Cancer Registry – The Only Thing Constant is Change! Read Our List of Key Cancer Registry Updates, Changes and Postponements to Know Before 2021

By nThrive | Posted: 10/12/2020

nThrive cancer registry and oncology solutions during COVID-19

The cancer registry is key to a solid cancer program and relies on a seasoned registry team to ensure accurate data collection that adheres to the Commission on Cancer (CoC) and State data reporting requirements.

CoC Cancer Program Standards are frequently updated and it is the Registry team that advises on the impact of changes in order to ensure compliance with the standards.  Health care organizations are seeing the value of their participation in other clinical registries, as well, to support performance measurement, reimbursement  and public health issues, as COVID-19.

To help you keep abreast of the changes and updates, the nThrive Cancer and Clinical Registry team has compiled a list of updates for quick reference.

Key Cancer Registry updates:

2021 Phase-in Standards Effective January 1

  • Standard 4.2 Oncology Nursing Credentials – Nurses providing direct oncology care who are not certified will be required to complete 36 cancer-related continuing nursing education hours every accreditation cycle.
  • Standard 4.8 Survivorship Program – Cancer Committee selects coordinator. The coordinator is to develop a team to collaborate with throughout the year to address cancer survivor needs.
  • Standard 5.7 Total Mesorectal Excision – Reviewer/surveyor to review the standardized synoptic pathology reports for rectal cancer patients with middle and low rectal cancers.
  • Standard 5.8 Pulmonary Resection – Reviewer/surveyor to review the standardized synoptic pathology reports for curative intent pulmonary resections.
  • Standard 6.4 Rapid Quality Reporting System (RQRS) Participation-To be renamed Rapid Cancer Reporting System (RCRS) Data Submission with the following requirements:
  1. All new and updated cancer cases submitted at least once a month.
  2. Submit all complete analytic cases for all disease sites via RCRS as specified by the annual call for data.
  3. RCRS data and required quality measure performance rates are reviewed by Cancer Committee twice a year and documented in the minutes.
  • Standard 7.1 Accountability and Quality Improvement Measures – 9 selected measures:
  1. Breast: BCSRT 90%; HT 90%; MASTRT 90%; nBx 80%
  2. Colon: 12RLN 85%
  3. Gastric: G15RLN 80%
  4. Non-Small Cell Lung: LCT 85%; LNoSurg 85%
  5. Rectrum: RECRTCT 85%
  • Standard 9.2 Commission on Cancer Special Studies – no studies planned for 2020 or 2021.
  • Retiring Standard in 2021 – Standard 6.3 Data Accuracy. This standard will be part of the RCRC Data Submission in 2021.

Impact of COVID-19 on the Commission on Cancer Accreditation Survey Process

Approximately 1,500 cancer centers across the nation hold American College of Physicians Commission on Cancer (CoC) accreditation. CoC-accredited cancer programs undergo triennial on-site visits, in which a trained CoC site visit reviewer/surveyor reviews required cancer program activity documentation to ensure compliance with the standards.

In early March, the CoC made the decision to postpone 2020 accreditation site visits for eight months. Test pilots of virtual site visits with a few CoC and NAPBC programs were conducted in July and August.

  • Virtual Surveys are being offered in addition to onsite surveys.
  • Onsite surveys have been on hold since March 2020.
  • Hospitals are rescheduling the surveys either to be conducted virtually now or onsite in 2021.
  • Your health care organization can host an onsite visit in 2020 or 2021 if the reviewer/surveyor and hospital both agree to it.
  • Hospitals opting to be surveyed in 2020 will be measured on the past three years – 2017, 2018 and 2019. The visits are being pushed back by six months.
  • Hospitals scheduled to be surveyed in 2021, 2022 and 2023 will be rescheduled for their survey one year later. This means that programs scheduled for 2021 will be surveyed in 2022 in the same month and will be evaluated on cancer program activity of 2020 and 2021.
  • A six-month extension is granted to organizations that received a deficiency from their last survey to provide documentation that resolves the deficiency. For example, if a survey was conducted in September 2019 and the hospital received a deficiency, they would normally have until September 2020 to submit the documentation. With this extension, the hospital has an additional six months, meaning their documentation is due March 2021.
  • Part of survey requirements mandate onsite cancer conferences to present each cancer case. Facilities are required to present 15% of their analytic cases annually. A lot of conferences have been cancelled due to COVID-19, although that could potentially be a risk to patient care.
  • There are now packaged offerings to conduct the conferences online. Hospitals are looking at these applications to conduct virtual conferencing, giving individuals the ability to remain socially distanced.
  • COVID-19 Accreditation Trackers have been developed for each program to assist with documenting the impact of COVID-19 on compliance with the CoC, NAPBC, and NAPRC accreditation standards.

Preparation for virtual accreditation event:

  • Allow extra time – at least two hours, according to one reviewer/surveyor.
  • Select electronic platform – e.g. Zoom, WebEx, etc.
  • Conduct a technology practice run between reviewer/surveyor and the CTR. Ensure the electronic platform is working
  • Set agenda (similar to onsite visit).
  • Prior to survey event, prepare a visual presentation tour (PowerPoint or video) of the facility to be shown at the survey event.
  • Also prior to survey event, de-identify path reports (remove all patient PHI)  in the College of American Pathologists review process (CAP review). This is CAP protocol.
  • Engage the use of Drop Box during the survey for large presentations to be provided to the C-Suite and the CC committee. Each departmental area and/or the surveyor requires a location to house their large presentation files.

Accreditation Survey Day

  • Zoom meeting.
  • Call in from home or office – usually, a limited number of staff are onsite. The CTR runs the meeting.
  • Ask remote participants to join the meeting with their cameras on to encourage dialogue and engagement.
  • During the survey, there will be one-on-one conversations between the reviewer/surveyor and the cancer liaison physician (the point of contact physician between the organization and the CoC) and Pathology (CAP Review) (CLP is required to prepare/share reports quarterly or semi-annually.
  • Connection can be tough for the staff who are calling in. Be sure to test the electronic meeting platform and on-camera participant presence to facilitate a smoother event.
  • Be willing to converse with the reviewer/surveyor prior to getting down to work. Generally, reviewers/surveyors try to connect with the participants to better understand them and to establish trust between the parties. This can prove to be more of a challenge when conducted virtually.

More about nThrive Cancer and Clinical Registry Services

The nThrive Cancer and Clinical Registry team provides CoC Program accreditation support. 100% of hospitals and health care organizations that engage our accreditation support – 10 to 15 a year – successfully attain full accreditation status.

nThrive Cancer and Clinical Registry abstracts more than 130,000 cases annually. The team provides additional registry services for:

  • COVID-19
  • Bariatrics
  • Bone Marrow
  • Cardiac
  • Stroke

If you’d like more information, visit our Cancer and Clinical Registry Services website and see how your hospital or health care organization can transform your cancer registry program today. Questions? Scroll down the page and fill out the Contact Us form. We’ll get back to you soon!