[4] Unit 3 ppt Notes - NCRA (9) Cancer Committee

Learning Objectives for the Cancer Committee Study

• Define the fundamental nature and purpose of a Cancer Committee.

• Describe the comprehensive responsibilities held by the Cancer Committee in a clinical setting.

• Identify the specific multidisciplinary members required for a functional committee.

• Review the mandatory attendance requirements for various Cancer Committee members.

• Explain the critical role and specific duties of the cancer registrar within this framework.

The Commission on Cancer (CoC) Accreditation Program

• Foundational Role: The Commission on Cancer (CoC) Accreditation Program is the governing body that establishes the standards ensuring necessary structures, processes, and outcomes are in place to deliver quality and comprehensive cancer care.

• Compliance Assessments: The CoC conducts regular surveys every 3 years at cancer programs to evaluate their compliance with these established standards.

• The Cancer Committee as a Requirement: A mandatory component of any CoC-accredited program is the existence and proper functioning of a Cancer Committee.

Definition and Leadership Scope of the Cancer Committee

• Organizational Nature: The Cancer Committee is a multidisciplinary leadership body composed of both physician and non-physician professionals.

• Primary Responsibility: The committee is charged with monitoring the structure and services of the cancer program.

• Leadership as the Key Element: Effective cancer programs rely on leadership for various stages of program management, including:

  • Goal setting.

  • Strategic planning.

  • Initiating new programs.

  • Implementing services.

  • Evaluating current practices.

  • Improving all cancer-related activities within the facility.

Key Responsibilities of the Cancer Committee

• Coordinator Appointments: The committee must annually appoint members to fill all required coordinator positions (see Membership section for details).

• Standards Monitoring: Maintaining and monitoring ongoing compliance with CoC standards.

• Goal Setting: Setting and monitoring annual programmatic and clinical goals for the facility.

• Data Integrity: Establishing and evaluating the quality of the cancer registry data gathered at the facility.

• Activity Monitoring:

  • Monitoring Cancer Conference activity and specific attendance levels.

  • Monitoring the percentage of patient accrual to clinical trials.

  • Assessing the effectiveness of community outreach activities.

  • Tracking overall Cancer Committee attendance.

• Educational and Clinical Quality:

  • Offering cancer-related educational activities for staff and the community.

  • Ensuring that pathology reports are compliant with required standards.

  • Conducting quality-of-care and outcomes studies to assess patient results.

  • Meeting established performance levels for all cancer related measures.

Meeting Frequency and Attendance Standards

• Frequency: The Cancer Committee must meet at least quarterly throughout the calendar year.

• Subcommittees: Working groups or subcommittees may be established to handle specific tasks.

• Attendance Threshold: Required members or their designated alternates must attend at least $75\%$ of all meetings held.

Cancer Committee Membership Requirements

Required Physician Members

The following medical specialties must be represented on the committee (at least one from each):

• Diagnostic Radiology

• Pathology

• General Surgery

• Medical Oncology

• Radiation Oncology

Required Non-Physician Members

• Cancer Program Administrator

• Oncology Nurse

• Patient Navigator

• Social Worker or Case Manager

• Oncology Data Specialists (ODS)

• Palliative Care Professional

• Genetics Professional

Required Coordinators

Members must be designated to coordinate the following specific areas (6):

• Cancer Conference - monitors the cancer conference activities including the types of activities presented and its attendance.

• Quality Improvement - monitors QI activities within the cancer program.

• Cancer Registry Quality - monitors the quality of cancer registry data.

• Clinical Research - tracks the number or percentage of patients enrolled in clinical trials.

• Community Outreach - monitors community outreach activities and reports them at least annually. These activities may include cancer prevention, screening, and education performed in the community.

• Psychosocial Services - Works to provide, improve, and expand the range of psychosocial services to make sure that patients have all the support and resources needed through the trying time of having cancer.

An individual cannot serve in more than 1 coordinator role. However, 1 of the required physicians or non-physician members may also fulfill a coordinator role.

Additional and Specialty Members

• Specialty physicians representing the top cancer sites treated at the facility (Ex: Neurology, Urology, Gynecology).

• Hospice representatives.

• Nutritionists.

• Rehabilitation specialists.

• Mental health professionals.

• Pharmacists.

• Pastoral care providers.

• Representatives from the American Cancer Society.

Leadership Roles: Chair and Cancer Liaison Physician

• Cancer Committee Chair: Leads the committee and oversees the general administration and direction of cancer-related activities.

• Cancer Liaison Physician (CLP):

  • Responsible for evaluating, interpreting, and reporting the cancer program’s performance.

  • Utilizes data from the National Cancer Database (NCDB).

  • Must report the results of their analysis to the cancer committee at least $4$ times each calendar year.

  • The CLP serves a term of $3$ years with eligibility to serve an unlimited number of terms based on performance as addressed by the CoC and the cancer committee.

  • A required physician member may also take the cancer committee chair or CLP role.

The Specific Role of the Cancer Registrar

• Meeting Coordination: Assisting in the coordination of committee meetings.

• Quality Control: Monitoring the Cancer Registry quality control plan to ensure data integrity.

• Studies and Reporting: Running reports for quality studies utilizing specific registry data.

• Mandatory Reporting Duties: The registrar must report to the Cancer Committee regarding:

  • The timeliness of abstracting (entering patient data).

  • The accuracy and completeness of the collected data from NCBD.

  • Annual follow-up rates for patients.

  • The status of submissions to the National Cancer Database and State Registry.

• Active Participation: participating in discussions and decision-making processes.

• Documentation and Compliance:

  • Ensuring all CoC standards are maintained.

  • Maintaining supporting documentation for the cancer program.

  • Documenting all committee actions by recording them in the CoC survey application record.

  • Taking and maintaining official meeting minutes.

Summary of Essential Functions

• The Cancer Committee is a multidisciplinary committee that is responsible for the planning, implementation, and improvement of all cancer-related activities.

• The committee requires a multidisciplinary membership to ensure a wide range of expertise.

• Mandatory meetings occur at least quarterly.

• Required members OR their designated alternate must attend at least 75% of those meetings.

• The cancer registrar plays a pivotal role by providing multiple reports and tracking data accuracy to meet CoC standards.