Changes stabilize categories Similar size facilities grouped together Allows for meaningful comparison Data Services Resources Eliminate categories with limited use Affiliate Hospital Cancer Program Integrated Cancer Program Pediatric Cancer Program Component Cancer Program Categories Table of criteria by category included in Appendix A Category definition Specifies eligibility requirements Defines criteria for standards 2

3 Integrated Network Cancer Program (INCP) Former name: Network Cancer Program Assignment reflects program scope Multiple components combine to provide comprehensive care Unified cancer committee and coordinated service locations Allows for inclusion of leased and joint venture facilities 6% clinical trial accrual required; 8% for Same as current standards Quality of Care Metrics (CP 3 R) evaluated for each facility and overall NCI-designated Comprehensive Cancer Center Program (NCIP) Name retained Assignment reflects program scope Designated Comprehensive Cancer Center by NCI May participate in post graduate medical education May be associated with a medical school Optional to complete SAR to participate in CoC Hospital Locator Exempt from some standards because of requirements by other agencies 20% clinical trial accrual required; level yet to be determined Academic Comprehensive Cancer Program (ACAD) Former name: Teaching Hospital Cancer Program Assignment reflects program scope Post graduate medical education Minimum annual analytic caseload is 500 Most diagnostic and treatment services provided on-site; some services referred 6% clinical trial accrual required; 8% for Increase from current standards 3

4 Veteran Affairs Cancer Program (VACP) Name retained Assignment reflects facility type Specific to VA facilities No minimum caseload Residencies optional Services available on-site or by referral Referral to CoC-accredited facility preferred 2% clinical trial accrual required; 4% for Same as current standards Comprehensive Community Cancer Program (CCCP) Former name: Community Hospital Comprehensive Cancer Program Assignment reflects program scope Emphasize comprehensive services Minimum annual analytic caseload is 500 4% clinical trial accrual required, 6% for Increase from current standards Community Cancer Program (CCP) Former name: Community Hospital Cancer Program Assignment reflects program scope Referral for diagnostic and/or treatment services is common Minimum annual analytic caseload is % clinical trial accrual required; 4% for New required level and increase for 4

5 Hospital Associate Cancer Program (HACP) Name retained Assignment reflects program scope Limited diagnostic and/or treatment services available on-site; referral very common 100 or fewer annual analytic cases Participation open to much smaller facilities Retain clinical trial accrual exemption; 2% for Same as current standards Pediatric Cancer Program (PCP) Combined category: Pediatric Hospital Cancer Program Pediatric Component Cancer Program Assignment reflects facility type and/or program scope Children s Hospital Children s component of an adult facility No minimum caseload required Diagnostic and treatment services for children are available on-site or by referral 30% clinical trial accrual required; 40% for Increase from current standards Freestanding Cancer Center Program (FCCP) Name retained Assignment reflects facility type Non-hospital facilities offering 1 or 2 treatment modalities Diagnostic and other treatment services available by referral No minimum caseload required Hospital partner not required 2% clinical trial accrual required; 4% for New required level and increase in 5

6 Cancer Program Categories Transition Programs notified of new category at end of 2011 Old and new category displayed in SAR 2012 survey evaluation based on old category Accreditation Awards Current awards Three year with Commendation Accreditation Three year Accreditation Three year with Contingency Accreditation Deferred Accreditation Non Accreditation Accreditation Awards Three year with Commendation Accreditation 1 or more is earned at survey Also given when contingency status is resolved if 1 or more earned at survey Three year Accreditation No s are earned at survey When program resolves Non Accreditation status 6

7 Accreditation Awards Three year with Contingency Accreditation 1 7 deficiencies given at survey Deferred Accreditation A new program with 1 deficiency at survey Non Accreditation 8 or more deficiencies given at survey Failure to resolve deficiency status Select standard can be resolved by working with CoC staff to regain Accreditation Percentage Distribution of Accreditation Awards Following Survey, Percent Full Accreditation /C Other* Accreditation Award *Non Accreditation, Deferred Accreditation Awards 2012 Accreditation Awards Three year with Commendation Accreditation Three year Accreditation Three year with Contingency Accreditation Non Accreditation 7

8 2012 Accreditation Awards Three year with Commendation Accreditation 1 or more is earned at survey Will not apply when program resolves contingency status Three year Accreditation No s are earned at survey Applied when program resolves deficiencies regardless of s earned at survey When program resolves Non Accreditation status 2012 Accreditation Awards Three year with Contingency Accreditation 1 7 deficiencies given at survey New program with 1 or 2 deficiencies in Program Management (12 months to resolve) Non Accreditation 8 or more deficiencies given at survey Failure to resolve deficiency status Select standard(s) can be resolved by working with CoC staff to regain Accreditation Commendations Created in 2004 Recognizes consistent exceptional performance for certain standards Can be earned for 1 or more standards 8

9 Outstanding Achievement Award Established in 2004 Programs strive for excellence in providing quality cancer care Motivate other programs to improve care Target group to provide best practice examples Accreditation Committee selects OAA criteria annually 7 or 8 standards with Recipients confirmed when all surveys completed Current criteria 2.11 Outcomes analysis 3.3 Abstracting timeliness 3.7 Data quality 4.6 CAP protocols 5.2 Clinical trial accrual 6.2 Screening and early detection programs 8.2 Quality improvements Trends of Annual Surveys to Outstanding Achievement Award Recipients, Surveys % 19% 17% 9% 9% 9% 14% Surveys OAA 9

10 90 recipients in repeat recipients (3 consecutive surveys) 2012 Commendations Standard 1.3 Cancer committee attendance (NEW) Standard 1.9 Clinical trial accrual Standard 1.11 Registrar education Standard 1.12 Public reporting of outcomes Standard 2.1 College of American Pathologists protocols Standard 2.2 Nursing credentials (NEW) Standard 5.2 Abstracting timeframe Standard 5.6 NCDB Data quality Cancer committee attendance (NEW) Each required member attends 75% of annual meetings each year Clinical trial accrual Achieve rate for category each year Registrar education All CTR staff attend regional or national meeting during 3 year cycle, and all registry staff participate in education annually Public reporting of outcomes Cancer committee develops report of patient or program outcomes annually Only for 10

11 College of American Pathologists protocols 90% of pathology reports include required elements, and 95% of reports use synoptic format Nursing credentials (NEW) 25% of chemo-trained nurses employed by facility are oncology certified. Abstracting timeframe At least 95% of cases are abstracted within the 6 month timeframe each year NCDB Data quality Data is error free on initial submission each year 2012 Changes Inclusions ALL s are used Exclusions NCIP facilities not eligible for OAA New programs not eligible for OAA at initial survey Summary Category changes more clearly define facilities Stabilize comparison groups New programs can be accredited with 1 or 2 deficiencies 3 yr with Commendation used only at survey recognizes exceptional work Commendations applied to full scope of care All s used for OAA to recognize exceptional work during 3 year survey period 11

12 Important Accreditation Facts: New Program Categories, Accreditation Awards, Questions? 12