5/12/2011. 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 M. Asa Carter, CTR Manager, Accreditation and Standards 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) 2% 2% 2% 4% 17% 38% 35% COMP CHCP THCP VACP NCIP NCP Other 1

2 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Hospital Comprehensive Cancer Program Perceive increased value or importance at higher level Some requirements outdated Changes stabilize categories Similar size facilities grouped together Allows for meaningful comparison Data Services Resources Eliminate categories with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 Network Cancer Program (NCP) Integrated Network Cancer Program (INCP) Determined by program components Option of leased and joint venture facilities 6% clinical trial accrual required, 8% for commendation Same as current standards Quality of Care Metrics (CP 3 R) evaluated for each facility and overall 2

3 Teaching Hospital Cancer Program (THCP) Academic Comprehensive Cancer Program (ACAD) Reflecting program scope Post graduate medical education Minimum caseload of 500 6% clinical trial accrual required, 8% for commendation Increase from current standards NCI-designated Comprehensive Cancer Center Program (NCIP) Name retained 20% clinical trial accrual required Outstanding Achievement Award not applicable Community Comprehensive Cancer Program (COMP) Comprehensive Community Cancer Program (CCCP) Emphasizes comprehensive services Minimum caseload of 500 4% clinical trial accrual required, 6% for commendation Increase from current standards 3

4 Community Hospital Cancer Program (CHCP) Community Cancer Program (CCP) Minimum caseload of cases 2% clinical trial accrual required, 4% for commendation New required level Hospital Associate Cancer Program (HACP) 100 or fewer cases Open to smaller facilities Retain clinical trial accrual exemption, 2% for commendation Same as current standards Veteran Affairs Cancer Program (VACP) Name retained No minimum caseload Residencies optional 2% clinical trial accrual required, 4% for commendation Same as current standards 4

5 Pediatric Cancer Program & Pediatric Cancer Program Component Pediatric Cancer Program (PCP) Combined No annual caseload requirement 30% clinical trial accrual required, 40% for commendation Increase from current standards Freestanding Cancer Center Program (FCCP) Name retained but criteria changed Allows participation by facilities with only 1 treatment modality Hospital partner not required No minimum caseload Allows for increased participation by more facilities 2% clinical trial accrual required, 4% for commendation New required level and increase in commendation Transition Programs notified of new category at end of 2011 Old and new category displayed in SAR 2012 survey evaluation based on old category 5

6 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 commendation is earned at survey Also given when contingency status is resolved if 1 or more commendation earned at survey Three year Accreditation No commendations are earned at survey When program resolves Non Accreditation status 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 6

7 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 2012 Accreditation Awards Three year with Commendation Accreditation 1 or more commendation is earned at survey Will not apply when program resolves contingency status Three year Accreditation No commendations are earned at survey Applied when program resolves deficiencies regardless of commendations earned at survey When program resolves Non Accreditation status 7

8 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 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 Outstanding Achievement Award Established in 2004 All programs eligible at survey except NCIP Programs strive for excellence in providing quality cancer care Motivate other programs to improve care Target group to provide best practice examples 8

9 Accreditation Committee selects OAA criteria annually 7 or 8 standards with commendation 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 90 recipients in repeat recipients (3 consecutive surveys) 9

10 2012 Proposed Commendations Abstracting timeframe Cancer committee attendance (NEW) NCDB Data quality College of American Pathologists protocols Nursing credentials (NEW) Clinical trial accrual Registrar education Additional commendations being considered by Leadership Team Abstracting timeframe At least 95% of cases are abstracted within the 6 month timeframe each year Cancer committee attendance (NEW) Each required member attends 75% of annual meetings each year NCDB Data quality Data is error free on initial submission each year College of American Pathologists protocols 95% of pathology reports include required elements, and 95% of reports use synoptic format Nursing credentials (NEW) Achieve commendation percentage of oncology nurses employed by the facility hold the OCN credential Commendation percentage TBD by Leadership Team Clinical trial accrual Achieve commendation 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 10

11 2012 Changes ALL commendations are OAA criteria 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 3yr with Commendation used only at survey recognizes exceptional work Commendations applied to full scope of care All commendations used for OAA to recognize exceptional work during 3 year survey period Important Accreditation Facts: New Program Categories, Accreditation Awards, 11

12 Questions? Please visit the CoC s CAnswer Forum to post questions on this Webinar. The URL and log in instructions can be found in an attachment posted along with the presentation handouts. 12