Standards and Conference Flashcards
Which statement is true regarding the CoC survey process?
A. The survey process is the same for all facilities.
B. Surveyors are employees of the CoC.
C. The cancer program team is allowed to respond to program deficiencies only following the conclusion of the site visit.
D. The process differs depending on the type of facility being surveyed.
D. The process differs depending on the type of facility being surveyed.
What type of Commission on Cancer (CoC) accreditation award is given to a new program rated deficient in 1 standard?
A. Three-Year Accreditation
B. Three-Year Accreditation with Contingency
C. Non-accreditation
D. None of the above
B. Three-Year Accreditation with Contingency
How long does an established cancer program have to resolve a Commission on Cancer (CoC) deficiency if it received a “Three-Year Accreditation with Contingency” award following a survey?
A. 12 months
B. 9 months
C. 6 months
D. 1 month
A. 12 months
How long is the CoC accreditation cycle?
Three years
Who assures the cancer program’s compliance with the standards and readiness for survey at any time?
A. The cancer liaison physician.
B. The cancer committee.
C. The CTR.
D. The cancer committee chair.
B. The cancer committee.
How often does the cancer committee assess the cancer program’s performance?
A. Annually.
B. Every three years.
C. Every six months.
D. Assessment is ongoing.
D. Assessment is ongoing.
Who appoints the key contact for the accreditation survey?
The cancer committee
Who coordinates the arrangements and preparations for the on-site visit?
A. The cancer program administrator
B. The key contact
C. The consultant team
D. The cancer liaison physician
B. The key contact
A CTR can be a member of the CoC-trained Cancer Program Consultant Team to help facilities establish and grow the cancer program.
True or False?
True
What should a cancer program do if there have been changes to its program or program staff during the 3-year accreditation cycle?
A. Nothing should be done as long as the program is still in compliance.
B. Contract a CoC consultant to perform a program assessment to avoid any deficiencies.
C. Apply for a postponement of their next on-site visit.
D. None of the above.
B. Contract a CoC consultant to perform a program assessment.
The CoC provides an initial survey notification to the cancer registrar at each program due for survey by what date of the year before the survey?
July 1
How much time does the on-site visit require?
A. One day (6 hours)
B. Two or more days for Network Cancer Programs.
C. Half a day (3 hours)
D. Both A and B
D. Both A and B
The on-site survey is
A. Evaluative
B. Educational
C. Both A and B
D. For information gathering only
C. Both A and B
Each year, the cancer committee reviews the performance measure data for cases of breast and colon cancer that are displayed in the CoC’s ______ report.
CP3R
Which inpatient unit must be part of the facility tour?
Medical oncology or its equivalent
To assess timeliness of abstracting, ____ abstracts in total are selected from the 3-year accreditation period and reviewed.
30
How many pathology reports are selected for review during the accreditation survey?
30
Within ___ weeks after the survey, the cancer program team meets to discuss the survey experience and complete the online post survey evaluation form.
2
To be accredited by the CoC, a program must be in compliance with at least ____% of the standards.
80%
A program surveyed by the CoC will be awarded one of three levels of accreditation. What are they?
Full Accreditation
Accreditation with Contingency
Nonaccreditation
What accreditation do established programs with fewer 1-7 deficiencies, or new programs with 1-2 deficiencies receive?
Accreditation with Contingency
What accreditation do established programs with 8 or more deficiencies, or new programs with 3 or more deficiencies receive?
Nonaccreditation
What accreditation does a program, established or new, receive when there are no deficiencies?
Full (3-year) Accreditation
How long does a cancer program have to resolve deficiencies and receive a full 3-year accreditation?
12 months
A new program that is not yet accredited, and is found to have only 1 deficiency will receive Accreditation Deferred status. What does this allow the program to do?
Resolve the deficiency and receive accreditation without a resurvey.
A program that receives Nonaccreditation is encouraged to make corrections to their program and reapply for another survey at a future time.
True or False?
True
A program can appeal its Accreditation Award for up to ____ days after distribution of the Accredited Cancer Program Performance Report.
30
Who reviews and confirms the Accreditation Award for each appeal that is submitted?
A. The cancer committee
B. The Program Review Subcommittee
C. The surveyors who performed the on-site visit.
D. A CoC-trained Cancer Program Consultant
B. The Program Review Subcommittee
CoC-accredited programs provide care to approximately ____% of newly diagnosed cancer patients each year, while representing only ____% of the acute care hospitals in the US and Puerto Rico.
80%, 25%
____ cases are presented at the cancer conference at the time of initial diagnosis with an emphasis on accurate staging and treatment options.
Prospective
_____ cases are discussed at the cancer conference after completion of all treatment, primarily for the purpose of education.
Retrospective
The CoC requires facilities to present cases based on
A. Most common site diagnosed at the facility in the last 12 months
B. The five major sites seen at the facility.
C. Sites chosen by the conference coordinator.
D. Sites chosen by the Cancer Liaison Physician.
B. The five major sites seen at the facility
The frequency of the cancer conference is based on
A. The CoC requirement of one conference per month.
B. The category of the program.
C. The number of cases required for presentation.
D. Both B and C
D. Both B and C
The cancer committee must document the established frequency of the cancer conference in the _______
Committee minutes
Physicians from which five specialties are required to be present at the cancer conference?
Surgery, Medical Oncology, Radiation Oncology, Diagnostic Radiology, Pathology
The cancer committee is required to record cancer conference attendance in the _____
Committee minutes
The CoC requires documentation of cancer conference discussions.
True or False?
False.
Who has a pivotal role in the process of creating and carrying out effective cancer conference plans?
A. The CTR
B. The Cancer Liaison Physician
C. The Cancer Committee Coordinator
D. The CoC
A. The CTR
Who is allowed to serve as an alternate for the cancer committee chair?
A. The CTR
B. The Cancer Liaison Physician
C. The Quality Coordinator.
D. Any of the above.
B. The Cancer Physician Liaison
What two cancer program coordinator positions may be held by a CTR?
Cancer Conference Coordinator
Cancer Registry Quality Coordinator
How often is the cancer committee required to meet?
A. Annually.
B. Quarterly.
C. Every 6 months.
D. Monthly.
B. Quarterly
Required physicians, allied health personnel, and cancer committee coordinators, or their alternate, must attend _____% of cancer committee meetings each calendar year.
A. 100%
B. 75%
C. 50%
D. 25%
B. 75%
Who informs the cancer committee about cancer conference activity?
Cancer Conference Coordinator
What percent of a facility’s annual caseload must be presented at the cancer conference?
15%
At least _____% of cases presented at a cancer conference must be prospective.
80%
Hospitals must be accredited by the following recognized authorities to achieve CoC accreditation.
A. The Joint Commission
B. State licensing authority
C. American College of Radiology
D. Any of the above.
B. State licensing authority
An approved cancer program has to include a full range of services to______ cancer patients.
A. Prevent, diagnose, follow and refer.
B. Prevent, diagnose, treat, rehabilitate, and follow.
C. Prevent, diagnose, treat, follow, and refer.
D. Prevent, diagnose, treat, follow, and counsel.
B. Prevent, diagnose, treat, rehabilitate and follow.
For services not available on site, the hospital must
A. Refer patients to other hospitals.
B. Find services for the patient at other hospitals.
C. Have a documented referral process in place.
D. None of the above.
C. Have a documented referral process in place.
To obtain CoC accreditation, what minimal (4) cancer program resources need to be in place?
Cancer Committee,
Cancer Conference,
Quality Management Program,
Cancer Registry
The quality of the cancer registry is monitored by
A. Medical staff
B. Cancer liaison physician
C. Cancer registrar
D. Cancer committee
D. Cancer committee
A _________ cancer program accessions more than 100 but less than 500 new analytic cases yearly; participates in cancer related research, and offers a full range of diagnostic and treatment services on site or by referral.
A. Comprehensive Community
B. Community
C. Integrated Network
D. Free Standing
B. Community
A ______ cancer program where multiple facilities provide care, at least one of which is a CoC-accredited facility; each facility must meet CoC standards; generally has one registry and one cancer committee.
A. Comprehensive Community
B. Hospital Associate
C. Integrated Network
D. NCI Designated Comprehensive Cancer Center
C. Integrated Network
A ______ cancer program accessions more than 500 new analytic cases yearly; participates in cancer-related research; offers a full range of diagnostic and services on site or by referral.
A. Community
B. Comprehensive Community
C. Integrated Network
D. NCI Designated Network
B. Comprehensive Community
A ______ cancer program is non-hospital based with at least one cancer treatment mode; refers to a CoC-accredited facility; clinical research is encouraged but not required; has no minimum caseload of new analytic cases.
A. Free-standing
B. Hospital Associate
C. Community
D. Pediatric
A. Free-Standing
A ______ cancer program accessions less than 100 new analytic cases annually, and offers a limited range of diagnostic and treatment services.
A. Community
B. Free-Standing
C. Hospital Associate
D. NCI Designated Network
C. Hospital Associate
A _____ cancer program includes at least 4 postgrad medical education residencies; accessions 500 or more new analytic cases yearly; participates in cancer related research; offers a full range of diagnostic and treatment services on site or by referral.
A. NCI-Designated Comprehensive
B. Hospital Associate Cancer Program
C. Academic Comprehensive
D. Integrated Network
C. Academic Comprehensive
Once the site visit has taken place, the PRQ will close _____
A. For six months.
B. Permanently.
C. For one year.
D. Until the survey has been reviewed and an accreditation decision has been made.
B. Permanently
What is a characteristic(s) of a Veterans Affairs Cancer Program (VACP)?
A. Participation in the training of resident physicians is required.
B. The facility can participate in cancer-related clinical research by enrolling patients in cancer-related clinical trials through a physician’s office.
C. Both (A) and (B)
D. Neither (A) nor (B)
B. The facility can participate in cancer-related clinical research by enrolling patients in cancer-related clinical trials through a physician’s office.
Who can approve cancer-related research studies eligible for accrual?
A. Cancer Committee
B. External Institutional Review Board
C. Internal Institutional Review Board
D. Both (B) and (C)
D. Both B and C
The PRQ closes ______ the on-site visit.
A. Two weeks after.
B. Two weeks before.
C. The day of.
D. 48 hours after.
B. Two weeks before.
In regard to the CoC Standards, what does EPR mean?
Estimated Performance Rate
Who determines the cutoff scores used to identify distressed patients per the psychosocial distressed screening tool?
A. Cancer Committee Chair
B. Cancer Liaison Physician
C. Psychosocial Services Coordinator
D. Cancer Committee
D. Cancer Committee
What type of CoC Quality Measure is used to generate information for decision making, and/or to monitor patterns and trends of care?
A. Accountability
B. Assessment
C. Quality Improvement
D. Surveillance
D. Surveillance
Who evaluates the policy and procedures to ensure oncology nursing competency is reviewed annually per the facility policy in the PRQ?
A. Chief Nursing Officer
B. Director of Nursing
C. Hospital Administrator
D. Cancer Committee
D. Cancer committee
Where are the CLP (Cancer Liaison Physician) Reports found?
A. Committee minutes
B. Attachment to the committee minutes
C. Cancer conference minutes
D. Both A and B
D. Both A and B
When should the Letter of Authority be written for a facility?
A. Annually
B. At least once each accreditation cycle
C. Immediately after receiving the three year accreditation award
D. A month prior to the on-site visit
B. At least once each accreditation cycle
Where must the compliance for Physician Credentials be documented?
A. In the PRQ
B. In the committee minutes
C. Both A and B
D. In the letter of authority
C. Both A and B
At a minimum, how many times per year are quality performance rates reviewed by the cancer committee?
A. Once.
B. Twice.
C. Four times.
D. There is no minimum.
B. Twice.
Standards ___ through ___ were developed from guidelines described in
Operative Standards for Cancer Surgery (OSCS).
5.3 through 5.8
A member of the cancer committee confirms the agenda for the survey at least _____ days before the on-site visit.
14
The facility completes or updates the PRQ at least _____ calendar days before the scheduled on-site visit.
30
What is the primary source of of documentation of cancer program activity?
The cancer committee minutes
Accreditation status notifications are distributed within 45 days of the survey’s completion. How are they delivered?
A. Certified mail
B. Email
C. Telephone
D. All of the above
B. Email
To be considered for initial accreditation, the cancer committee is required to ensure clinical services, the cancer committee itself, cancer conference, and a quality management program have been in place at the facility for ______
A. Two years.
B. Six months.
C. A year.
D. Three years.
C. A year
The annual assessment of a cancer program’s eligibility requirements is carried out by the _____ and documented in the _____.
Cancer committee
Cancer committee minutes
Who is responsible for establishing a registry reference date and ensuring the registry database includes complete data and follow up activity?
A. The CTR
B. Cancer committee
C. HIM department
D. Cancer Registry Coordinator
B. Cancer committee
Who is responsible for completing the online application for accreditation and designating a main contact for the cancer program?
A. The CTR.
B. The Cancer Registry Coordinator.
C. The Cancer Committee.
D. The Cancer Liaison Physician
C. The Cancer Committee
The cancer committee must be chaired by _____
A. A CTR
B. A physician of oncology
C. A physician of any specialty
D. The Cancer Program Administrator
C. A physician of any specialty
What are the 7 REQUIRED physician members of the cancer committee?
Medical Oncologist, Radiation Oncologist, Surgeon, Pathologist, Diagnostic Radiologist, Cancer Liaison Physician, Cancer Committee Chair
What are the 4 REQUIRED NON-physician members of the cancer committee?
(CCOS)
Cancer Program Administrator,
Certified Tumor Registrar,
Oncology Nurse,
Social worker
An individual cannot serve in more than one coordinator role per year.
True or False?
True
Each calendar year, the _____ appoints all required cancer committee coordinators for a ____ year term.
Cancer committee
One calendar
The ______ is responsible for monitoring the Cancer Conference activity.
A. CTR
B. Cancer Committee
C. Cancer Liaison Physician
D. Cancer Conference Coordinator
D. Cancer Conference Coordinator
A CTR can serve as the Cancer Conference Coordinator.
True or False?
True
At least once annually, the ______ reports all cancer conference activity to the cancer committee and recommends corrective action if needed.
A. Cancer Liaison Physician
B. CTR
C. Cancer Conference Coordinator
D. Quality Coordinator
C. Cancer Conference Coordinator
Where can the Cancer Conference Coordinator’s evaluation of the Cancer Conference be found?
A. Cancer Committee minutes.
B. Cancer Conference minutes.
C. Conference Quality Report.
D. Both A and B.
B. Cancer Conference minutes.
How often does the Cancer Conference Coordinator monitor and evaluate the activity of the Cancer Conference?
A. Quarterly.
B. Bi-annually.
C. Annually.
D. Once per accreditation cycle.
C Annually.
The mechanism for evaluating and improving patient outcomes is called ______
A. Quality improvement
B. Quality control
C. Quality assurance
D. Quality evaluation
A. Quality improvement
A cancer registrar can serve as the Quality Improvement Coordinator.
True or False?
False. A CTR cannot serve as the Quality Improvement Coordinator (but CAN serve as the Cancer Registry Quality Coordinator.)
Quality improvements made in the cancer program are documented in the _____ and shared with medical staff and administration.
A. Cancer Conference minutes.
B. Cancer Committee minutes.
C. Quality Improvement Report
D. Both A and C
B. Cancer Committee minutes
A CTR can serve as the Cancer Registry Quality Coordinator.
True or False?
True.
This coordinator monitors the prevention and screening activities of a cancer program.
A. Cancer Registry Quality Coordinator
B. Quality Improvement Coordinator
C. Community Outreach Coordinator
D. Prevention and Screening Program Coordinator
C. Community Outreach Coordinator
Which member of the Cancer Committee is responsible for tracking patients enrolled in clinical trials?
A. CTR
B. Clinical Research Coordinator
C. Cancer Liaison Physician
D. Outcomes Coordinator
B. Clinical Research Coordinator
The CoC standards constitute a standard of care.
True or False?
False. They are qualifications for accreditation.
There are approximately _____ CoC-accredited cancer programs in the US and Puerto Rico.
1,500
A Standard 7.3 Quality Improvement Initiative project or Standard 7.4 Cancer Program Goal that extends into a second year will only count
A. For the second year.
B. For the year it is initiated.
C. For both years.
D. For the year the cancer committee chooses.
B. For the year it was initiated.
Ratings for each standard are assigned based on consensus by the cancer program’s site reviewer and
A. The cancer committee.
B. The Cancer Liaison Physician.
C. CoC staff.
D. Cancer program coordinator.
C. CoC staff.
The Cancer Committee Chair must be
A. A physician of any specialty.
B. A medical oncologist.
C. An oncology nurse.
D. Any of the above.
A. A physician of any specialty.
What happens to the requirement for a radiation oncologist member of the cancer committee if all radiation oncology services are provided by referral and the facility does not have a radiation oncologist on staff?
A. A cancer committee cannot be formed.
B. A non-staff radiation oncologist is required.
C. The requirement becomes a recommendation.
D. The facility has three years to make on-site radiation oncology services available.
C. The requirement becomes a recommendation.
Who has budget authority for the cancer program?
A. CTR.
B. Cancer Liaison Physician.
C. Cancer Program Administrator.
D. Cancer Committee Chair.
C. Cancer Program Administrator.
What are the 6 required coordinator members of the Cancer Committee?
(3 C’s, PQS)
Cancer Conference Coordinator Cancer Registry Quality Coordinator Clinical Research Coordinator Psychosocial Services Coordinator Quality Improvement Coordinator Survivorship Program Coordinator
Which coordinator is responsible for overseeing Standard 2.5: Multidisciplinary Cancer Conference?
Cancer Conference Coordinator
Which coordinator is responsible for overseeing Standard 7.3: Quality Improvement Initiative?
Quality Improvement Coordinator
Which coordinator is responsible for overseeing Standard 6.1: Cancer Registry Quality Control and Standard 4.3: Cancer Registry Staff Credentials?
Cancer Registry Quality Coordinator
Which coordinator is responsible for overseeing Standard 9.1: Clinical Research Accrual?
Clinical Research Coordinator
Which coordinator is responsible for overseeing Standard 5.2: Psychosocial Distress Screening?
Psychosocial Services Coordinator.
Which coordinator is responsible for overseeing Standard 4.8: Survivorship Program?
Survivorship Program Coordinator
What are the 8 STRONGLY RECOMMENDED but not required members of the cancer committee?
(AGPPPRRS)
American Cancer Society rep Genetics Palliative Care Pastoral care Pharmacist Registered dietitian Rehabilitation Specialty physicians representing the 5 major cancer sites at the program.
Who is considered the physician quality leader of the cancer committee?
The Cancer Liaison Physician
The CLP must identify, analyze, and present NCDB data pertinent to the cancer program to the cancer committee at a minimum of ____ meetings per calendar year.
2
What must be used for the basis of the CLP reports?
Data from the NCDB.
CLP reports documented in the ____
A. Cancer committee minutes.
B. An attachment to the cancer committee minutes.
C. Both A and B.
D. Cancer Conference minutes.
C. Both A and B
Which cancer committee member must attend the CoC site visit and meet with the reviewer to discuss the cancer program?
The Cancer Liaison Physician
It is recommended that cancer committee meetings be scheduled in which month of each quarter?
A. First.
B. Second.
C. Third.
D. There is no recommendation.
A. First
Does the CoC site visit qualify as one of the required quarterly meetings of the cancer committee?
No.
Each calendar year, who monitors and evaluates the multidisciplinary cancer case conference activity and reports the findings to the cancer committee?
Cancer Conference Coordinator
Which coordinator performs an annual evaluation of cancer conference frequency, conference attendance, number of cases, and percentage of prospective cases and reports their findings to the cancer committee?
Cancer Conference Coordinator
The method to document multidisciplinary cancer conference activity is left to the discretion of the cancer committee.
True or False?
True.
During the on-site review, the surveyor will attend a multidisciplinary cancer conference.
True or False?
True
If licensure of a facility is not required by the state, the facility
A. May not become CoC accredited.
B. Has this standard waived.
C. Must be accredited or licensed by a recognized federal, state, or local authority instead.
D. May become CoC accredited after a waiting period.
C. Must be accredited or licensed by a recognized federal, state, or local authority instead.
According to Standard 3.2, a cancer program must provide diagnostic imaging services, radiation oncology services, and systemic therapy services
A. On site only.
B. By referral.
C. On site or by referral.
D. None of the above.
C. On site or by referral.
Quality assurance practices must be in place and submitted in the PRQ for all required cancer treatment services available
A. On site.
B. By referral.
C. Both A and B.
D. None of the above.
A. On site.
If a nurse providing direct oncology care is not certified then the nurse
A. Must complete 36 cancer related continuing education contact hours each year.
B. Must complete 36 cancer related continuing education contact hours every accreditation cycle.
C. May only provide supportive care, not direct care.
D. Obtain certification prior to the next accreditation cycle.
B. Must complete 36 cancer related continuing education contact hours every accreditation cycle.
Standard 4.2: Oncology Nursing Credentials does not apply to
A. Registered nurses with more than 10 years of general nursing experience.
B. Nurses who have occasional contact with cancer patients.
C. Operating room or recovery nurses.
D. B and C.
D. B and C
Physicians’ credentials and oncology nurses’ credentials are reviewed each
A. Year.
B. Accreditation cycle.
C. Quarter.
D. Semi-annually.
A. Year.
Each _____non-CTR members of the cancer registry staff must demonstrate completion of 3 hours of cancer-related continuing education.
A. Year.
B. Calendar year.
C. Accreditation cycle.
D. Quarter.
B. Calendar year.
Each _____, the cancer committee monitors, evaluates, and makes recommendations for improvements to palliative care services. The evaluation is documented in _______
A. Calendar year, PRQ.
B. Calendar year, committee minutes.
C. Quarter, committee minutes.
D. Quarter, conference minutes.
B. Calendar year, committee minutes.
All physicians involved in the evaluation and management of cancer patients must
A. Be board certified.
B. Be board certified and demonstrate 12 cancer-related CME hours per calendar year.
C. Be board certified or demonstrate 12 cancer-related CME hours per calendar year.
D. None of the above.
C. Be board certified or demonstrate 12 cancer-related CME hours per calendar year.
What is true about Standard 4.1 Physician Credentials?
A. They only apply to physicians who are in fellowship or residency.
B. They only apply to physicians who are involved in the care of cancer patients at the facility for at least one calendar year.
C. They only apply to physicians within the first 5 years immediately following graduation from residency.
D. Both A and B
B. They only apply to physicians who are involved in the care of cancer patients at the facility for at least one calendar year.
All registered nurses and advanced practice nurses providing direct oncology care must demonstrate which of the following:
A. Current cancer specific certification in the nurses specialty by an accredited certification program.
B. Ongoing education by earning 36 cancer related continuing education nursing contact hours each accreditation cycle.
C. A and B
D. A or B
D. A or B
Nurses in the process of obtaining a cancer specific certification must provide
A. Documentation of cancer related continuing education.
B. Documentation of progress toward certification.
C. Both A and B
D. None of the above
B. Documentation of progress toward certification
Palliative care services must be available to patients
A. On site.
B. By referral.
C. On site or by referral.
D. Only at the patient’s request.
C. On site or by referral.
Rehabilitation care services must be available
A. On site.
B. On site or by referral.
C. On site and by referral.
D. None of the above.
B. On site or by referral.
Who develops a survivorship program team?
A. Cancer committee.
B. Survivorship Program Coordinator.
C. Cancer Liaison Physician.
D. Cancer program administrator.
B. Survivorship Program Coordinator
Who determines a list of survivorship services and programs available on site or by referral?
A. Survivorship Program Coordinator.
B. Survivorship Program Team.
C. Cancer Program Administrator.
D. Cancer Committee.
B. Survivorship Program Team.
A minimum of _____ survivorship services must be offered each year.
3
Delivery of a survivorship care plan to patients is a required component of the Survey Program under Standard 4.8.
True or False.
False. Delivery of a survivorship care plan to patients is recommended but not required.
What percentage of pathology reports must be structured using the synoptic reporting format as defined by the CAP cancer protocols?
90%
Per Standard 5.2, how many times must a cancer patient be screened for distress during the patient’s first course of treatment?
Once
How often does the Cancer Registry Quality Coordinator evaluate cancer registry activity and report their findings to the cancer committee?
At least annually.
What is the nationwide oncology outcomes database used as a clinical surveillance mechanism to monitor changes and variations in patterns of cancer care and patient outcomes?
NCDB
Who monitors the resolution and resubmission of problematic cases rejected by the NCDB’s Annual Call for Data?
The cancer committee.
What enables accredited cancer programs to report data on patients concurrently and receive notifications of treatment expectations?
A. Annual Call for Data.
B. Rapid Cancer Reporting System.
C. Edit Report.
D. Both A and B
B. Rapid Cancer Reporting System
A CoC-accredited cancer program’s participation in RCRS submissions throughout the accreditation cycle is
A. Recommended.
B. Required.
C. At the discretion of the Cancer Program Administrator.
D. A and C
B. Required.
RCRS data and required quality measure performance rates are reviewed by the cancer committee at least _____ per calendar year, and are documented in the cancer committee minutes.
Twice
For all eligible cases, an ____% follow up rate is maintained from 2004 or the cancer registry reference date, whichever is most recent.
80%
Who monitors the cancer program’s expected Estimated Performance Rates for accountability and quality improvement?
The cancer committee.
Access to the PRQ is provided to which four members of the cancer program?
Registrar
Cancer Committee Chair
Cancer Program Administrator
Cancer Liaison Physician
What is the primary source for documentation of cancer program activity?
Cancer committee minutes
Access to the PRQ and PAR is through which CoC password protected web-based portal?
Datalinks
The facility completes or updates the PRQ at least ____ calendar days before the scheduled on-site visit?
30
Completion of the PRQ/PAR should be a team effort of members of the cancer committee.
True or False?
True.
The Post Survey Evaluation is a required component of the cancer program survey.
True or False?
True
Where do programs complete the PSE (Post Survey Evaluation)?
Online within the PRQ
The PSE is required to be completed within ____ days of the on-site survey?
14
At a minimum, the site reviewer must meet with which three staff members during the site visit?
Chief Executive Officer or other C-level administrator.
Cancer Liaison Physician
Cancer Committee Chair
Do medical records reviewed on site during the site visit have to be de-identified?
No.
Accreditation status notifications are distributed via email approximately ____ days, or as soon as practical, following the completed site visit.
45
The committee responsible for cancer program leadership is multidisciplinary and represents the full scope of cancer care and services.
True or False?
True.
Bonus: What CoC Standard does this describe?
2.1
A cancer program’s scope of services offered and need for additional committee members is based on
A. The number of cases accessioned annually
B. The hospital category
C. The major cancer sites seen by the program
D. All of the above
C. The major cancer sites seen by the program
If an appointed committee member can no longer serve, when must a new member be appointed and where is that appointment documented?
A. As soon as possible, committee minutes
B. At the next committee meeting, committee minutes
C. Within 30 days, cancer conference minutes
D. At the next cancer conference, cancer conference minutes
B. At the next committee meeting, committee minutes
The Cancer Liaison Physician can fulfill two other cancer committee roles. What are they?
Physician of any specialty.
Cancer Committee Chair alternate.
What is the maximum number of cancer committee roles one individual may serve?
Three
Two coordinator roles
One of the required physician or non-physician specialties.
Both the cancer committee and the cancer conference must meet quarterly.
True or False?
False. The cancer committee meets quarterly. The frequency of the cancer conference is determined by the cancer program.
To be in compliance with standard 2.3, the cancer committee must meet at least
A. Once per quarter
B. Once a year
C. Twice a year
A. Once per quarter
To be in compliance with standard 2.2 , the CLP or alternate identifies, analyzes and presents NCDB data to the cancer committee at least ____ and be present during the on-site visit.
A. Once a year
B. Twice a year
C. Quarterly
B. Twice a year
To be in compliance with Standard 2.4, each required member or designated alternate must attend _____% of the cancer committee meetings held.
75%
Who is responsible for evaluating and reporting cancer Conference activity to the cancer committee?
The cancer conference coordinator
How often does the cancer conference coordinator evaluate and report cancer conference activity to the cancer committee?
Anually
Where can you find the cancer conference coordinator’s report on the cancer conference activity?
The cancer conference minutes
What four elements are included in the cancer conference coordinator’s report to the cancer committee?
- Frequency of the conference.
- Attendance of required physician members.
- Elements of discussion for each case.
- Action plan to resolve any deficiencies.
How the activity of the cancer conference is documented is up to the discretion of
The cancer committee
Who is responsible for making sure 15% of analytic cases are presented at the cancer conference, and that 80% of those cases are prospective?
The cancer conference coordinator
Multidisciplinary team evaluation of cancer patients improves which of the following
A. Clinical decision making
B. Outcomes
C. Patient experience
D. All of the above
D. All of the above
The cancer conference coordinator can be a CTR.
True or False?
True
The CLP report is required to be included in the cancer committee minutes.
True or False
True
When should the Letter of Authority be updated?
A. Annually
B. Quarterly
C. Any time new programs are developed
D. (C) and once each accreditation cycle.
D. (C) and once each accreditation cycle
All physicians managing patients with cancer must be board certified or demonstrate ongoing cancer-related education by earning _____ CME hours per ______
12, calendar year
In what two places must the physician credentials be documented?
In the committee minutes and in the PRQ
Oncology Nursing credentials will be evaluated each _____
A. Accreditation cycle
B. Year
C. Quarter
B. Year
In the synoptic format for pathology reports, all core elements must be reported
A. Only if applicable
B. Whether applicable or not
C. At the discretion of the facility
B. Whether applicable or not
Cancer pathology reports eligible for synoptic reporting are
A. Definitive surgical resection of primary invasive cancers
B. Definitive surgical resection of ductal carcinoma in situ
C. Definitive surgical resection following neoadjuvant therapy who have residual tumor
D. All of the above
D. All of the above
According to Standard 5.2 Psychosocial Distress Screening, patients must be assessed for distress through direct contact. Other than a face-to-face visit, what qualifies as direct contact?
A. Email
B. Telephone
C. Telemedicine
D. B and c
D. B and C
Where are the results of a patient’s psychosocial distress screening documented?
In the patient’s medical record
What three elements should the annual psychosocial services summary include?
Number of patients screened.
Number of patients referred for services.
Where patients were referred
What is the process for resolving a deficiency in Standard 6.2 Data Submission where the diagnosis year wasn’t submitted, the diagnosis year had far fewer than expected new and updated cases, or a diagnosis year was submitted after the Call for Data due date?
Upload the NCDB email notification showing the full analytic caseload for the deficient year was submitted without errors.
OR
Screenshot the information in the “View Detail” on the NCDB Submission History.
Which Cancer Committee Coordinator…
Monitors each area of the registry.
Recommends corrective action if necessary.
Reports results, recommendations, and outcomes to the cancer committee at least annually?
Cancer Registry Quality Coordinator
A review of a minimum of _____percent of the analytic caseload (up to _____ cases annually) is required per year to review accuracy as per Standard 6.1 Cancer Registry Quality Control
10%, 200
How many patient-, system-, or provider-based barriers to accessing health care and/or psychosocial care should the Cancer Committee identify and focus on improving per year?
At least one
How many phase-in standards are there in the 2020 standards?
8
What are the phase-in standards for 2020?
4.2, 4.8, 5.3-5.8
Cancer committees are required to provide an annual review of how many standards?
12
How many times per year must RQRS data and performance be reported to the cancer committee?
Twice per year
Which member of the cancer committee is responsible for supervising the Quality Initiatives?
The Cancer Liaison Physician or the Quality Improvement Coordinator
The frequency of the cancer conference is determined by
A. Cancer Committee
B. Cancer Program
C. Number of Analytic Cases
D. Cancer Conference Coordinator
B. Cancer program
How many Quality Improvement initiatives take place annually under the supervision of the CLP or the Quality Improvement Coordinator?
At least one
Which member of the cancer committee CANNOT be the Community Outreach Coordinator?
The CTR
Which two required physician members of the Cancer Committee can also represent one of the other required physician specialties?
Cancer Committee Chair, Cancer Liaison Physician
Which required member of the Cancer Committee can be a physician of any specialty?
Cancer Committee Chair
Which required non-physician member of the Cancer Committee has budget authority for the cancer program?
Cancer Program Administrator
Which coordinator oversees the multidisciplinary cancer conference?
Cancer Conference Coordinator
Which coordinator oversees the Quality Improvement Initiative?
Quality Improvement Coordinator
Which coordinator oversees Clinical Research Accrual?
Clinical Research Coordinator
Which coordinator oversees Psychosocial Distress Screening?
Psychosocial Services Coordinator
Which coordinator oversees the Survivorship Program?
Survivorship Program Coordinator
